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DISEASES 



NERVOUS SYSTEM 

A TEXT-BOOK OF 

NEUROLOGY AXD PSYCHIATRY 



BY 

SMITH ELY JFXLIFFE, M.D., Ph.D. 

AIMTNCT PIIC)KE*S<1H (iF UISCAHErt~F THE MIND ANU NKKVOUH HYMTEM, NEW YORK 
rfJHT-CHAIHATE MEDICAL HCHOOL AND HOSPITAL 

AND 

WILLIAM A. WHITE, M.D. 

EBINTENDF.NT (»F HT. ELIZABETK'm IHtHPITAL, WA»H1N(;T(I\, D, C; PROFESMtR OF NERVOUS 

AND MENTAL DIMEASEH. liEliRIJETOWN VNtVEHHITY; rUUFEHBdK OF NERVOUS 

ANU MENTAL DlrtEAHEn, I;E0R(1E WAHHINIJTON t:NIvrRl!lITT, AND 

LETTL'KF.R ON IliVCHIATRY, V. H. AKMV AND V. H. NAVV 

MEDICAL SCllOOI.H 



SFXOXD EDITIOS, REVHiED, REWHITTES ASP ESLAUGED 
ILLUSTRATED WITH 424 ENGRAVINGS AND 11 PLATES 




LEA & KEHKiEK 

PII II-ADKI-rillA AND NKW VfHtK 



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Copyright 
LEA ft FEBIGER 

1917 



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TO 

HELENA LEEMING JELUFFE 

WHOSE LOFTY PURPOSE, 

IDEAL STRIVING, AND NEVER-FAILING COOPERATION, 

HAVE BEEN A CONSTANT STIMULUS TO PROGRESSIVE ENDEAVOR, 

THIS BOOK IS DEDICATED 

AS A TOKEN OP LOVE AND ESTEEM 



45383 

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PEEFACE. 



To the reading public, the teachers of neurology and psychiatry, 
and the many, friends who have offered us the opportunity to 
improve and enlarge this volume, the authors express their sincere 
appreciation and thanks. 

To further still more the presentation of the subject of disorders of 
the nervous system the present edition has undergone considerable 
revision. We ha\'e added a general introduction which sets forth the 
general purposes of the volume. The chapters on the vegetative 
nervous system and the endocrinopathies, both topics of surpassingly 
increasing importance in medical science, have been entirely rewritten 
and radically expanded, fairlj' i)resenting as we believe, the chief gains 
of practical importance to the medical profession, general as well as 
specialistic. The entire growth of medicine is becoming more and 
more dynamic and functional and this present edition would seek still 
further to emphasize this aspect of the activities of the body as shown 
in nervous functioning. 

The immense material which has been contributed by the ruthless 
vivisection methods of war lias been carefully gone o\'er and woven 
with the fabric of every chapter of this revision. Special emphasis 
has been given to the i>ractical aspects of warfare injuries of the per- 
ipheral and central nervous systems, and the increasing importance 
assumed by mental adaptation under warfare conditions specifically 
discussed. 

The chapters dealing with those functions of life in the human being 
which are termed mind, have been enlarged and revised and still further 
integrated with the life of the body as a whole. We have thus sought 
to keep closer to the Ilippocratic ideal, studying the "whole man," 
feeling certain that a correct body of neurological science can only be 
built up by keeping such a principle in mind. 

S. E. J. 
W. A. W. 

New York and Washington, 1917. 



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PREFACE TO THE FIRST EDTTION. 



TnE diseases o( the nervous sj-stem are no longer compassed by a 
de»eripLioii of the ^ross leiuons of the brain, sfHiiiil cord, cranial and 
peripheral ntTves. The more limited sxTnptoniHtologi,' of disorders of 
these structures, which in this work lias been calleil sensorimotor 
nciirolox,v, has l>ecn expande<] in iwu directions — in one by tlie increase 
in nur knowledge of the historically oldest portion of the nervous 
systctn, namely, the sjTn|>athetie and iiutnnomie Ivegetntive) nervous 
system and in tlic r>ther by the increase in our kno\v|e<ige of the 
mechani.^ns that opemte at the psychic or mental levels. 

The vcKCtaiive nervous system is in close functional Tt^latinns with 
the endiK-rinous glands, and, although some of the crHhH-rinojMthies 
nwy ultimately turn out not to be exclusively nervous alfectioiis, still 
tbc9e organs of internal secretion are so closely related frtim all points 
of view, eml>ryulu}o<'al. finatumicid. physiological, i>atholn(;ieid, and 
pharmacodynamic, with the vegetative nervous system that their 
dLsonlered functions must ncaU be considered in a work dealing with 
the diseases of the ner\'oiw system. The sj-mptomatoloRy of tliis 
rrgion constitutes the bonlerland of neumlogy and inti*nial nu^icine. 

At the highest level stand the mental nier-hanisnis in which action 
rceei\'es a sjTnbolie representation. Here the ncn'ous system is also 
the nieilium thnni^h which that form of physiDto^cal or pathological 
artivity i-alled iiindiirt is brought about. These mechanisms, while 
(iperaling consciously, larj^ly through the sensorimotor channels of 
adjustuirnt.are also intimately relate*! to the \-egetative levels where 
through the enmtions they net uncoiLsciously. 

The authors have kept in mind the concept of the individual as a 
biohigicnl unit temiing by development and conduct ttiward certain 
broadly defined goals and Iiavr mnsidercd the m-rvnus Nysteni as 
only a l>art of that larger whole. The pan. however, jmrtakes of tlie 
unit,v of Uw whole and, so far as possible, the attempt has l»een made 
Ui arrange the diseaK-s of the ner\*ous system in accord with this 
es'olucioriar>* euncvpt. 



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VIII PREFACE TO THE FIRST EDITION 

For i>ni('tifa! piinM)scs and for the reasons stated the woi 
therefore been divided into three parts dealing respectively' wi 
vegetative, the sensorimotor, and the psycliic levels, the react 
all {)f wliich eonie to pass through the nie<liun] of the ner\'ous s 

Man is not only a metabolic apparatus, accurately adjuste 
marvelous efficiency through the intricacies of the vegetative 
logical mechanisms, nor do his sensorimotor functions mak 
solely a feeling, moving animal, seeking pleasure and avoiding 
conquering time and space by the enhancement of his sensory 
bilities and the magnification of his motor p(jwers; nor yet is he 
sively a psycliical machine, which by means of a nuisterly sy 
handling of the vast horde of realities about him has given him 
unlimited pctwcrs. He is all three, and a neurology of today thi 
to interj)ret nervous disturbances in terms of all three of these 
takes too narrow a view of the function of that nuvster sp 
evolution, the nervous system. 

For these reasons the treatise has bee^n called prinnirily a w 
the diseases of the nervous system rather than two books, ( 
ncurohigy and one on i>sychiatry, which would pt^rijetuate a dlsti 
which the authors believe to be wliolly artificial. 

S. E. 
W. A. 

New Yokk and WAsiiix<iToN, 1915. 



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CONTEXTS. 



Introduction; On Some Principles Umlerlying a Claasification of Diseases 
of the Nervous Svst^in 1' 



CHAPTER I. 



Methods of Kxaminatiox of the Nervouh Svmtem. 



Qw^tioiitiuire 

Family History 

History of Patient .... 

Adult Dispiisfd 

Prc'sc'nt lUncs-s .... 
fk'ncral (Hwcrvatioiis . 
riiy.-ii('al Kxiiniinalimi . 
WEC'tiitive N'crvouM System Examination 

Kniiorrinous AnnmalieH 
Sonsorinioti)r I^\amin:itii>ii 

('r;ini;il Ncrvc:^ 

U>\iil ari'l Neck 

rpIHT I'.xtrcmitifs 

Til'- Mu-icliK iif the Trunk 

Tlic l>iwiT IO\trei»ilic,-i 
l{<'(lexes i)f IjiiNT EMremity . 
Kefic.vrs iif i)ic l.ciwrr I'-Xt reitiilies 

Tremors 

I^liierilir .'N■n^il^ilil y 
Protopiitliie Sensihility 
Dti'P Si'iisiliilily .... 
\':isomiit<ir iiikI Trii|iliic Disturlui 
StatiLs ('oriK)ri.i .... 
.Mf'ni:tl Ex;»min:iliii[i Mellioils , 
P^yelmiiriiilyj^is 
Th<; Ctimiilex 
T<fliniv .... 



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CONTENTS 

PART I. 
THE PHYSICOCHEMTCAL SYSTEMS. 

THE NECROLOGY OF METABOLISM. 



CIL^ITIOR II. 

VeHBTATIVK or VlSCBRAL NeUHOLOGY, 

The Autondiiiic and Sympatliclic Systems — The Internal Stwretions . 

Sympathetic and Aulonomic Divisioas 

Special Pntli(»I<)n_v 

p]ye Sympalholir 

Glaucuiiiii 

Tear Cllands 

Mucous and Salivary (ilund.^ 

iNock Sympathetic 

Orvical Sympathftii- 

Cia.ttrc)-intPHliiial Synflronioa 

I'jtophaKii.') 

Stomach and Intestines 

Rectum 

Geni to-urinary System 

Respiratory Api)ara1us 

Vascular Apparatus 

Heart 

Bloodvessels: Vasomotor Neuros&s 

Tonic IIy[)oremias 

Erythromelalnia 

Spa.stic Anemic Group 

Raynaud's Disease 

Intermittent ('laudicafion 

(Ophthalmic Migraine 

Ophthalnioplegie, FaciopleRie, Hemiplegic Migraine — Periodic 

Palai(5s 

Vaj^oinotor Irrital)ility Group 

AnKioneurotic Edema 

Venetativp Skin Disorders 

S<;leroderina 

Multiple Xciirotic Gangrene of the Skin "... 

Swea( Secretory Mccliaiiisms 

Hony Syndromes 

IMooil Syndromes 

("hlorOBLs 

r'osinophilia 



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CONTENTS XI 

CHAPTER in. 
The Endocrinopathies. 

Internal Secretions. General Considerations . . . . ' 167 

TheThyreopathies; Thyreooea 173 

Hypothyreoses 174 

Myxedema 174 

Cretinism 180 

Sporadic Cretinism 181 

Cretinoid Degeneration 184 

Goiter 184 

Goiter Heart 185 

Endemic Cretinism 186 

Endemic Deaf-mutism 187 

Mild an<l Mixed HypothjToid States 188 

Hypcrthyreosea . 194 

Exophthalmic Goiter 194 

Parathyroid Syndromes 202 

Tetany 202 

DineaBcs of the Hypophysis — Pituitary 208 

Hyperpituitarism 209 

Acromegaly and Gigantism 209 

Hypopituitarism 212 

Dj'apituitariHni 214 

lofundihiilar Syndmmi's 217 

Diseases of the Pineal Organ 217 

Pineal Syndrome 217 

Diseases of the Suprarenal Body _. 218 

Suprarenal Syndromes 218 

Hypoadrcnalemia 219 

Addison's Disease 219 

Hyiwradrenalomiji 220 

Disease of the Gonadal Systems 220 

Genital Syndromes 220 

Afcenitalism, Hy|>ergcnitaliHm, Hy!K)genitalism 220 

Mermnphrodiijsin . . 221 

Ap-nitalism : Kimuclis 221 

DysRenitiilisni 22."I 

^ltiltus 'rhyniolyniphiilictiH 224 

Di.-a-a'M's of the l'an<rciis 227 

Paiirrcatir Syniinmics 227 

Di««':L-M's of the Miisiles . 228 

Muscle Syndromes 22S 

Myasthenia Gravis 22S 

Tlu>niS4'irs Diwawc- Myotonia Conci'nita 2;iO 

Myaloniii Atrophica ... 230 

Till' Muscular Dystrophies or Myopalliies 2-i2 

Fatty Syndromes 2;i!» 

Olx-sity ... 2;i!t 

.VdiiKisis Dolorosa 240 

Ifemy ami I(igamentoa< Syndromes: Osteopathies, .\rt hropat hies .... 241 

Achondroplasia 242 

Oittoomalacia 24:i 



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XII CONTENTS 

PART II. 

" SENSORIMOTOR SYSTEMS. 

SENSORIMOTOR NEUROLOGY. 



CHAPTER IV. 

Cranial Nerves. 

I. Diseases of the Olfactory Tract 245 

II, Diseases of the Visual Apparatus 250 

RetinitiB 252 

Optic Norve 253 

Diseases of Oi)tic X(*r\-e 253 

(a) Axial Neuritis 253 

(ft) Interstitial Perijihcrai Neuritis 257 

(c) Diffuse Neuritis 259 

Disease at or alx)ut the Chiasm 260 

Thalamip Pathway 261 

Cortex Pathway 262 

III. IV, VI. Diseases of the Oculomotor Nerves 265 

Third Ner\-c Palsies 266 

Chronic Progressive Eye Palsies 271 

Fourth Nerve Palsies 271 

.^ixth N'ervc Palsies 271 

C()iubino<l Piilsies 272 

V. Disea.ses of the Trigcniinnl Ncr\"e 278 

Mfitor Part 278 

Sensory Pari 280 

Pnigressive Facial llciniatn)i>liy 285 

VII. Diseases oi the Pacini Nerve 285 

Cortical Palsies 286 

Puntim: Facial Ix^sioiLu 288 

PiTiphcral Facial Palsies 288 

VIII. Diseases of the Aiitiitory and Vestibular Pathways 292 

AuiUtory Nerve 2113 

\'e.'itiliutar Nerve 2iH) 

Vesliliuliir \'crtiKocs 2US 

IX. X. Diseases uf the I^iryngeal Nerves liOl 

XI, XII. Diseanes of the Spinal Acccs.«orj- and IIyi>i)gl()ssal Ncrvcn . 30G 

.\r(fssoriiL'* 300 

1 lypoglossu.' y07 

Speecli Disturlianccs 311 

Aphasias 31.^ 

Auditory Aphasia 320 

Visual .\pliusia 320 



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CONTENTS xm 

CHAPTER V. 

AFFECnoNs OF THE FebIpheral Neurons: Sensory and Motor. 

Neuralgiafl 322 

Special Localized Forms of Neuralgias 332 

Trigeminal Neuralgia, Tic Douloureux 332 

Cervico-occipital Neuralgia 335 

Diaphragmatic Neuralgia 336 

Brachial Neuralgia 337 

Intercostal Neuralgia 340 

Lumbar Plexus Neuralgia 341 

The Sciaticas 341 

Lumbo-abduniinal Neuralgia 346 

Testicular Neuralgia 347 

Crural Neuralgia 347 

Femoral Neuralgia 347 

Obturator Neuralgia 347 

Neuralgias of the Pudendal Plexua 348 

Neuralgias of the Coccygeal Plexua 348 

Herpes Zoster; Shingles; Zona. Radiculogaaglionic Syndrome (Acute Pos- 
terior Poliomyelitis) 348 

Radiculitis 351 

Neuritis 354 

Polyneuritis, Multiple Neuritis 355 

Alcoholic Multiple Neuritis 357 

Lead NeuritiH 360 

Arsenical Neurit is 360 

Infectious Disease Types 3f)l 

Plexus Palsies '.H\2 

Hrachial Plexus Palsies :i(i2 

Total llnirhial Palsy ;i(Vj 

Inferior ]U»A Tyjte 3ti;") 

Supericir Hrachiid Plexus Palsy 365 

Mi\ed Tyi»rs 365 

Lumbosacral l'lexa'4 367 

Peripheral Palsies ;J6!) 

Peripheral Palsies due to War Injuries 370 

Injuri»« to Facial Nerve 377 

Spinal Accessor)' Nerve ;{7S 

Cervii-al Rib :i7S 

The lAmfc Thdracic Nerve 37S 

The Circumdex Nerve 37fl 

rinar Nerve 379 

Musculocutaneous Nerve ;iSO 

Median Nerrc :{H0 

Hailial or Musculospirul Nerve ;j82 

Sciatic Nerve 384 

External Popliteal Nerve ;tS4 

Internal Po[ilitcal Nerve ;iM4 



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XIV CONTENTS 

CHAPTER VI. 
Lehions of the Spinal Cord. 

Acute PoUocncephalomyelitis 

Spinal Forms 

Acute Amrcnding Form — Landry'n Paralysis 

Bulbar ami Pontine Forma 

Enccplialic or C-erebral Form 

Cerel)cllar Forms 

Meningitic Forms 

Polyneuritic Forms 

Incomi)lcte or Minor Forma 

Primary Pn>grt'!wive Mui<i'iilar Atrophies 

Group 1. The Progressive Nuclear Atrophies: (1) Spinal, {2) Bulbar, 

and (3) Mesencephalic Forms 

Spinal 

Chronic Poliomyelitis 

Aran-Duchenne Type. Progressive Mufwular Atrophy 

Infantile Hereditary Forms 

Bull>o[X)ntinc Types. Chronic Progressive Bulbar Palsies. . . 
Pontomesencephalic Forms — Chronic Progressive Ophthalmo- 
plegia 

Group 2. The Neural, Ncuritie, or Spinal Neurilic Atrophies 

Peroneal-forejinn Type 

Talx>tic TyiK! 

Aniyotniphic Lateml Sclerosis 

Fracture and Dislocation Syndromes 

Comjiression of the Conl 

Bone Hyi>ertrophies 

Tulx^rculcwis (Caries) 

Spinal Cord Tumors 

Lateral Sclerosis Group 

Combined Scleroses. Combined Degeneration 

Combined Selcrosi.s 

Combined Sclerosis in Paresis 

Toxic Forms 

Senile Fonns 

Syringoencci)halomyelia 

Multiple Sclerosis 

CHAPTER VII. 
Lerion at the Level of the Medulla, Pons, Bhain Stem or Midbrj 

Medullarj' Syndromes 

Lesions of the Pons 

Inferior Alternate Paralysis 

Peduncle Syndromes 

Midpeduncle Syndromes 

CoriMjra Quadrigemina Syndromes 

Itabies 

Tetanus 



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CONTENTS XV 

CHAPTER Vm. 
Paralysib Aoitans, Chobba, and Related Syndromes. 

Paralysis Agitans Group 498 

Dystonia Mmculorum Deformans . 507 

Progressive Lenticular Degeneration 509 

Dyssynei^a Cerebellaris Progressiva — Chronic Progressive Cerebellar Tremor 51 1 

The Choreas 512 

Chorea Minor 513 

Huntington's Chorea 517 

CHAPTER IX. 

Cerebellab Stndboh^s. 

Chief Syndromes 531 

Inferior Cerebellar Peduncle — Corpus Restiforme 531 

Lesions of the Middle Cerebellar Peduncle 532 

Lesions of the Superior Cerebellar Peduncles 532 

Cerebellar Aplasia 532 

Hemorrhage of Cerebellum 537 

Cysts of Cerebellum 537 

Tumors of Cerebellum 537 

Abscess of Ccrel>ellum 540 

Posterior Fossa Syndromes 54 1 

PontocerelxsUar Angle Syndromes 543 

CHAPTER X. 

Diseases of the Meninges. 

Dural Disease 544 

Meningeal Apoplexy 544 

Inflammation of Dura 547 

Pachymeningitis Externa 547 

Pachymenmgitis Interna Simplex 547 

Pachymeningitis Interna Hemorrhagica 547 

Diseases of the Arachnoid and Pia. Leptomenin^tis 549 

Acute Leptomemngitjdcs 549 

Infectious Meningitis 554 

Epidemic Cerebrospinal Mcningitia 554 

Tuberculous Meningitis 556 

Serous Meningitis 557 

Syphilitic Meningitis 557 

Chronic Leptomeningitis 559 

Hydrocephalus 559 

Sunstroke 562 

CHAPTER XL 

Diseases of the Brain. 

Eiicephalitis — Abscess of the Brain 563 

Acute Encephalitis 564 

AbBccss of the Brsin '^"■'^ 



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XVI CONTENTS 

CHAPTER XII. 

Diseases of the Brain (Continued). 

VaiMiuIar Disturbances — Cerebral Apoplexies 

Vascular Instability 

Anemia 

Hyijercmia 

Orebral ArtcrioscierosiB 

C'crebral Apoplexies 

Henidtrhagc, Thrombosis, I^mliolism 

The Apoplectic Attack 

The Thalamic Syndrome 

Sensory ('hangc!! in (Cortical I.x>sions, Suprathalamic Pathways 

Apraxia 

, Sinus Thrombosis 

CHAI*TER XIII. 

Tpmors of the Brain. 

True Tumors ... 

Infectious Tumors 

Parasitic Cj'stic Tumors 

Aneunsmal Tumors 

Frontal Ijobe Tumors 

Central Convolution Tumors 

Parietal Ijobe Tumors 

Temporal Lobe Tumors 

Occipital Ix)l>e Tumors 

Corpus Callosum Tumors 

Optic Thalamus Tumors 

CHAPTER XIV. 
Kyphius of the Nervous System, 

Syphilis of the C'ranial Bones Causing Nervous Symptoms . . . . 

Syphilitic Meningitis of the Base 

Syphilitic Meningitis of the Convexity 

Cerebral Syphilis 

Va.scular Types 

Parenchymatous Types (Paresis) 

Dementing Forms 

Depressed Forms 

Expansive Forms 

.Agitated Forms 

Irregular Forms 

Juvenile Paresis 

Syphilitic Psychoses • 

Talies 

Syphilitic MeningomycUtis 

Congenital or Hereditary Syphilis 



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CONTENTS xvil 



PART III. 



PSYCHICAL OR SYMBOLIC SYSTEMS. 

NEUROSES, PSYCHONEUROSES, PSYCHOSES. 



CHAPTER XV. 

The Psychoneuroses and Actual Neubobek. 

The Psychoneuroses 712 

Hysteria 712 

Compulsion Neurosis 719 

Anxiety Hyeteria 728 

The Actual Neuroses 729 

Anxiety Neurosis 729 

Neurasthenia 737 

Mixed Neuroaes 739 

CHAPTER XVI. 

Manic-depressivi: Psychoses. 

Manic Phase 751 

Depressive Phase 757 

The Periodical Types 760 

TTie Cyclothymiaa 762 

The Mixed States 764 

Involution Melancholia 765 

CHAITER XVII. 

The Paranoia Group. 

Paranoia of Kraei)elin 77(» 

Mixed an<i Alwrrant Forms 777 

Parnphreniafi 77S 

CHAPTER XVHI. 

Kl'ILKi'SY AND CoNVri,SlVE Tvi'ES OF ReaCTIOS. 

Chuwic-al I';pileiip\' 793 

Attenuateil Forow. Afferl Epilepsia 796 

EpilciKiios of (iross Brain DiseiL-w- 797 

CHAITER XIX. 
Dementia Pre<()X (Schizoi-hrenia) Groit, 

Dcnicntiii Simplex S15 

Heltephrrnia 816 

Catatonia 819 

Paranoiri Forms 822 

Mixed and AtypintI StatoM 8:^3 



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xviii CONTENTS 

CHAPTER XX. 

Infection — Exhaustion PsYciiosEa. 

Prefcbrile, Febrile, ami Postfebrile Psychosea 

Infection and Initial Delirium 

Fever Delirium 

ExhauHtion Psychosea 

Collapse Delirium 

Acute Hallucinatory Confusion (Amentia) 

Typhoid Fever 

CHAPTER XXI. 

The Toxic Psychoses. 
Alcoholism 

Drunkenness 

C'hronic Alcoholism 

Delirium Tremens 

KoRsakow's Psychosis . . '. 

AlrohoUc Hallucinosis 

Alcoholic Pseudopareais 

Alcoholic Pseudoparanoia 

Alcoholic Epilepsy 

Dream States 

Dii>8omania 

Opium 

Cocain 

Misccllaneou» Intoxicants 

Bromides 

Carbon Monoxide 

Lead 

Mcrcurj- 

I'rcmia _. 

Diabetes Mellilus 

Gastro-int«stinal Diseases 

Pellagra 

CHAPTER XXII. 
Psychoses yVssociated with Organic Diseases. 



Apoplexy . 
Traumatism , 
Acute Chorea 
Chronic Chorea 
Paralysis A^itaos 
Multiple Sclerosis 
Polyneuritis 
Heart Disea-W 



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CONTENTS XIX 

CHAPTER XIlI. 

Presenile, Senile, and Ahtebiosclbrotic Psychoseh. 

The Presenile Psychoses 866 

Involution Melancholia 866 

Other Psychoses of this Period 870 

The Senile Psychoses 872 

Intermediate Conditions 872 

Normal Senile Involution 872 

Simple Senile Deterioration 874 

Senile DeUrium . 874 

Presbyophrenia 874 

Alzheimer's Disease 877 

Arteriosclerotic Psychoses - 878 

Arterioeclerotic Brain Atrophy 878 

Subcortical Encephalitis 878 

Perivascular Gliosis 878 

Senile Cortical Devastation 879 

CHAPTER XXIV. 

Idiocy, Iubecility, Feeble-mtndbdnbss, and Ciiaracterolooical 
Defect Gboqps. 

Feeble-mindedness 886 

ImbeciUty 886 

Moral Imbecility 886 

Idio-imbecility 886 

Idiocy . 886 

Amaurotic Family Types 888 

Sclerotic Types 888 

Cretinism 890 

Mongolism 893 

Hydrocephalic Types 894 

Microcephalic Types 896 

Paralytic Types S98 

Traumatic Tyiiea 898 

Epileptic Types 898 

Inflammatory Types 899 

Sensorial Types 899 

Syphilitic Tyi>es 000 

Idiot-eavanta 90t 

Mild Grades of Defect 902 

Psychopathic Constitution 904 

Anomalies of the Sexual Instinct 006 

Quantitative Anomalies _ iKXi 

Qualitative AnomaUes 906 

Masturbation 906 

Active Algolagnia 906 

Passive Algolagnia 906 

Homoeexuality 906 

Narcissism 906 

Fetichism 906 

Bestiality 90 

Eaiubitionism 9( 

Necrophilia IK 

Iimx 90. 



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DISEASES OF THE NERVOUS SYSTEM. 



INTRODUCTION. 

ON SOMK I'lUNCIPIJCS INDKRLYING A CLASSIFKATION 
OK PISEA.SICS OF TIFE NEUVOLS SYSTEM. 

rLAs»iriCATio,N8 hiive value as offering a condensed resum^ of 
exlstin;; attitudes of mind with reference to the nature and relations 
i»f the thintfs classifieft Thi*y hIsi» serve as a ooiMTPte setting forth of 
newer ainttpt-s, which, but for the effort, woulil tcnil to HnKcr indefi- 
nilfly in ohJer se^lin^s. 

For a Um^ time the nervous sj-stem has l>een considered as ii thing 
«l>urt, a sort of consecrated territory, where ordy the initialed coultl 
enter. It was a place for ni,vster>' and for bewilderment. 

The mim) wa.< more con>ciTated and myi^terious .still, and was dealt 
with metaphysically until its relations tn the nervous system were 
mui-h more vagne tlian the relations of the nervous system to the rest 
irf the liody. 'HiLs state of affairs has liecu crystallized by the titles 
of our text-l»Hiks, whidi set forth that they deal willi nervous and 
mental dl-n-ases. inferring that these two gnrnps hfl\e little relatiou, 
the one u> the other, and. by tlie a&uiv token, fail to indicate tliat (hey 
either or Uyth have any relation to the re^t of the btxly. 

All this U wn>ng. The hutniLn individual is a biological unit, his 
wiTal jiart'' iin- |Hirts iif that nuity, and be himself is still part of a 
greater whole, a pnrticular iustauiv of the manifestation nf life. Any 
!iy>ttem of classification, no mutter how far it attempts (o go in formulat- 
ing dtstini-t disease trends, sliouM not fail altogether to permit clic 
broader view of the interrelations to show through. 

I'nmi llu- point of view of the nervous system, how is this to be doue^ 
lleeent ilevelopments in physiology- and in internal mt^iciue [wint the 
way. fieferi-m-e Is made to tl>e de\eIo()menl in knowledge of the 
vegetative nervous system and of tlie ciidruTitie glands. These develoi>- 
menis luive senn! the twof»ild purjKise tif bringing the ncvrral functitms 
of mnn into a el<>s<.T knit harmnny and iit the same time cnrrelating 
that lianiiiitiy uith the tnanifcsiations of the organic acti\iti<'s a> 
fotmd in lower animals. The last has l)cen the result liecause the 
developroents have had to do with what are called lower, simpler or, 
nutrr pn)iMrl\ , phylogcneticjilly okler fonns of activity, or m(xle.*) of 
rmctiot). 
2 



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18 



Ih'TRODVCTION 



Winkxt here, in the term "phylo^enetically olrler," is the key to th( 
principle i>f f'lu.s,sifiniti«*n — a principlt- tluil has Ktnjj Koveriui! in the bio 
tdgiful si-ifnt-eH, the siiiipler aiu\ uUlvr merging by insensible gra<l:itIom 
into the iiiope complex and more recent. It has taken long periods o 
time aii<) the aecunnihition of great masses of detailed obscn'iition 
before those facts of wilier hearing have emerged that have sen'ed t 
bring all this material together wnder wider generalizations. Th 
older hyi^itheses have l>ei-onie more and m»ire inadeiinate; in the 
prime they were useful, but. like nil hypotheses, their present aspe 
of diiiginess is only a sign of progress. 

For a long time it has Ijeen asserted that the nervous system b t^ 
means by wliich all of tlic several parts of the human unit arc Intcgrat 
by a s|K't'ies of enmplicateil adjustments to given ends. It can 
perceived how this integration is actually brought to pass by raa 
of the vegetative ner\nus system and the chemical regulators 
metabolism, at a iihysicochendeal level, unii how by the success 
comjiodnding of reflexes at the sensorimotor level, the human ii 
is furtlier iiitcgrati'd. so that it <"ati as a whole work jnore consistei 
toward liroadly <lefine4l goals, the integration manifesting itself at : 
eessively higher and higher levels in the historj' of the individual, 
of the species. , 

Viewed in this way the individual is seen struggling along 
path of evolution in constant conflict between an inherent iiv 
that wouKI keep it at ii given level, but gradually a/l\ ancing by a s 
fif give and take compromises that finally bring it to Ix'tter adjusti 
with its cnviroiuucnt al ever higher levels of integration. 

Sherrington has lx-»utifully illustrated this integrative action o 
nervous system in the simple reflex with its Jnnen'ation of ag< 
on the one hand and aiitagitnists on the other, and the ehanneli 
(hml cii'mtiion pathways for nervous discharge. Thi.s law of confl 
tendencies, i)athways of oppiisites—^ambi valence — where the 
issue for higher intergratlons is made possible at the seiisori 
level by the tension of rectjiroeal irmcrvatiotis, is found also to 
rule in the vegetative nervous sj-stem, with its double set of phai 
dynamically (lemonstratc<l ()pposed elements, mediated, at If 
part, b.v equally opposed, exciting and inhibiting chemical suhf 
secreted by the endocrinous glands, the hormones. I 

l-'inally an analogous ambivalent mechanism is seen working 
highest, tlie mt>st complex level, the psychic, which determines t 
v<\iU the assistance of the phenomena called consciousness, iu ' 
psychological s.\'ml>olism is found n-placing sens*>ry and ni(it()r i 
and exciting and inhibiting hormones. T 

For practical purposes, then, the nervous system may be 
into these three levels of activity, the vegetative, the sensi 
anil the psychic. 

Tliis llin-cfoUl division of the reactions of the nervous syste 
fundamental basis on which o classificution may be founde 



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CLASSIFICATJO^ OF OlSEASES OF TUB NERVOUS SYSTEM 10 

binloRical activities which maintuin life at the lowest level are physical 
and chemical, and thus that portion of the nen'ous system which hn.*; 
ilirect oontrollinp iuHiiences over these activities Is properly Hesignat«l 
as the vegetative nervous system, ami that part of neurologTi' which 
ha.'i to (h) with a roiusitleration of the.sc physieoclienjical systems, 
heruuse it deals with the nervous cocitml of the viscera and of 
metaholi-sm, is properly designated as visceral or vegetative neu- 
rology. 

In this region of vegetali^ e neimilogy a rich variety of ftistnrl)ance3 
is found, involving the gSiiitdular, gabtro-intestitial, genito-nrlnary, 
vaiicular, rcspiratnri,', muscular, cutaneous and bony systems. In 
addition there are certain complex clinical (froiips involving, for the 
most part, the glands of internal secretion, the end ocrinopat hies. 
Here is a rich tieU which has Ix^en imeqnally cultivated since Urown- 
S/kpianl first tried to iliscover the fountain of youth iu tlie te.'^tienlar 
extracts. 

While the sjtnptomatologj' of the neurological rlisturbances of the 
tear, uuicnus and salivary glands is a comparatively- liniitictl one. a 
viTv rich synijrtomatology 1ms grown up alxmt the vascular system 
in the group of vasomotor neuroses. There is also a large field in 
various directi(ms, for example, in tfie gastr(>-inte.stina! and in the 
cutaneous disorders, which, however, arc for the most part taken over 
by the specialties dealing with these rt'speetive systems, but in which 
nevertheless many di>onlerN will receive an adetpiate explanation only 
thnnigh the nnderstanditig of visceral neunilogy. Sane portiuns of the 
field are as yet Um little known to offer mneh that is of value, as, for 
example, the neurology of the Ixjuy system and the nervous mechanism 
underlying the rcgiilafion of the bliMvd cells and the relations of tlie 
vegetative nervous system to innmniity and anaphylaxis, while in 
other systems the di^^turbunces are known only as contributing symp- 
tctms in fairly well-defined clinical groups, as. for example, myasthenia 
gra^■is as a disturbance of the muscle vegetative mechanisms. 

The endoerinopathies naturally form a considerable part of visceral 
neurology, and nian\' of the disturbanc-es of the several systems are 
still best iiicludetl in the various clinical groups that are considererl aa 
due to ilisturbnnees in one or more of the endocrinous glandij. This 
field twlay occupies the main foeus of attention of the me<lical 
practitioners, and much that is false is being taught; but out of the 
divergent trt-nds sound harmonies will be evolved. 

If tlie vegetative nervoas system has for its function in tlu' main 
the maintenance of the vegetative, that is, the metabolic proce3se,s af 
life, such as nutrition, growth, development and involution, the next 
higher level, the sensorimotor, has as its fiuiction, in the main, further 
iiitegratitiii by providing the means for the balancefl interrelations of 
the various motor organs of the bmly. It has to provide that all the 
various parts of the raaehiiie work hannnniously together, that the 
functions of the various organs are not only propeHy timed in relation 



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20 



ISTRODVCTiOS 



^ 



one to the others, but also adequately relatwl on the IiasU of the 
functional demands made on them. 

Tliis field of senwirimotftr neurology, ineluding the disorders of the 
cranial and peripheral nenea, the spinal cord, medulla. |»ons brain 
stein, midbrain, c-erebelhim and eerebruni, is that portion of neurology 
to whieh the term "neurolog>*" is generally thought of as applyinfc, 
ti) all intents and purjjoses. exclusively. Here the field is pretty well 
cultivated, and classifications based on anatomical divisions are pretty 
well accepted. 

The third, the highest, the psychic level is the most complex. Its 
function is no longer simply one of integration of the various parts of 
the iniilvidual hut at it> hiphcst, conscious level it hiw to ilo not only 
with the relation of the indivitlnal as a whole to Iiis environment but 
more es[X'eially to his social environment. 

At this level it has been the prevalent custom to think only of 
consciousness, and of conduct consciously repulatetl by intelligence. 
Ideas are symbols: they are symbols of the contemplated action on 
things, through which the individual comes to an efficient adjustment 
with his environment by controlling them. The symlml therefore 
iMttHiies a carrier of energy which is translated into conduct. 

The ways in which these psychic synibolizations work at the highest 
conscious levels is pretty well formulated in current psychology, and 
these ways work very well so lung as there Is iiolhiiig uiiustia! the 
matter with the whole machine. The great error of the psychologist, 
however, has l)een to suppose that the uiatter stopped Iiere. The 
lower animals exhibit most complex forms of l>ehavior without iU 
being thought necessary to ascribe conscious motives (intelligence) 
to them in explanation. Very complicated a<tivities \n\v down in the 
liiulogic-al scale are ascribed to tropisms, while for man It has been 
8uppose«l that what he did he consciously intended. Recent studies 
in psycbopathology have shown the inadcmiiLcy of this conception, 
and it Is llinn»ughly well established that lying back nf cotisciousness 
ifl a much larger, a much more im[>i)r(ant territory wliicit furnishes a 
psychic motivation of conduct, and, in fact, that conscious processes 
as they are known to the individual are largely, if not altogether 
determined by what lies in tliis region— the uncon.'w.'ious. 

Psychic symlM)ls— i*ieas, feelings — must therefore Ix; traced farther 
bnck tlian the cons<-ious level at which tlie individual Is aiKiuainted 
M-ith them in order to understand their real meanings. Psychoanalysis 
is as imi>ortatit for the understanding of the eonstniction of the psyche 
«.•* disM'clion is for the miderstiiuding of the structure^ of the iMxly, or 
chemical analysis for the understanding of the constitution of the 
moletrule. 

'I*he greatest deficien('>' in the psycbologj' of the nineteenth century 
relative to the uiutt'i-staiiding of hnmuu conduct bus l>ecn the neglect 
Tif llif unconscious. 

For ceithiriea man lias marveled anc] speculated and gathered 




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CLASH/ Fir ATrOS OP WSF.ASES OF THF NKRVOUS SYSTEM 21 

observations conecrning the exquisite siihtlctics of wlaptatlon of plant 
strurtures to their pnvironment. Studeiils of nature liave recorded 
in ene.vcIope<li(' pn>portioiLS tlie intricacies of Nature's story of tlie 
conduct f)f the lower rfnimnis from protozoa to hiphesl ape. Thew 
a(■tivitie^ have Infri n-Ifgated to tropisais and to instincts. Man 
alone has suppaswl that he could explain his own conduct by reference 
to that whit'li appears in his consciousness, unmindful of the millions 
of years of e\olution prece<iing that which lie has dcsiKniilcd h^ his 
conscious activities. 

With the help of the h.V'pothe.si.s of the unconscious, however, it has 
come to Ix; recojjTiizwi that the psyche has its embrj'olopy and its 
comparative anatomy -in short, its history— just as the body lias, 
and in precisely the same way as iti the case of the body this history 
hiis to Ite utilized l«*fi(re it can be lutdcrstnod. 

So lon^ as the unconsc-imis fjiJIctl to be rci-oKuizeii, just 30 long wa.s 
the gap lietween so-called body and siw-alled mind too wide to be 
bridited, and st> there arusc the two cunwpts. body and mind, which 
gave origin to the necessity of defining their relations. Consciousness 
covered over and obscured tlic inner organs of the psyche jiLst as the 
skin hides the iiuier organs of tlie Innly from vision. But just as a 
knowledge of the body first l>efttnie possible by the removal of the skin 
and the revealing of the structures that lay beneath, so a knowledge 
of the pgyehe Hi-st I^ecame possible when ilie outer covering of cnn- 
Bciousness wils i»enetratcil and whitt lay at greater depth was revealed. 
As soon as this was done, the wonderful historj' of the psyche began 
to give up its secrets, and the distinction between body and mind liegun 
to dissolve, until now it has come to Ix* auisidered that the psyche Is 
the end-result in an orderly scries of progressions in which the botly 
has used successively more complex tools to deal with the problems 
c}f integration and adjustment. 

I'he hormone is the tyjte of tool at the physicochemical level, the 
reHcx at the sensorimotor level, and finally, the sjTnbol at the psychic 
level. 

In the phylogenetie history of tluit development which culminates 
in man, the s,\Tnho] has Ixfii developed after trying anil laying aside 
in the past all other tools, because it alone ofTers the means of 
uidinnted development t»f man's crMitml over nature. The hormone, 
the reflex, are conf]iie<l in their capacities for rcactitm within relatively 
narrow limits of possibilities. The synnbol is capable of infinite change 
and adjustnu'nt. an<l so has gn>wn out of the necessity created by ever, 
increasing demands. The growth from the lowest to the highest, from 
the youngest to the oklest. from the simplest to the most complex has 
been here, a.s everywhere in iiudire, wiilunit gaps. 



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CHAPTKR I. 

METHODS OF KXAMINATION OF TflK NKUVOl'S SYSTKM: 

I'nE student of diseases of the nervous system, be they vefjetative, 
sensorimotor up mental, slumM have at liis <-oinman(l a [jractit-Hl. sys- 
tematic si'rics of mt'thods forcxamininf; liis paticiit.s. Such a scheme of 
cose examiimtion shdul*! above all !«• orderly, and linffiriciitly extensive 
to enable him to make a rapid sizinj; up of the character of the dia- 
turbance umter invesiiRation. It should not l>e binxlenod with c!etails 
for wliieh an apphcatiori will lie round in only the rni-estnf disnrders. 

A comprehensive iietinthiitical hiNtury shtnih! incOude a careful 
study of the 

I. Family History. 
II. History of Patient. 
III. History of the Pivsent Illness. 
IV. General Observations. 
V. Physical Kxainination. 
VI. Vegetative Kxamination. 
VII. Sensorimotor Examination. 
VIII. Menial Kxaniin;ition. 
l*'or the sake of coiivcnieiiee tlie <'hief fai-tors to be covered are 
here given in the form of a printeil (juestionnnirc. Such printed 
schemes Imvc their ad\anta^es and their dissuJx'antagi's. Hut if 
carefully and thinkinjily followed the iidvantjitres far outweigh the 
disadvantages. For the bcpiiiner in neuroloj;>*, to whom this book is 
addressed especially, sncli a questionnaire, well jrrmmdcd in the mind, 
is the first step in the developtneiit icf a lechnie of ease examination 
which will prove invaluable. It is not tlionj^ht that another form 
may not prove as satisfactory, but some i5e(inite sehenie is indis- 
[jensable. 

Questionnairo. — 'V\w heuriiiig, size, form of binding, of rtding, etc., 
RiII be determined by local conditions and by si>ecial needs. The 
definite faets which are noted in the questionnaire are n<jt by any 
means all of the facts to Iw collected, and such a printed question 
blank is ((iven jjurely as a guide, rather than as a finished prochict. 
As a practical lilank for out-patient dispensary work it is invaluable 

Land also for note-taking in private work. In lii>spital work with 
nervous ilisorders, where it is hoped that autopsy material may put 
opportunities for anatonuad research in one's hands, such a blank is 
naturally too didadic anil inelastic. Its main oulliiK'S, h<vwever, 
Bie still desinible. The first page is devoted to the family history 



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23 

and tlic ^»llfiit Fiu-ts in the early hi.story of the [mtieiit wIiirK are Hisi- 
cusst'd ill (Iftall in the follow-jng pages. 

The initiitl faets are the name, in fitli. timideii name in married 
u'umen. age, reiiitlenee. wnnal status, niarrii'd. single, widowed, divureed, 
aii<l race. In ooiiiitries where immifrration is active, it is desiruhle to 
know not only the birthplace (if a patient, hul also his racial st{K'k. 

I. Family Biatotj.^ i nforvmut (name, relationship to jmtient, 
address). 

(irntiiijiiirfivtt; itarrnh (uncli's and mints); SihUiige, 

('hUdreiJ (with abortions and rnisetirriagi's). 

XoTK. — In securing tlie family historj* it must l)c rememhcreil that 
it is equally important to get a record of all the well memhers of the 
family as well as the sick ones and not stop with .securing the latter, 
as is often, done. The patient's relation r<» hercHlitiiry tentlencics can 
only be determined by securing the fullest information about his 
ancestors. 



BhO 



t>' c. 



a (n) [n] (n) (n) [n] [ij iini~§ 



N 



k 



Flo, I. — ^Pwii^mc rharf. JlLiutrutmii how l«ii diifcvUvv iitmnit* ■an]' liavw fiily tifU*ctive 
chil'lrpn. A, iJiuholii'; (.'. r-riniiruiUjiU''; IJ, iii/tiiit, ilks] in infuncy: f. (cvlili>>mitiil<.vl; 
.V, iiuniiiil; 7', iiilmn-iiluua. <Ciu<ldncii, 1010,) 

It is desirable to get a family histori- as well as an objective history 
Ixith from the iwtient and from other meniU-rs uf the fainil\. 

The first factor to be investigated is heredity. The usual facts 
gathered w>neerning heredity are frennently worthless. Better no 
facta concerning the extremely complicated question of hen:dity than 
false ones. In ordinar>' investigation the research new! not be oxhauft- 
tive. A i-omplete consiileratioii of hereillty is lie.st left to sjR'eial 
eugenic students whose business it has become to pmperly eolhitc 
aud weigh the mass of niateriul nei'ded to bring out sjilieiit factors 
in the here<lity problem. The main facts noted iu the questionnaire 
are .sufficient, sjivc in the consideration of certain disorders in wliicb 
hereditarj' factors are knoxm. such as Iliuitington's chorea. Thomsen's 
diseasi'. dialx-les insipidus, deaf-mutism, certain optic atrophies, etc. 

{'unatinguiniiy in the parents is first to be inquired into; the degree 
of relationship should Ije explicitly cxpre33e<l. Hough charts constnieted 
on the plan of Fig. I should be used to show the relationshi|is. 



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No. 14260. 



Diagno^: Tabes. 



NAME, J. J&nes. Age, 4S. 

Residence, 444 Spring St. 
Date, Jan. 5, 1910. 
Referred by Dr. X. 



Occup.: Cleric. M.S.W.\V.\ 
Race, C/.S. lnU.S.42yr8. 
Examined by Dr. J. 



Parents related : 
Mental: 
Nervous: 
Epilepsy : 

Diabetes: 
Syph.:0 
Eruptions: ? 
Read : 6 years. 



Heredity : 

F., d. 70; apoplery. 

M., d. 64> cancer. 

Children: Only child. 

TBC:0 

Alcohol; 
Birth: Normal. 
Walk: A'. Speak: ,Y. 
Children's Diseases: Measles. 
Enuresis : Thumb : Nail-biting, etc. : 
Sleep-walking: Stammering: 

Other Childish Traits: Cheek-biting. 
Education: Pnh. Sch., High Sch., to 17 years. 
Adult Diseases: 

Sj-phiiis: 26 years. Treatment: 1 month, 

Shocks: Internal: Ilg. 

Habits: Ale: + Tob.: -H + 

Sex: Moderate Indulgence. 

Trauma: 

Occupation Toxemias : 

Convulsions (injury, tongue, urine): 
Constitution: Healthy. Weight: 150. 
Marriage: .1/ 32. 

Menses: 

Cliildrcu: 1 ; d. in infancy (con ignitions). 
Mis.: ;.'; ,{ iiKis. Dead: 



I'irst page of Quest ioiniaire: Made out from examination of a 
l)iiti('iit witli Tabes. 
'/ = iic^'ativf. -f = present, i)<)sitivc. X = nornml or average. 



History: 

Chief complaint: 
Slight unsteadi- 
ness in gait and 
severe "rheumatic" 
neuralgic pains in 
lower extremities 
for past four years. 
Five years ago had 
a transitory attack 
of dizziness, with 
double vision and 
an eye palsy, cross- 
eye, which lasted 
two months. 

Occasional weak- 
ness of the bladder, 
dribbling. Pares- 
thesiiB occasional. 



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STATUS NERVOSITM 



Cranium: Hor., N. 

Sensibility: 0. K. 

As^Tnmetr}' : 

CnnulNerres: 

fOI. ter.:0. A'. 
I. Smeil: 



Bin., N. Vert., A'. 
Deformity : 



Subjective: 



■lAsafet.:a A'. 

Positionof Eyes: O.K. 



"■ ^'^^'^^ I L. 20/100. 



Reflexes: 



Hemianopsia: Scotomata: 
Fundus: Fields: Limited; eon. 

III., IV., VI. Eye movements: 0. K. 
Nystagmus : Palp. 6ss. : R = L. 
Diplopia: 0; 5 years ago. Ptosis: + 
Pupils: R > L,9 and 4 'mm. 

Light: Lost L; dim. R. 
Accom.: 0. K. 
Symph.: Dim. R > L. 
{ Consensual; Lost L-\'R. 
Oculocardiac reflex : 0. K. 
V. Motor: 0. K. 

Sens()ry: (). K. Jaw-jerk: 0. K. 
Tender spots: Cornea: 0. K. 

Conjunctiva; 0. A'. 
VII. At rest: 0. A'. R = h. 

Forehead: O.K. P^yes closet! : 0. A'. 
Teeth: a A. Whistle: 0. A. 
Involuntary: 0. K. Uosenbach: 0. K. 
VIII. Hearing: Dim. Pitiuilibrium: 0. A'. 
Rinne: + Weber: + 

Tinnitus: Vertigo: ? 

0. K. = normal. 



History — Contin'd. 



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STATUS NERVOSUM 



Cranial Nerves (continued): 

IX., X., XL, XII. Fauces: 0. A'. 



Speech: 0. A'. 
Tongue: Straight. 
Scars: 
Tremor: 
Taste: a A'. 
Shoulders: 0. K. 
Upper Extremity : 
Atrophy: 
Hypertrophy: 
Spasm : 
H\*potonus: + + 
Aluscular power: Divi. 
Dynanom. : 
Nerve trunks: Not tender. 



Stammering: 
Swallow: 0. A'. 

Respiratory: 0. K. 
Cardiac: 0. K. 
Neck: a A. 

Malformations: 
SjTnmetries: 0. K. 

Twitching: 
R = L. 



History — ( 



Triceps Rx.: Dim. 
Tremor: rt Rest:0 
Ataxia: + F.N.T.: 
Stereognosis : 0. K. 
Light touch; 0. K. 
Position: 0. K. 
Pain: 0. K. 
Vasomotor: 
Hair, pigmentation, etc. 
Trunk: 
Power: 0. K. 
Spine: 0. A. 
Epigastric Rx.: + 
Cremaster Rx.: + 
Bladder: Sluggish. 
Light touch: 0. A. 
Deep Sens.: Dim. 
Pain: 0. K. 



Radial Rx.: Dim. 

Static: 
Atax. K.K.T.:.-l/a:r. 

Adiadokok.: 
Diapason: Dim. 
Thermal: 0. A. 
Trophic: 



Deformity: 
Malposition: 
Abdom. Rx.: + 
Anal. Rx.: + 
Rectum: Sluggish. 
Localization: 0. K. 
Diapason: Dim. 
Thermal: 0. A. 



F. N. T. = finger-nose test. 
F. F. T. = finger-finger test. 



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STATUS NERVOSUM 



Asynergia: +. Slight. 
Trophic: 

Pigmentation: O. K. 
Deformity : 



Tnmk (continued) : 

Equilib.: Unsteady. 

Vasomotor: 

Dermographia: 
Lower Extremity: 

Atrophy : + ; legs fiabby. 

Hypertrophy : Asymmetries : 

Spasm : Kernig : 

Hypotonus : + + Tremor : 

Muscular power: Diminished. 

Synergistic tests: R = L. 

Patellar; Achilles: Clonus: 

Babinski : Chad : Opp ; 



Xerve; Tender. 
L. touch: Dim. 
Deep: Dim. 
Localization : 0. K. 



Las^gue: Tender. 
Pain: 0. A'. 
Therm.: 0. A'. 

Position: Impaired. 
Diapason: Impaired. 
Romberg: + + + 



K. H. T.:.l/aj. 

Gait: Markedly ataxic. 
Closed eyes: Made worse. Sidewise: 
On heels: On toes: 

Asynergia: (). K. 

Vasomotor : Trophic : 

Status Corporis : Medium nutrition. 



Heart; 0. K. 
\i]iHtd: 0. K. 
l.uiigs: (). K. 
Abdomen; 0. K. 
Liver: 0. K. 
Urine: (). K. 
Ccrebnispinal fluid; 
Wass.: ++ Cells: 50. (ilolmlin: + + 



Murmurs: 
Wassermunii: H — h 
Arteries: O. K. 
HliMMi-pressurc: lO'i. 
Skin:0. K. 
.Joints: 0. A'. 



History — Contin'd. 



Treatment: 

Intraspinous in- 
jecticms of salvar- 
sanized serum. 
(Swift-Ellis). 
Course of mercurial 
inunctions. 



K. 11. T. = knee-heel test. 



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MRTTtODS OF EXAMrSATfON OF THE IfERVOUS SYSTEM 

Consanguinity may or may not have any relation to nervous dts- 
iirtlere; it much depends nn the stock. Had factors present in one 
or another insiy !«> ahsohitely missed in the deeendunt-s. for Men- 
delion laws seem fairly well established. With the preseiitn^ of 
dmninant neuropjithie traits of tlie same kiini in both aseendauts, tlie 
chances are less hopeful in t}ie deeeudants. In Imman fecundity but 
few of the ova are iiupregiiated. and each ovum undoubtetlly eontains 
its oMi individualistie jjnmpinp of liereditary factors. 'I'he chance 
element seems tiHi great tit estimate. One featiin* of eon.sH ngi unity 
not to be overlooked is that many relatives (lirst cousins, second 
cousins] marry each other l»ecanse of a neuropathic tendency. It is 
not impossible then (hdt the evil results; of wpnsnnpiiinity sometimes 
seen is a din*ct triuismissimi of the neuropathic trails that were pri- 
tnarily res|mnsible fur the rnarriagi-. At all evt-iils the studies of 
\Voo<ls,' Cox,» Limdborjr,' I'uniictt,' Bateson,* Kiirplus,* and the 
numerojs pJiixTs of Karl Pcarsc»n,' all give hojw of now and more 
definite outlooks in the stu<ly of the relationshi|) of heredity to disease 
in peneral, ami of disorders of the nervous system in particular. 

Abraham* and others have given some suggestive discussions (mii- 
ceming the tendency for related neitnrties to marry. 

Organ Jnfrnorilif. — 'I'he concept of inferior organs, recently set 
forth by Adier, must needs be taken into i-onsidentlion in the matter 
of heredity in a nmcli bnwidcr sense than heretufore. Inferior organs, 
in their phylogenetic relH.tionshi|>s Imve to be considen-d and the indirect 
results noted rather than nttenipting to follow out hereility along the 
concrete lines heretofore in evidence. For example, it has receutly 
iK-en shown that in the a.s<-endants of fjellagrines there was a noticeable 
tendency to di.seases of the skin and of the gastro-enteric tract. In 
the interpretation of such a fact the evitlenl relatltmshi]) of the skin 
and mucous niendtrane of the stnmacli and intestines has to be cor- 
related with the presuinetl ftiologicsi! factor of the disejis*^ as worked 
out by Guldbcrger and his as-swiates. His work indicates quite clearly 
that it is a metjibolism disorder belonging in the group with lieriheri 
and scurvy an<l dependent ujxjn a deficient diet. The toxemia result- 
ing produces the sj-mptomatologj- which largely manifests itself as a 
peculiar form of dermatitis associated with a gastro-enteritis. The lack 
of some vitamine is the neeessary and specific etiological factor, while 
the toxin which ri'sults prwluces its ciTcct upon the inferior organs, the 
skin and mm-ous membrane. Viewing the facts of hen-dity in this* 
larger way will undoubtedly broaden our concept of various diseases. 



' HtmKiity in Royalty, 1900, • pHj-rhifttrwehpii Npuroloniwhe lllmlm, IDW. 

' Ueber t^vgotuvriitioii. I(t0l * Mt'nddUm in KplaciuH to nU(>a.4t>, 

* Brun. IWW 

' Zur Kennuiiw lifT VnrialMliUlt iind Verarhtins nm Zentralriprvetuij-rtt^in, lfl<)7. 

* llintiM>tri!!t>. 

■ Die Su-]lunjt der VerwnndUMicho in dtr Psyiiholocic tier Neiinufen, Juhrliuch t. 



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FAMILY HISTORY 



29 



Mnttal Jhstmlrr. — Tlii' preserii-e nf mental iHwinler in llu* direct 
ancestrv' is i*f nionieiit. The evideiK-e drawn from Hunts and uiK-Ies is 
of value, while that from cousins is open to the influence of another 
stock. It is useless to record the fact "insane" without any definite 
knowU'dftc of the particular mental disturbance. It is important to 
reiterate that tlie old Morel -/teller \\c\v, that »ll mental disturbances 
are one disease with different stapes is absurd. Insanity as a disease 
entity has no existence. One should be as specific as jiossible. for 
then- is a distinct tendency for special ty]K*s to lie passed <lown as 
dominants. Mental pcculinrities should be noted: great avarice. 
I'ri^nidity. qnrcmr.ss, e<-trutricitic.s, ifreat i-apHbility. niarkcii inoiipaci- 
ties. tem]ieramental ]>cculiaritics, inability of husband and wife to 
f;et alonj;, suicides (valuable as evi<jence only if cause )>e known), all 
tliese may W nf ci>nsidenible service in ofTerinp a clue to many different 
cases, in psydio neuroses and |»sychoses particularly. The occurrence 



^ 



tl 2 sl 4 h\ «J_ tI ai 9I1C 
11 -» -* «. DHg □ □ • OH 



HI 



IV 



Pva. 2. — pMliffW i)f » fMnily •howitiR HuniinitUifi'H r-hrxva. AITofitwl imitwim (indi- 
ait«d by \AMk tvwAxAaS arc tUwi^y* <tcrivi-<l fr>m ufFectcd pureuu. Ftum ori4poiil <laU 
ramUuHl by Dr. H, K. JollifTc: ^mi family. (Davrapnrt.) 

of the hysterical type of reaction in the parents or in the brothers or 
sisters should not be overlooked, but deductions therefntm should be 
foum1e<l un prei-i.sc enteria, not haphazard git^^'^hiK. 

I)efinite nenou» rfjVWrr* tlrnt need investigation in the ancestry 
Mre, !i" far as known, but coiuimratively few. The more importiint 
nre tics, myiH-lonias. Huntington's chorea, Thomseii's disease, myoj)- 
atbirs, certain conpeiiilal brain (Icfeets, as ciTel>cllHr defects, s|>wch 
defi-cU, skin defects, optic defects (color-hIindiH,s.sJ. f'nrcful history 
taking *-ill undoubtedly reveal other defect neuroses, for the v«-y 
fundniiiental .<ttudy of Kar|^ilu» iIim'. f-it.) has shown that brain form, 
brain e>1t»icctonic, cord form, cord myelotcctonic. etc., are directly 
tmn-vtiiitteii. Oruiiri iH-(-iipa(ion neumst'S. sitnic luipnunes. many 
eyc-itraiiis, etc., nre pos.sibiy due to the continuous transmission of 
Ktrtwiural variatIon.s.' 

< CAmriAiv K'Mn: Die M itu]pnt-i>nisk#U cW Orcuian, Urcan Infarinrily, X«rv, aod 
Mvnt. MuuiVKpb tWtiw. No. 'J4. 



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:jl) METHODS OF KXAMISATiOS OF THE SRKVOVS SYSTEM 

t'ltihfmi.—'Vhc owiirifnt'e of ejjilcjxsy in the n.srrnHants, as epileiwiy, 
im-aiis little. Kpik*])sy, like many aiuftlicr iliseasc so-t-alli'ii. is resolv- 
iihle into many (lilt'rrrnt disdrdfr;;. The rt>nviilstve Me):Eiire is nnly Hri 
rnd-n-sull of a vast variety of antcotxient events in only a few of ulilch 
can lierwlilary fartors Im* said to be inijinrtjint. 

JlrtihfJi.tm. — AliH)lK>Iisni, if extvssive. shnuli] never Ixr ovcrhwikcd. 
If |)ossible llie cause ^^uMll^i be reeonleil, for in tlie last uiialysls aknihol- 
ism is to be repmled as the imlivitlual's attempt to escape certain 
diffirultics. Aleoholism may mean hysU-rieal or compnisive reactions. 
It may be a scbizophrcnic symptum. Pericidirity in drinking slionid 
ln> rarofully inquired into. iMirtienlarly in its relation to the eyclotliyniic 
constitnlinn (mnnic-flepressive psychiisis). 

Mi/fmirte. — The hereditary factor in mip^ine is miirli exaggerated. 
Tlie extreme frequency of the diseiuse lias servcil tii bring about this 
confusion.' 

7'uhrrciilo»i'* n"t? J^hheteji. — TiilKTculnt^is. diabetes, tendency to, 
arthritic dislurbaniv.s are faelur^ in hen-iUty, the exact siffuLHoance 
of which it is Imnl to estimate; tuberculosis also especially, because of 
its extreme frequency. The prescna- of diabetes in a parent sliunid 
not be overlooked. It seems to play a larjje role in nervous and mental 
cJisorders. 

Sfiphilijt. — Syphilis as an antecedent facltir should never be disre- 
garded. Not only iliR*.s one meet with congenital talK*s. paresis, hydro- 
cephalus, optic atniphies, deaftiess. etc.. liul evidence is accunuilatiiiK 
timt reinforces the iK-IIef that a syphilitic heritage is rcs|Kjnsihle for 
much nervous and mental disurder, of a less trafiic thoiifih perhaps 
more amioying eharni'ter than those just mentioned. Objective evi- 
deuees of a s>i)hilitic inheritance should be looked for in the teeth, 
bony formation, pelvic, chest, and cranial crniTiinrs, etc. Wasst-nnann 
test.s of the MoimI of susp^Tted parents niiiy even lie necessiiry to 
clear up a diaRnasis, say of jl meningeal di^tlIr^la^<•e of liidilen etiol"jr>' 
in an infant, chilti. nr even vouuk adult. The evidence of conpenital 
WnssermaiHi reactitms is still too undecided at this date to permit 
one In W satisfied with tlie results, espcmlly if negative, obtained from 
the bIoo<l of the |Nitierit. 

II. Histoiy of Patient.— /^VM; childhood dUeasex; whai teamed to 
walk and falh. 

Diseases (especially convulsions, delirium, heml-injury, gonorrhea, 
syphilis, rheumatism, neuritis). 

tfnhitji (alcohol, dni^. ami sexual). 

J/nm'fijfr; Meitntnuilutti; gyuntilu^irni. 

PrcTHwf ttltrirk/f (s|>ecial jitteiition to so-c«lifd hysterii.'nj, to ner\oua 
break-doKii, and to melancholic {H>riods). 

Crvurn and mmlrmmnor* 

Mental make-up. 

■Sot dioplcr (Ml MifreJne iu Onler: Modern Mcdioinr, lOlfi, wrond odition, vul. vi. 



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tllsrOHY OF FATISNT 



31 



Note.— The historj- of the early life of t}ic patient is especially 
importAiit in order to oblJiin n comprehensive idea of the .sort of 
person the iMtieiit was before becoming III. A given ilisonicr r»f the 
nen'ous system oiinnot Ix* fully understood without understamlin£. 
not only tiie cirennihtanees that gave rise to it. but the other and more 
im[>ortaiit factor, the make-up of the individual in whom the disorder 
ueeun*. 

The obje<live examination i>a.sses on to the l/irfh ot the [Mitieni. 
Was it normal, or in.<trumcntal, or of excessive length? I lemorrliage, 
anidrnts, or pressure palsies may thus receive tlu'ir interpretation. 

I>id the child Iwirn to mtlh at an average periinl. /*, f., from nine to 
fifteen months (Prcycr). ami if n»it were there definite fac:ts — excessive 
weight, intercnrrent disease -to explain the tanliness? Was there 



M 



Vin, 3.— CancBnital i^'phllb "unto the. Lhird fenerAtinn." Hyphititir father nf Unl 
OHMraUou. Smoud, ihne prMoitlure liirLlw, two (k-iul rliitdtvu, nod nnv djiuK nL 
alstam mrmilui. (VinvKiital «>-pliililJr nrst, with HiiK'tiintrm trliul. Thi<; palicnt 
BAitM, Mid bad n child with snulBw, who died iil szi> nl m i*v«k4. RciuHiuiuit »ii^lor 
ImeI bilaiitilB tw^iiupleciB. llutrhinson bfotti. iind ttvriititw. (Molt.) 

preeorttyy Endoc-rinous dborder usually umlerlies great precocity 
in lirwly devck»pment. Was sprech acquired early or late? and ditl 
the child learn to nyu! at the iLsiial |x*rio*i (five to eight \ ears, aminling 
to opportunities afforded)? These facts are of much iniixirtani-e, 
especially in estimating mental eaiwcily, and for young children the 
pn)lMibililies concerning development an<l the im-cH for special tmining. 
( hildnn whi) Irani to wiilk and tidk as late as twenty-six to thirty- 
eight ntonihs res|>ectively often n'main very Iwckward. Tlte relations 
of fti»eei-h to menial development are extremely close. Speiial t*'sts, 
IK the RiiH'l-Sinion or other sjiecial s^-ales, are essential in plaiing the 
trilectual age <>f the child. (See Section on Mental Kxaminatiun.) 
I>ifli*idiie-4 in teething, CNin'ciHlIy wln-n iittcndcil with (innulsions. 
tiboulil be noted. Tlie nuliitie citest form should not \m overlooked. 



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32 MBTUOVS OP EXAMINATION OF THE NBIiVOUS SYSTEM 

f'onceminp chiidren's diseases, much ran be said. Severe measles, 
or scarlet fever, or other disorders may lay the foundation of a lator 
developinp epil^^psy; diplitlierta may oauw various forms of neuritis 
with, at times, pennanently vveakeiied jxiuxTb. Tuberculosis plays a 
very important role. TIic important of influeTiza is often overlooked 
while tlie rehition of the acute streptoctxric infections, and their 
resultinp joint involvements to chorea is well esiablishetl. Excessive 
fatigue, or exhaustion, either from an infectious disease, apart from 
its toxemia, or from ovcrexcrcisc or strain in rapidly growing children, 
bears a close relation also to choreic reactions, i'he infections also 
affect the endocrinous glands, th>Toiditis. lu^iophyseal cysts, etc., and 
thus nmv exert a great inUuentre in the motalKtlisni of the growing 
child. 

Very close attention should lie paid to the aural afTections of cliildrcn, 
and the nasopharyngeal cavities should be scrutinized for adenoids or 
other foreign bodies that interfere with free respiration, sound sleep 
or the proiwr hygiene of the nasopharyngeal nuicmiti membranes. 

Intestinal worms should not be overlooked. They may be the cause 
of infantile convulsions or of milder neurotic disturbances. 

F.nurejsu should never he overlooked. If contimiinp jjast the third 
or fourth year it affords valuable evidence of a neurotic predisposition. 
Thiniib-surlciug, nail-biting, and other little habits may be includt'd in 
this plare. StaTumering should \>e carefully inquired into, akfp-walkiitg 
also. 

The e<lucatiou of the patient, especially if a mental disorder or a 
psychoneurosis is under investigation, should Ik; ver.' thoroughly 
gone into. A knowledge of the earliest impressions gained, the 
picture books used, the principal childish associations formed, special 
tastes, animosities or dislikes are essential to the understanding of 
the obsessional, hysterical or allied reatiiocis, The ideals incul- 
cated, the religious and ethical training gained iu the early years 
usually give a definite stamp to the personality atjd umsi Ijc known if 
the adult personality is to be understood. The grosser factors of the 
classes passed, and the schooling received are absolutely essential 
in estimating the grade of later mental capacity, and the application 
of intelli^;eiiw tests in the study of the psychoses or psyohoneiu'oses. 

Adult Diseases.— S\7»hilis stands in the Krst rank, ("are should be 
exercised in obtaining a syphilitic historj*. Did you ever have a 
chancre? is the usual method of asking the question. TIic query, 
I low oltl were yon when you had a sore on the penis? nlthough perhaps 
more abrupt, will give a higher percentage of positive answers, espe- 
cially in those cases where its pr^-vious existence is largely inferred, as 
in general paresis or tabes. If tite direct question is to be avoided, 
as in the case of many women, married or otlier\vise, the questions 
concerning syphilitic symptoms arc <Icsirable. The presence of sjTup- 
toms of continuous sore throat, hair-falling, etc. .\ physical exfiniina- 
tion for mucous plaques, leukoplakia of tl»e niuuth, and scars on the 



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ADULT OiSBASBS 



33 



penis slimiM never l:»c omittcil. In wonicii iho mtiwius mcinhraiies 
o( tbc cheeks aiul sides of the tonpuc should always be examined. 

Further, tlie Waswermann hlowi iwirtion .should be obtained in all 
rases where any rioubt exists. Although the j)en-entaire of imkniiwii 
rjv-phihtie infeetiuns is low, m'^enheles.'i siieh exist. A single Wasser- 
rnniiii te.sl , i»»sltive or nexative, is not wmchjsive. mid gnvit aire should 
be tjiken in the eh(.Kisin}r of a proixT aenilogist. The subject of technic 
is a complicated and immeuiisely important one.' 

The :suhse4]iietit liistorj- of the syphilitic infection is dentmble and 
the cliiiracter and lenjrth of time of treatment should be recorded. 

(lonorrhen is not nnimjmrtant. It is of special relevancy in all 
Arthritic di.sorders. in choreas (vuginal (lischargi*) in youitK children, 
and in meningeal excitements. Gonorrheal neuritis is known. 

Arthritis in its various fornw calls for careful observation. Here 
one would Iwst record observations, and not attempt n diagnosis of 
the JDint conditions. Tooth infection from the Streplorocais n'riWarw 
is of importance a^ a chronic infection in producing several neurological 
or psyeliotio sjTidromeJt. 

The rule of the infectiims in mental fHithology is very marked. 
Tv-phoid fever uu<l influcnzjj txith constitute severe infections with 
marked UtfluenL-e nn ner^'ous tissues. 

I'nder vhocks is included sudden mental and moral influences 
tending to disturb t!w* emotional life. Ixiss of money, of panmts, 
hiLnlxind, chililrcii, or lined omv, intcrfen^nce with one's hopes of a 
career, nnfcirtunate entiinRlements, all cjdl for investigation. The 
great importance of emotional disturlwnce in all nervous reactions 
should I»c borne constantly in mind. 

As to habitx, particidar attention should \k directed to alcoholism. 
It plays a most imjxvrtant role in diseases of tlic nervous system. 
There is much ili%ergence of opinion ;is to what may constitute alcohol- 
ism. Aeeunite ret-ording; of the exact amounts oon-stimed will afford 
the student the bi'^t rriteria by which he later can judge for himself 
fnun his nttii can'fully kept reci^nls. The use of other narcotics, as 
opitini and its allies, encaine, the alrohol hypnotics, bromides, etc.^ call 
for rc-ctird. 

Occupalifm tnrevnuji should not \ie overlooketl. They are daily 

.ftMUming imrejised importance in America by reason of the increasing 

f'nuinlK'f (if dangemns iK'fii|Nitifins, AVorkers In lejid, arsenie. niercur>', 

copper. |jew1er, pottery, dyes, sulphur tTimp<mn«ls, and olliers suffer 

often from obscure sjTnptoms. due to chronic poisonings. Occupation 

fatigues explain many neurasthenias. 

The xfTiial hal/ih shouhl Ik* in(iuin>d into. Ijb«'nil indulgence in 
masturluitiitn, flc, while usually s<*lf-<orrective, at times works liavoc 
with the non'ous system. Sexual abstinence in the mjirried as well 

■ lluiii ^itii Ibsirtkin ill Nvunil'tc}- ntnl I'lyrhiHlry, Nrrvmui mkI MotiIiiI 

I>w>ur .M S«nm. No. A. N«w York. 1910. KapUn: rtcroJogj' in Ncrvou* 

ptMUM. |'riii^)cii>lii*, IWU- 

a 



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34 METHODS OF EXAAftNATlON OF THE XERVOUS SYSTEM 

as the uimmrriptl is at times an important element in the neuroses 
iHiixifty nrurnsis). The rarer aiiomtilous st-xual munifei^tatiuiiscnU for 
investigation in some cases. Genital masturbation is not the only 
type of inaHturbatiuii. 

Special attention should be paid to conmilnre seiztirrs, either 
occiuTing in the young or in adult life. (Vrtain facts about such 
convulsions slionid nerer be omitteil. These are the presence of 
rlizzincss. or of objects revoKing (direction 1o he noted) ; of the state 
of (imscimi.snfss; wliether there is injurj' to tlie body during such 
attacks; if the toiiKuc be injured; if urine or fetvs bo voided during 
the attack ; and if there be amnesia, complete or partial^ following the 
attack- 

'I"hc intiuencc of rioimcc or injury to the botiy is often of extreme 
impi»rtancc. If there is accompauymg mental shock the fact tihould 
not be omitted. 

The jzeneral consiituiion of the patient — his or her funeral capacity 
for work and fatigue — is to be noted. The question of geneml tem- 
jHTanient, of outlook on life, nmy 1^ tentatively entered in this 
place. 

In the case of women, sf>ecial attention should be directed to the 
vientttninl history. The numlKT and character of the birtlis, the 
health of the children, tlic nunibcr of miscarriages with causes should 
be recorded. 

III. Present IUnes8.—y?iJtf^' cau^r: physical paiiis; dhahilHteif: menial 
ami vfotnl chnngpx; rrnvtional condition: hallucinatirnui and tfchwions; 
judgment; memory; »nlcide am! hotuicidf; imtiyftt. 

NoTK. — Tniler this head an inquiry is maili^ into all the circumstances 
surrounding atid condilioniiig tlie onset of tJie disorder, tlie patient's 
attitude toward it anrl his insight. 

Subjeclirc Jfitit'irt/.—Thc patient's own account of liis illness can 
eitlier precede or follow the outlines of the family history and his 
general pn-vious cuudition. The liislory Is rccctrded in the question- 
naire on the side of the blank, thus keeping it separate from the pre- 
ceding and after-coming facts. 

It is advisable for the patient to fix as nearly as possible the date 
of the onset of his illness. Certain facts which may or may not have 
had any connection with the ninlady under studj' may jiid in fixing 
such a jK'ritHl of transition bctwtrn health ami sickness. The nature 
of its onset, whether acute and progressive, or acute anrl regressive, 
insidious and irregular, or very severe and inuncdiatc. What did the 
patient notice at that time? Then griiduatly trace, step by st«p, 
iiour by hour, day by day, week by week, or year by >ear, the develop- 
ment of the disorilcr. What new symptoms have been added to the 
first — what have disappeared: has the picture remained the same, or 
has it gradually or suddenly altered? 

A methoilical going over of the locomotor, sensory, emotional, intel- 
lectuali skin, digestive, n-spiratory, and secretorj' systems should 



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PHYSICAL RXAMtm 



35 



follow the patient's own account of tlic difficulty. Paim felt should 
In? roughly chartwl and carefully locate<). If certnin symptoms have 
difwppcarcd, attention should be paid to the mode of their onset ami 
of their departure. It is im]N>rt.ant to ascertain just what etTect tlie 
illness has upon the .social, fainilial, pliysical or psychical life in onler 
to estimate tlio severity of certain sjinptoms. Also, has the patient 
con-sulted other physicians, or has he visittnl institutions or other than 
trained medical men of various kinds? What was the trentnieut? 
Its effect* 

A thorough subjertive anamnesis is one of the most difficult, and at 
the same time most important features of a ncun»lo|rical or mental 
examination, particularly the latter. If the i^'ndual evolution of the 
iliMinler Ls carefully elucidated, there is little danger of ^»ing wrong. 
If one hops from nm^ thinj; to another, however, mistakes will be 
fre^iuent. 

IV. General Observationa. ^ Facial erpresnimi; appearance and 
liewponor; mnrrmnttn: disabilities: tjnits; awmmiiat of inneruiiion; 
ipeech: mcnUil. 

NoTt;.— The general observation of the jiatient is, of course, always 
important: whether he appears silly, resentful, indifferent; whether 
be luu maiuierisms, eU*. It is particularly in]j>ortant, however, in 
stuporous and ilelirious patients who cither will nut sfK'ak or are not 
resf»oni>ivc and therefore not accessible. These patients should be 
ved particularly as to their gi-ncral altitude of body and limbs, 
'tlie expnsuuoii of the face, the reflexes, and the reactions — volitional, 
emotional, and organic (hunger, .sexual, responding to calls of nature, 
etc.). 

The Ohjeriife Examination. — Puring the subjective examination 

mny facts c<»ncrrniiig the general attituile tif the patient liavc licen 

^piinrd. His expression and carriage, in bed or able to Iw altout, 

the cliaractcr of his intelligence and the responsibility of his answers. 

I.H hi.-* rnin<l i-I<'»r and is he oriente*!? 

V. Physical Exunination.- Form: nutritum; weight: height; tkitt; 
Ltmen and jttintx. 

Orcubiius: xcnrfi tespi-tially |Mrnis and movith). 

litiipiratiiry xijntem. 

Vircvfalitrij nynteni; heart jMuitiun, aise and atniudji; Idooil^treMure, 

Gntii<Mir>unri/ nifAtcm. 

Gojitro-inlrxlijiai tract: jitttmach eonttnt (if indicaled); glandu: afxiumen. 

Sputum (if indicated). 

Hhind awiptt^itJtm (if indicaterl). 

Crrriinutpina! /fitid (if indicateil). 

Criuf (alwHy^). 

XtrrK.— It is liardly nw.-essary to iiisi.>*t u|M»n tlu* necessity for a 
thorough physical examination in every case. !t is espwially iniptjr- 
tjuit in the dcliria in which the mental disorder may be the cxprcs.sion 
of an ohoHiire physical condition. 



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36 METHODS OF EXAMINATION OF THE NERVOUS SYSTEM 

As has already been noted, a scheme is of great advantage, 
beginners particularly. With increasing experience, one may dep 
from a hard-and-fast method of case-taking, but in the beginni 
the student should habituate himself to a rigid and exhaustive meth 
if he would avoid careless work. 

The cranium should first be inspected. Is it regularly shaped 
is there assjinmetry? Measurements of the vertical, binauricul 
and horizontal diameters should be taken. 

The position, general form, and character of the ears should 
noted, and the arch of the palate observed. The occurrence of isolati 
or even several, so-called signs of degeneration may be record) 
There is no necessary connection between such anomalies and nerve 
or mental disease. They are found in superior as well as infer 
deviates. The departure from the average is worthy of record, h 
the hasty generalizations of the Lombroso school should be avoidi 
These deviations from the average structures will be discusf 
later. 

Careful and thorough percussion of the skull may reveal lo 
points of tenderness (brain tumor), etc. The presence of cicatri 
(epilepsies), depressions (fractures), or abnormal elevations is to 
noted. In special cases, J-ray examination of the skull is of gi 
value, and should alwa^'s be made for suspected fractures, for m 
brain tumors (acromegaly), etc. 

VI. VegetatiTe System Examination. — A systematic presentatioi 
methods for examinating the vegetative reactions is only just b 
formulated. The vegetative system consists of two more or 
opposed systems, the autonomic, or extended vagus system, and the { 
pathetic proper. An hyperactive autonomic type of reaction has 
termed by Eppinger and Hess, vagotonic; of the sympathetic, 
pathicotonic. These two contrasting tj-pes show a number of • 
acteristic anomalies which are fairly constant and capable of obje 
examination. Not only are there a variety of anomalies of the 
nomic and sjTnpathetic reactions to be observed but a host of cl 
signs are known which are dependant upon disorder of the n: 
olism of different parts' of the body due to disturbances of the glai 
internal secretion, cndocrinopathies. Many of these are very m 
as in m\T£edema, or acromegaly for instance; others, however, ai 
striking, but close obsen^ation will reveal a great many met 
variations which may be relegated to a uriiglandular or polygia 
defect. 

In this section attention will first be briefly centered upon si 
the objective signs to be looked for resulting from disturbances 
vegetative reflexes, and secondly to those more closely related it 
crinous modifications. The two series of observations are very 
related at times. More thorough discussion of the sjTidro 
diseases arc found in the first section of this book on diseases 
vegetative nervous system and the cndocrinopathies. 



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VSGETATIVK SYSTBH EXAStlNATiON 



37 



VegeiattTe System Examination. — Vngotoniji and synipathic-ijtonia.' 
Mill! jcradfs nr tn.'inl;i uf llu'st.' have Wrn termed the vagntonic and 
sympRthicDtonic constitutions. Speaking generally, tlicy are llie 
cold-bkxxled and the warm-blooded. The vagotonic (vagus tonus or 
s.nnpiitlietic jjaralysis) shows relative insusceptihihty to syui])atlietic 
timuli; hence cold akin, resen-ed, slow pulse, deep-set eyes, contracted 
"pupils. The skin is apt to sweat readily, at times in })atehesur blotches; 
the palms are apt to Ik thick. They are ufnially underiinurished. 
Short-sighted tiess is frequent. Aineifonn eruptions, partimlarly of the 
Iwu'k, tLMial. Tliey fre<iueiitly suidlim as tlu-y talk, ami sccni tn have 
niueli saliva in the mouth. Sore thniats are frequent. The fauelal 
reflexes are usually diminished. Increase of hair alxnit nipples and 
masculine distribution of the pubic hair ts frMpient in the vagotonic 
%oman. 

I'ikiCaqiine test shows marked hy]H'rsensitiveness and is a useful 
mode of exainiiuitinn. This is to be given hyp(Mlerniically, O.ltl to 
tHHW gm. Higier recommends O.tHHil perkiloof IhkIv weight. These 
tests are to Ik* interpreted like all others solely as monosymptomatic 
and wcighefl witli other signs. 

Tlie tn-iid of the snnpathicotonic (sjtniwthetic tonus or autonomic 
paniIysi-<) U towanl IIh- wnnn-bliKiilt'^l type. N'ivacioiL'iiiess, dilated 
pupils glistening eye, puis*- rapid, skin warm and dry. There is 
relative insustrptihility to pih>carpine and also to iitro])ine (0.(101 to 
O.flOOtVi grn.), while ndrenaliu, O.OIM gin., increa-ses all of tlie signs 
present. 

Paiholngical innerxaiion of the vegetative systems shows its«'lf in 
tite e>*es, rK»se, mouth, skin. res|Mration, eireulatorj'. <iig«'stive. uro- 
genital, cutaneous, and mctaltolic systems. They result from endo- 
erinoiw disturbances, but chiefly from emotional, i. r,, psychic disturl>- 
■ncrs (symbolic systems, unmiiscious). 

I. Mrtnlitlir .S'lyH*.— Variutiiins in fat and sugar tolerance, eosino- 
philia. pipiientations, lytnphoc>"tosis. 

;;. CutnmmiH iSfji^r/y. Horripilation [painful hair raising), goose 
flcah, contrai-tioiis of testicle and ul the nipple, seborrhea, hypertri- 
eliOBU, t>aldnes.H, hyi>eridn>sis, bromidrosiM, local syncopes, aero- 
eyaiiortls, purpura, pniritus, iiallor, dennographism, er>'th«na, 
urticaria. 

3. UfirjiiwUtrt/ Signn. — Asthmatic attacks, laryngeal sjaisms, Ascli- 
r's sign (oculocartliac reflex), pressure tipoii the eyelwll leailing to 

mrtng of tlie puUe with stopping of respiration in expiralor>' phase, 
coryzas, bronchitides. 

4. Circulaiori/ .Si'(;nj».^Hradycardia, tachycanlia, irrt*gular extra- 
systolic pulse, dromotropia, vasomotor anginas, [H-ripbcmt ant-mia 
and h>'peren)ia.s, at'roej'anosis, intennittent claudication, high tension. 

' Epftuicr niiiJ Unm: VftgMiinui. inuuJolM] Ity JrilirTu iiimI Kiaun, NrrvouN and 
MmiAl l>iMiu^ Mi>m>Km|>h ti*tit*. Su. 20. Nmr Yurk. Al»n (viasuU IWker and Sbds: 
Tr. Amm. Aai. Ptiy>., ISU. ». 471. 



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38 MKTflODS OF BXAMtXATlOi\ OF THE SEHVOt'S SYSTEM 

6, ffigejffire Sign.''. — * Ulicky diarrheu (sj-mpathicotonic), spastic 
C!Oniti[Mti()n (vanot(inic), hyperc-lilorhydria. achylia. gastric atony, 
pylorospasni, ftastrosmforrliea, esophagisni, Iij-persalivation, entero- 
colitiK. 

ti. (ienitiMiriimrij, Reteiilioii, incx>ntincnce, menstrual anomalies, 
e'lAtvlninry <nstiiri)iin('es. teiiesnuis, renal colic, priapism, frigidity, 
UiM fit power. 




Kio. <|. i-iiiimp' liiiJr. ti5iid'XTiuou» dMlurbancM.) (A. Juttpfaon.) 

7, Cffitiutl Aufotiomic Sigm- — Eyes: Mydriasis or inyosis, Klfinooma, 
\tt^•^tft\^^f li'l "'''■*' "^P"^'"** "^ ttwtmiinodation, von Gracf'sMot-hius sign, 
PUtiitUtUnUitits, riioplilliJilinos. dryness of eyeballs. Locwi's te-st (mlrena- 
Mm Miylfittti'* adn-iialinhy conjunctiva, I to UNH) solution). Irre^liir 
i„, f "^fi-lwag's siun (irrfj;ular auil infre<iuent winking); nose signs 
rti ii.iu*, or fxci-fisivc sttrrtion (hay fever), frequent spitting or 

, r \. MMUldl. 

I I Jlm-m-f of various drugs upon difffrent Immohes of the two 

. sliown on iwige U^. 
i I.. . Mirinns anouinlics should be lookwl for in summing up the 
Ultvi' ri-ai-tivitics. 
■I J \ \( tMA i.i Es.— These are hore li.sted. The \-arious sj-n- 

11 -i-d Iflit-r. The niorpliological examination includes 



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VSGETATIVE SYSTR.V EXAMINATION 



39 



iiw|K*t'lion of the fiicies, genprnl somatic tlevelopment, genlto-urinary 
tJpvelupiiiciiL uf male atid female. 

Faciet. — Acronu'galic, cretinistic, m>'xedematous, exophthalmic, 
Ad<li.soman, emiuclioiil. gerodcnnic, uiojiK"Ioi<It iiifaiitilf, juvenile, 
lymphatic, (hlorotic, a<lenDid. ovarian face of Spencer Wells. 

(ieneral lieirlopmrnt. — Weight and statnn'. excessive ol>esity or 
tiiiiuH*^- MitT(js4imia, macmsomia, dispnipurtioiiale development of 
upper and lower extremities, of the distal and proximal Hnib lenKtiu. 
Epi[»liyseiil adfificHtions. i-ervlrodorsal kyphosis, genu valniim. 

Grnital lh-n-lopmcui.— {a) In nude: Kxteriial ^nital:s. descent of 
testielefi. lieunl, iliiitributioii of pubic hair and hair of Unly. voice, 
feetimlity or sterility, psychosexual i;lmraeters, ardor, eroticisiu, 
sXfjM of remini.4ni, precocious or retarded pulwrty. (i) In female: 
Kxtcmal and internal nenitals, breasts, pubic hair formation, male 



Tta. &. — nypa-ovariun. (A. JoAcbon.) 

tyxttf rUing in middle line, female t>i'pe straight across. men.stniation. 
ardor, eroticism, satisfaction in si>xual act, i>s,\'chnM'XuaI chanu'ters, 
fecundity or sterility, masculine .sij;ns. pre<-ociousor tanJy meiustruution, 
menopause, character of pregnancy. 

I. Examination of trophic changes or disturbances. 

(tt) In tSA-JH.— Mj'xetleuiatous infill rations. sclenKlerma, piginen- 
ition idyschn^mia). circumscribed or diffused, activity of vesicant--*, 
»rlrophic,s, utrn[»hie-s and precot-ious senile changes, anidnisis, 
byiw*ridn»si:i, eruptions, c:hronie ulcerations, circuniscril)ed liftoma- 
bKus, iuli|M>si7f. 

(it) Hair and SaiU. — rharncter of hair : roujih, fine, curly, dry. color; 
eyela-nhe-* and cyebrtiws. General liairine-is dlytributiou. Crescents 
in nails, character of nail developments, splits and ridge:^. 

(e) Tteth. -Primary and scauidan,* dentition, dental forms, dental 
mrftiukcv)!, ridges early cftrie:^; color, efialky-white or yellowish. 



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40 METHODS OF EXAMINATION OF THE NERVOUS SYSTEM 

(d) Mucous Membranes. — Pigmentation, hyperplastic, atrophic or 
catarrhal, lingual hypertrophy, ridges, etc. 

ifi) Lens. — Early cataract, opacities, floating bodies in vitreous. 

(/) Ligaments, Muscles, Bones. — Atrophies, abnormal fragility, 
osseous growths, hypertrophy of bone, joints, muscular atrophy, hyper- 
trophy, rheumatismal swellings, epiphyseal anomalies. 

(g) Blood. — Blood count, eosinophilia, lymphatic hyperplasise. 

(A) Chemoregulatory. — Albumin, phosphorus, iodine, sugar toler- 
ance, calcium and magnesium, metabolism, respiratory gases, alveolar 
carbon-dioxide tension. Ilj-perthermia, hj^wthermia. 

II. Examination of neuro-endocrine signs.: 

Vegetative nervous system — see p. 36. 

III. Direct examination of endocrinous glands: 

Hypophysis: Kella turcica by .r-rays, signs of hj'pophyseal tumor, 
results of hypophyseal extract. 

Thyroid: Size (20 to 30 gms. average), goiter and its character, 
retrosternal goiter, thyroid antibodies, thyroidine sensibility. 

Tlyvius: Radioscopy of region, tumor of superior mediastinum 
thymic antibodies. 

Suprarenal: Circulating adrenalin dosage, pain in suprarena 
region, tumor, sensibility to adrenalin; adrenalin mydriasis, pigmen 
tation. 

Cenital Glands: Modification in size, neoplasms, effect of extracts 

Pineal: Signs of tumor. 

Pancreas: Sugar in urine. 
, The development of the two sides of the face is to be eomparec 
the width of the nostrils noted, and particular attention given to tt 
character, texture, and color of the hair, and skin of the face an 
mucous membranes. 

VII. Sensorimotor Examination. — Cranial Nerves. — These should 1 
systematically tested. 

I. Smell. — There are no satisfactory quantitative tests for sm- 
apart from special physiological psychological tests that are of servi 
in research work only. The smell in each nostril should be test 
separately, preferably by some well-known substance (oil of turpf 
tine) and by a substance resembling well-known foods (asafeti( 
onions) or bodily excretion (feces). The nostril of one side is stoppi 
and with the eyes closed the patient is asked to smell from a bot 
containing the odorous substance; the other side is then tested w 
the same or different substance and comparisons are made. Variatii 
in smell are verj* frequent, and muchcare must be exercised in draw 
conclusions from smell anomalies. Influenza interferes with smell te 
Local conditions, empyema of the antrum, etc., must be exclud 
Irritating substances, like ammonia, etc., should noi be used. A sea 
for subjective smell disturbances may be made at the smne ti 
Anosmia, unilateral or bilateral, is often present in fractures of 
skull, in frontal lobe brain tumors and in certain epilepsies. 



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^KSStmi MOTOR EX A MIS A TiON—CKASTj 

II. Eyeii. — Sight >>l)i>iild \iv ti-stitl liy llic Sik-Hcei or oIIht tyjie t-ards. 
Thesi* hIkiuIiI Ih- ui'll ilhiininutcfl arul the piiticnt i^luiuld stand with 
tlir window light behind hiiu. Each eye should Uc tested M'paratcly. 



fKi. 0. — Cn»P(«l tuittJyopiu iu a. «ttM> of hystoru. (SiDwart.) 

Palimtjt unable to dii^tinf^ii^h tlie largest letters shouM be tested sa 
to tlicir ability to see tlif (ingiTH. delerniinc light mid dKrlc. S<»me 
jmtients sif Wtter in a dim light timii in hriglit light (lienHTfllopia) 
(sec Plate V, p. 2.'i2, for family tree of patients who Ixtome blind in dim 
light —night-blindness, nyetalopia). Myopias and astigmatisms are 
important to In-ar in mind in testing the sight fvnirtioiis. 



ihA' 



fr- 



no. 7. — Rii^l knamiyutuiM h«ntiino|Mta to a roMf ul Mifbtuiiti uf Uu> l«Il ompiul lab*. 

iKu-wfcrt ) 

f'ulur V'»i()n is important. Oiloml wtHtls art* nnit<'lieil as to 
ahuiten in the full daylight. In enlor-lillnilness, if of the rrtl-gn-en 
\'ftrietj', gny- or stniw-eolureil wools niv scleeted. In total culor- 



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42 METHODS OF EXAMINATION OF THE NERVOUS SYSTEM 

blindness the individual confuses all colors; comparative degrees 
brightness alone are distinguished. A number of ridiculous blund 
may be made in testing for color-blindness with the wool tests. 

The field of vision should be tested with avoidance of suggest! 
factors. This may be done with a perimeter, which frequen 
introduces the error of suggestion, or the rapid finger test employt 
The patient sits about three feet from the examiner. Each eye 
tested separately. The patient puts his hand over his left eye, a 
looks fixedly at the examiner's left eye, the right eye being closi 
With the left hand held midway between patient and examiner soi 
distance to one side, it is then gradually brought toward the midi 
line, the fingers being waved slightly. The patient is directed to s 
"now" as soon as he catches sight of the slightly waving fingt 
Four axes should be tested. \'ariations from the examiner's o' 
fields can be noted. A square of white paper (1 cm.) on a gray a 
may be used instead of the fingers. For a general test of the co 
fields squares of different colors may be used. The most striki 
features to be sought for are hemianopsia, temporal or nasal; concent 
limitations, irregular limitations, quadrant hemianopsias, psyc 
blindness and seotomata. Hemianopsia should always be searcl 
for. It may be done rapidly by use of the usual finger-sight test anc 
there are any anomalies careful chartings by a perimeter should 
made. Seotomata are sought for in the same manner. Single pt 
metric studies are to be warned against. Frequent examinatii 
especially for the different color fields are necessary, especially 
trace advancing changes. For careful perimetric work the methc 
of Bjerrum should Ijc followed out.^ A useful method of mak 
jjerimetric charts is by means of a modified Bjerrura screen. A la 
sheet of white paper 12 to 15 inches square is covered with a thin bl; 
cloth or black paper and both fastened to a board. A small thu 
tackjin the center can serve as a fixation-point for the patient's t 
The test object is carried on the blunt end of a steel pen, 0.5 
in length which is fixed transversely across the dark end of a metal 
so that its point projects about 1 mm. on the opposite side. The 
object thus fixed on the end of the rod is moved slowly from the b 
region across the screen until the patient sees it, then the carri* 
simply pressed against the board so that the pin penetrates the ( 
and marks the paper beneath it. A large number of observal 
can thus be quickly made and they can be easily transferred to a 
imeter chart. 

In all cases the fundus should be examined. A knowledge ol 
eye-ground changes is essential for good neurological investiga 
Works on ophthalmology must be consulted for the many anom 
but the most important to be observed are signs of pressure, of atn 
of retinal hemorrhage or congestion, and irregular pallors (tem 

*Sco Walker: Arch, of OphthalmoloKy, 1915, p. 369. Cushing and Walker: 
1915, p. 341. 



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SBffSOKl MOTOR EXAMINATION— CRAlf I At NBRVSS 

pallor in multiple sclerosis), edeina, ehoroiditis, retinitis, venous 
congestion, arterial occlusions, etc. Optic atrophy may exist without 
hiiiidness. (See I'"ig. -. Plate VI, paj^* 257.) 

Thinl, Fourth, and Sijth (.'ranial AVrrf*. — The functions of the third, 
fourth, ami sixth cranial ner\-e.s are conveniently tested, tirst together 
ami later separately. Ability to move both eyes outwardly (external 
reetiw) indicates integrity of the sixth cranial ner\-e. If the eyes can 
l»e moved frei-ly, amply and equally ujiward. tiowTiuanl, ami inward, 
the third and fourth cninial nerx'es are tisvuilly intact. 



.V 



ft- — ni*iiirh*t>«* ot vlijon rmm bullel wound nf p->4t«rbr und of tbe CAWrine 
fiMfun. (L>ni«r uid H'llnuw.) 

Having seen if the eyes move freely in all directions, ny-^tagmus is 
li-stPi! for under the .<uime conditions. It consists of a slow movement 
of the bulb in »>nc din^i-tinti, with a rapid jerk hack in the opixwite 
direct iuii. Notes on the direction of the slow and rapid movements 
should be made. They arc of f^reat value in delermininj: lab\ rinthine 
and cerebellar nystagmus. Nystagmus may be present on central 
Buitiitn, or only iK'<\»me apparent a^ the eyw are directed to one side. 
Slight inminrs of llie glol»es on extreme lateral i«wition may be of small 
diugnostic importance. Nystagmus should be tested for in the vertical 
aiul horizontal aihl aha In oblique axes. Kotatory nystagmus may 
[be looked for. 

In tlic pn'scntr of a nystugmus, cfrtain suiiplcmentary tests are 
Advt<uihle. Tlu> moi^t iniiKirtant are the turning sttxil. and hot- and 
ouW-water tests. In Oie former the patient is seattxl on a revolving 



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RlgKI nipt 



Pio, 11. — Wwnwr'e "MrtLSnol nieniof>'" for tlic double imagm in ocular parr 
(Opbthnlmir' Rpviuw, IKHA). A alui'W,-)! titr piMiriiin nf thr imufMW in panJyids < 
rottt iiiuaclnt: B. in paralysis of ihc obliiiuf ntuNrlw-, Tlie d^tu-d Imtw indioatA "i 
JinagM, tliP thirk hlnek ltiii"-n " inw"' im/ifccH (Slrwm-t ) 

backwnni to test vnvU senucirfiiljir fiinal. SiM'cijilIy cimstrnctwl c 
are iiwiied for careful work, (^'et' Testing uf 1j«1)\ rhith, p. 550 



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^BNSOmStOTOR 



f— CRANIAL SERVES 45 



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JYI 






V 



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W 



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Ob 



Fc-i.- 



Hn 



E. 



FTm 



iCrtt. 



T?. 



Nrt 



Vllft 
!FI, 



V* 



Irif" 



.VDlv 

-VUic- 



VII 



ViT 



SsR" 



'VI 



X 



rm. IS, — Pootioo fyti-irome, vJUi «yc> pitl^n uf c«utnil oricin and ByrLmDmyeUc <U»- 

inn. Tboro in Imvv « iiroMsd hoininiMwihcHia with nluriuitiag inamlysiii of Uw 

r| Mill VII mitiil tM'ritw, ttiN!«llit«un <>f tb>- V nwrvo Hn* tii livinorrhaicv in the U(«nd 

luwvr pnnloa ul ilir iiriritim- l<-tniM>ntum of Uio Ivft •Jilc. Th« riofd-kmtd fiifun 

lb» HMniuw^itu-«t;> <liwi ittcfl u in 'i/riHgomiKiia (h«mtaaaUeaia and bcmi- 

> UimnHiMMthMa iliin Cn Liiuim nt tlir mavinl wtiinory pnthways iif Ibt) Inlvrd portiun o[ 

tiw nxinilnr Utrmmtinn). Their i* prwr^ntinn of the tautile Hod prwOinl MnaibQitiat 

aivl u( liw stcKOKirafUc •£(»<■. U-cattM* •>( ttur iiionmploU sxtoiwioit of Uw baaon to tbo 

letuoMrua </fm). Tli'> U/l-hnn'f fiyurt ^homi <l) atrophia pAtmljnIa of tbe VII 

witfa rax^inn uf il4>sro).>rali<>n, Ina'^phihAlmin. droopinit of tho lips, low of f&dal 

r, panJynt uf ilip onliiv k>fi fnrUI tVIIl iiidiniti-H i Tift, a); (2) aanUiooia of 

[MM, foUowiruc invoWi'iiiniit <>( ili" (WnnidiiiK nxii of ilii' irEvmitiua (see V on a"): 

— -^'■■«4i nf Um* i-vUmal rpf-tni writh ronvprvnl «triil>u>niii!« h>- rauoa of the nvrr- 

Im Milaconiat*. Pnrlliirriinn-. I lion' i^ a pmnlyais -if ih« Ut«ra) movotncnU 

>«lb bfwanJ tlio li-f< tuttwli)i-Wri<ltnK llx^ inUicnly nf iba iHwUrior luaititii> 

diiMii fdprinjjiu l/*/!- !. xf tli,' ir>ir|»u* of Itti- VI and of the H'tjurt'iil rvli<<u1ar f'trmnttoo. 

TVp |p*t"n "f rvilori'ii iiu'trii*. iiii'l itf tin- Inliyrititliinr ch-uIi inrinri' fitior" whlrti iiiiile 

lb t.V/li t'l i>ii> ii^irtfii of ili)> III dnfl VI rAiiM<a iliiat. Hr rrciMtn ofiltp 

'•' nittAKoiiut* (h<' |>»timl looks to tho ruhl. tAftrr UvjcHne.) For 

tuona of tliv aoatoauckl sketdi we mtctiaa on Midhrmin. 



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46 MKTHODR OF BXAiflNATrOX OF THE S'BItVOUS SYSTEM 



Hot or CiiU\ water is syriiipfii (r^ntly into the external auditory 
meatus <if each ear. A large hulh syringe ]& used, ("old rausea a 
defiriiti^ rotiitory nystagmus towani the ear not irrigated. T\w 
jjatient also has vertigo and marked <listurl)anfe tif equililirium. If 
hot water be used the qiilek nystagfnir ranvement will l>e toward the 
ear irrigaletl, and the ataxia is difTerent. The prt'^^^'tl(.r of labyrinthine 
trouble or cerebellar disorder in^'olvitli; the vestibular appHraiiis cause 
mtMlificatioiis in the character of this nystagmus. (See Vestibular Tesfci.) 
i)il»iopia is next tested for. The patient should bo asked if 
lie has ever seen double and a single light, or one finger held to the 
right or left, up or down, used to test if double vision exists. Should 
it be present the position of the images in relation t-o one another 

slartild be noteil; whether they separate 
ur ajjproHch as the candle is farther or 
nearer, and a red glass should l>e plated 
Wftire otieor the other eye totletennine 
the loeatii.Hi of the uiiages, and their 
relative [xisition. 

The a(Toinpan\ irig sehenics are of 
value in memorizing the iniiseles in- 
volved (Fig. II): 

Monocular diplopia, seeing double 
with one eye, is ocoisionally met 
with. It is due to gro.ss corneal or eye 
defects, occasionally in central scoto- 
matn, but usually it is a product of 
pn>]'ection in hysteria. 

PufiiLt.^ Tlie size should 1h* com- 
pared and noted. Itight equals left, 
right larger limn left or the vrrita and 
recorded thus: (r = I :r > I, 1 > r), 
and a rough measure given, 2, 3, 4 
mm., as the case may l>v; mydriasis. 
myosis. The form and the presence of 
irregularities, changes in outline, oval, polygonal, ragged, and the implan- 
tation (ectopia) should be carefully noted. Particular attention .should 
l>e directed to the estimation of changes duo to drugs, to aerident.s or 
injuries, violent emotions, to inflainmalory products, iind to chani;e.s due 
to chest ilisordent or neck di.sor<lers or to other involvenient.s nf the tf r- 
vieal sympatheties. The special examination fur the testing of these 
vegetative pupillary retlexes has already been taken up. (See p. 37.) 
Unecjual pu]>ils from vegetative nerve pathway disturbances are not 
infre(|Uent. 

Pupillary unrest is a normal phenomenon. It is best seen with a 
lens. Its absence often indicates oi^nic disease of the visual path- 
ways. 
The reactions to light should then be tested, at first with clear 




Fiu. i:{. — liicyiiality (h( pujiiln. 
Left pupil UriEPr thai) right. Immn- 
hile. Cewliml tuinor. 




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RKSSOKtmnOH h:XA\it.\'.\rif>.\-^RAMAL yKKVKS 



47 



finyliplii, llii* piiticiiL loukiiij; at sonic ilistniit object. In bed cases, 
electric hand lamp5 arc ver>- seniccablc; with these the light is liest 
dimted somewhat obli()tiely. The reaction may he prooipt and wide, 
pracnpt am) re^tricteil, sinw, .slu^ish, dimini.^hfd or absent. ICach 
eye is to he tesle«i separately, and then the consensuni test applietl 
by ilhtniinatiti^ one eye only and nntinp the reartion in the r»iher. 
Hea<]y fatigability of the pupillary reactions to light slionid lie tested 
and the results noted. 









Mfimfn 



in-tu 



nnwUdml- 






Atprtmum 



I 



yW. K.— T'- — ftii ft titf rliirf cya rrRexna: (1) Pli|>(llar>' wflt'x: ItMiiia; opiir; X; 
qii ' X^ ucul'ituoUji iitH')eir«. oi-uli'iiii>U>r r)t>i\<^; ciltnry Rflii|^ii>ti; 

Irii. I 'IfMiiiB oyen M liK'it. Rxliiui; "lui'-: X , iMrjxip* ijitiulhierniina, 

MvyBArt'a titim: x, UriaJ iitHeuB; (nciiil nen'v: liil iiium^Im. i3) Wiukiaii on 
mi|in>arfa laT otimt: ItfiliiA: »|iii'>, X: mrpuni riiimlruotninB nr pulvintir. pst^roal 
cmicuUto; cortex; iij-rnniidal trart; X: (ncM ruKlmt; f»cud nerv«: lid. (Smm- paltm 
alK) In 3.) Hi Comntl reflex: Comra; tncDtniniu: uinni. nui'JMta: fariaj niiHriii; 
fMialMm:1ld. <ljrwMM)<>w«ky-. FuokUoneo d. Z<'nunliwrvcTuiyaU>tn. p. t'£!. K^n. 20.J 

W'lrrnirke's ht-miupic pheiinmenon should be sniidht for in heniiiin- 
oripdai. In iliis the pupil does not rt-act if the light fiill^ upon the 
Uind segment of the retina. It is indicative of a lesion in tlie optic 
Drtirones U'twivn the chiasm and the ainnira quad ri gen lina. 

Testi for the acoommiKlation reflexes are then made. The |Hitient 
looks at tiic (ingcr as it w niovrrl near to or away from the eye, and 
tbere is f.t>rre.-<ixinding contraction or dilatation of the pupils. Here 
the reaction may be prompt or slow, with alight or market) amplitude. 
lo blind people ihc request to look at their own nose and then across 




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METHODS OF EXAMISATION OF TUB NERVOUS SYSTEM 



tilt' room iiiav l)rinjt out the reartion. A lost or partially lost light 
reHcK, with miini paired! acrommodation reflex, is known aa the Argytl- 
Itnhrtijtnn pupil, it may Im* present in one or both eyes, anrf may he 
partial or omiplftc. It ts due to a dissociation of the sensorimotor 
n'HCtioTis. luul nmy lie |iiTscnt in a variety of diseases, although it is 
most frequently fouiui in syphilitic disonJers (Fig. 13). 

The meelianisni is variously although not entirely satisfaetorily 
explained In-cause of the complexity of the afferent and efTerent 
filxrr tracts and their comicctions fl^wandowsky scheme, sec Fig. 14). 
Marina's h,\7M)thesi3 of iU peripheral origin (disease of ciliary ganglion) 

explains many of the tabetic and 
paretic cases, but does not explain 
some of the traumatic or mesen- 
cephalic cases. C'ajal's scheme is 
JUS follows: 

1. lietinal neuron with Its ojitlc 
fibers ramifying in the anterior cor^ 
pora quadrigemiria. 

2. The iricseriLTphalic neuron with 
its axis-cylinder formation of the 
Ijostcrior commissure. 

H. The neuron of the Interstitial 
micleus of the tegmentum (calotte) 
with its collaterals destined to the 
motor nuclei. 

1. The neuron of the hnlhar nuclei 
of the oculomotor communis et ex- 
ternus and of the patlieticus with 
axis-cylinders going to the muscles of 
tlie eje. 

The sympathetic reflex is tested 
by pincliing the skin of the cheel* or some other part of the body. 
'Fhe pupils dilate under the iuHiicnt c of painful stimuli. 

0|>htl)alnioplegia externa is the name given to a paralysis of the 
external eye musctes; ophthalmoplegia interna to those of the pupil, 
which is widely dilated and immohile to light and convergence. Com- 
plete ophthalmoplegia is found \vhen all of the pupillary phenomena 
are absent ami there is loss of all eye movements with ptosis. 

Ptosis consifiLs In a rlroopiufi "f tlie upi«'r lid, pai-alysis of levator 
paliiehra-. whirli is supplietl hy filaments from the third nerve. 

Heunehcrg's reflex, consisting in a spastic action c-ontmction of the 
orbicularis oris when the hard palate is stroked, may be mentioned 
with the reHexes of the cranial nerves. 

The f'ftit { Tri(innitiu.t) AVrr^ (see p. 59-t)2). — The motor functions 
of the hfth nerve are tested by ha\ing the patient move his jaw to the 
right and left. The examinerV band, exerting cnntrary pressure, can 
determine dilFerentYs in innervation (external pterygoid, temporals). 




I'l... l."i. Tji1k'» wiLti liil.iUT.kl iiLii.w. 
Operated upon lo hold oj elid opeo. 



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SSffSORIMOTOR KXA^fl\^r/0^—CR^^■f^I. SKKVKS 



49 



le finper wrapix^rl in a towel can bo uscA to bite upon to (k-terniine 
variations in hitf {massptrr, teinpfiral). 'I'h*' .-ctate of lianiness of 
the temporals and masseter muscles can be directly jiulpated. The 
jaw .sliouli! Ik- protrudw) (interiial iiteryguid). 

The use of a tuning-fork of Inw pitch is useful in iletennining loss 
of function of the tensor tynipani nmsclc. 

In one-?idcd paralysis of the motor fibers of the fiftli ncr\*e, llie 
opened jaw deviates to the paralj^^d si<le b}' the action of Uie sound 
external pteryyuid. The patient chews on the sound side. It raay 
or may not Itc accompanicil by seawry chanpe.s. Klevation of the 
ejrli<i on stronj; biting' is a frrtpicrit assiH-iaterl mnveinent. 

Tlie jaw n-flc.x may lie tested at the same time. With the mouth 
partly open a pencil or Rat object is placed upon the teelh and lightly 
tapi>ci) with the hainuier There is a quick contraction of the mas- 
M-ter* an<l teniporaU. and usually an associated movement of closing 
the eyelids. 

The nrnxiiry functions of the fifth nerve demand verj' careful testing 
by reason of its nide distribution. 

The supra- orbitid, infra-orbital and mental ]Kiiiits kIiouIiI first be 
pn,-sscd upon to ilctenniue the dcprir of srnsitiveiu'ss. Then tlie 
palpebral, i-onjundivul, ainl corneal rellcxe^ should Ik* tested. 'ITiis 
is liest done with a lon^ pin with u ghibular ^laK-i lica<l. With the 
patient lookinp away from the examiner, the palpebral marf^in is 
tourlH*(l \riib the lieail of the pin, then the conjunctiva, and finally 
the choroid, and running alonp the t^lohe oxer tin- cornea tlie etfect 
in iH>ti-d. Iluth eyes should \h- coni[Mired and the tear Hecretion 
nulcfl. 

Tlie nnuHMit of tear MNTetion may Ik- measurc-d by hanging two 
nail 9lri|M of litn)us [)Ht>er on each lower lid, by Ix-ndiiig in the paper 

the tup so as to make a snudi leilge 1o hung. The rate of moistening 
of the two sides will show quantitative variations in the amounts 
aecrned. 

The onlinary sensibility of the fatv sliould l>e tested first with a 
cnmel-liair brush -the tw<i sides romiNired. Then witli the point and 
head of a \'ery shaqi pin; then the skin should lie pitiehetl on each side 
wkI diircrrnees noted. I>cep pressure over tlie malar, frontal, and 
juw Imnes made to determine dtvp jiressure sense, ami the use of hot and 
cold test-tul>es to learn if variations in thermal senne exi.nt. Finally 
a slowly vibrating tuning-fork should l>e applied to tlie bones of the 
hfftd to tletermine their iKHiy sensibility. 

The tntrrior of t))(> mouth aiul the surfau' of the tongue should not 
be negli-<-ied in these tests, ami special care should he taken in outlining 
clumges in the ear areas, and nithin the auditor^' caiul. 

Tareful inspcciiofi of the teeth should not Im- omitted, and anomalies 
of dentition carefully noted. The two sides of tlic bony structures 
nf the face should l>c eotiiiNtrrii for tmny atrophies (hemiatrophy) 
or h>'pertrophie> (uerumrgaly). 



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SENSORIMOTOR EXAMINATION-CRANIAL NERVES 



51 



Not only should the presence of paralysis or paresis be carefully 
noted, but spasms obser\-ed under voluntary and emotional reaction. 
Their degree, character, and intensity should be carefully recorded. 

Sensorj', secretorj", and motor functions are to be tested, and many 
differences are to be noted in the distribution of the palsies according 
to the location of the lesion of this nerve: (1) after its exit from the 



Ttute it Saliva 



---Su-f«f 
-—Te<in 
— Ttutr it tialiru 




l\i*t, -Imiin/ai" 



Yui. 2*1. — Diagram of faeiiil nerve, shiiwirie cfjur.to iif secretary iirnl of VmW liU'r.s. 

(Stewart.) 

styl(imasti>id foramen, (2) within the Fallopian acqueduct, ^i) iK'twcun 
its cmtTjjence from the pons and the geniculate ganglion, or (4) within 
the fKin-s. (See Fig. 20.) 

The Eighth {Cochlear and I'esiihuhr) AVrrcv. — Here two entirely 
different nerves with absolutely separate functions necfl to he tested. 
They are the cochlear nerves (hearing) and the vestibular nerves 
(e<|uilibrium). 



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52 METHODS OF EXAMINATION OF TUB SERVOVS SYSTBif 

HeariiiK Is nmnl'Iv tested tiMwt sutisf art only by s])ee».'h. Having 
first ascertaineil that the au(iitor>' canals are free from wax, the exam- 
iner, snme six (o tni fet't away, prKrmuneew thnt' niimhiTs, linking 
tlie patient, who has luie ear closeil, to rejHrat them after him. The 
vni(v is tlien raised or lowereiJ, antl the Histanrc varied to determine 
the hraririg capacity. The opposite ear is leste<! in the same maimer 
unil coHipnrisoiLs made. A wateh-tick or tuning-fork may also be 
used, t'areful tests with tuning-forks and whistles arc needed in 
eoniphcated cases. 

Hoiiy conduction slumld also I>e tested. This is done hy putting: the 
vihratinji tuning-fork o^er the mastoid, and the patient indicates 
when he no lonper hears it, the fork is then l>rouKht to the auditorj* 
meatus to test the air (-(induction, iiinne's test is positive. /. i».. air 
conduction present after kiss of Imnc coiidnctioii is (he nnnnnl fominla: 
the negative Ilinne Indicates middle-ear disorder. The tuning-fork 
on the center of the fort^head is heard in hotli ears etjunlly Under 
normal conditions fVVeber). In middle-ear affections it may he heard 
unequally on the two sides. Positive Weher (('. r., louder on affected 
sidej witi^ negative liinne is largely indicative of middlen-ar djsttrder. 
Deafness due to ecntral disortier is usually associated with other 
localizing siKn.s. yet it may he an isolated ])heiuimenon of beginning 
tumor, enreplialitic process, tahes, multiple sclenisis, etc. 

Forks of very slow vibration are of value in determining the func- 
tional capHcity of the stapedius muscles. Tests with continuous 
tone series folkiwing Bezold's methods are indicated in all <'uinplieatefl 
raws, jiinei' defects in lower or in higlier tone perception usually 
indicate a di(Terc-nee in the site of tlie lesion. 

Certain |»itients show hyperaeusis, tinnitus. Ringing in tlie ears 
i» on extremely elusive sign. It is an cvidentv usually of middle-ear 
or of iriK'hlear irritation. 'I he sounds varj' greatly. They may be 
bruling. hustzing. or whistling, and may at times be the jxtint of 
rfeiHirture of illusions, or hallucinations. The pulsating t^ycs of 
tinnitus are u.-iually associated with the heart beat. They are found 
in certain tumors, in aneurisms, or in anxiety states ynth cardiac 
irregularities. Continuous tinnitus, low-pitehinl or high-pitched, is 
the more common. The effects uiwn the tinnitus by lying do\ni and 
also the clfcets of certain drugs, amyl nitrite, etc., arc of siTvitv in 
diffcrtrntiating the causes and probable site of a tinnitus. 

Auditory-orhicuiaris Hefiex. — ^^\hen a loud sound is heard close by 
there is a tightening of the orbicularis paljKbrarum fibers, cliieHy 
those innervated by the cer\'ical sympathetic. This is a useful test 
for ps\choRpnic deafness. One ear lieing tightly clostnl with cotton, 
the jsitictit fatrs the physician who with a nutgnifying gla.ss of about 
two inches f«M-us miinitely observes the orbicularis muscle response to 
tlie luuil luvnk of a bicycle or automobile horn which is blomi ju-st 
liehind the patient or In a closely contiguous simc-e. IVuctically no 
one con consciously iidiibit this symjjathetie i-eflex re.siwnse. 



I 



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iRIMOTOH KXAMlSATWft— CRANIAL SERVES 



53 



Vrrtiiju. — Tliis Ix'Iuiijrs largely to the syniptomatnlujry of tW vestilv 
ular apiNirutiiH. Equilibration is an cxtrpiiwly miiiplox iKljiLsttnent 
invoKing the t-omparativc integrity of u lan^ nunilxT of neurones fnun 
the jR'riphory to the roordinatinf; ivntent, which latter itre fairly satis- 
fuftorily proveii to l)e in tlie eerehenum. The vestibular appjiratiis is 
the ehief f^angUon of the eraiiinl eml of this whole appanitus or system 
trrmcij by Shen'in|j;ton the proprioceptive system. The ccrel>elhim 
is its ehief eenter A etmiprehensive anatotnieal survey of the path- 
ini\-s involveti is to be found in the extremely vahmble plute workeil 
out by I>ejeriiie, (S'ee Plate VIl, p. 274.) 



(Schalli^r.i 



Fio. 22. — Dyamptm of Bahitwki dfvul- 
oped on RlUtnptlng u> xmkt hold of u kUm. 
Tb* Buaen an beld very far ojieii. 
(Thomw.) 



TriflK fur Kf/Hilihriiiitnt.-''r\w more stJii»lftr»l er|uilibration tests are 
l)ir Itomlierf! iiml llie Bubin.ski asynerp'c tests. The* Romberg test 
in (4)tuitictl by having the [Mtient slnntl erect with eloseil eyes, with 
he*-l.-' and toey top^-f lur. Under normal nmditioiis tliere slioulH be only 
ft vrr> slight ^fttiiying. but the i)en«on with weli-inarkcd liomberg swaj-g 
ndevise. i>r backward, or forward, or may even fall if the feet art* not 
vprrod upart. Slight degrees of Rumberg. or unilateral localization of 



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64 MKTllObH OF EXAMtSATWS OF THE NERVOCS SYSTEM 

Hombcrt;, may be broti);ht out by liaving the patient staml uii oiio nr 
the utiwT foot. Other obwrvations of the liomiierK ran lie made by 
hnvinf! iIm- (Milieiit U^ntl forward or backwartl or ^idewL'^e. and in this 
way ((uantttiiliM' >ni;p*sti<ins may l»e itTfivwl as toiti*.' localizatitm of 
t\w (iU'r tntri.s invdlv ttl. 

In *rrt»inwirU'llnrdi.stiirlwnw,s there is a siienal loss i>f equilibrium 
which H^tbin^i lia.t tenm\l astfuerpa. This may be teste*! in u number 
iJ ditTt-nuil ways. The more valuable are by means of walking. The 
iwlivtit ^l^ualI^ Iws a t:rent <ie»l uf ataxia and walks vith dlfKculty. 
U imp|H»rteil nn either wle. it is noticed that in watkinp be shows a 
li)arki*d lendeney !«> widk frt»ni underneath himself, so that bis legs 
Hiudly »rv |>ut out far in advanee of his eentiT of gmvity. The same 
ly|M' of livvi of ivrrWtUr n|iiilibrinm may In- deniimstniled by having 
tU- )>atk'nl ?-iM\i\ ereit ami then sluwly Iwiid iMickftiinl, making an 
nrr i/r nrtk. In the iH-dthy condition the musc-ular adaptation 
Ik'IkU tU' kttit'^ ft>nvard and tlu* individual attunes u well-balaiieed 
iMMitiiui; but in tin- «\\nernie. the lep* are held .>traiKht. the trunk is 
lirnt Iwekwani and tlu- |»alirnt has a tendency to fall baokwanl. .A, 
luitieni. on icHL-^pini; a k'"^^ opens the hand far wider than needed, 
riii^ iri dy^nirtria. a sijin t4 iTirU'Ilar disturbam«. 

|'»»f the upi««-r evlnMuitii'^ n similar tyi»e of museidar inrofirHination 
>Ju»tt^ it"**'!* '" t'"' 'M'i'"' </'<'</< '^■"^■""■^"f tests. These Tests an> made 



Kv l»^"'l! *''** i^»*"'"^ |H'rfonn irrtain sdternatinK or opiiosing move- 
iJ ,, ^vr\ ni|«dl> . »Hh as (piiekly pr^HuitinK and supinating the Itand 




ih^wNMt*'^< "^■•^' j^"j"^^^^.„„.„^,; ilirv art' done elumsily. irrepilarly and 
!r*T" k I. .abui: on tU- gnvlv of *iw.ry traet involvement. 
"^'^^ ' a*,, rtpulibriun. *.f the trunk the patient .hould l>e on the 

■ »r|H-. f»J»KHk i*nd with the Uffs drawn up m the obstetrieal 
W .,,»,tiidendJe variation will W fonml. Tin- lieahhy 

f„iav barxl foumUtititi. eau equilibrate fairly well; 

lihK- ^tt*\i"K. »1>''*' »'»' "*''^'*' I"'*"'"^ ^"""^-^^ consid- 
V .. V ■ ■ ^,i,,„t\ «Ui. anil eertain t > la-s of cases with fmnto- 

■ ' ' ' -lurUl"-*-- •■*1'"^^ "''"* '^ l*'"'^^'" as niUilqttic 

\t\vr ^w ft> iim '•"■ » '^'rtain length of time the 

, (K,"d with Miffieienl rigidity to enable 

, ,..M^n of v«t»K-plie rigidity is e<msidered 

. ,4 ivrt'MUr defei-l. 

u {\w 9*\it tHiiipi*-* "" miportaut place. 

I (,. w«l»^ »1">'« " ""'^''' ^^ " straight 

I,.. »bouhl U- aAv*\ to suddenly reverse. 

\ "h^Mh Hide. ^houhlUMe.^..l and then 






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}ftASUL .VERVES 

d^turhanrie of riiiiilibrtuu) l>c prest^nt, it will become intensiHwl. und 
stnUCtrinj; to the right or to the left, forwiinl or Iwckw-arrl. i\il| be noted 
(latcropiilsioii, propulsion, ctr relnipulsion). 

The jMiticm slinuld aUo be ipste<! by walking on the toes, on the lieels; 
be should nUi lie aaked to walk sidewise. 

Inspc(±iou of the shoes (heel an<l sole) is highly desirable if tlierc are 
minor modifiention*^ of gait, there are characteristic worn spots for 
vftrimis fnrnis of niolor wcfikiu-ss t>r stiffness. 

\'iirions rnodifiriition'* In gnit are known as ataxic, as reeling or 
drunken, h.s spastic, scissors piit. hj)fh stepping (steppagej. shuffling, 
prndnhnn gait of lieniiplegics, gait with littk-, short Kte[)s, titubating, 
chnr»*ic. pnipulsion. Stilted gait is a type seen in schizophrenia. 
Irregular gait-* are nnteil in hysTcriads; here walking sldewisc is UM-fiil 
in di.slinguishing an Iiysteri(".il hmiipli-gic fn»ni n lieniorrlmgic one. 
The hysteric swings the leg out in the arc i»f a cirL-le, the heiniplegic 
Tftlfn the |wlvis and the toes stick to the ground (s|As(ic). 

The subjwtive seiijic of gid<HrieHs is often extremely (H>mplieatef!. 
Certain |mlienis complain of objects inrning aliout them, in which 
fUiv the direction of the moving cfbject. in lenns of the Imnds of a 
clock, shouli) always W' noted. As-stM-iatlon of giddiness or vertigo 
nith rye rlistnrimneeiA is very widesprea<l. 

The Hnmtiy tet>ts by hi'al and ciilil, hy ennipM-s.'wd air, by the 
re\(il\ing chair, have already Ihtii mentioned in the consideration of 
n%Magnius, and need iml Ik- reju'ated here. Tlie.v are prin^irily t**sts 
for the labyrinthine function, tlie nystagmus being only an iic^-eswiry 
phenomenon. 

I^thyririthiue tests iire exlrcinely complicated and are discussed niitre 
fully in di.>4-:i.vr> nf the M-^tiliiilitr m-rve (p. 21>2). Certain [lointing t*-sts 
are of fter\ itr and are usually made with the frntient in the revolving 
ehairiiT with the ai<] of the calorie reactions. With the caloric reactitins 
the Irst is iM-rfonned as follows: TIk' patient seal*"*l on a stt«il with the 
cjTs ektted brings his arm forward and toxK-hes a fixed object directly 
in fnmt of him -usujdiy the fingiT of the tester. He then relaxes the 
miin, allon-ing it to fall to the side and then raising it readily tou<'hes the 
object. Vjuh liaml is thus tested, anil the lesLs are varied in the \*er- 
tie»l and liorizonlal planes. (In syringing the left ear, fur instance, 
with cold water, and repealing tin* tests, tlii*n* is a ninrkiil rieviation of 
the intinling to iIk- left ; or. in terms of the n.>"stagmus which is normally 
induced, be overshoots in tite direction of the slow movement of the 
n> * ; - - Changing of the axis of the Iwdy will change the direction 
o) -ing of the target. 'ri>ese te.sis are itanpliraied but of great 

iuipurtwiwe and should In* carefully studi«fi in sjieeial works. They are 
uf particular value in stiidv ing irreU-llar disorders (*/. r.). 

Kmmitialwn t^ the Pharynx. — Careful note should lie made of the 
position of the fauces while at rest unrl during jdionation. und of the 
nownH-nts of the >i>ft pahite during phonation. The pharyngeal 
reltrxea arc tejrtcd by toueJiing aucccsaively the right antl kft pillar. 



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50 METHODS OF EXAUISATIOS OF TBS SBBroVS SYSTEM 

and the vomitioi; rvflex b brst tested by irritating the back of the 
phao'nx nitb a wuodrn i-puida. 

^Xliile under normal conditions tbe u\'al]i :^b<tulil hang id the middle 
line, a certain amount of variatioD lu ptKiitiitn is ver>' freqiH'ntly 
obsen-ed. 

While tbe phanux is beini; examined, note should be made of tbe 
pliaryngeal v»ult, and idso of the nmttiur of tbe pofltericir phorAiigeal 
anils. KiirtlHT. tht- ititi-jjrity nf t!»f suiierior plianti^rciil inuwles 
shoulil lie tested by luiving the jtntit-nt snalluw. and imiiitg whetlier 
t\w Ri't is coordinated, or whetlaT there is re^irgitation thniugl) tbe 
n4ise. 




Vui. 23, — Oroula Utyavaal pantsnai. (Bttrw*llj /. Mt oMuctor p>ral>-sis durins 
imvintion: II, lift aMuebir puMljraia during phoiutioa; ///, l«{t rofurrvnt lAr)-nR«U 
paralyito, diiriiMt fauiiirHlinn; IV, Mt racuiTant Iwj'Oa'ial p«riil>-«w, duriaa phniistion. 

Kjiiminaliun nf Tfutf. — Taste is a complex fiinrtion and iitilize:> at 
iMMt Hini" didcn'rit iHTves. It is l)est tcstiMl by siihitions which are 
awrrt (nuKiir). hittiT ((|uiiiini'), add (vjnejjiar), salty isalt solutions). 
Thf <Hihitii)iiN nhimld \»- kept in uide-mouthed Iwttles, and are applied 
ill Aiiiidl (luaiititii-H hy ineans of a ulass rod applied to ilitferent parts 
of tlir tiiiiKtii* to drtc-nnine tlie fiiiu-tionul capacity of these parts. 
Snmll iiiitoiiiit.>> Mlidiild !«■ iwd, and it is best to re.'ierve the bitter test 
until llie jjisi, finnn»'iuin(; with the sweet, and follnnnng with the sour, 
llir "Mdt. ami thf bitter. The mouth »liiiuhl be wa-shed out between 
till' lentH if (iiffful rii'oniA are to Ik* made. 

Taale ean almi l»p teittetl by mearLS of a minimal tjiatvanie eurrent 



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rNRORLUOrOH EXA MINA TION— CRANIAL 

when the iKtsitivr- prile will prodiire an arid tjiste, the negati\"e pole 
nn ittt^nliiie nr fu\\\ tmv. 

While testing for taste the rondhion irf the secretion of the buecol 
nmi-iiu.s iitcinhraiK- c-aii Ix* tested. This is hest done liy nihliin^ tlie 
door of tlie mouth with a glass rod and noting the rapidity of exen- tloii 
nnd the amount 

Eramination of thr iMrynj.^-'Vhis naturally has to he carried out 
by meun.s of a ]ar>'ngologi(ral mirror, n'heii nml|)<isiti<m or changed 
{Kisitinn nf the vtH-jil tiirds (hiring inspimlion. expimtion aiul phonatiuii 
are oIj3(T\ed. Fig. '2',i shows the position of the vocal cords in four 
ehanicteristjc jwHes. 

Exmiiiuaiiim of Sjteech.—A complete analysis of the function of 
lunpnngi- will not Ihi entered into in this ])Ia<t'. The chief points of 
neurological interest to l>e ubser\ed are whether the fongiie is pn)tnided 
in ll»e middle line, whether it is freely movahle. up. down, right and 
left, and lun U- made to push uut Utlh cheeks. Careful search should 
he maile for sizars on the tongue, acid the pn'seiue of a leukojilakia on 
the *idcs of the tongue or of tlie mucous membrane of the cheeks sliould 
not lie overl*ioke«!. 

Trcworit of'tlie tongue may be vcr>' fine, involving the whole organ 
(fibrillar}'), or coarse and Irregular. CoiL^iderable attention should lie 
drv«itrd to the :4i-nrch fur tongue tremors. 

In testinf! onlinan,' si>eeeh, certain test phrases are advisable. ITie 
pfttient sliiiuld In' dinxteii to n-|M>at the iilphalH-i, iind the lunntiers 
tip to twenty-five, and should repeat something well known, such as 
the I^nl's Prayer, or souk' bit of ixx'try, and during the repetition 
enn'ful attention iiihoidd Ix* dirccteil to the enunciation of the iiidividuul 
letter*, to the presence ot stumbling over W(»rds. of running words 
rther. to the omissions of words, or the omission iif syllables, and 
' fMitir-uIitrly to the repetition and the displuivnK-nt of sylhibles. In 
order to bring out some of these defects, certain test phras<'s are utilized. 
Among tla- most \alunble an* the following: Truly Hurul; Third 
Kidini; :Vrtillery nrigacic; ^^ethodist Fpiscopn); National Intelligi'nwr. 
Nutumtly the type of vnst will suggest (vrtain defects, which can then 
be exnmine<l for. 

In stating the speech defects dne to laryngeal loss, special attention 
!«hoidd l»e dirci-ted to the preseiiw of ctjugh. of stridor, and tti llie jHteh 
of thi' breathing. 

The >peeeh Is further (e>teil by having the i>atient re|M'at foreign 
worth, read sp<p|itane<iusly, read after writing, and defiiu.' spoken, 
written, and printe<] words. 

AphttMte Siaha.—\ brief apliasic status should include the following 
tntx: 

FirA awertain the usual hahiLs of the jialient and of the pnn>nts Hith 
*refrfenee to the use of tin- right and left hand in ever>-<iny acts, 

I. Is spontaneous speech |)ossihle and is it intelligible or non-intelli- 
pi^y Record should Ix' nuule of the choice of words, complete stenrn 



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5S METHODS OF EXAMISATIOS OF THE SEHVOVS SYSTEM 

grams of the words uttered should be made. Attention should be given 
to variations in pronunciation, cndeiUT, and rhjthin. Observe "word 
aakd."' "jargon iqiliasia," "jumbled, precipitate speech," "stumbling 
sijeech," "turreiit ^|»t•(■^•h," "tint-fMitato siwrch." 

2. Does llie [Mitient iindrrstand words? This is tested hy asking liim 
questions, whieli slmnld nut Ik* tiM) simple, siic-ti as what \& his name? 
etc. He shniilil Iw n^kcil to touch his nose, his K-ft i-ar. the top of his 
bend, his riglit knet*. These tihould nil l>e asked without any trace of 
movonu-iit on the part of the int|uin.'rand preferably so tliat the patient 
cannot mh' the lip nuiveniPiits. 

3. The knowletlge of wTitten or printed words shouhi be tested. The 
ttaine commands as previou^dy mentioned {'1\ shiailil he written out an<i 
shottTi to him. 

4. < "an tlif [intient repeat words sjwken such as Sasaktai. Constanti- 
nople, Ikm pdlini, or mouse, rose, sunfish, etc. 

5. Can he write si>tint«nct>usly, left hatul, or on typewriter. 01>ser\'e 
misphieinK and similar defects, as in speaking 1 1 ). Is he abh- to write 
from rliclatinii? Is he able to L-opy what be sees? 

0. ('an he tiaine objects jM>irUed out; i.s he able to recognize objects 
after tlieir name is spoken, or their names written? Can he pick out 
object.'* named, ^^Tittcn, or shn«ni? 

7. Can be obey eonuiiand.'^ ealliiiK for simple gestures, such as bow- 
ing, Ilinnvini; a kiss, elenchiiiK the hand in di-Manee, either hi response 
to s]>okeii wish or to imitative p-sture? 

S. Clin he uiiderstaml tlie use of objects, such as striking a match, 
using a paiKT cutler? (Aprnxi<' tests). 

Stiiltrrhiff is a spaMnodic form of s|HH.*eh ihsturbance wbicli calls for 
.^lH■t■ial menliou. Certiiin iwtients show a ver\' marked slmvnig of 
spei-eh (hradylaha). while others show an iiiterinillcnt euuneialion, 
and still others a pecuhar, monotonous, scmising-wmg type uf etnmtia- 
tionknomi as "sk'annhigsjx'cch," In complicated s|x^ch disturbances 
due to in^■olvement of the liy[K>gIii.s,sal nerve orir obtains the so-calk"*! 
bulbar thick speech: the patient sjjeaks as thoui;h lie had a hot potato 
in his mouth. Fiirther, in extensive spttrh disturbances due to 
coexisting lesions in dilTereiil parts of tl»e speecli meclmnism one 
has otiier disturliance:? kno^Ti as anaithria, or more particularly as 
dysarthria, or " jumhied spewh." Special attention should be j:i\en in 
stuttering or stammering to the tv-^H-. whether dental, lingual, labial 
etc., and a list made of the characteristic hitches of the patient. It ^\ill 
be found they usually have some sjTubolic significance, which the 
ps>choanal\tic technic may reveal. 

The Tnith AVrw.— The study of the heart ad ion and tests is referred 
to tl»e .<swtion on tlie Vegetative Ner\ous System. 

The ICltventh or Spinal Aarxsim/ Serrc. — ^Tliis ner\-e supplies the 
8ternomastQid and tlie trapezius. Its functional eajiacity is testetl 
by tbo ability to raise tlie shoulders and to turn the neck, pfi'ssure 
bang made on thechtn in resistancr. There arc a nundn^r of striking 



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*SR EXTREMl 



69 



{lifcpln cements n^iiItiiiK from paralysis of this nerve wliich will be 
iliiw-ussefl later under the head of Paralysis. 

yintb. Tenth, and Turljlh yerres. — Tlu* glosstjpharyngeal, vagiis, 
ftiii) hyjiopliissiil iMTves mny Ix- roiisiden-d more nr less Uip-tluT in 
tbcir U-aUiig. The glossupiiaryiip-al is involved in llie fiinetion of 
of the posterior third of the tongue and of tbc s<»ft palate. It is 
■ISO a nerve of common sensation for the back of the tongue, part 
of the soft ]>alate, and upper part of the phar^Tix. It supplies tlic 
middle fiuistrictor of the pharynx atu\ the stylopharyngeus with 
motor fd«T*. For further details of the testlnn of the otlier nerves see 
the Hiapter on Cranial Nerves. 

Head and Neck. — Tbc muscles thnt move the liiiul and reek, their 
function, their ner\'e supply, and the ^ipitial sejrnient in wbidi lite 
motor sjniapscs arc located arc as follows (Figs. 27, 28, 2^ and 30): 



tnyuidw. 



RMtua napitia ftnlli^. 
, Rntua rspitb IntenUU. 

Bnriwam auxlhu. 

Sorinw piHtimu. 

Bialvniu luitieuii. 

HplentiB npitiK. 
Tra|iefiiu. 

I tfWfiMK'lt-iiltinuutaui. 

iL^vrntae Kagull MrwpuU. 

''OUiiiuai niptnor. 
Otili(|(iua iiifwrior 



VvMfmos. 
DuprtMca tlw anslc nf \Uf 

jaw wi'l DMiitli ' ilniHii 

loiuu nii'I wriiikim tlip 

akin of th<? nwk. 
tVxinu g[ Uin ImouI. 
Latiirnl ninvotnent And 

•lislit r^Utiuo. 
Kst«iMionniv(l ml«lktnoii 

NUnf niOt'. 
La Ittntl mil I'l-nittiit niMl 

■lichl oxtciMion. 
LalrraJ tnovi'iniMit and 

•lilthi extausiuii. 
LaUirsI itMiveniDDl aiHl 

aUglil cxWiiAioii. 
Extmaoa. 

LalTiil. npxioii at»rl mta- 

lion lo iit>|iiMJ(«> «ii|«. 
I^iml anil mlJtUiirt uii 

MUtw aido. Kaiao anslo 

r>( acapiilA. 
Ext«nMoa anil rnlalion 

•>D mttop aidv. 
ExtwiwMi wid n>tniioti to 

Hiil.tiioti t(i iwiija (iflf. 



NkBVB HcFrLV ANI> 

Fni-ial. C2. 



Cervical linuirhra. CI. CM. 
Antflfior oemnal, Cl-fl. 

Pdtlt'rinr (Tr\-iral. CI. 

.\nt4Tiur riTvii-al. ('2-S. 

AnttTwr (vrvii-al. C.^-K. 

AuUrlur rorvical, C-l-7. 

Cervical nnrea. C2-ti, 
Kiiirinl ncnsmary, eeevietl, 

(■■.•-4. 
.Sjiitiiil »rrcamtiy, mrvUmi, 

a 4. 

Anitwior cervical, C3-S. 

Po»l«ior wrviral, CI-S. 
Posterior conifal. Cl. 
Pnat4>rinr ri'mral. <"2, 



Upper Extremities. — A s>'siematie eKamination of the upper extrcni- 
itiex i» next in order, the tnustnlar nppitnitus first elainiioK attention. 
two sides nf the ImhIv shoidil l>e exauiined svsteinati<'jdlv. (See 
27t«3U.) 
'AlMim.'jlies of stmctiire silwuld first Ik- noted, such as habit or oceu|>a- 
tionul i)o:«ition*. allerations of posture, etc. Gross dilTcrenees in the 
ausT t<{ the bones, the wrists, hands, etc., should Ik* measured. 

,-ttnrj>ky.—'\'\iiK may htr detiTtnineil by simple jmlpatiim and by 
mnuturt-tuent. After natural differvmvs in the muscular volume 
an: tukrn Into cunjtideralion. striking variations slauild U- curefully 



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UPPER BXTRKMITIES 



61 



nwftsured. The circuinfi'reiKt's over the biceps ami junt Ix'low the 
elhow-s on the tw<i sides slinuhl I* compared. Special iudividual 
musciihir atrophies may be pickcfl out later by means iif eied-rical 
reai-tinn tests. Atrophies nf the nails, skin, or hairy strtietures can 
be ntvjrded here, or nnfh'r the heading 'I'mphie Ditsiirders, whieli 
appears hiter in the qiR'stionnaire. 

//y|jfr(rf»/iAy. This isln-st bmunhtout by pai[>atioii and by m<?asure- 
ment. One weight should be gi\'en to natural variutluiis ri^ht and 
left sides— and to ilie inlluence of certain occupations— blacksmiths, 
ircin-workers, etc. 

Htjfutttni tiji.—T\\U is indinited by imtisiial flareidity of the niuscii- 
latiin^ am) miivements. .Sudtlen pnttmtion or suj)iiuition (»f the arm, 
extension or flexion at the slioulder-, wrist- or el bow- joints, may sfiow 
sudden sharp resistances, followed by marked fhimdity. Marked 
overpxteiisiofi, rtf,, is a siftii of liypotonus. 



I, 2Q. — Mariiod bypotnona in a ttntiMit iriih nmyatntiia rtmgrnn^. i,SfiMt&Auv.) 

Sparm. — Tlii.s indicates hj-pertcfniis. When permanently present 
contractum result. The iwrticular mn.seles which *how h^TXTtonus, 
or Sfiastieity or contractures, should tie recorded. In certain spastic 
cnndftknis th»» hjiiertonus may Ih> relieved by [jas.'yve movements. 

ijtuntlar I'uarr. — This is first ter-teil by having the jjatient execute 
all the chief mo\'cments of the shouhlers and arms. The chief tests 
ftic as follown: 

Shautder, Arm, Hand, and Fingers. — Deltoid. — Request tl»c |>atieut 
to raise the arms Literally to a horizontal position. Inability so to do 
indicates deltoid weiikness or paralysis. 

Traprtiiit, — Ask the patient to raise tlie shoulders as eh>se to his 
ears as poeisihle aKiiiiisl the pressure of the examiner's liamls. This 
will demonstrate the strength of the upper i»art of the trapezius. 
The middle and kiwcr in.irtions ore tested by desiriuR him to bring 
_tlw .'Kaptila! as cIoKe toj^-ther as possibk:. 
xLaiitgimun Porjti.- {{ai^- the arms laterally to a level, then, while 
>in|; them fully extended, bring the arms duwunnnl and backward, 



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64 METHODS OF EXAMINATION OF TUB NERVOUS SYSTEM 



as if to make the hands meet bejond the sacnmi. T\\e examiner 
8tandinfi[ behind the patient resists the movement. 

IWiortil MiiM-leti. — Stretch nut the arms straight in fmnt and then 
approxiniiile the hands against rt'sistanttr hy tlw exainiiiLT, meanwhile 
wateliing Ixilh heads of the i>etrt{)ral mnsele. 

Scrriihui Mtifjrni:i. — IX-sire tlie pjititr]it to push witli his haiirls Hj;ainst 
lliose of the examiner «r against a solid object. If the sernitiis lias 
lost its powvr the swipula will project and the dJKEtations of the musele, 
which ordinarily sliould lie visible, will not lie seen. Inspiration is 
u-eakenfd in paresis or paralysis. 

It is hanlly possible to detect paralj*sis nf the levator angnli scapulte 
and rhomljoids unless the trapezius is also involved. 

liiiKjNi, — I-et the patient Ilex his extended arm, his elhow restinR 
ill the iihserver's left hand, while the lattcr's riKht hand, K^'S'^phiK tl»C 
wrist of the patient, offers the necessary resistance. Also supitmtc 
tlw hand itjcainst resistarKt;. 

Tricfjm.—T\ie triceps may be tested as are the bleeps, excepting 
that the previously flexed arm is to be extende<l apainst resistance. 

Sujnvnkir I oiigm. Test m* for the hiix-ps, cxcrpt that the hand 
shouM 1k» midway between supination and pronation. If the muscle 
is paraly'/ed it will fail to become conspicuous on the radial side nf the 
uppiT jiart of the fi»rearni. 

/'7i".i(»f.t I if t hi- n'ji'.v/.^CiraspinK the patient's hand, ihe palm l>ei«g 
upward, desire liitu to iK'nd tlie liatiil up toward bis forearm agaiub't 
resistance. 

Kxtrumirit of t fir Wrht. — The patient's liand l»einp held palm down- 
ward, he is required tf) bend it backward against resistarnf . Moderate 
wx'akness of the e.xtcii.sors of tlic wTist may Ik- manifested by iisking 
him to .squeeze the examiner's hand, in which case tlte wri.st will lK;coine 
involuntarily flexed, the weakened extensors being miable to counteract 
the flexors. Marked or complete paraljiiis of the extensors causes 
wTist-drop. 

Flfjcrrs of the Fingem.—fit'CHu^ of the usual difference in the strenRth 
of the two hands the examiner should crtws bis fuirarms and place his 
right hand in the right hand of the patient, and vice pptm. Then let 
the patient squeeze the hands. If the observer keeps his own lingers 
extended and bunched loosely together he will Iw able to withstand a 
verk* hearty grasp without disctmifort. 

Addndor ] 'oil his. ^ Ask the patient to pinch with his thumb and 
finger one of the examiner's fingers. 

Oftpoiiens PfiUicis. — Oesire the patient to appnixiniate the ends 
of the little finger and the ihundt — while thus approximated the 
examiner pulls his finger through. Ability to do so easily shows 
weakness of the upixnicns. 

The inlrrmsf't and hiwhrirales muscles of the band flex the proximal 
phaiangt's, and extend the middle and terminal phalanges. The dorsal 
interossci abduct, the jwlmar adduct, the lingers from and towird 
a longitudinal line dra-mi through the center of the middle finger.- 



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Test by making tlie pHtient separate and approximate the fingers, 
and flex the proximal phalanges, kecpinj; the riidHle anil terminal 
phalanges extentU'd. Paralysis of these musrles eau.''e.s "elaw-hantl." 
The strength uf the hand gtasp is well tested hy the d>niiini»meter. 
Readings of three tcj^ts for each hand should be recorded. Uyiia- 
mometer records are available for definite eouiparisons. Further, the 
dynamometer is useful by many re|)eated readings (20) for obtaining 
an idea of the fatigability of umscles (neurasthenia, myastlicnia. 
alterations in attention, etc.). Weiler has e4)nstnieted a useful (iyna- 
mometer with a graphit register. Tilney has aU) de\ised a u^eful 
instrument. Kxpressed in tabular fonn the nniseles, their action, 
ner\-e supply, and spinal synapses are as foliows: 

MUIMI-Eli UK rfHlH'U>EH CilnDLE, ACTION* AXD Sl-JNAL STNAMIC SkOUKICTH. 

NEnvn SuppLr xko 
Actios. 
T'Aesc mttjccle* nort Ihe 
glurutdfr girdU: 



MeecLK. 
Ttupesiin. 



8FtVAt. AKOUIt\T. 

Spiii&I ttcoeoMory. c-ervk-aJ 
plcxua, mMolln N. aralUK- 



(jiliMnnius (Joth!. 
Lovntur M'npuliE. 

Rhoinbuiclvi. 

Pectornlis niuiur unci ininur. 

SutwlaviuH. 

SerniliiB mti|[uu.v 



tion. 
T ni iH** iuH^ H| It H! r 

fibers. 
Levator ouupulii:. 



T<oiiBMilMi'Ji|>ulHr, CO-K. 



BCiipular. C3-5. 
fUiotiibuidel. 
StemuhyoitL 
Omohyoid. 
Deprfjiaion. 

TrA|>«iiuii (low«r tilH^nn). ICxtcriial timl ialonml n[il<*- 
rior thurut-ic. C j ".('8,1)1. 



P'Mlifrioi tcnpuUr. C5. 



Hmrhiml plextu, CS-H. 



IVMtvrior tliurncic. C5 -7. 



Subdnvhis. 
pMtanLliii minor. 
LatMUmus tjorai. 
Ppcumlia majrjT 0'*wpr 
fibers). 
CJ>) HurisuitUd iiluiiv. 

.Snmiluii mniiuUs. 
PtyHoralia ninjor. 
Peotonlis niuor. 

TrappiiUM. 
Rfa'iitjiNittloi. 
Lniisaimua doral. 

MuaiXKB ur SKtiouiKR Joint, Airridrnt and Spinal Stnami Smombir*. 
AMuftion: 

Deltoid. 

!^ 11 pnk9i)i i ttn t IJ*>. 
.1 (Mud ton. 

Ti»FC!« innjnr nnr) minor. 

PiM-toralin niujur. 

LBtiMamtiH dnni. 

Coracu bmctiialut. 

BioepB. 

Triosiw. 
Fttxicn t/orword) : 

Dcltoifl <ftnt*rior), 

8ul>capuluris. 

Pertarulifl mojVir. 

ContoobrBehi&lu. 

BUiepH. 



DvlUMfl. 

TcTtM niIiM>r. 

Stitiru»i)iitiiuiti.\ 
Infritniiiiiuttw, / 



Term uiujor. 



Tcm major. 



CirRUtullQii, (-V-tt. 



•SiiprMCKpuliir. CSd. 



Lower Bobecapular, C&-4. 



IjOw«r nbseapukr, CV-0. 



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KnU'iuuir IntiKTw pttlUfi*. 

A tUmor miurirj o/ Ifte /orearm: 

Promitor radii itram. 

Fleiur rarpL rndiolis. 

Pnlmftri* lonipiM. 

V\vxot sublinkus difdinniiii. 

PIbxot eaipi ulnftrU. 

Flexor profundus diollonui). 

Ftfxiir liiiiK^iN pulUns. 

Proaatur giudtatun. 
UiucitM of fhfi hand: 

Abductor pollicia. 

Oppooona pollicis. 

Flexor Iwvvw poUicis (superf.). 

llvxor brvria iJoUicia (deep). 

AdducMr obllqtm* tmUiri.-). 

Adduclnr IruuavcrMis polltci*. 

Lunihriridm, t lutd 2. 

LumhricalM. 3 niid 4. 

luMrouci. 

"•••lor brvvu minimi diicili. 
witor miaiini digiti. 



oogic 



TUB MVSCLER OF THE TliViVK 



m 



ITic actions of tlieae groups are multiform and are best considered 
sepiiratcly. SiuRle iniiseles art- iint cjipatjie (4 l}eirig isolated from the 
fcroup actions, sva a nile. Tlie clbow-jnint action has been given. 
Actions of pronation and supination are important. 



Pnonation: 
Pronntor radii t«reM. 
ProDAlor (luadntua. 
Brni-fairmuliflliit. 
Flrxnr cartii railinlDf. 



Stri'tNATiON: 
Stipirintor mHii l»rcvig, 

Extvuvon ul lliuriiK iiritl li»ici;ni. 



AcnOK AT THK WftlST-JOlNT. 



FUxian: 

Plnxor mrpi nulifilis. 

PalnuiriA luiigUM. 

L/>n|c noxon nf thumh And finKors. 

Addtuitioti: 

Fli-srw pan" wlnofw- 
Fxteiuxtr i-iirtii iitniiriii. 



£xt«Deora ot wriai. 
KxUinmre of ihomh. 
Est«natira of f)HK«rH. 

AMtutioit: 

H*xor oarpi rtv'lialw. 
Kxtrrira)ni of wriML. 
Exlenwimof tliiiint). 



FiKOKS Action. 



Fleiiun: 

FloKor Mihlimttn diiptorum. 
Flexor iircifuntliiii ili|pl/>rurn. 
l,iiiii)irii-alea.lOn metncaniuiihitlHtiKenl 
Iiilcn^wH-i. J juintH. 
Flexor hrevifl minimi dicitL 

Adtiiu-itan ■ 

l>:iliiiiii iiiUmaMq tto th« mM'll« line itt 
niidillv ftnitt'T). 



RxitTiavm: 

£xt«tuor oommuiiifl diiiiloruin. 

EKtvriMir tiiflLrtH. 

Ext«L*-ir mininii i-liKili. 

I^umliririUn'. i Artitix on inivrphaJaiigral 

iDberosAoi. / joiiibi. 

.-I Ikluctityn; 
LumbricatM. 
Flflxor biw v'ui and Opponvna miiiinii diititi 

(from inner siHo ol hamt). 
Dnrsiil tntenimri (Emm niidtlU* tine of 
middle finger). 



Tbumb Action. 



FlrrwH^ 

Upponens poltieis (carpomi^tBCArpnl). 

Flexor broviH poIUois. \ CarponmUicariiaJ 
Addu<^kr pAllieU. | uid tncMaciir- 
Abductor poUicia. ) popbatungetd. 
Flexor longiu poUicIa <aU Joints). 

AtlductioH: 
Adduclon of the thumb. 
MuKur brovis poliida. 
npiKiiiwiF' p«lliri«. 
IriUifiitwi (1 dorsal). 



Ext«UBor omaa mctariirpi paUieln («irpo> 

Extofiflor brevis paUitis (rntT>oincui4?nr|ial 
aikd niPtncArpophaJuneonl). 

Ext4>n.«>r lonxus polUeis (all injou). 

AbdueiioH' 
AIkIucIot polUcift. 
Esuwaoni of thumb. 



The Mmcles of the Trunk.— The erector muscle.'* of the spine are 
exuniiited liy causing the jmtient to He face dowinvjird am! asking him 
tr> raise the head and slnnilders withcjut a.ssistarce fnnn the hands. 
Unless paralyzed the erei-tors become eleiirly visible during the attempt. 
The abdominal museles are tested in a similar manner, except that the 
(wtient lies on the t>ack while making an effort to raise the head. 



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FlU. 3], — Jtad'cuhir tH) (li^ K-fi; ntnl /iri lAern! {P) (In riglil) iiirirr\iH jim 
muHclra of lh>* pitrriitil Mdu <>1 l.hn Uiwrr i<:iin?niily. Lctt^ra niii) ubltroviiitic 



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72 METHODS OF EXAMINATION OF THE NERVOUS SYSTEM 



M11BC1.E8 07 THK Thigh and Buttock and Spinal Stnapse Seombnts. 
Pectineus. 



Sartorius. 

Iliacus. 

Pnoaa. 

Quadriceps extensor. 

Vostua extemiia. 

Rectus femom. 

Cnireus. 

Vastus internus. 
Tensor fascis femoris. 
Gluteus minimus. 
Gluteus medius. 
Gluteus maximua. 
Biceps (s. h.). 
Pyrifonnifl. 
Adductor loagus. 
Gracilis. 

Adductor brevis. 
Obturator externus. 
Adductor maenus. 
Semimembranosus. 
Semite ndinoBus. 
Biceps (I. h.). 

Quadratus femoris. 

Gemellus inferior. 

Gemellus superior. 

Obturator internus. 



Sacral plexus. 



L2 3. 

L2 3. 

L2-4. 

Anterior crural, L2-4. 

L3-*. 



Superior luteal, L4-5 Si. 

Inferior gluteal, L5, Sl-2. 

Peroneal. L5, Sl-2. 

Sacral plexus, Sl-2. 
] L2 3. 

I Obturator, L2-4. 
[L3-4. 
J L3^. 

Obturator, L3-4. 
1 L4-5, SI. 
} Sciatic. lA-a. Si. 
J L5. Sl-2. 

L4 5,S1. 



Sl-3. 



Most of these muscles act upon the pelvis and on the hips and 

knee-joints. 

Hip-joint MovEifENTs. 



Flexion : 

Sartorius, 

Iliacus. 

Psoas. 

Rectus femoris. 

Pectineus. 

Adductor lonfius. 

Gracilis 

Obturator ex tern us. 
Afiduction: 

Pectineus 

Adductor longUR. 

Adductor brevi.s. 

Adductor magnus. 

firai'ilis. 

Qiiadrntu.'i femoris. 

Gluteus ni>'ixinii>^< (lower fil)ors). 



tnliTHid niltUiun: 

Tensor fiLrfcia; femoris. 
CJliiteiUi nu'ilius (anterior). 
( lliiiciH niJnimvM liuitorior). 



Extenewn: 

Gluteus maximus. 

Gluteus medius. 

Gluteus minimus. 

Biceps. 

Semite n dinosus . 

Semimem bra nosus. 

Adductor maxnus. 

Abduction: 

Tensor fascis femoris. 

Gluteus medius. 

Obturator extern us. 

Pyriformis. 

Obturator internus. 

Gemelti. 

Sartorius. 

Gluteus maxim us 
(upper fibers), 
ExUmai rotation: 

Obturator extern us. 

Gluteus maximus (tower). 

Quad rat us femoris. 

Gluteus medius. 

Gluteus minimus. 

Pyriformis. 

Obttirator internus. } During extension. 

Genielli. 

Siirtoriutt. 

Iliopsoas. 

Pcctiiioufl. 

Adductom. 

Biceps flexor cruris. 



During flexion. 



Posterior. 



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BiiHTiMi llvsur rrurui. 



TUB LOWER KXTRBMITIBS 

KKn-JDtKT MOVBUENTH. 

FUxion. EJtmxion. 

Sorlontw. Qundricepa cxlcnaor. 

BtDutndiiioaiu. 

Ciaatrocsieintuft. 

rUuUri*. 

pDfjIilmu. 

SsrtoriuK. 
Gradlb. 

HvTui loutliniHnu. 
Hfrniiiiiui i ImutuMui. 
l'opUt«Ufl. 

The Lower Extremities. — The tnvvrlcit of the hmrr f.rfnviifies art' for 
die must pjtrl iM-'st ifslt'tl with tlie jialieiit Iviiip down (see Figs. 27 
to 32): 

FlffjoM of the Thigh. — Tlie patient lying upiin his hack, nsk him 
to raise the lej; rrrmi the Wd, ajjuiiL^t rcslstantr, the kiitt" bfiiiji kept 
strai^it. Tliis determines the strengtli mainly of the ileopsoas, 
partly of the quathii.'ep.s. 

ExtnimrJi of Thigh. — Tlie ieg being kept straight and the patient 
lying U])on liis baek. raise the fout and a»k hlin ici hriiig it dunii 
upon the Ix'd against resistance. This determines the strength of 
the gluteus niaximiis and partly of the hani.string muscles. 

AiMiiictor.t of Thigh.— With the leg arros-s the middle line ask the 
patient to carr>- it toward the outer side against re^ir^tariee. thus testing 
mainly ttie gluteus medius. 

Inrotahrs vf Thigh. — \\ith the giatient on \m liaek, flex the knw to a 
right angle, grasp the foot, and oppose resistanee while he inrotates 
the thigh, tL'sting niatnly tlie gluteus nnnlmus. 

(}vtrot(itor.t nf (he Thigh.- Similarly test the i»ower of outrntation, 
thus determining the condition of the obturators, pipTiformis. gemelU, 
and quadratus fenioris. 

Flexors of the Knee. — The patient lying upon his baek. desire him 
to bend the knee while the examiner resists the movement hy grasping 
the ankle, thus aseertainlng the power of the bieeps, semimembranosus, 
and seniiteiidinosus. 

Ejthnmrs nf thr Ktiir. — With the patient on the back, flex the knee, 
and by pressure on the smjIc cif the f«Jot resist his endeavor to extend the 
knee. Tlie quadriceps foinnris is the principal muscle eoneenied. 

riuntfir Flf.ror.-i yl'.xinisoTs) of IIif Foul.—With the leg straight 
resist, hy pressure upon the st»le of the foot, the patient's endeavor 
to bring the tarsus in a line with the leg. thus testing the giLstroc- 
nemiuft, soleus, peroneus longus and brens. Have patient stand 
on toes. 

Dorjtijief-lors of the Foot. — With the leg straight, resist the |iatient's 
altcmpt uf dorsal flexion of the foot, thus testing the tibialis antieus 



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Mu*eU. 

Tfljialu aiitiruii. 
Rxl«iim>r iinipriiw polljrtit. 
ExWnoor logiifiLH diKitonuii. 
*L'ronwi« wrtiufl, 
PcTOiieuw lonicus, 
FonineUH lirevu. 
RKWtuutr hreviM (lit(iu»niiii. 
I'lantaria. 
PnpHious. 
CJaatiucaeniiUH. 

Fl(>xi>r loninis diccitoniin. 
TiliiiJit« 1Hl^Li^ll^. 

AlidiifiUrr liiiLlu'*iK. 

Flexor bwi-ia dieitonini. 

FIcKur brvvis hallucis. 

Finrt lunjbricaleft. 

Secnod, tliifJ, fourtb liuubricalM;. 

I'ifiitr HoiwtHoriiu. 

Adductors twlhids. 

Flt^xor brevia minimi diirli> 
Abdnclur imiiiiui dijpli. 



MovxuEfm or tbe ANKLx-joiirr. 



TibisUa Btitieuii. 
Eiunsnr ooTiiniunin dieilftnuii. 
KKtetwur pmprius pullicus. 
Ptrotimu tortiua. 



iBntinufl, 
Tibiaiu poflttciu. 



Bxlention: 
tiastrocncmiiis. 
PUntorU. 
Soleua. 

TlUttUa poHlJriui. 
l'cTon«iui louKua. 
Pcrttnoiin liiTvU. 
ni>x<>r lujiicua dwtomin. 
FlL'U>r luiigiiK hnlhiria. 

Evrrgion: 

PeroiteiL4 U'rtliin. 
P«rt>n«u« LoriKUa. 
Pvrjiiviia brem. 



MOVKMBKTW or THK TlWII AT TBH MltTATAHftUI-llALANCIBAi, JOIKTS. 



Fletor loncufl dJKiturum. 

AcomkHiu. 

Irftmbrioataa. 

Plnor Inngua halliirbt. 

Flu Mir lirevia hiiUurU. 

KU-sor lirevin di|[ib>mm. 

FlvKur lirevia tuiaimi diipli. 



liUtenaor lonjtus diKitarunu 
Exteiuor br«\'la diiiiuiniia. 
ExtMnwr i>n>priud ti&lluda. 



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REFLEXES OF UPPER EXTERmTTES 



n 



Mm'KMUTra or the TqBS at THK MBTATAinOF-BALANQBAL JoENTH (OMlf UIHMI) . 

Ahditrtion: A'^•i<iclu^n■ 
Atxluctur htUlucu. AfMui'tiircH Uollitcl*, 

T>tmH) intcrriMM. CLajilar int«TOn»ci. 

Alxluc'I'T puiiiiiii diititi. 

MoTKUKim or thk Toe* at tkh iNTKntKALANOicAi. Joint*. 



Flexion: 

Floxpr bn*vU dLidtnruii). 
Flcitnr Inneii.'* iliKitonim, 
Flexor lunKus liollufu. 



Exifntinn: 
KxU'iuHir Imitius <li|[iti<ni[ii. 
Kxhtiiiuir brevU iitKili>riiin. 
Inleroawi. 
Lumbri onion. 
Extensor propriiu hallu«if. 



Reflexes of Upper Extrendtles. — fiup'rjjchf atiri />r//.— Tlu-sf Hrt' ihvn 
takfii up. TIhis*' of the cnmial nerves have bffti t-imsicleri'il. Tlit' 
im|}<>rtiint reflexes of the ui)per extremities are: 

KlkiW itr Trireim ./rrt.— This is Ih".*-! testeil l>y siipiwrlinti tlit piitient's 
arm at the elbow by iillowin(f the fureanii to hjing Haceidly over the 
edge of a ehair. The stroke is mmle just ahovo the olerranon, and 
the re-uetinn coiisi-jts In an extension (»f the ffiR-arni ihie to eontriu-tion 
of the Irieeps muscle. 

liwHvs Perimtml licjlfj'. — The niilius ixTiosteal reflex eonsists in a 
slight flexion of the arm im the forearm when tlie radius is tappe<l just 
three or four inelies abme tlie external con^lyle. 

Supinator Jerk:— The supinator jerk is obtained by striking the 
muscle alMiut midway Ix'twuen the ellK)w and wrist, the ann bi-in^t 
supported at the wrist. It consists in a slight extension of the pendant 
wriat. 



iMki. 
Bleep*. 

SupliiHlor loaexu. 

WrUt. 
CarpomctacuuriMiL 



Melhiid •>! elicilinit. 
Tap Iticvpn UitLclou. 
Tap tric«ps tendon. 
Tap ndinl styloid. 

Tap (K>ior tondorw at wri*t. 
Tap bwk of wrisl. 



R«*poiuw. 
Bioepa coiilrart«. 
Trit-ope roiitrarts. 
r^ipiimtorIn'niiusiy>n- 

trncta. 
Finjijor!* are flexed. 
FinBon ari^QXteDcl^. 



SMtueot. 
C&iuidCS. 
Ca. « and 7. 
CS and CO. 

CfitoCft. 

r<v ui Di. 



JacDl»ohn's radius reflex consists in u shght flexion of the fingers, 
partirulariy of the terminal phalanges when the radius of the extended 
oiitst retched hand supported by the observer's hand is suddenly 
tap[)ed with a hammer. 

The suiR'rfieial n-fle\es of the trunk shnuUI next l>e tested. Both 
sides sliould always l»e tested and recorded O if alisent, + if present; 
n » L or R > Lj U > h, or U, o, L^, or ri're ('(*rvt«.asthe(«!*' may be. 



Epiiwtrir. 

Ablominal. 

CrrmanlOTic. 
Glul«ul. 

Bulbcnttvc-njoaufl. 

SiDwrliriul Uilal. 



Stroke down«'ard (roin 

nippltr. 
Stroke flowQ from co«1ji] 

inuriati. 
^^trr>k« inner oule nf thiidi- 
ii^lroke nkin i^vcr buttookui. 

Pinch doraum of kIuos ponis. 

Priok skin nf pM-in^iim. 



iLpijU^stHum dim pica. 

Abdouiinnl ntiutcleti 

fotitnirL. 
TiMticle Li piilliod up. 
GluUrnl tiiUM-W mo- 

iraet. 
Coiuprvsaor urathra 

I'^mtrai'L. 
KxU>mftl sphinotor 

nxiLraClH. 



V7 to OU. 

Dl 1 lo L2. 

LI to L2. 
U to LA. 

S3toS4. 

S5 And mnu*. 




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7ft MKTHODS OF EXAMrNATION OF THE ffBRVOUS SYSTE}f 

Reflexes o( the Lower Extremities.- The knee-jerk (ErlvWestplial's' 
si^) is one of the maniaiiiiltiir. The knee-jt'rk may bo tL^st«d in a 
variety of ways. One of the best is to have the patient sit upon a 
table, whiih |x'miit.s the limits to hang freely, then tell hini to look 
at the ceiling, or divert his attention, the tendon just Itelow the 
patellar is tappetl, or tlie ijulieni is dipceteil to eross one leg over the 
knee of the other leg und the tendon is struck in a similar manner 
Exiigperated, active, normal, slu^sli, or absent resjMjnscs should bt 
re<'ordcii. .Another method is to have the patient sitting, and the heel.' 
upon the floor, hut the legs comfortably extended. The tendon is ihei 
tapped. Mere a simnltanenus tapping of l»oth tendons may 1m* tried 

In certain patients the attention must be diverted, otherwise th 
leg is held rigidly which destroys the reflex. Tlie patient may h 
duveted to repeat the Lord's Piuyer, or compute small sums i 
nrithnK'tic. or (x>nvcr»e with an assistant, thus diverting the attentic 
Jroni tlie testing. Jendrassik thought of the ex[jedicut of tititixing 
forced muscular act in the upper extremity to leinforce the knee-jer 
This may be carried out by having the jjatient make Imni fists at 
given signal, wlicn the tendon is tapped, ur by having him grasp I 
hands and pull at the given signal. By reinforcement a very w*!! 
knee-jerk uiiiy Ix* made ver\' evident. ' 

Achillea Jerk.— Tin's is best tested by having the patient kneel up 
ft chair, the foot being just free of the edge. The Achilles tendon 
then tjLjuJfd, and there results pulling up of the heel. 

I'or [)«tients in bed, the leg should he everted, .slightly flex 
and the font extended to put the tenilon on slight tension. One pep 
in a Imiidn-d has lost the Acliilles or kiK-e-jerk. i 

.(riA/c-f/oHj/.f.— ^To elicit ankle-clonus requires some care. It is I 
obtained by supijorliiig the patient's leg along the under side, 
patient coojicrating by thorough rclaxatitjn. then the free hand gn 
the foot, and makes a sudden upwanl. dorsal Ucxion, holding 
f(K)t fairly firmly flexed at the end of the movement when a si 
of (Jonie extensions and flexions take plim*. The leg should be slig 
everteil, and thi- knee siimewhat flcxeil. A fal.s*' chmus c»)nsist8 in 
a dozen flexions und extensions; true clonus eontjniies for some t 

Plantar lir/lex.— Uy stroking the sole of the foot, either a 
external or intenml border, a quick plantjir flexion of all the 
including the great ttx* takes pliice. This is n<trmal plantar fle 
As many imlividuals are ticklish, there is frecptently a sudden je 
of the whole foot, or such a protective movement is manifested 
in the tendons of the great toe. 'Wh .should be distinguished 
true tlorsal extension or the Jiahin/tki rejler.^ This eon»ist.s i 
comparatively slow dorsd extension of the great toe when the p 
reflex is testi-d and at the same time tliere is a slight spreadiuji 
of the other toes. 

' Ry ilic tonii tivrsai eiUmtnan ui hem nMftnt riiiiiiK of Uw Iocs. \iy Balti' 
t«nt) ploHlar extention v%a uwd. W* M?» uijut ihe worda in ifa* ordin&iy M 
rviputliiiiif Miv fact thiit by mhuc i^lantnr rxtt'iinidii in tniulc- iiyiiouytuoiis wi| 
flexion, nnd plttntar flexion witli dor«al oxivniiiaii. 



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REFLRXES OF THE LOWER EXTREMITIES 



77 



If till- patient is in U'd— as Ik'sIiuuIiI Iw for testing- u fully tli-vduijed 
tuhiiinki sign foiisists in the slow dursal rai:$ing of the (ireat Xoq, the 

ircaiJing of the other toes, a slight rotation of the thiph on the hip, 
kiitl li eontractiim of the fasjiii lata of the thifih- 1ti order to develop 

le whole test the fiTt >liniiid he warm, tin- ihi^li sliichtiy rotuteil 



Pn. 33. — KxUuuiuii nf IIh- k-n-.t 



,k.) 



ii.il'iiuiki iiliuitu 



jitemnlly. the knee ^Hghtly U-iit. mid tlie >troke made either oii the 
-jHlrr nr iiim-r iMtnler of tlw «.ile by either a fairly sharp iii?strumetit, 
the Gnger-iiaii, or a blunt-pointed instrument. As there is great varia- 
tion in the thiekness of the skin of the soles of the feet, the various ways 
of bringiiif! out a liahinski pheimnietion should Ik- trieil tti eaeh ease. 



, M.-^TW t'tuij't'-'i, iii""iiii'Tiri.iry .ij liii- I.t.-iiiiii9ki, rniiKUii; nrwti Uh.' PXtriuiun OH 
•Unkitm iMiuwih ih<> pxioniiit mnllmliui. ((.*ha(l(l(i''k ) 

rartiruUr attention Khouh] be dintiMl to the dangent of confasinR 
ie pnifivtivr. puIlinE^lw«y motion on ticklinj^. whirh aiuses a umrkeil, 
[uirk ditrsal nai-iin^ nf tlu- Kreat Uk', with a tnie Habiii^ki phenomenon. 
CaFrfuI n-ennl should be made «>f the irrrgularitie.'* in pliintar 
In wmc f*atieni^ there will he plantar Hexiun of the small 



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78 MKTnons oy Kx^^tl^ATn^s of tiih skrvous system 



toes hilt 11(1 rpftctiiin iif iUv big tm'. At times this may Ijc as sidnlficant 
Hs a tnie (lunuil exttMislon. It h to Ih- Ixjrne in iiiin*! tliat dorsiil raising 
of tlie great tw is iiomial in infants and children up to the age of 
sueeessful walking. A rnimlter vf elosely related reflexes have been 
(li'seribed, having much the siinie signifieaiioe as the Uabinski sign, but , 
iK-iiig lessi-onstaiit, and at times eiiiitradietor\'. These are: 

Strihrifjet! fiejft'x. — TIlis follows forceful jjressure over the anterior 
tibial region with a resultant dorsal extension of the great toe. It is 
found in u number of conditions otiier than those of fmietional di*- 
turlMMce of the pynmiidal tnirts. 

Ojiprnhrim Hefiry.- Here the inner surfart* of the leg is sharjjly 
and deeply stroked by the thumb from tlie middle to the ankle behind 
the nmlle<ilns. It brings out a great toe dorsid extension. 

Thr Pnrtuloxiail Hi-jlt'ir. -Called by a variety of itaiues, as tleseribec' 
by (Gordon, it consists in a dorsid extension of the great toe followin] 
the grasping of the deep nnis<-les of ihe calf and making a forecfu 
indention along their external border. 

Meixdel- Ha'ktrreir. — This reflex consists of the dorsal extension c 
the toes, esiM-eially the second jiiid fifth, when ihc dorsum of flie for 
is tJLj>|«'d alxiut at the base of the middle toc.s. In reflex irritabilit 
this rt^Hcx is augiuented. If plantar llexion takes place the autho' 
regard it as a sign <)f organic affection.' 

Chathhirk.—'Xhvs produces a toe extension by stroking the side of tl 
ankle (l-'ig. :J4). 



Rrflei 

Kn*e 

Ank]<r-fli>iiua. 

Planlar. 
UnliiiiRki. 

Oppvuhcini. 



Mclbiuitl '^'F <ililuiiii7iK. 
Th|) patellar lotidon. 
Tap ivnilii .\(;hilli», 
Siiihlcn <l(jnafl'L'siuii fool. 

Stroke Mvles <A f«>t. 
t<lri>k<> iKilra u( fpct. 

i^tmkp inner side uf calf. 

Uee|> prvwurv ill I'ulf. 



ll«<>lt. 
L«R cxt«aii»d. 
Pliiittnr Clpxiiin fiMil. 
Qiii<*k up-andihiwii 

inuvviiioulA, 
PlanUr lt«non nil toM. 
I^tirenl esLciuiiiiii itr«it> 

lie, 
Donwl extciiHiuii erval 

Uoraal exten-niuQ (cnist 



I,oc«tum. i 
L3 sDd U. i 
^. M. \ 

Pyramidttl trf 

(I^. 32). 
L3. S2. 
PyruiiidtU In 

(I<3, S2). 
]'>TunLdjd tn 

I^-nuuidal U 
(W. S2).» 




Tremors. — The trt'mi>rs of tlie upper extremitie.s alone r-laim atJ 
tioii. Those of the head may be fine and oscillatory, nodfling, rh; 
niical, or jerky. The rapidity of the tremors should be noted. 

TrcuKirs of the hand ami wrist shouM first Ik' tested with the peiu 
hand supported at the wrist. Then with hands extended and tin 
wide apart gMir tremors come out. Or with the hands in me 
UivuviijioT tremors lieeiime evident. 

Stiitietremorsareeither fine and rapid (eight to twelve ]>erseeonf: 
eoarsi' and slow ffourtosix persemnd). They nmy be irregular. V 
mvolvingthe wiiole arm one .-^jjcaksof movements nit licr than trei 



' Kriui: Lcipxig Dismrtiitioo. tOl I. 

* For ft ramplde dlBousAlnn of reflex nrtion mm* ShprrinRtfuit .Joiir. Ph>-*i(>I., 101 
iv. I1ie complicated problem of niedullaiy retlexra in amplified iu a thmis of A. 
PoriA, 1913. 



4 

101 
CA. 

J 



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'ATfOl 



TSORY .Vfiffi 



I^)cniiHitor tri'iiHirs an- in n'iilit\ ataxias. TIu-m* utHxIiis are hrouj^ht 
(mt Itest tiy Imvin^' the patient bring liis index fiiigt'rs fmm any [Kisition 
slowly to till' vnd uf the nosf. first, witli i-yos niieii, tlu'u w-jth eyes 
closcil. test IxitJi sides (KriKer-iiose test — V. N. Tj.or the imlex fingers 
shoiilc! be brought to touch eaeh other ( finger-tiiigcr test — (*'. F. T.). 
Here «>arse irrpKular movements (ataxins) may be hnnifiht out. Tlie 
patient's fin>i^r may overshoot the nose (d^-smetria). The patient's 
ataxia inrrenses mftrkerlly as the niise Is i-eaehed (intention tremor), 
or inereases only just as the objeet sinight is nrrived ut. 

Ataxia in the loiver extremities is testeil by the km^e-lu'el t«st 
(K. H. T.), the patient, on his buck, is direcletl to touch tlie left knee 
with the right hee!. and net' eer»a. 

Athetoid movements an- coarse, shiw, sinuous, progressive, rhyth- 
mit:al movements in tiie fingers, ann, or trunk. 

Choreie movements are irregular, coarse, or fine movements, Eon- 
rhjlliinieal and non-coordinated — tliey are jerkj- movements. 

Assoeiated movements are involuntary movements of the opposite 
side, iiidiiei'd by a voluntary act, Not infrequently they an- ipiitr 
non-homologous movements (abduction of left leg when making effort 
with right arm). 

Localizeti convulsive movements and Jacksonian epileptic move- 
ments consist of sudden convulsive involuntarj* extensions and flexions 
without loss of con.seiousness. 

rtV*.— These are invohuitarj-, coordinated movements of psychic 
origin. 

VitufokoHjiein'a. — Tliis signifies the ability to perform alternate 
rapid coordinnted movements, of antagnjiistie musi'les. Certain 
patients show a loss of this ability (adiadokokinesis). Tlie tests 
most frequently applied are quick pronation and supination (tf the 
semiflexed hand; [jiano-phiyiiig movements or qui<-k flexion and 
extension of the forearm on the arm. 'Hie term is applicable only 
in tlic absence of motor paresis or gross anesthesia.' 

Apriijrin. — This, stx'aking generally, consists in the lowi of ability 
to perform purposeful movernentB. The tests are to have the [Milient 
throw a kiss, make a salute, a U'ckoning gestun-, a tlm-atening 
gesture, or to gci tlmnigh an irnagiujiry act, such as taking a match 
nut t)f a Uix and lighting it or l)iow.ing it out- It is also elicited by 
testing the uewssary movements in using objects coiTectly. 

EXAMINATION OF SENSORY NEKTOUS STSTEM. 

Tlic most important of the tests of the sensory nervous system are 
for: (1) light touch, (2) pain. C-i) thennal wn-sations, and (i) deep 
sensibility. Head has suggi-stcd ihc tenns epicritic, pn)topathic, and 
deep sensibility for the three t,\i)es of sensibility which he maintains 
exist. 

' Plnitlk! Uhiub and praprwoi^plJve rvllrz, Shrrnustou : Quart. Jour. Pliyaiul.. 19UU. ii. 



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rXPLAKATION OP PLATE T. 

Tlu' IVrBmidiil Tnu-t iu its Cortit-tispimil hihI ( 'nrtiw>- 
nu<'leaT I*ortions. 

Tho portiroiiiwiiiHtiry (nortipospinivl) CoM. la ocilarod light red; the cortieoaudmu' 
purttoii. Co.\, clarkiT ri-'l. I'be retiiiiliir vulwUtote (S.R.} ot Ht» taguiwituiii In yellow 
luid ibc tnotui' iiiiHr: of ihr i-mniikl nt'r%-i,M iiruriitK. TEu> rortlmpnntine portions and 
the ccrobcUjkr pulba of tbc t^tnueutiuu arv uiuitU'd- 

Abl'rfriai wnt: Aq. aqueduct of Sylvius; Cia, aaWior WKRicnt: Ci'dr). knoo; Cip, 
pOfiterior seiiineDl: CirP, rvtrolc'ntipuliu- Henmcot of ttxc interniil capeulo: CoM, oortico- 
apjnol »j-stPiu (ptiik); C'OA', oortioonuolMr ayitlrni {red» ot the pyranddal tract, VP; 
Flp, tHwtrrior loriKitiidiriid (iUMTi«*iiLii» ; FFim. PPiip, luitvniir niiil prwuriiw ix>iiliiiu 
Glieri); FPtlC rrowieil i)jriiimd«J Kntct; PPf/d, ilired |iyranit<l»l trufl ; fPnk, liAmoUtoml 
Ijyrtunidot libi-n: fal', nicdullRO' aberrant fil>(.'r»; f»p. putkliiio nl^prrant fib«)n: fabp. 
miydtilUry. pontine alierruiit litwra: fw-ih, siihihalftuiii- or luperior twnlin« ftbemni 
(ibon: fcne. fe/ut. nvMM^d and dirwL rprviiMl ^'oriiiormfloar fibere; Ln, loriis meer: 
SC, caudate nucliMia; A'C, Liil of ciiudatv MU(.'lt.'u.-< ; .V('r>, nuclei ot posteriur c<olumiu 
(Goll and Rtirrlit<'!i); A'/.i, AVyi, .V/i^, the iJimn .-wKmiTitA nt thr Uwtinibir nuMotui; ffp. 
pontiii« Du^lvk^ Pi/p, deep poe lnmnis<nii> ; PLt. suportiml pea Icmuucua or abcmnt 
ponLiiiL' fibers; a. b. c. the three tnodmt by whirh ihe pontine Aberrant fiber* ent«r the 
third iierve uudei; Pul, itulvLnar; Qa. Qp, untorior and poaterior oorpura guadriiniiiuaB : 
RgRni, n<icirin of rhe mtditti) lemniscus: H^. the rrujdiftn lemniscua ; Sgr. <)vd>epeadymal 
Oray euhnUinct-; SK. ivtirulur fnrmntion, Rttlnrod yoUtiw: T!t. tluiliintiLK: V4. fourth 
VMitrirJff; VP, [lymniidiU tract; lit, IV, nurl^ii luirl root fitn'M of the oriilomotAriu* 
&IkI Inji'liWri'i mT\-e»; V'm. nuHaus nnd runt Rbpn uf lh<^ Iriai'DiiiiUA ( ma^t inn tors) ; 
Vll. IX, Xt. XII. iiuvlei and rwol filxn o( ihv fitoial (!'//), nIoMopharynKeai (IXi, 
njdiiid wrwatury <.Xf), iumI by|K>KlnN.4u] (A'/f). nervos; Xa, Anterior root of Uie apinml 
vajTia; X-XI. ruiil ii^tcr* of the >piiiiU vuKiut. 

The cnraphnlir trunk and ibt (hrr^ (cmil diviHiaiiA, ORTchnd {wvhinrlivi t,P), thr ponit 
IPO), itie nii^hilLn {B), ia ahuwn in t««iltnl ft'cticii with iU> connertioiu with the intomal 
cu|Niiili> [Cia, ('iff, Cip. Cirf} and tho (hnliuiiUM iTht ii\ po.rt, nnd ft-ith the •piiial «jrJ 
(A/) f'tr the other part. The unIitw »effmcnt L-crntuinM the pyramidal tiofl < T.P) (and 
U iiiailc up frum uliovt t^k>w) i>f the foot composed of the fiheni pftminn ihrounh tho 
kucv iCtv) and tlif pi)flt4-ni>r ■^■Kinenl (Ci'tO 'd the iiitvrnnl mpHute, the aiilerior N^iniicnt 
nf the pon,* »Tth the poutiue tiuclei (A'p) and the .intffrior {FP^m) and posterior {FPvpi 
pontine Glicn and the anterior pyramid of tlie raedutla iPy I : Mid the poMrrior nt^mrnl 
or trgjnmtutn, ia aeptiraCed above by the luniH iiixer {LS), below it ahuta the posleriur 
ixinline fillers {FPop.), and the pyramid of tlie ineduUit {Pu). 

T)m ttgmtmiuvi ia made up oi (1> ■ K"y>' vulMtoucu the rvTtcuIur funiMlvvn (S.R) — 
ralond yellow — which extends from tlie nuhthnlnmif region {R*Th) to ihe lateral columns 
of (he oonl and eonlsiiiH the motor uueLoi of the crunioi nvrvos — colored oranite^Hiia]>oacd 
In two loniptitdtiial roliunos: the anterior rolumn tndiidcii ihc moU^r nuclei of tho trixeni- 
inuji (I'm), the fm-inl (Vll), ihn nucleua amliiguua of tho anterior BpimU vagiia mioletu. 
(.Vu); the [fonterior ivlumn iiirludev tliu iiuvlei of the illh mid (f 10 pair, the niielvi 
of ihe (('/), tht! liKiK niiHeUN of tlio iij'jxiKliiHHid (\II) luid t\\v l^'UK iuferior iiuriri or 
•plnil wwMWofy {XI): \^1) of the lonicitudiiial bbera of wliith a pnrt kt'JUp thvm»i>lvnt in 
fMeUm more or lew rotnpa)-;t Vt form the potttrior langiludinnt fnarirulim tFlpf nod the 
mcdtoN JnniuaiMM (ffm), The malifin lemnueiu, rcproaetita an imporlanl seosury path- 
way whirh terminstM in the thalamus (Tit) and tnkM part of Iia orijpn from the posterior 
rulunin nurlvi (Ooll niid burdiirh}. The itonterior lunifU'idin'tl /•isciculut conuHta of 
Vi jiii|Mrrtaiil nMfoeialion fi>ier »yuurxn t^twceti ttie nii^'leE of thc'iK^ulomotoriuii, thu niiinal 



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82 METHODS OF EXAMINATION OF THE NERVOUS 

1. Epicritic sensibility is that which recognizes light 
tinguishes small differences between the points of a co 
recognizes small variations in the temperature of objects. 




Fiu. 35. — IlIuBtrating the sesmeDtal spinal aensoiy areaa. FroDt 

2. Protopathic sensibility recognizes pain and extreoc 
and cold. 

3. Deep sensibility recognizes deep pain and muscle 
sense. Bony sensibility is included here. 



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84 METlWDJi OF BXAAtt.\ATIO.\ OF TUB NBBVOUS SYSTEM 

ometers are indispensable. Those mostly in uw arc >'an Firy's liairs 
or Franz's simple psthesiomctpr. 

'i'lie (MitientV ImmIv slimild W explurftl sysU-niatifHlly. He is askt«l lo 
say "Yes" every lime he is tiiuclicil. aiti] then asked to loc-aliz*' tlie 
»pot toudicd. Tlio tvstinfj: should bo made with the |»ationt first l.NinR 
down, and ibie attention shoiiKi Ik.* Ki^'cn to the chanw-ter {ihiekness. 
etc.) (if the iiiciividual patirnt'.s skin in drawing iiuu-lusiuns from the 
tests.. In pninti over the extremitit^s care should be taken to eircle 
the limb with the tout-hrs as well as jctmur up and ilirwni- it is speeially 
desirable to avoid suggestive (]ue>-tiuns, such as, Do you feci this? 
What do you feel? etc. In certain cases, usually hysterical, one will 
get the steady res|Mitisc "Xn" to i-iifh tourli over the stwalled anes- 
tlietie area. This is a highly- suppcstive reaction. Modifications of 
light tiaieh should l»c charted and marke<i on the skin with an anilin 
pencil. Such imlicatiotis are vcrj* useful as landmarks furlwalization. 
There may Ix* anesthesia to light touch or hyix-resthcsia. the iratient 




Kici. 97. — Holoim'i eotnpuaa for tenting Inueh dlaeriniinfttJoH, 

feeling very acutely. In id] hairy parts the skin should he shaved for 
Accurate testing, (ttlierwise euttiai-wuol drawn across the skin hy 
iMMidiiig the hairs will defonn the surface and si> give a deep sensibility 
rcHpnnac to test for light touch. (So; Flutes IX and X for the path- 
ways invnlvwl.) 

A WelN'r <'ntnpass is iisefid for testing the individual eaiwcity for 
ni'ogni/,ing mic or (wn points. That dcviwd by (lordoii Holmes is 
the most pructind. There is u great variability in individuals and 
in dilTereiit regiuuH. Some of the availnble figures for the niinimum 
si']Niratirui distance rewignized as tvvn point^ are as follows: 



TouKuo . 
t^itmim d( Biicrrn 

KomuTD 

l-'iirwhfuitl 

livg: hii<>k of foot 
llM-k . . . 
Arui* nnd (hicli 



IJ> mm. 

3 3 mm, 

3.4 aim. 

S.A mm. 

U.l aim. 
10 to IS mm. 
2:i to SO mm. 
.K) la 40 mm. 
SO tu 80 mm, 
7(1 to SO mm. 



Furtlu-r ti-sts may In* made of epteritic light tou«'li by placing 
variously shajK'd objecl> on the skin. Such tests are very \Hliiable 
ill sjKHrial com'S. 



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EXAMISATIOS Of .-^ffjV.WRK ^jSRVnUS SYSTEM 



85 



\)^i 



Kpk'ritif thermal sensihility. This is most msUy testeiJ hy use of 
the hack of the finf;or for wiirm, uml the im*tiLl liwui of a ptTfUSsiuii 
hiiiTiiricr for cool. Kpicritic tiifimal sensibiHiy recognizes differences 
ns small as tvvu to five (lejriTes of teinptTuture, 
while protopathic sensibility is unable to 
rcw)K"'5^P (lilTcrcTH'es iMrtweeii 41^ and 2tf ('. 
Loss of epicritic .sensibility for heat, uith 
presen'ation rf protopathio thermal sensi- 
bility, is nnt uiittiinmriii. The reverse, while 
rare, is ofcasiinmlly fuiirid, 

In making ntreful thermal tests an elee- 
ini-jil tlierninnietcr. as contrived by Mills, is 



pi 



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i.s; 



llfTS 



LSI 



Li g 



8S 



r-i-/ 



\33 



iS3 



V 



,t-- 



i.51 



it 



Flo. 38.— IllustrnlitiK thp ym. 39.— lUualTHtinit rh« M>xni«nt«l iplttal sotuwry 
M«mentat HpiniJ seiutorj' nrcju of llir lower cxtTmiitias. 

MVfui. Side view. 

useful. In ordinary routine work test-tubes with ice-water and hot 
ftTiter may be used, or metal tubes whifli have been pluuged in cold 
or hot water. It Is not sufiknent to test [xitients for extremes of heat 
ami cold alone; minute ililferenft-'s should be tested for as well. 




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86 METHODS OF EXAMINATION OF THE NERVOUS SYSTEM 



§//}. 



J} 



m 



l~os 



V 



^, 



^ 



\ 



-Du 



ir^ini 



l-DU 



-— S4 



1.1- 



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SI*--, 



-LS 



Frotopathic Sensibility.— Pain. — This 
is quickest tested by pinching the skin 
between the nail and the finger. A 
sharp-pointed pin with a round glass 
head is also useful. The patient is 
asked to distinguish between head and 
point. Absence of pain (analgesia) 
should be carefully charted as well as 
increased pain sensibility (hyperalgesia). 
The limbs should always be tested in 
their circumference as well as in their 
length, care being taken not to overlook 
thin strips of analgesia from root lesions. 
Hair sensibility should also be tested by 
pulling the hair. Painful faradic stim- 
ulation is at times of value in deter- 
mining the value of an existing analgesia. 

Deep Sensibility. — Here deep pressure 
pain, muscle and joint sense and bonj 
sensibility are to be tested. Deep press 
ure with the thumb and fingers, or ; 
special instrument (baresthesiometer) 
is used. The pressure should be su 
ficient to cause pain. 

Muscle and joint aenae are tested 1 
first showing the patient that one mov 
the thumb and big toe up or down 
and then repeating movements up 
down while the eyes of the patient i 
closed. Further, weights may be ui 
on the supported and unsupported ha 
and the ability to estimate differen 
observed; or the patient is requestef 
imitate with one hand a definite p 
tion of the other hand. 

Bcmy sensibility is tested by a tun 
fork of low vibrating capacity. Th 
placed still vibrating, upon bony surfi 
and sensation is intact when ^e pa' 
feels the thrill. It is a highly impo] 
test, particularly in lesions of the pe 
eral nerves, spinal cord, and thalam 

Sensibility of the nerve trunks to ( 
pressure should then be tested. I 



Fiu. 40. — Cutaneous reflex sonee of hyperalgesia, showing their relations w 
spinal root segments and their vegetative nervoua-eyatem connections. The 
areas are to be referred to the internal surfaces. (After Dejerine.) 



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EXAMINATION OF SENSORY NERVOUS SYSTEM 



87 



upixT arm the brafliiiil plexus l)ram-lu's Jii tlie ne<'k and under tlic ana 
are palpable and along the iniifr ami nnd eI(x)W-joint one may reach the 
median, radial, and ulnar. Anesthesia of the ulnar (Bienmcki) is 
frequently a talielir symptom. 

The radicular and jieriplieral seniuiry distributions are shown in 
Figs. 27, 28, 29, 3(J. M and 32. 

In the lower limb the striatic, anterior crural, eutaueous femoris, 
tibialis, and suporfieial peroncus are palpable. 



TVjMporaJ (i>r> 



r«rt(Mii UM> 



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SrAuSrfat (£»} 



Ttrnportf/roittnt WiA- 



eipUnH.t>l'>) 



'~iliiUiiJitiiiir 



iVolit 



tttferior larYiitaat' 



6 



L,-<a 



d) 



Pia. 41. — CuumcouH nflex lonoa of liyp«ralE(.>«iu uf lb« bend. neck, and shouldon in 
ilkeir reUliniia to vt>Kt>taUvK nerve (samaUt^J duilurbanoea. (Afl^r Uejerino.) 

Ijusegxie's 7Vjrf.— This c-onsists in flexing the extcndeil leg, keeping 
it extended by pres.sure on the knee, on the abdomen, when in iieuritic 
pro(?esses a sharp pain (i>opliteai space) is brought out. It is an 
intlispeiisablc* test in the presence of suspeclcd ulcoholisni. 

The distribution of pain in neiural^c or ncuritic atTectioits sboulil 
\yc carefully charted. With the sensory examination, gnostic and 
praxic tests should Ik- L-arricd out. 

Stcreognosis signifies the ability to recogniKe objects by touch. 
Astereognosts, first described by l'ucl»ck in 1S44, is its alwence. In a 



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8S METHODS OF EXAMINATION OF THE NERVOUS SYSTEM 

wider sense the tests indicate the perception of spatial and quality 
relations through the sense of touch. Objects should not only be 
named but their qualities described — shape, margins, density, etc. 
A lump of sugar, thimble, match box, marble, knife, pencil, scissors, 
etc., are useful test objects. 

Apraxia consists in^ the loss of ability to carry out a purposeful 
movement, not dependent on a palsy. The most useful tests have 
been referred to. The student is specially referred to Plates IX and X 
for ttie interpretation of his finding and their anatomical foundations. 

Vasomotor and Trophic DutnrbanceB. — The presence of dermographia, 
of blushing, of redness, or blanching of the skin should be looked 
for. ricers, thickness of skin, drj-ness, or other trophic disorders 
should be charted. Reflex hj-peralgesias (referred pains) should always 
\ye inquired for. Patients refer to them chiefly as "sore spots." 
(See Figs. 40 and 41.) 

Scheme for Teattng SenslbUltjr. — ^The following sdieme for testing 
sensibility is advised: 

A. Spontaneous Sematiom: Pain, numbness, tingling, position of 
the limb, idea of the limb, hallucinations or illusions. 

It. Loss of Senmtion: 

1. Touch. 

(a) Light touch, cotton-wool on hairless and shaved 

hair-clad parts; threshold with von Frey's hairs. 

(6) I*ressure touch, threshold with pressure esthesiometer. 

2. Localization: Naming the part touched. Henri's, oi 

Head's method, target, etc. 

3. Roughness: Threshold with Graham-Brown's esthesi 

ometer. Sand-paper tests, discrimination of relativt 
roughness. 

4. Tickling and scraping: Tickling on soles and palmt 

Cotton-wool rubbed over hair-clad parts. Light scrap 
ing with finger-nails. 

5. Vibration, tuning-fork : Loss or diminution of sensibilit; 

Alteration in the character of the sensation evoked. 
0. Compass points; Points simultaneously applied. Poin 
successively applied. 

7. Pain: 

(a) Superficial pain: pinprick; threshold with algesii 
eter; reaction to measured painful stimuli. 

(6) Pressure i>ain: threshold with the algometer; reacti 
to painful pressure. 

8. Temperature: Thresholds for heat and cold. Effect 

adaptation on threshold. Discrimination of diffen 
degrees of heat and cold. Affective reactions: (a) 
extreme degrees, (b) to warmth. 

' Cans: Zeit. f. d. g. N. u. P., 1910. xxxi. 



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MESTAL EXAMISATIOX METHODS 



89 



9, Positinn: By iniitating with x\\v scuinil linih tlie jKisIlicin 
of tin* atri'dcd lifiili; l»y |iniiitLng with tht* siiuiul limb; 
measurement <if (Iffct-l hy Ilurslt-y's im-lhtjtl. 

10. Passive nioveiiK'nt; Appreciation nf tnoveiiient. Reeog- 
iiitiim of the diredions of movement. Measurement of 
the angle of the smallest movement whieh nui Im* 
apprt'eiated; falling ai^*ay of the unsupported Unib when 
the eyes are closed, 

11. Adive movement: Imitation of movement by th^ .soimd 
limb; ability ttt toueli a known spii.t; rnejisiu-emenl of 
the defect by Ilnntley's method. 

12. Weight: 
(a) With hantl siipiM>rted: Uecogiiition of ditTeir'nees in 

wvijrhts ai)plie<i ?ucit'ssively to one hand. Apprc- 
<'iation of increase or decrease of weiKht. .(.'om- 
ixirison of two weights placed one in each hiind. 
(fc) With hand uiisup]M>rte(l: ('umiMiriamof two weights 
placed one iii each hanil. Itecofcnitinn of differ- 
ences in weights applied successively to one hand. 

13. Sis!c: F^ifferenec; tbresliuld. Distinction of the head from 
the point of a pin, 

14. Shape (two diuiensioual). 

15. Form (three dimensional): Kccogmtion of commoTi objects 
by their form. 

16. Textures. 

17. Dominoes: Ability to count points by touch. 
IS. Consistence. 

19. Testicidar sensibility: 
(a) I^iglit pressure. 
(t) Painful prcssun.'. 

20. Sensibility of gluns jx-nis to measured prick. 

Status Corporta.— A s\*stcmatic physical examination is a .tinr f/wci 
jum. The main facts to be noted in the (luestioTmairc arcthe«)n<liti»n 
of the heart, the presence of murmurs, the character of the arteries 
(hard, tortuous), blood-pressure, the haigs, presence of tumor in 
abdomen, enlargement of liver, and the condition of ihe mine, the 
blood witli s[>ecial reference to lenkiM-v-tnsis as an index fur liiiiden 
•soun-es of infection, and tlu- ciTcbrospiual (liiiil. 



MENTAL EXAMINATION METHODS. 

In no cle[>artment nf medicine is a complete examination i>f the 
patient more intportant than in that of psychiatry. Tins examina- 
tion must not only include the symptoms that the i»atieiit may present 
when seen, but miL-^t als*) include the most detailed obtainable aiiani- 
nesls. It must Ik- l>ome in mind that ii psyclmsis is a new ciMiditinn in 



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90 METHODS OF EXAMINATION OF THE NERVOUS SYSTEM 

an individual who was previously well. Above all it is not a something 
that comes from without, which attacks and seizes on the patient like, 
for example, a pathogenic microorganism, but is rather to be considered 
as a type of reaction of the individual to certain inimical conditions. 
In order, therefore, to understand a particular case it is of the highest 
importance to ha^'e, as fully as possible, a conception of the individual 
before he became afflicted, so that the symptoms which are the expres- 
sions of this reaction may be understood. 

The scheme of examination which follows is directed primarily to 
elucidating the mental state. It is taken for granted that the student 
is familiar with the various methods of physical examination. The 
omission of specific directions as to the physical examination is not, 
however, to be taken as an indication that it is considered unimportant. 
On the contrarj', a physical examination in minute detail is of the utmost 
importance and unless it is made the risk is bound to be run that the 
key to the whole situation will be overlooked. 

The principal value that a scheme of examination may have, how- 
ever, is in formulating tests that call for an actual record of the patient's 
reaction and not the conclusions of the examiner. Hospital records 
are filled with such remarks as "the patient shows lack of judgment" 
or is "disoriented" or has "failure of memory." All of these are 
conclusions and are not — records of facts. Such histories are useless 
to anyone except perhaps the persons who wrote them. The reader 
of a history is entitled to a statement of the facts on which the con- 
clusions are based and then he is at liberty to form his own conclusior 
from the identical premises. How much better and more accuratf 
than the statement " defective memory" would be this test: The patien 
in the course of the examination is given the address 375 Oxford Hi 
After five minutes he is asked to recall it. He gives the numbe 
170, but cannot give the name of the street. Here is a definite fac 
A multiplicity of such facts gives one a basis for conclusions about tV 
patient. Of such statements should the record of an examination \ 
composed. 

Mental Examination. — Orientation: time; place; persons. 

General memory; family; school; occupation; marriage; childre 
diseases. 

Emotional statvs: insight; sleep; dreams. 

Ilallvdnatums: auditor^'; visual; other senses. 

Speech: voluntary'; writing (name, date, the United States of Amen 
the Commonwealth of Massachusetts); auditory; visual; test-phraf 
(Statistical, j)erturbation, Third Riding Artillery Brigade.) 

Stories ("Cowbov," "Gilded Boy," "Polar Bear," "Shark," "G. 
Girl"). 

Special memory: Civil War; names of two generals; three Europ 
countries; capital of native State; President; 45319628; 359841 
487631; 955217; 7368; 487; 352; 375 Oxford Street (after 3 t 
minutes). 



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MESTAL SXAMiSATJOy METHODS 



91 



.\fa.tsfhn {hunter, do^. gun. forest, rabbit; man, wood, coal, stove, 
(limicr; nwtlle. thread, button, vest; pifx'. match, sinoke; pen, iuk, 
letter). 

Ziehm (horse and ox; dwarf and ohilH; lie and mistake; water ami 
iee). 7 X tj; o(i- IS; 23-11; SI-»; x-o=17; x-S=l;i; have 5()c: 
buy eherries 12e, butter 7e, bread Hte; how murh change? 

Fonrnrif (ittil hirkwonl asaoduHmm (inoiith;- davs of week; "021^(1, 
25729. t)4l,S.2(>o, 497). 

(ietieral utfonnafiojt : cost of pustage; color of stamps; holtflay^ and 
meaning (Christmas. Kaster, Fimrth of July). 

Fimhh cnie early bird catches the worm;" '" Lies have short legs;" 
".Set a thief tn catch a thief;" " Hurn a candle at both ends"). 

Ktbicai quejuliimJi: 

Drawing diagram (after five fwconds' exposure). 

XiVTK. — Here esjM'cia] cniition is iieede<i to avoid R'tiinliiiR conchi- 
sions. For exiunjile; I'nih'r orientation the patient's actual answer.** 
to .such questions as, Wien were you lx»ni? How oM are you? What 
tlay is this? etc.. should be put down. 

The stories which are named arc as follows: 

"f'owboy Ston*."— A cowboy from Arizona went to San Francisco 
with his dog, which he left at a dealer's while he purchased a new 
suit of clothes. Dressed finely, lie went to the dog, whistled to liim, 
called him by name and pattetl him. But the dog would have nothiuff 
to do with him iti his new hat anil coat but {jave a mournful howl. 
( 'oiixinR was of tio effect, so the cowboy went away ami donued his old 
>pinnerits, whereujion the dn^ immediately showed his wiUI joy on 
Seeing bis master as he thought he ought to be. 

"Gilded Boy Storj." — It is related that at the coronation of one 
of the popes, alwrnt three hundred years agt), a little l»oy was chosen to 
art the part of au angel; and in tirder that his appearance might Ix' 
as gorgeous as possible he was covere<l from head to foot with a coating 
of gold foil. He was soon taken sink, and although every known 
means was employe<l for his recovery, except the removal of his fatal 
golden covering, be died within a few luturs. 

"Polar Hear Story." — A fcitiale polurlM-ar with two cubs whs pursued 
by sailors over an ice field. .She urged her cubs forward by ruiniing 
before them, and, as it were, begging them to come on. At last in 
dread of their capture she pushed, then carried aud pitched each 
Ix'fore ber, until tliey actually escaped. The polar bear is a witnderful 
swiouuer antl diver. In the <-apture of seals lying on the itv. it <lives 
some distance off and swimming undenteath the water, suddenly 
comes up cU)sr t() the .seals, shutting off their retreat to the sea. 

"Shark Stun,-." — The son of a governor of Indiana was first officer 
on an Oriental steamer. When in the Indian Ocean the ixKit was 
overtaken by a typlnHin iimi was violently tosseil almut. The iffltcer 
was sutldenly thromi overboard. A life-preserver was thrown to 
him, hut, on account of the heavy sea, difficulty was* encountered in 
Uuuehing the b*)at. The crew, however, rushed to the side of tlw 



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92 METHODS OF SXAhtlSATWN OF THE NEHYOVS SYSTSU 




\-es3el to keep him in sifrht. but before their shudderinfr eyes the unlucky 
yninijc man wiis jirasjx'tl hy om* of tht: sharks encircrling the steamer 
an<i was ilrau'ii mimUt tlie water, Iraviiig only a dark st«'ak of bluod. 
(Adaptfil fniiu Ziehen.) 

"GwmI (lirl St«r>-." — Oiicv upon u time there was a girl whose 
father and motlier were dead, and who was so poor that finally she 
had nothing Init the eluthes on her hai-k and a httk- pieee of hread in 
her haiul. She was deserted hy pver>-b<xly. but simt' she was good and 
honest she went into the worh! witli confidenee in God. As she ■v\'ent 
along she was met hy a [Kwir ohl man who said, "Give me something 
to eat, I am hungry.'' Tlie girl gave hlni the piece nf bread iiml went 
on farther. Sihui afterwiird slie ent-ountered ti little girl fr«v.ing 
and ahnost naked, who Ix-gged for her elothes. The g(MHl girl gave the 
p(M>r child the wannest of her gannents. Night t-ame un. the gocKl j^rl 
waLS tired, (i>lil, and Iniiigry. She traveled into tiie wochIs. an<i, tt-ander- 
ing (dT the nmd. she knelt and prayed to (iiwl. As r^he knelt she saw 
the stiirs falling all alxint Iht, and when she looked she funnil they were 
many briglit gold dollars. (Adiipted fnwn Ziehen.) 

These stories which are used have been selected with great care. 
They an* es|x"aally valuable. It is rc-tniirkabk- the amount of infornni- 
tion that one ^-an obtain from getting a patient to rt'iK'at one or two. 
iVfet'ts of memory and attention show immediately, while the manic 
tendeney to elal>orate is eharaeteristie. They sliuuld never lie omitted. 
The enwboy stor\' is usually the easiest, while the gcHwl girl story is 
hard, bi'cansi* of the greiit iirnoiuit of detjiil. Tlie emotional feature 
i»f llie 'Streak of hloud" in the shark story is jiurtieularly impressive 
and nmy l>c alxiut the only tVuturc of the storj' reproduced. 

In the special memor\' test.of course, different people will have to 
}k treated difTereiitiy. A I'olish immigrant just landed would hardly 
know aljont the Civil War. The imi^irtant thing, howwer, is to 
reeord actual qLiestidii and uiiswer. 

In the Masselon tests the patient is asked to ineoFporate such 
words as pen. ink, letter, into a selitence. 

In the Ziehen test the patient is asked to tell the difference between 
horsi- and ox. dwarf and ehihl, etc. 

The prnhlem of calculating the change left from oOe after making 
certain purchases is an excellent example of the usefulness of standard 
questions. Everyone on the hospital staff knoi\'S that the answer 
is 21e: and ulthoiigli this is u little thing, when nndtlpUed many time; 
it makes K gn-at deid of (lilTrrence in the ea.se wilh which one eitri gi 
over a his-tory or appreciate it when read. 

The forward and backward associations arc valuable as roughl; 
quantitative. The average pers<m should be able to give .six number 
forward and five numl>ers ba^-kwani. This test will disclose just ho\ 
many the patient citn give and is one of the valuable tests for repeatiTi 
from time to time during the course of the psychosis. It is also ver 
valuable In ilctecting the nudingen^r. A definite intention to hlund( 
is usually readily distingui.'<hable from a natund blunder. t 



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In the FInckli test the jMilipiit is asked the tnruning cif sayin;^ or 
proverbs sueh ns. "The early bird catches the wonn.'' 

Such ethical questions can W asked as, What would you do if you 
saw a man drop a $10 bill? 

In addition to the tests given in the tabk" frequent use is made of 
the Kbhinghaus test which consists of having; the piitient ri>mpletc a 
sentence in which certain words Iiave been left out. such as: 1 Rot up 
in the . . . and after washing my . . . WTnt to ... Or 
better often is Ziehen's nioihTi cation of this test. Tlic patient is asked 
to complete such a sentemt* ns tliis: If it rains . . , beejiuse 
... in spite of . . . The Bourdon test is very vhIubIjIc as a 
measure of attention. It consists of getting the patient to strike out 
certain recurring letters or niunbers in a standard page and timing the 
result. A similar test is the tapping test— timing the numWr of taps 
tliat can Ik- made in a given time, say thirty seconds. 

The cases will be numerous in which it will be found desirable or 
neccsiwrj' to pursue the examination further in some direction. No 
scheme can cover all fMissibilities an<l would Im" useless if it did. I»eeause 
intpossibic to carry out. Much must of necessity l»e left to the juilg- 
ment of the examiner. Hy following this plan, however, it is believed 
that the general ajid imjwrtant features necessary for a wsi- record will 
be ctjvered in the large majority of cases. 

It is useful, after completing the examination, to accent the sig- 
nificant features in a .short summary, which might include a pmvisional 
diagnosis if the facts warranted. 

The tests here described are for the most part inteUigence test.s. 
Even such q\iestions as might be propounded under t lie head of "ethical 
questions" may very easily have ordy the Mihie of ititcllig»'n<v tests 
bex-ause the patient will quite Hkely answer in Jic(i)rdanir with the 
conventional ideas with which he is jK-rfectly familiar nither than 
answer in aceordancr with the way in which he feels. While the intelli- 
gence tests are important and while In taking them in a routine nuinner 
one can get a gtwid deal of information from the patient, often informa- 
tion of matters that lie dec|)er than mere questions of intelligence. .•*till 
they are by no means uli-sufficienl. The inlellett is after all only 
sn|terficial as a guiile to iiitiiha't. The deei)er motives that move men 
to action ciinie from the realm iff feeling, inul if the syinptoilis are to 
be explained ur undei-stooil the enintional springs uf coudud must 
In- ffithonieii, 

Tlie same criticism may be made of the Hutet-Simon tc^sts which 
were devised for detemiining the degree of mental defect expressed in 
terms of the psyeliolngieal {q. r.) age. These tests are valuable in 
skine<l hanrls for the more pronounced degrees of dcfe<-t , but asdevck>i>- 
n»ent pro<'(M'dsthey become progTes.sively more unreliable in proportion 
to the increased psychic niiiss, the im|K)s.sibiIity of stancli>rdi2ation 
because of the wide iiidi\ iilntd ditVereiKvs, and tlie greater probability 
of ilistortion from unknown emutional sources. 

More rectMitly u definite attempt Ims U-en niade by Hoch and 



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94 smruoDs of bxamisatios of the nervous system 

Amsdcn' to formulate a scheme of examination, dirvftctl more esjx'cially 
to the niFi't-tive aspert of the psyrhe. To lusp such a scheme as this, 
however, and in general to gain any real in&ight beneatli the surface of 
the psychic life, the technic of psychoanalysis needs to be used. 




PSYCHOANALYSIS. 

Psj'choanalysis is the method hy which the human minii is, so to 
speak, dissM'tcd, and by means of which the ludden mrittives of conduct 
are sought. If nnjlhing like a complete understanding of patients 
is to K" had tlie methods of psychoanalysis must be used. This is 
hardly the p!aw to discuss these methods at length. It would require 
more space than a text-book of this character could properly give it. 
The student is referred to .<*pecial works. Here only will be given the 
briefest suggestions.' 

The Complex.— Tlw mind cannot be wmceived of as consisting of 
or containing ideas which are de|ioHited here and there, helter-skelter, 
without order, as the scraps of paper that are thrown carelessly into 
a waste basket. Quite the contrary'. Ideas are grouped about central 
exfx'riences. constellate<l one may say, built into coherent and harmoni- 
ous .structures not unlike the way in which bricks and stones are brought 
ti>gether tu funn buildings and these builitiiigs are again groiijied to 
form the larger whole— the city. 'Hie significant fact in this connection 
is that the cruiriit that holds the bricks and stones together, the binding 
substance, is fei'Hi'y. 

This orderly arraiigfrncut of ideas upon a l>ac-kground of feeling 
which sen-es to unite ihcm is what gives character, individuality to 
tlie personality. Hie creating of the profier feeling-tone about things 
and events is one of the main functions of education. 

Xow it BO happens that in certain t^\'pes of individuals a cunstellation 
of ideas, grouped about a central event that ooniiitions a highly |Miitifu' 
emotional state, is crowded out of clear consciousness - repressed — int< 
the uncimscious and so tends to lead an existence which is rclativel' 
inde|K'ndent and in .so doing gives origin to various symptoms. Siicl 
a constellation i.s termed a "complex" in psychoanalysis. 

The comptex, crowded out of relation with the personal oonseJou! 
ness. seeks U\t cxpres.sion notwitkstanding and bec-ausc it is not synth< 
tized with the rest of consciousness, because the individual is not awa' 
of its existence, its expression cannot Ix^ contrt)lled and guided into tl 
usual clianncls. and thus it creates symptoms. 

The extreme difficulty in locating and uncovering the complex: 
due to the symbolic forms in which it usually manifests itself, 't 
painful memories of disagreeable experiences, unethical, unconvi 
tional, and otherwise iui|M.>ssilile «nd hateful wishes while crowded c 

'Guide V* the rXttcrijuive Pludy nf tlie PerwHinlity wUli RiH'i'iii! RrftrenPC to 
TakincMr AiiiimnMiP!) (if ('nam uf INycluis'«, Uov. nf Nc?unil. and P^hIi.. IUI3, zi. 

' Uitxchmunu: rreudVThfforiexof the NeuroBeJi. New York. Jung: The«iO'ot P>sy 
anill}-Hifl. New Vork. JoUiffo; Twhtiir of feyrhoiinalysw. PeycUoanalytio Rci 
Vow Ynrk. Wliife: Fonndnlif.ii* <A Ch-irmfti^r Furmaiion, MArmllljtn A Co. 
Mhu'b UnooiiHoiuua Coiifliel. Dudd. Moad & Co., 1017. 



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of mind by what Freiwl has so uptly termed the "censor of conscious- 
ness" nevertheless struggle to find expR'ssioii. The ctmiplex cries for 
recognition, the censor will have none of it — the fipht is on, the conflict 
(vftpcs, until finally ft sort of compromise is reached by permitting the 
complex to come into clear consciousness but only on pain of not di** 
closing its true self, that is, it is permitted to appear under the cloak of 
a complete disguise. 

For example, Freud's case of EHziibeth. She was engaged in nursing 
her sick father who afterward rlied. One evening, spent away from 
home at tlie solicitation uf the family, she met a young uian of whom 
she was very fond and he accompanied her back home. On the 
walk home she quite gjtve herself up to the happiness of the occasion 
and walked along oblivious of her duties. On reaching home she 
found her father much worse and bitterly reproached hcr-seU for for- 
getting him in her own pleasure. She immediately repressed thi.s 
disagreeable thought from her consciousness. Now she had, each 
morning, to change the dressings on her father's swollen leg. To do this 
she took his leg up<m her right thigh. The suppressecl coniplex seized 
upon the feeling of weight and pain of her father's leg uprni her thigh 
as a handy and efficient means of expression and so the repressed 
wish comes into consciousness under the di.sguise of a painful area of the 
right thigh c(trrespoii(]ing in extent and location to the place upon 
which .-(he rested her father's leg. 

This is the sort of mechanism that accomits for many unusual and 
strange experiences that otherwise appear to be without reast)n. 
Unexplained forgetting, slips of the tongue, certain mental attitudes, 
mofxls, and even the dimiinant tmlts of cimrncter are due to the 
activity of submergcil complexes while the phenomena of dreams are 
explained !n the same way. 

The unconscious methods are very logical. As already descrilwd 
the complex often expresses itself symlwlicully {.tj/m Mitm), often by 
tlic transfer of an emotion from a painful event to a less (Miinful or 
indifferent event {dvrplacemeiU) , often, as in hj-steria. by the conversion 
of the conflict into a physical symptom (convergion). In the phobias, 
obsessions and compulsive tj-jje of disturbance, the repressed affect 
undei^oes a gnbstitution. In tins way the symbol carrier of the 
repressed wishes, the symptom, is a most ingenious disguise. 

Dream's.— The analysis of dreams is for the purpose of determining 
the presence and nature of complexes which are exercising a controlling 
effect upon the patient's conduct and feelings. The dream api)cars as 
a quite senseless experience to the pj»tient and upon the face of it it 
would appear also to be senseless. A very little effort, however, will 
show that there i.s a certain ro\igh meaning to the dream. For example. 
the scenes of the dream will l>e representatious, usuallj' more or less 
fragmentary, of things which have happened in the life of the individual 
during the previous twenty-four hours uiul may easily Ik- associated 
in his mind with events of some moment to him. As soon as this is 
pointed out the patient will acknowledge it, if he does not know it 



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whole theorj- of iniitiiaiity is the theory of a defense merhaiiism of 
the human aninm). The dream is jiist such a meclmnism. and if w hat is 
Hoing on ill rlie iniinlnf tlie patient wtmlil Ik^ kimwii, what tht- piitieiit 
is (lefi'iuliiiK hlmst-lf from, wlitit are the disintegrnting fat-tors at work 
at the ps.vchologieal Jfvvl, tlic fasicst acecss to the knowledge of these 
factors can be fouii4l if the meanings of the dream can be lc«me<I. 
Dream nnalysia is a most important tixtl for tl»e luira veiling and 
iR-atment of all of the neuroses and psyclioneuroses and for the 
nnderstanding of the psychoses. 

Technic.^The terhnic of psyehoanalysis is an art more suci-essful 
in some hands than in others. However, the general methods of 
procedure may be brieHy onthned. 

In the first iiistuncv the physiciau must \k fully imbueil with a 
jirnfciiind belief that mental symptoms have, cadi imd every ime of 
tliem. a meaniiij: and a meaning wliieh can be brought to light and will 
show them to lie logical and understandable in each instanct*. He 
must then have imtienre to listen to the story of his patient, and not 
only listen to it, hut listen to it attentively for the purpose of tr\ing 
to find the meaning in it, for the puqiose of trying to hiul out where 
the vital points are whieh i-an be attacked to In-st advantagi'. 

It is true that the dream analysis is the main avenue lo tlic under- 
standing of the unconscious motives of action, but all sorts uf hints 
may come from other s*jurces. For example one of the authors was 
rct-ently listening to the .^tor>- of a patient. In the course of that story 
the patient mis-spoke and said quinine when he intended to say calomel. 
Realizing that a "slip of the tongue" of this.*ort must have its meaning 
and is ni>t un acciilental oiTiirrenee, liecause nothing mental is acci- 
dental, the slip of the tiingue was analyTied ami le<l directly back to 
one of the most imjK)rtant emotional events in the life of the patient, 
an event which threw n flotwl of light iiiHtn his jisyehoiieurosis. 

Nothing is tiwj trivial to be wortliy of analysis, nothing but may 
thron* light njjon the situation. All the little slips of the tongue, 
furgotten incidents, points at which two rt-citals of an occurrence lUi 
not agree, even witticisms, arc neces.sar>' to trace out besides the 
analysis of the dream life, and offer an abundance of material in the 
itinrse of the analysis. 

TIk" method of pnn-ednre is the method of free assiK-iation. \Vliether 
it i»e the analysis of some eonipcvnent fif u dream or of a slip of the 
tongue, or what not. the method of free association is the one eini>loyed, 
Tlic patient should Ijc nloiic with the physinan. It is pradically 
im|>ossibIe to conduct an analysis, ut lensi Ix-yond the surface, in any 
other way. Under circumstances of quiet and freedom from iiitcrnii)- 
tion, as far as ixtssible. the ditfcR'Ut points wliich aa* to Ik* analyzed 
are taken up. The patient is instructeil to take a certain element 
of the dream whirh he has just recnnntc<l. for example, and hold it 
in his niind. and ilien tell freely all of the ideas that «*me to him. 
He is told in tell all of the ideas without any effort on liis part of 
selection, no matter whether the iiteas appear to him to have any 
7 



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98 METHODS OF EXAMINATION OF THE NERVOUS SYSTEM 

relationship with the portion of the dream that be has been told to 
keep in mind or not, and no matter whether they appear ridiculous 
or have other qualities that incline him to lay them aside. He must 
tell them all just as a man might sit at the window of a railroad train 
and jot down, as far as possible, everything that he sees pass the 
window as the train speeds on. 

The theory of this procedure is that if the patient does not direct 
the thought in any way every idea that comes must of necessity have 
some relation to the event held before the mind about which enlight- 
enment is sought. This is the method of unravelling the tangled net- 
work of the mental life and while it may be supplemented by word 
association or other means, still it would seem as experience increases, 
that no other method is needed, that this answers all the purposes. 
It takes a long time, as a rule, however, to effect an analysis — weeks, 
months, perhaps longer. It must be remembered that what has taken 
years to form cannot be unraveled in an hour. 

It will probably occur to many to wonder how it is that one car 
expect to find memories reaching back for years sufficiently wel 
preser\'ed to be helpful. As a matter of fact the memories of a) 
repressed experiences are perfectly clear no matter how old. Th 
explanation for this is that being repressed they are dissociated froi 
the everj--day events of life, they are kept in their original form, the 
have not been subjected to the attrition and amalgamation with tl 
intricacies of associational life. They do not fade out by this proce 
of absorjition as do the memories of indifferent events, but rema 
where e\er after they may be brought to light by analysis and used 
helps for cure. 

It will be seen from tKis short description what a far-reachi 
method tliis is. A method of analysis from which no event of li 
no matter how apparently trivial, is free. A method that in 
results lajs bare not only the immediate antecedents and causes of ■ 
symptoms, but the whole innermost life of the patient, reaching b; 
even to the period of early childhood; This of course takes tu 
A case of any complexity and difficulty quite generally takes sevi 
months, of at least three stances each week, to reach a final result. 

The object of psychoanalysis is not merely a dissection of the paj 
and the discover^' of the roots of the psychosis or neurosis, as the ■ 
may be, but is distinctly therapeutic. The physician tries to show 
patient to himself as he really is. The patient is thus enabled tc 
how his symptoms are the results of hanging on to infantile waj 
pleasure -seeking, self-indulgences, which ate repulsive to his better 
When he has seen this the path is pointed along which he mui 
toward the effective sublimation, socialization, of his infantile tende 
in activities that are useful and which meet with conscious appr 
The object of psychoanalysis then is to liberate the psychic ei 
which is bound up in infantile ways of pleasure-seeking and set i 
for socially useful ends. 



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PART L 
THE PHYSICOCHEMICAL SYSTEMS. 

THE NEUROLOGY OF METABOLISM. 

CHAPTKH H. 

VEGETATIVE Oil \ISCEIIAL NEIUOLOGY. 

TBffi AtrrOKOMIC AND SYMPATHETIC NERVODS SYSTEMS— 
THE INTERNAL SECRJSTIONS. 

A TllORnrnilLV ninsistcnt plnltiiiR nf this i-nornums clmpter iti 
nriin>li>K> Im luit yet possible. All of tW tlisonliTs here bronjilit 
titp'tliiT timy not lie foiitnl ultimately to Ite l>est prouix^l liere. Tlie 
^eiirnil as.Miioptioii fiJlnweJ, ImweM-r. is that they ull helniiy to <li»- 
orHers of ii iMirticiiliir ^jroup of organs, partly nervous, partly glatiduljir, 
the pntper futietioiiinpf of which tn their complex rejniUtion an*! 
riiririliimtion of metahnlir aetivities are Koverned hy a homogeiwoiis 
sprir* iif stnidun-s, the vrp*tative nervous system. 

(VrtAtii of tUvM' origins are elosely relate*! to nervous structures, 
hypofihyais (autrnor, uiul pituitary, posterior lobes), epiphysis, 
ih^Toiii:*. panithyntids. supnireimls, and hlood glands, and have been 
\TiriousIy bniujiht Innether as the endtK-rinous glands or glands of 
intenial i^rrelion- while others are di^timtly non-nervou.s. liver, 
jjaiH-rettH, testieleft, iiiterstitiHl bodies, th\inus, ovaries, nteriis, lungs, 
vtorrmrh. hrnrt, etc., hut their functions, like those of the endfK'rinous 
glands, are nirtntnatlcally eontrnlled and interrelated by one or nther 
of the tw<i [H>rtions of the vi-|*rlativc system, the xifmjHiffirttc imifKT, 
kim) the juirafiitiijMithftir or nutimnmir.* 

The vegetative iK-r\ous system consists of those nervotis structures 
which supply, hy afferent «nd efferent pathways, impulses to the special 
icnae orgua, smooth muscle fil)crs, and all those automatically working 

^Aav tii"-r Vnn,|jitivw luler Vifuvnlf Ni-oniloicio. Encvtioimo <ivr Netirolofio uitd 
Aqt^^' '-"t- >■• ^'<*' I' l^"'' ■* <^>n]|ilf<l<> ilim^uanQii o< tUa cmonlliBttOB mb 

Bpphuti'' ViHt^i/>riia, Sorvoua >t)(I MouiaI Diw*Jo MoiiDRTsph, No. 30, N«ir. 

Tork* lOI.'i. li'b'k'-ll: lnvi'lunli>r>* N'v^'uuH Synlriu, lUiQ. Nwl PnUin: Ni!rvinia RflSB- 
Imoo qf McUtir-linn. 1U13, GHn-aiini: rAioUtgia (kl 8ii»[iatico, 1670. OwMlKoo • 
nMfe; Pifadufb (M ttl»>(atK». 101,^. 



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rEOETAriVM OR i'lSCERAL SFAROWGY 



orjtans sucih as the heart. hiiiKs, inte^ines, genital appurutus. blood- 
vessels, exrreton- plnnils. skin ninl organs nf external and internal 
seeretion, sueh as ihe Iimt, stonmch, |>uiuTeas. Intestinal ulnnJs, unil 
the thyroid, th\iniis, adrenals, parathyroid, hyiKiphysis and epiphysis, 
v\x\, rvspet-tivfly. 

All of these stmetun's are <'oiistaiitly in function, and their dis-i 
tiirbanees are manifotd; either arisiiii: from aJfeet activities such as I 
fear, rage, jealousy, pain, as seen in many neuroses and pksychonenroses 
representeil as paljiitatinn uf the heart, anorexia, fainting, crying,, 
diarrlH'a, mydriasis, eosimi|)hiliii, etc., or frmii infectiims or iiitoxica- 
tions. resulting in reactions such as reddening, swelling, gm>seBesh, 
taehyeanlia. »lr>ness of the nioutli. stetKK-ardia, gastric or visceral 
crises, Argj-lUKobertson jnipil, etc.. or showing such anomalies of 
metabolism as niyxc<lcma. aeromegaly, selcroderma, dwarfism. m<)n- 
golism, riinuchoidbtm, disonlercd hliHul states, etc. 

It has recpiired a long linie fur orthmlox medicine to accept wlial 
has iMt-n knowii fnipirieally for (.vnturies that euiotional factors an 
eiipablf nf producing acute as well as chronic s-tnictunil alteration 
(soH-alled organic ilisease) as well as lK*iiig ixinstnntly operative ii 
causing siwalled, and badly so-called, functional disease. The stud 
of the vegetative system has enabled this gap in knowledge to t 
bridged by showing the exact mechanisms by which these structure 
i-tMijHTating «ilh certain of the eniliwritiiius glaTiils. ina> jinMlui 
imtholngical conilltions. Dialictt's MK-llitns resulting from an emution 
shock is tt^'ll recognized. The Allen treatment of pancreatic iliabet* 
by means of starvation. n.'W»gnizes the possibility of a "functiona 
disturbance of the pantTeas, which may disap)>ear with rest. IMsea* 
nf the skin, as aloj>ecia areata, eczema, psoriasis have cmotior 
origins among others as etioKigieal factors. The mechanisms thniu 
which such profound organic clisturl>anees are brought a^HJut oj^en 
thpougli the ^■egetative nervous system. 

The role of tliis syst<.-in in its reactions to mental stimuli has Im 
stuflied recently and for u jKriwl nf years by Pawlow. Cannon c 
others by experimental methods and has helped to give an intcrpretat 
status for empirically held beliefs. Starting with the well-known f 
that the vegetative nervous system takes its origin from the crar 
cervical, thorai-ie-luinijar and sacral n-gions of the i-cn-broisp 
axis, these studies attempt to correlate the activity nf these port 
of tlie system with thn-e distinct ly|K-s (►f emotions. As a resiJ 
physiological experiment whenever the innen-ation from tlie tlmrl 
luinbnr (sympathetic) p4)rtion of the system meets, in a \'iscuB, 
innervation from either the cranial-^■r^^'^^al or the saeral por 
there is always an opposition in the effects pn)dnced. In the eye 
ctmtraction of the pupil is due to impulses received fnan the cc 
autonomic, while tlie <)ilaiation of the pupil is effected by nerve f 
which i-omc from the thoracic ])ortion of the syni]jathctic. Agair 
secretor\' and tonic motor innervation of the stuinach come tin 



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AVTONOMtV AND SYMPATHBTir NBRVOUH SYSTEMS 101 



th 



from s^-mpathetic 



s iicrve Irom s^-mpatlietic nfun>ns wlii<-l) Imvt' their origin in 
the rervical clivisimi of that sy-^tciii. Stiinulalion (if tlic splandiiiic 
nerves onuses an inliibition r»f both the .'^■e^etory and motor fmutions 
of the stomach. The VLs<-erii of tlie |M'lvis an* likewise <Ioiil)ly iiiiier- 
vaterl. The sviiipiitlietir neumns from the thuraciv-himbar :^epiient 
muse relaxation «f the tower entj of the intestine. The sacral nutonomie 
filnTs for t!ie .'ijime organ omsi* coiitrnc-tion. The bladder and reprt*- 
ductive i>r{^n^ are similarly innervati'd. ('f.irn-w])ondinK to tlic tliree 
[Mirty of the ve^etJitivc \vstein nml the orgim.s a.ssoeiate<l with tbeni, 
jtfeoriiinji to Cuiiiion, there are tliree tyix's of response to emotions. The 
entninl portion of the system, by rcKuIutinji the secretion and motion 
of the dijjestive orKans. is coneeriied with biiildinjr up the resen-es of 
hwhly slrenpth. The emotions correlMte*! wath these physiological 
activities are bo(lil\' satisfaction and well-being. The vegetative 
syatem is cont.rnied csiiecially with the fnnc-tions of the suprarenal 
g)an<l. Tlie physiological effef.-ts of the secretion of this glaiitl art iden- 
tieal with the cfTeets of stimulntinK the thontcie-iunibur .symjmthetic 
sj"sten); tlie pupil is dilated, t!ie heart is actvlerated, the functions of 
the iitomach arc iidiibilerl. ajul tlic glands of the :skin ami the erector 
muscles of the hair are excited. Glycogen in the hver is liberated in 
the form of dexunsc, with the result that sugar is available for piu.'H-'les. 
The emotions which call for a sudden summoning of muscular energy 
are rage and fear, .sinw corTe!ate<l with them are the instincts of 
fighting and flight. The functions of the pelvic viscem are mainly in 
the nature of emptying accumulated secretions. 'J'lic emotions de- 
pending on these fuiu^ions are those of satiety and repletion. Cannon's 
very iTude classification of the enioti4>nal reactions is hnrdly to l»e 
accepteil. but tlie underlying facts conceniuig the iutcrrclutionship 
l'>etween psychogenic (siTiihoUc), i. c, emotional foctors and neuronic 
iiiechauistic allcralioris ()f physic-al structures arc iticouU-ovcrliblc' 

The vegetative nen,ous .system in its c,s.sence is a primitive, archaic 
remnant of the ganglionic or mctiiineric system of the lower verte- 
brates. Its chief i-entral swit^'hboard is in the midbrain. In the 
evolution of higher animals its development has been left behind, as it 
were, by the relatively more ini]K>rtant (i. r., for purjiosi'sof civilizjition 
and culture) neopalliuTn or cortex, with its rich corticH!-a.sso<'ialion 
.system, but with whi«-h it has remained! in <-lose relationship, since 
these structures underlying consciousness and intelligente have grown 
out of the phylogenetically older sj'stems. Thus it comes alx>ut that 
the ganglionic system which in man serves the vegetative functions of 
the body is represented in the primary mctameres, the spinal cord, 
iigain in the bniin stem, ciMitral gray matter and midbrain, lenticular 
nuck-us and optic thalamus ihyjxfthalamns), and finally in the cortex 
where tlie different orgiins under vegetative control have localization 



* CanwHt: Fc*r, RuRe, Huiif!>>r and Pain uid the N'erroiia ^yalepo, Ai>|d«toii ft Co., 
Npw York. 



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102 



VEGETATIVE OR VISCERAL NEUROLOGY 



as surely as those of the bodily musculature. As yet the con 
cardiac area is uncharted. 

To speak of the vegetative nervous system as unconsciou: 
contradistinction to the sensorimotor system as conscious has 



Spinat Ganglion 



SUn Snirfbltflv 




Flu. 42. — Diatn'^mof the central connections and peripheral distribution of the ve 
live system, ; the motor, . and the sensory fibers. (Higter. 

longer any value, since conscious as well as uncoascious activ 
produce marked reactions in both systems. 








X.HI 



3. 12.. 



Fill, 43. — .'^ympjithetic nuclei at the seventh dorsal and fourth sacral levels of the 
cord. (Tinmie, Jour. Nerv. and Meiit. Dis., 1914.) 

The central or spinal synapses are probably located in Clj 
columns and in the lateral gray of the spinal cord (Jacobsobn) 
43). From here the centrifugal fibers pass through the anterior 
to and from the sympathetic vertebral ganglion as rami communic 



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avtosomw Affb sifMpATNSTir xenvoos systems u 

itll>u.s and miiii (tuuiniuiiic-antfs gri^iis rf^s|Krc*t.ive),v tu Ix.* ilii^tribiiti'il 
to the vessels, glands, uiistripcd muscles, etc., when' tlie effector 
niator ganglift {analu(;;ous to the anterior liorii cells of the st-iisuri- 
motor rcHex arct miike the final syim[>se. Tliis reflex arc (two tyiK*? of 
nhich nre recojciiiiied ) is shuun in the work of Gaskell to diirer umlciiall.v 
from the ordinar\- reHex arc of the voluntar>- s>*stein as is seen in the 



«f/ 



n 



.*" 



rj£ 






n 



Fio. 44. — Thn reflex paths in the cord. (Cftskcll.) A, of the Mrworiniotor volun- 
lU7 sy«tvtn. Tht! rvr^cptur ucninxLi nm in tttc iNiatoriur nxit, llicLr i-ttlln tj-iiiK in llir 
pOfUrior root icnnxliu. P.R.G. The connc-tor tiyruipM! n«iin)Tii( lie within ilip d'lnwtl 
bnni. D.H., uiii itiiikv wilU Ibc cQvcloc aruruiu ly-iuic iii the vtiiiUiii tiunis. V.U.. u 
ajrnapae w'itli the motor ncuran, wliich cm«rBH (rum thm f^nrd un tho mutur gpinal dctvb. 
B, vf the v^ic^laliv* nervous eyvtcini. The iwoculur ururDii* run in l.hr |>(Jiik-ri(ir nwl 
lui a M^tinory iiournn, mmliitig its firat fiyoapac iii the ooUd of the latoritl h'irii. /.f/- (Jkcub- 
sr^hn'a )tyn)t>'itti('[i(- nuclfti, Ftg. 43j. Thi> eanaecUtt neuron niiiH mit with ttic nu^tor 
iinrvG uH the vhlte raniue com[UiiuiL-&ua, nmkiDA its syQftpsc viub the eflcK7tar Dcuron 
ID liw fiynipnthciio t;nriKl<A, Su-O. Thr nlTitrcnr nfuron mna in Kniy runiii.t iiimrniinlenn!) 
to till* viM-un ilirvctly or tbn>UBh iuU.'ri<tiliil«Hi cuiiiioutur iieumiu), iiiukiiiii ii tauii oyiiaiMW 
within the viwiin itavif iFlu- 40]. 

accompany iiij; ilhistmtioiis. 'I'his is the original type for each 
metiunere, the symmetry of which, however, has been niuch dis- 
torted. 'Phis (listorlioii is sh.'inii as an irrcf^nlar or ini-oiLstaiit locali/u- 
tioii of the ganglia, or synapses, or as an inajnslaney of the com- 
municating branches, irregular (listril)ution of the centers in the 
cerebrospinal axis or as an incongruity of tht* embryonal mctameres 
with the !ti>inal and cranial segments (Figs. 44HU}). 



k. 



Digit 



zedbyGoOgle 



KH 



rsiosTATivK on visceral sevrowgy 



The chief ftnntomicnl results <"oncfrning this procws of distortion 
in the Iwiuf re(;i<m may lie rtfapitiiliiteil hs fullou's: In the skull the 
ilititortinn is gn'aicsl as many iiirtuiniTcs art Hiiatoniical ct»ii};lnnicrutrs. 
Many of the ^antHi" urt* modifit'd intervertebral gungliii. sm-h us the 
Kenirulale and the (lasserian; others are eouipound jtunglia due to 
the amalfi^matioii of a spinal with a .^^Tiiwithctic f^ngliou as the 
jugular and vagus ganglia; other pure intenertebral ganglia are the 
eiliary, otic, spheiin|>alatine, subrmixilUiry and .snWinguai whirh supply 
the smfMith muscles of the eye. the vessels, the tear, sahvarj' and 
muitius plands rej«p(.vtively. Some of the eliief anutomieal features 
for the liead ganglia may be seen in the superb charts from Muller.^ 



o 



fist 



o- 



Mi 



■Mr 



\f6 



4^ 



X Y 



jir 



Fra. 45. — Roflpx piithn in the hiilbttr ngloa. (Giulivll.) A. iho Hmsuritnotor k> 
tpni. Till.- M!iisor.v ii(iun)ii rutin ui tlm lifUi aom. V., tts r-cll liwliim furiaiuc the Ctfljncrii 
XHiijf^ioD. G.G. Thp ooniiofUir npiimn sjiiApar nocurs in th<> d«8r«ndinK TDOt at tl 
fifth, D.S.y.. null an Hluctor if>-iuipi>o in Ihw twelfth ticrvo nuclcuB. .V..V//-; B, f 
ftympallietir ayvteiii. TIip tweptor n<<aron runs iu the t*nth nerve. ,V, th» r«U hnji 
niukJns ui> iho vacui* BHtiicli^^n. V.O.. mikina it« «riiiiiM.'liir HviieipM- iii ih« dunuU vnt 
TtHit, D..\.X. Tho tvjiiiiofliir Rlwr niakt^ its Hynnpao with i.h* eftfftar in the imi4i 
iuiibiK>>i>"- ^'-A.', C. 'ho t>nnu(yin|)nlh(itl(' or itjtfMKitiiic »ynl4?ii>, Tht> rcfpp 
iii-tir'tii ruit-H In the teiitli nt'r\'i>, .V. The fint rvtmiDcUir .lyimiwi' furminK thf> nurif 
iiiletvalnfiift t>f SLft<)«rini, \.l.. pari of ihc drtnml vskiu :>ynnpM> icTouii, D..\JC. 1 
f'iiiiiN-''l<>r neuron mux tiiil willi Um^ vhkiu*. A', riiiiilly ninkins nil cffectur aynai 
wjine vi»cu», or iilexu*. Aucrtuii-h's iiImcim for (he inteBlinan. etc. 



napM 



. The upper ganglinii. ganglion ecrvieale supremuni, obtains 
preeelhilar fibers from the last cervical (('S) and upper dorsal (Dl' 
segments juid inner\*ates the vessels, hair muscles and skin glands 
the head, the dilator pupillie and Miiller's orbital muscle. The infei 
eervical ganglion with its closely related stellate ganglion <lerives 
pregangliar fibers from the l)l-">. and gives rise tn the aeeclera 
nerve f>f the heart and probably the vasoconstrictor fibers of 
puhinmarj- vessels. 

■ EiAier, loe. cit 




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AVTOSOMIC AM) SY.Sff'ATllETIC \KRVOV.S .Sl'.Trff.WX 105 

'Hie larpr,-*t ^ii|;liiin nf ihi* iiI)'loincM, tlir (fliar, luis its chief rtwt in 
the celiac plexus in the major and minor splanchnic nerves, the former 
of which Climes from D'1-9, the latter from 1)10-12. As the mesenteric 



«f 



'**f 



id 



V 



J7 



STOli^ 



cH 



Ll 



%0,t, 



\S' 



FMi. W.-'Th* va0ui nerve, 1'., ntnudiu ronocvlor and HTtn-uir nvumiui u fnr u 

tho i]r»nilir ■(ihiiirUr. PuTthrr efTwI'ir (Aympatb«Uc? und aiilOQomir) uMiroiui li« 

•rithiii tlie vixTorn lliii—iilm llir- pclvir nprvp, /'„ miitaiTio nirin«H-trir (and cffM-tnr) 

ii*iirriir (or Uu> mrral oulAirw. ivriiiuiol vflMitur imurdnn lyioK witliiii tlu* wulU of tlio 

latir tnmtttM' hihI l>liwlil«-r. Tht> vh^mb Uiua nBrrica roniivrior iicuniiia f» ihc iii'>t«ir 

•flwtor c«U« of ibc liciirt. /V.. wlurlt. GuImU ■t*t4M. have tn do with tho ^ow wavp- 

lik* MinUKirUitna uiily i?l found in rertaiii tortoiaea. Tbc v-acun alaa rarrim cnnniM^tiir 

Btwr* K) iWefffv-iijni in l)u> Iminctii. f./i., aiiil alM> mrrwrlor Alwni to thccfftrtora within 

the wail* tA itw Rall-tila'lilpr aiwJ Utn rltiru. /.J. ivuitalJinir iiT(«nu>), tn the walla ol 

I (hrr»>pltstftB, fK, tho •tomn'-li. Af.. MiA ■mall hiti^iJnc. ■'I./, Tluy pHvi>Miorv«, aynapacs 

f bt Uic wrraJ nntt, .S\ j^, .9, riirriaa cDiiaectoc fi)wr« In <]il' vffo-iut^ iii Ibe larg* inlwHiH. 

L/^f . and hlad-for. A. 



nen-rs tlif^' innervate ihe 5tnnHu-h RlancU, liver, pancreas, splorn. 
kiiliieys, atlrrTutU, unti iIltl■^tinlll ctniuUas far ih the asiviHllii); colnn. 
Hit inferiur nieM-nUTte pin(;liiiii iririvt-* its prt'celluhir TiIktw from 




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ice VEGETATIVE OR VISCERAL NEUROLOGY 

Ll-3 and sends its postganglionic fibers to the colon and as the hj-po- 
gastric, in part, to the anus, bladder, sphincter of bladder and genitals. 

A series of blood glands, chroma^ne cell containing structures 
(paraganglia) have been regarded as dosely related to these clearly 
recognized ganglia of the vegetative system. The most important of 
these are: {a) Faraganglion caroticum, (6) paraganglion coccygeus, (c) 
paraganglion aorticum, and (d) paraganglion suprarenalis or adrenals. 

Sympathetic and Autonomic Divisions. — Anatomically as well as 
pharmacologically it appears that two types of physiological activity 
are present in the vegetative nervous system. These have been termed 
the sj-mpathetic and the parasympathetic or autonomic. All these 
non-voluntarily influenced organs, smooth muscle structures, heart 
muscle, glands, whose nerve fibers are derived from the spinal cord 
from the first dorsal above to the fourth lumbar segment below, 
belong in the sympathetic system in the narrower sense. All others 
are controlled through the parasympathetic or autonomic. The 
uppermost come from the midbrain, enter the dliary ganglion, and are 
distributed to the smooth internal muscles of the eye. A second or 
bulbar autonomic system passes through the facial and goes as the 
tensor tympani to the salivary glands. The glossophaiyngeus anc 
vagus belong to this bulbar autonomic system. A sacral autonomit 
system supplies the organs of the pelvis and genitalia. 

How this division will prove out in clinical work is yet to be tested 
but is has become a necessary working hypothesis to harmonize th 
results of pharmacological experimentation.' This is particularly t 
be seen in the reactions of the vegetative nervous system to certai 
products of the endocrinous glands, i. e., hormones, and to certai 
toxic and anaphylactic substances, notably nicotin. Inasmuch ; 
the vagus constitutes the chief representative of the autonomic systei 
the terminology is applied to it more particularly. 

Thus atropin, its related alkaloids and the nitrates paralyze t 
vagus and its end-organs (vagoparaljtic). The former paralyzes t 
positive or stimulating element of the autonomic system, causi 
mydriasis, lessenetl secretion; the latter a paralysis of the negative 
dejiressing clement, gives rise to vasodilatation. Vasospastic dru 
such as muscariii, pilocarpin, picrotoxin, and physostigmin, ca 
lowering of blmwl-pressure, weakening of the heart action, brai 
cardia, myosis, increased secretions, and increased peristalsis. Morp 
gives similar reactions but its action is extremely complicated.' 

A number of the products of the endocrinous system act as v« 
tonics; among these is cholin, from the cortex of the suprarer 
Cholin's hormone autonomic stimulation s^inptoms are my< 
diminished peristalsis, contraction of the uterus, bladder, bror 
diminished cardiac force and rhj-thm, pallor of skin with increased, 
sweat and paresis of the abdominal bloodvessels. The sympati 

I Petren u. ThnrliiiK: Ztaclir. f. in Med., 17.1. Bauer, D.; Arch. f. klin. Med., 
* Kraun: Jour. Nen*. and Ment. DLt., 1917. 



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ACTOSOMtC ASP SYMPATHETIC MiltVOlS SYSTE\t.S 109 



The active pririnpile (if tlif hypophxsij^ atts upnn liuth systems t<i 
produce pictures of hypo- nr hyiierpitiiitarisni or a mixture of l«)th, 
dyspituitarism. Adrenalin, from the medidlary portion of the adrenal, 
causes tachycardia, increase of hlcM«l-prest=iiire from contraction of the 
bltKidvesseU. mydriasis and exophthalmfts. paresis and anemia of the 
res(Mrattir\' and stnnuii-li tracts, Jncreast- of sphindcr toinis and of the 
secretion of tTrtain ghinds, inobili/ation of plyconen, and increase in 
its oxidation. 'The amount of adrenalin set free by acute, coiistious 
fear lias Ixm measure*! by raiiiion, the elTect of chronic, unconscious 
fear is undoubte<lly as forceful. The antapoiiistic u<-ti<in nf the sym- 
pathicotropic adreiiahn and the vagotropic pilix-arpin shows itself in 
that adrenalin can counteract » pihwarpin eosinophilia and piloairpin 
an adrenal glycosuria. Other remarkable opposing; reactions are 
known showing the striking antagonistic physiolngiral possibilities of 
the vegetative system. 

The chief contrasting activities of tliese two systems are here shown 
in tiihular form as taken from the studies of I'Vohlich, Kppinger, 
Hess, Loe«i and others (see page 108). 

Tnasimieh as tins Hjiem is very markedly under psychical Infliicnees, 
particularly of the affects, its relations to what is kntixni a> atTccti\ity 
and amhivalcncy in psychaanal\tic literature is of fftr-reaclnrig impor- 
tance. The vagotonic and s>tnpathicntonit' types as described by 
Kppinger anil I less have already been touched u|Km in the chapter on 
Kxaniiiwtion of the ^'epetative Nervou?i System. It is important to 
bear In mind that these are n-action tremls ratlicr than clear-cut types. 
(See cliji]iters on l*>ychoneurosi's and Psychoses. ) 

Special Patholo^. Eye Sympathetic. - The ciliary, pupillary 
sphincter and dilator muscles. Midler's orbital muscles, ami the tear 
glands are all Ncgetati\e (organs of the eye which are iinicrvatcil In 
part by autonomic and in part by sjmpathetic fil>ers. Tlie pupillary 
inne^^■ati<^n is of special moment. The synapse of the dilator sym- 
pathetic fibers is the ciliospinal center in l>]-IJ. These fibers pass 
through to the sufXTior cervical ganglion where a synapse is made. 
Here fil)er.-i jw.ss to the (Jasserian ganglion, join with the trigi'ininus 
and in the long ciliary ner\'es. jiass to the vessels, dilator pupilla-, 
und to Midler's muscle, which pushes the eyeball forward. An auto- 
niimic pathway (sphincter) pusses by means of the m-uiouiotoriiMis 
und eiliary ganglion. Connections with the cerebrospinal axis are 
many, The «_entral course of the pR'cclhdar fil)ers of the siniHitli ciliary 
muscle of ai-connnodation of the iris sphincter is not certainl.v Hxed, 
although the evidence points to a midbrain synapse in the anterior 
median nucleus of the oculomotor. (See Ocnlomcttor.) 

Several importjint clinical conditions depend upon the complicated 
pupillary innervation, the chief of which are: (1) idisolnlely .stiff 
pupils, (2) Argyll-Hnbertson pupil, (3) sympathetic imralysis, (4) 
variations and deformities in pupils. 




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no 



VEGETATIVE OR VISCERAL NEUROLOGY 



1. Ill the first all automatic stimuli to the iris muscle are inoperative 
with the exception of the si.'mpathetic, which of itself has a minimal 
action. The pupils are dilated and distorted. Since the ciliary 
ganglion sen'es for autonomic tonic activity, any disturbance of the 
ganglion gives rise to great dilatation, which is more marked than is 
produced by nuclear or peripheral lesions of the oculomotor. Absolute 
rigidity is seen particularly in fainting, high grades of anxiety or fear, 
frequently in hysteria, in most epileptic convulsive attacks, and in 



To nvn~wtritttnl jiirt of ^ 



Mvdultn 



Cord 



Clltu-i'i'Inut ^(nlrt. 




L'lltr Ltd 



Dilator Pupilla 

Qatar rian (hinffflon 
aiuM-lf of Miillrr 



MiitdU Otrslrol OanalUM 



IiyferiOT Orirfairtt Oangtioti 



Flu. ts. — DiaKr.'iiii iif niurse of uruliiimpilhio' fil>orwof cervical Hyniputhptic. (Stewart.) 

ct'ntnil cerebrospinal syphilis. Pupillary inequalities are frequent in 
the psychoneuroscs and such anomalies have special significance in the 
study of the repressions of unamscious material. 

2. T he Argyll-HolxTtson pupil is a complicated phenomenon. It 
has already been describe<l. (See Examination.) It is an extremely 
common sign in cerebral syphilis, as seen in tabes and paresis 
particularly. It is occasionally found in extreme alcoholism (Korsaka\i 
l>articularly), and occurs from rare and isolated lesions of the corpora 
quadrigemina. In apes, Karplus and Kreidl have shown that e 



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AVTONOMrr AHD SYMPATHETJC NBRVOUS SYSTEMS 111 

aeveraiK-e of comnii^r^ural H.siiociution filxTs pn^iting in the arm of the 
anterior corpora qiiadriRvmiiia to the aiilerolateral border ()f ihc 
anterior corpus will cause a bilateral reflex pupillary riRidity with 
retention of pupiilnr*' Tictivity for arfommotlatinn. (•on^■e^f;enlre and 
psyohleal stimuli, riirtmie nieninKeul exmlates in syphilis pressing 
upon these fibers may account for the frequency of tliis symptom in 
tabes and paresis. Kxplanatiuiis are ruDHTous. however, and may be 
consulted in the literature. (W'illbrund and SaciiKcr. Die Nrumktgie 
dea .htgef.) 

3. Syrapatbctic paralysis, or llonier's syndrome, is charucteriwd 
by retraction of the bulb, narrowing of the palpebnd fissure, dropping 
of the upi>er and raising of the li>wer litl and mynsis, mth eanscrvation 
of the iwyehiriil ;ind liffht rcHexes i>f rhe pupil. 



Fi«. ^».— Piirtinl Bi-niju-.l 



tj-ndrfjjTH^ of rinhl pyc in «K<>[)hthiilatic cuiwr. 



Topograptiiealiy the picture results from ])ix'ssure on the sympa- 
thetic fibers fgoitcr), a lesion of the cervicfKJorsal cord (hemutomyelia). 
gliosis (syriiigc)en(vphaliunyflia). myelitis, especially' of the up[HT 
dorsal region ( Dejerine— Klumpke, Uudge's centers), thromlwsis of 
tiie posterior inferior cerebellar artery, cervieodorsal nwliculitis. and 
in certain hysterical ctinversion.s, compulsive ties, and psychotic 
projections. 

4. Combinations of the tliri*e jii.st reeii'nleil. 

Tests with cocain and iidrenalin an- of value in determifiing the 
sympathietttropic activity, a 2 per cent, cocain solution stimulating the 
dilator filx'R. A failure to aiu.se mydriasis Is evidence of ^^'eakness 



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112 



VBGETATIVE OR VISCERAL SEVROLOGY 



of tlie synijmtliiftic. ^^'lu■^(■ sucli a i)an'sis-pr(>(!udn^ lesion may He, 
pre- or (jostj^anplinnic. abnvc or briow the su]»erior ccnical ganglion, 
can be determined by the use of a 1 per cent, solution of the Hympathico- 
tonir liormone arlrenalin. Six drops in five minute.'^ normally oau.ses 
no attior. If after fifteen minutes. Iioufver. there is ii marked dilata- 
tion the lesion is ixpstgiingliimic. Ailrenalin mydriasis is frefpiently 
present in anterior and miildle fossa disturbiuiees (orbital disease, 
fraotupe of base). This is through the activity of the sympathetic 
fibers of the earotid plexus which joins with tlie tri^'iuinus at the 
Gasserian ganglion, 'fhus a combination of distiirl>anee.'i of the supra- 
orbital, with adrenalin mydriasis due to postganglionic sympathetic 
[Niralysis. may give important evidence as to the locahxHtion of 
a tumor, or fracture of the base of the skull. Double-side adrenAlin 
myilriasis (Litwi's reaction* is !ilsf» seen in hy|ierth>Toidism, pancreatic 
diabetes, iind in increased irritabihty of the syniiHithctic nervous 
system in genciiil. 

VHgotonic rcailioiis give rise to accuMHiiodiilion cramps with 
hichrymation whicii may be diminished by atnipin. In youth, when 
vagotonia is more pronounced, airopin acts less protractedly tlian in 
older [H'ople. and [)ilocarpin in the eye may cause von Graefe's symptom 
as H sign of an increase in the tonus of the autonomic levator pulpebne. 

There are a number of eye affections whose jMithogeny is in (Mirt 
depemlent \i\xix\ vegetative ner\*e disturbance. Only a few of the 
more ini|Hirt!int ciin Ih' referred to hen*, iiml briefly. 

Glaucoma.- -This serious aiTection of ihe eye. sjR'uking of the acute 
inflamiriHtory or congestive ty|ie, is i\\iv to a ilislurbanee in intraocidnr 
lensiou whicli is largely dependent upon sympathetic control. The 
precise mechanisms are stiQ incompletely analyzed. The adniini»- 
Iration of atropin by its jHiralyzing action on autonomic fibers — 
paralysis of sphincter iridis, ciliary muscle — also i>roduoc3 marked 
increase in intraocular tension, and hence augments the dif1ic\ilties. 
Piloearpin and cserinc ('phys<istigmin). witli tlieir oj)po.sing actions 
on the symjuithetic, decrease intraocular tension and hence alienate 
(teHj|Miranly in the early stjigcs} tiic syntlronie. Kxcision of the 
cervical sympntht'tic ganglion diminishes the tension, and is resorted 
to in the treatment of glaucoma, thus showing the definite part played 
by the vegetative nerves in this alTertioii. 

Jlprjyes vornce. herpe.t ophi}wbuirun, hpmtii'ts neiirnpfirntytim are 
among the eye alVei-tions due to implication of vegetative fibers, 
located chiefly in the trigeminus sheaths, or in the Gasserian ganglion. 
Keratitis ueumparnl.v-tiea occurs not infrequently as a complicatitip 
ill resection of the ganglion, liesd-tion of the cenncal s>Tnpathetic 
seems to cure this keratitis (<'imoroni). 

Acute edemas of the conjunctiva, of the n-lina and iris. analogou.s 
t« Quincke's edema are to Ik" clnss«'d prolwhly with vegetative nen'e 
disorders. These have largely iKen disguised under pseudonyms as 
"rheumatic," or "litheuiic," or "gouty." 



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ACTOyOMIC AND SYMPATHETIC XERVOVS SYSTEMS 113 

Certain forms of accommodation disorders (hypermetropias.niynpiaa, 
spa.sm». etc.), frequently railed "eye-strains" are, projwrly speaking, 
vegetative disorders of the ciliary muscle. A few of them are largely 
jwycho^nic ifi origin. 

Tear Glands. — These are autonomicully innervated through the 
sujKTior oiTvjeal ganglion and syinjxitlu't-inilly through the splienu- 
jmlatine ganglion. Irritation of the neek synipathetics caut^s Increase. 
j>aresis of tl]e same, dimiiiatiim in tlie secretions. The postix'Ilnhir 
branches of the neck gangHii, Hceretory or vasomntcjr fibers, pass In 
the internal carotid plexus reaching the glands either by the wa,y of the 
ophthalmic plexus or thnnigh the ravernuus plexu.s and the laehr\-nml 
sensor^' branch of the trigeminus. The secretion is markedly under 
physical iiiilueiiee us is umversally recognized. 



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Flo. U). — The iniiervnlioii u( Iho snlivary Klunds: t/lp. ]mrc>tiil: aum. miboinxilkry; 
O't, mililtnitutti : at;*. OiiMrriiiri iUiUKli'in. 'i^. linuuiil nor%v: nm. luAiiUiliuLir iicrvc: nVIl, 
fmi'al nerve inirl<'U(i; c)ti. '■Iiorda t.>*mi>aiii; VH. Inrial (icrv-p; tX. Kl<<*s(>f)hiiryti|t»ii] 
nrrw: ns. nurlenm sal ■%*» tori lu: gp, |K>tnwtil Kiitucli'rn ; n. nyinpiilhctir; ra. »yiiit>'illii>tic 
bmnr.h«n; ifr, miiiaixxOliuy gfttiglioii; nh, hypofilmRal RMve; re, ratniui rommunieiuu. 
[B»rhter«w.) 

Mneous and Salivary Glands.— The vegetative rontml of these is 
exercised through the spheuopahitine, otic, subniaxillHry, and sub- 
lingual glands. The sphenopalatine sends only uutononiie vusfxliintor 
HIkts through the |M>slerior nusal nerves to the mucous meniliniiie 
of the ni<se; synipiithetic vasocontrictor fibers come from the cervica! 
sjTnpathetifs, 
8 



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114 VEGETATIVE OR VISCERAL NEUROLOGY 

The parotid gland has both a sympathetic and autonomic suppi; 
the former from the cervical sympathetic, the latter through the ot 
ganglion. The small superficial petrosal is its viator or precelluli 
root, the auriculotemporalis of the trigeminus is its postcellular brand 
The autonomic bulbar center is Kohnstamm's nucleus salivatorit 
inferior. Autonomic stimulation delivers a different type of secretic 
from sympathetic stimulation. Lesions of the tympanic in the mastoi 
operation give rise to parotid disturbance, and may be looked for i 
middle-ear disease. 

The submaxillary and sublingual glands have a sympathetic and a 
autonomic supply. The latter of which causes vasodilator and secretoi 
stimulating efTects has its autonomic bulbar center in Kohnstamm 
superior salivatory nucleus, its rami commimicans albi in the chord 
t\-mpani and through the lingual to the gland. The sjTnpathet 
vasoconstriction and secretory stimulating fibers are derived from tl 
cer\ical sympathetic. Autonomic stimulation causes the full, thii 
water>', salty secretion, cut off by atropin; the sympathetic, the scant; 
viscous (organic constituent) secretion acted upon by cocain, cholii 
adrenalin. Xertistomia (Hadden), xerostomia senilis, xerophobii 
excessiAe production of frothy mucous, constant spitting of mucous i 
schizophrenia (often s\Tnbolic of semen), scanty secretions as seen i 
anxious states, in stage-fright and other tjTpes of fright, sometime 
iniconscious, as in marked depressions, etc., are among the disordei 
of the secretions of these glanck of neurological and psychiatric interes 
Tiie symbolic significance of spitting is extremely complex and fertil 
in suggestions and its study, particidarly in the psychoneuroses an 
psychoses, only just beginning. Cortical, glossopharyngeal, an 
trigeminal associations are the basis for reflex stimulation of th 
glands. 

Neck Sympathetic. — The superior cervical sympathetic supplie: 
tliroiigli the internal carotid nerve and the internal carotid plexu; 
the dilator of the pupils, Miiller's muscle, tear, parotid, maxillar 
and lingual glands, the pilomotors, vasoconstrictors, and sweat gland 
of the face. 

Cervical Sympathetic.^ — Partial syndromes due to implication ( 
parts of the cervical sympathetic fitters have just been described imde 
eye, tear gland and mucous and salivary gland disturbances. Moi 
extended syndromes both of stimulation or of paralysis of the cervict 
sympathctics are frequently seen and arc of considerable importanct 
In militar}' practice cervical s^Tnpathetic wounds are frequent. A 
has been pointed out filxTs from many diverse sources converge withi 
the cervical symiMithetic. The action of these fibers, in response 1 
stimulation or to paralysis, shows a great \'ariety of combinatioi 
such as vasoconstriction, vasodilatation of the cerebral vessels givii 
rise to congestion, hyperemia, anemia, migraine, epileptic attacks, et( 
of the thjToid \'essels, causing var^iing states of dysthjToidism ; of t! 
base of the orbit, causing enophthalmos, exophthalmos; the fundus 



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AUtVSOMIC AND SYMPArUBTIC NERVOUS SYSTEMS 115 

the eye fglaucuma); of the salivary and liiiffual ghititls hariatiims in 
seeretion. xcrostoma, etc.) : of the skiu of the face and head (anidrosis, 
bjTXTidrosis, selxirrhea, horripilution, skin eruptions, acne, eczema, 
anomalies in pigmentation, liair, beard, eyebrows) mtKlifications of 
active un-striped musrle, partial ptosis, widening or namiwinj; of the 
palpebral fissures, rlilntiition or eontraetinn of the pnpils, accelera- 
tion or retardation of tl»e heart action. These results, single synip- 



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Flo. .<il.— IiuiorvMtiuii o( the digKwtivw tmci. (Aflcr Mfllln^.) 

tarns or in variini.s conihi nations, may be prodiioed by lesions in 

the neek, in the (vrebral eortex, medulla, anri spinal cord (tnumiu, 
tumor, syphihs. iniiltiple sc-lenisis, syriiigix-neeplialoniyelia, etc.), in tlie 
brachial plexus, in the ehest c-a\ity (tuberculosis, tuinors, pneumonia), 
depending upon The unalomica! pathways or synapses impliaited. 

The typical crmiplete picture of a cervical syuipathelie stimnlntinn 
will shrjw dilatatiiHi of the pupils, exoplithalnu^s. from retraction of 
the lids and protrusion of the hnlhs, increa.sed intraociibr tension. 



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myopin, siiTHnaxillun' Hnil piirotlil liv[HTse(T»'tinn fsym|i«tlM'tit' swllva- 
tiuii. t!ii<'k aiui (timpHnitnely sparse), ntrrliar nttrltTutinn, vas<»- 
fonstriction of the skin of tin* licacl. iwck; vasdcimstriftiuti of tliL' 
mcniiigt's, the bmin, tlie eyes, thi? mucoiia membrane of t!»e mouth 
am] luiiRiie, ami nf the th.\T«id Kl^nd. 

An amik»^>iii< pirtiin^ nf sympa- 
ihftie iMiralysis (Heriiani-Uomer 
syiiilitrtne), well n^iitrai'teil pupil, 
(Jnniiiishet] intraocular teiisitm, 
abrilitioii of ciliospinnl reflex, loss 
of eot-ain ililatatitm. n'tnictitm of 
tlie eyeballs (eiiophthalmos), h.^■pe^- 
metropia, loss of hister of e^, 
slight ptosis from palsy of Miiller's 
muscle, pasily overrome hy volun- 
tary aftion of III X, dilatation of 
llie amjunctival ^'essels, ltomi> 
lateral rij;e in temperature of the 
side of the face, increase in the 
lachrymal se<Tetions, Kialorrhea 
(thin, watery secretion), slowinj^ of 
the heart, ani<lro»is, and seborrhea 
sicca. 

Vegetative disturbances in 9.\na\- 
lowiuR are eonimonplaecs of every- 
day incdical practice. The universal 
so-called "hysterical globus," "the 
lump in the throat," which Demo- 
critus desml>ed as the wandering 
uterus, is one of the most familiar. 
It is a very etunplrx ptifiiomenon, 
aurl it.s etiology is multiform (psycho- 
Rnal\tically siK>aking, much over- 
determined). Ill the psyehoneuroses 
it is often a symbol of disgust, a 
surrogate for ^(lmitillg, an uiicon- 
snous remnant of infantile fowl 
impregnation fantasies; again il is a 
syniptiHU of fear (inferiority s>TJibi>l) 
largely determined by the unconscious i»ei'piiig and exhibitionistit 
infantile trends. 

I^x-al con.strietionfi of the esophagus are fre(|uent!y met with in 
neurotic individuals. The areoin]mnyirg j-ray phiiiograph show; 
such a variable strii-tun- due to vaj:otonie ilisturhaiict ii] a cas( 
of anxiety hyslcrisL in tt-liicli nnnination was u prominent fcatun 
and wliieh cfnild \k induee<i by irritating the patient by even th' 
simplest forms of contra -indication. 



Via. 52. — SchiMnnlic arriiniw'iiHMil of 
cudUr iipr\t^: n.V.rhief motor nuclnia; 

In, *U(tfirii>r lurynKciil dfrvit; a, t^nipa* 
llwtlL'; pin. solar i/lcxus: pte, fafii-ir 
jjlexm; J.iipjipr itmrr liriiinli Ki htwrl, : 
S, SKV-tfl^WBlor; 5, itttonial iiif<?rior 
Watii'li; i-'uiijior and iiif<'ri<jr rxU'raul 
briicipli; 6, Ari«;i VioiL-owJiii. (Befh* 
t^tri'w.) 



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AUTOXOMir AND SY.XfPATIfETIC XERVOUS SYSTEMS 117 

Gastro-intestinal Syndromes. — TKe vagus plnys siit-h a large role 
in llii">i* distiirbaiitvs tliat a ffw wortls iiiav !»' said i-tiinvniinf; its 
stHK-tiiri- (Fig. i^y). 

The vagufi like tin- oi-ulctiiiotor, glosiMjpharyngeul ami facial Is a 
mixed nerve and contains motor, sensory and uutononilc fibers. The 
soniatumotnr ntu-k'Us is the tiiichMis tiTnhicinis; rht' luielfiis Sdlltarius 



Tia. ^. — Vagriionic I'duiractiun of c»ophMitU». 

1ft the senaon* nucleus; the vl.seeral nurleus fcir llie heart, lungs, and 
dip.«tive system is the nucleus dorsalis vagi lying on the Huor nf the 
fourth veirtriile. AH thrre sets of fibers travel thruugh the jugular and 
nochwtis gunglia tw fnnii the vagus, the jugular ganglitm j>n>I>ahty 
forming the synapse for sympathetic eiiruier-tioiis and aiiasttiniosi's. 
Tlie two gmiglia ixiiiit to two nerves phylogcnctieally: {a) The pure 
motor branches arc the rami pha^J^lgeus; {h) the pure sensor}' branches 



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lis 



VEGETATIVE OR VISCERAL NEUROLOGY 



are the meningeal and superior larj*ngeal; (c) the mixed motor- 
sensor>'-visceral is the recurrent lar^Tigeal sending motor fibers to the 
larynx, receiving sensory fibers from the trachea and the visceral 
fibers supplying the heart, aorta, and vessels of the larjTix; (d) the 
purely visceral branches pass to the digestive tract, the heart, the 
liver, and the lungs. 

Only the \'isceral branches will be taken up here, the motor and 
sensory l)eing discussed later under the Cranial Nerves. 




Flu. 64, — Innervation of the mcchaiusia of swallowing: Sn, substantia nigra; Vm, 
n\nU)T nucleuB of the trigeminus; V's, sonaory root of the trigeoiinus; /Xm, motor nucleus 
of the glotMopharyngeus; A'//, nucleua of the hypoglossus; X», nenoory nucleus of the 
vagus, pm, soft palato; apa, palatal vault; app. pharyngeal vault. (Bechterew.) 

Esophagus. — The entire digestive tract is served by the sympathetic 
(narrow sense), whereas the vagus (autonomic) only supplies the lower 
two-thirds of the esophagus, the stomach, and the intestines to the 
descending colon. The combined action is stimulating (autonomic) 
and depressing (s>Tnpathetic), which actions are apparently reversed 
in the case of the heart muscle. Local gangUon ceils seem to regulate 
the motor functions. Tactile and chemical stimuli are apparently 
unresponded to in the upper part of the esophagus. Thermal stimuli 
above 40" C, below 30° C., are felt (Boring). Deep pressure sensi* 
bility is present, but the pathways are not definitely located. The 
lovf^T end of the esophagus responds to chemical and thermal and 
possibly other types of stimuli (Heart-burn). 



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AUrOSOMir ASD SYMPATHETIC NSRVOV.S SYSTEMS 119 

Stomach and Intestines. — I-^h-hI gaiiglimi wlls in tlie walls of the 
dij^csiivt* trail art" vi-ry frtqut-nt and arc to l>e rcgardeil as the terminal 
motor neuron of the veR^tative systems. (Sih; Fig. 40.) The slimiaeli 
is strrtiigly under a^somtive relations nith sight, hearing and smell 
iind it.s HlT»-ft fpsyt'hiod) reactivity is extremely sensitive. Ordinarj- 
senhihility Ui tactile and themiid stimuli are luckinu, but deep seti.-^- 
hility filx-rs are pr<'st*nt and carrj' 
pressure stimuli (pain, colic, crises). 
The pathwaj-s used (or these are 
pmbahly throngh the vagus (stimu- 
lating) and the splatu'hnics (inhib- 
iting). Fig. 4*> .-^liows the distribu- 
ti<in of the vagus 6bers (Fig. 50). 
Thus both autonomic and sympa- 



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fui. &y — SehMM of Htonuefa iniMtrvu- 
ikm ; «. h, Bsnclia In Willi ol the •tomnoh : 
nX; tmifttty (iucImm af lh« vacua: nXm, 
■Hrtor roul of tbv t«k<w; n«. ■itl«whnir. 
(MMllWnw.) 



Fr«i. 56. — 8dicm» o( iatMtiual iiiaervft- 
tifin: I'l, smftll intastlBe; r. loirpr ixul of 
t)i« Unp) inUvUiw; pl^, rvlixc pIvKuv; ptk, 
bypociwtno pirauii: »p(, (tpbiirhnic; c,t, 
ffpinsl c9Dt*r ijf iiil^xUnnl inokonitfulA; .V, 
vaipis; nXtn, mnbur iiudMiH of thn vu^tiM', 
*|jr#, MOtoiy nurlrus of t)ie> vkioh. 
(DochloPew.) 



tlictic nystems are utili7<-d. Kppingcr and Hess ha%*e seemed to show 
tlwt in tlie lar>iigcal. bronchial. cMiphageal. gastric, inte^iitud, genital 
and nrtal <-ri:*t's. in laU-s ixmiculiirly, the autonomic .system cmly is 
invo|ve<l; the vag\is bulbar airtononiic for tin' upper ty|)e:i, the pelvic 
auti>mimir serk* for ilie lower ones. Fcwrster desrribcfl vagus ami 
]hiiu4imc (?) rrbcs. Tlie former are with«mt pain, hut with nausm» 



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120 



ITATirE OR Vise} 



^notxxiY 



h^TMTspcn'tuin. ami \e]iiiitirijc, the lattrr with jHiiii iiinl liyperesthetio 
skiti zones, and jricn-jtst'i! epigastric mid iihdniiiinal reflexi-s. 

The loca! tupo^rHphieiil lUnjjiiosis an<l tlic physiolngieid iiiiderstaild- 
iiijC uf iRTvaus liyspt'psias, the motility ami secri'tcry aiit«ii!ilies 
(Hchylidf hy]X'r«'(Tctioii. hyixTiicidity, inerfnse of gas. ptoses, h<mr- 
glass ctmtractions}. '-Imuges induced in Addison's diseuse and in exoph- 
thtdtnif porter and m ail of which s\Tnpathetic (psychical) itxflueiu-es 
play a large role is as yet not thoroughly analyzed, itadiographic 
study is aiding in u kuDwledgi- of lliesi- iiiicmtrilies, e.si>ecially the 
motor OIK'S, bill the altenitlims seen must he interpreted as ratitU* 
and not a,s cnvjte«. The emotional, t, e., i>sychicnl factors are the 
iimws, tiie nnnmalies the results. After years of inahidjtislnirnt 
permanent changer* rrsult and a vicious circle is established in whicli 
cause and result are incxtriciibly intemnvcn in their general effec-ts. 

Indiviifuai and social ailjitslmeiit at psychological levels seems 
to influenre them much more effectually than measures addressed 
to mtnlify the per\-erte'd chemisms and motility, especially at the 
heginning of thc-^c ilisonlers. Then- is little doulit that [ong-cunti tilled 
psyrhira! distiirlunires uliich cause vcr\ pronouin'ii! s<*rretory and 
niutur anomalies may ultimately induce deiinite structural changes. 
Many visceroptows are uf this tytK'. The relaxation is due to irregu- 
laritie.s in the reciprocal innervation of the sympathetic and autonomic 
pathways, inrluccd in many instances through psychical mnladjust- 
merits. Possibly toxic factors may ultimately play an important role, 
or put iti another way, in certain patient-s the emotional factors are 
un<loiibte<lly the primary one.**, in others it may he, although this must 
he proved, mere asseveration is not sufficient, toxic factors (intestinal 
alhsorption) may pl!a.\ tlte primary role. Speaking of the intestine as 
a "sewer"' is for tin- most part nii incorrect figure uf speech. 

The vagus, by way of the solar ganglia, stimulating the terminal 
neurons, depresses the |>erEstnlsis and secretions of the intestines. The 
intestinal movements, however, may take plat-u independently. The 
tactile-niechanism-retlcxes arc continuously a<'tive; chemical reflexes 
arc opcrali\c during the jHissage of absorptive material. Kach have 
their sympathetic and autonomic pathways— working independently 
one of the other. The chief psychoretlex pathways seem to act 
thR)Ugh the vagus; thus at the upper end such psyclioreHex activities 
show increase of .secretion with apj»etite, loss of secretion with worry, 
fear, and, ai-titigoii the HUtiiEHiiiil<* pchic arc, the various constipations 
and diarrheas sr> fret|uently of psychic origin; the anal erotic and 
anxiety nenrr>sis phenomena so well elaborated by Freud being among ' 
them, Purely syn»imtlietic disturbances with increased peristalsis 
and serous Huid may result from loss of function of the splanclmics, 
citlier as a vital reaction Ut cutting, trauma, etc.. or to psyciucal 
influenees, as from shock, emotion, fear, and desire; possibly from 
toxic reflexes, hyperthyroidism, anaphylactic .substances, inte.stinal 
putrefactive products, etc. 



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AVToyoMir AS'h syhpatuktic SRRvors .fv.'^TEMfi 121 

Th<^ frrrat iai|>i>rtaiKt> r>r the Hiitititfunlr and synijmlliftir coiitnil 
frtiiors nil the vt^sst'ls of the abcloniiniil cavity niiil orpins cHiiiiut ho 
more than meiitiunt'd. Mltc the pmpheral vasculur rcKu'utioiis are 
ill liirect cntitriist with the ahdotnitml ones, ami Iienct* the purely 
mechaniral hihI vital process i>f ad jiistinetit orhloiNi-prcsdurereKtilatiori 
takea place. The interpretatinn of the phenomena nf shuck must come 
ahiiut through a study of these facti irs. hut such lannut be taken up here.' 

Another feature of uctJvily of llie vej.ftntive nervous system concerns 
itsflf with the ga^slro-ititestinal fernieiit'i, and the speeific s*Tretions 
or hormones ((rastrins. i^strosecitline. enterukinascs of the various 
authors). Many hormones of the endocrinous (jlands umlouhtedly 
influence the jiastro-intestina] functions. The diarrhea of exophthal- 
raie goiter ithyreoghihuhm is a classical example of this influet)0«. 
fJastric uli-er, duiHlenaJ ulc-ers rejiuHinn fnmi iriereasiii iidreiuijin 
activities are otJier less compreheiuled reiu-tions in tliis important 
field. Ilrre the adreuHlcrnia is directly under autonomic control and 
is largely a resix>us<' to f'.iir — conscious mid more temporary, uncon- 
:ious and usually more persisting. Hence when it is said tliat these 
'disortlers appear in asthenic states, this means the asthenic states are 
usually uncoiLscious fear states and arc interprctahte through ])syeho- 
niialysis. 

Westplial lias shown further t]mt in a large number of i»eptie ulcers 
he has nbttervetl the signs of vegetative disonler such as dtlntcti pupUs, 
rxophthalnius. increased secretions, hra4lycardia. si>astic constipation, 
iiicren-sed vascularity of the th\rt)id, h>ss ()f aUlnininal reflexes, increase*! 
knee-jerks, strong reactions to ndrciiHliii, ntropiii and piltH-arpiii. Ac- 
ifimiiaiiying s>iiiptonis of vegetative nature were gastriwuccnrrhea, 
pylurospasm, hour-gla-ss iijutraction. 'Hie gastric miieoua mem- 
hrane contains a hypothelicul hormone which innuences the activity 
of pf.Tistalsis (peristalsis honnonci llirougli the syni|jathetic imthwaj-s. 
Ilortnono] as a definite sulistance has enteretl the theraiR'utic tield of 
iieurokigy anil promises much material for spet^-ulation and interpreta- 
tion at least. l)irect indications are slowly cn.'sta!lizing. 

R«ctmn, — The chief innervation is through the heinorrhniilal pleXll* 
and lIic inferior nies»-nteric. Hoth autonomic ami eerehrospinal influ- 
eim-s arv aiiive. \'«luiitary muscle activities play a large role in 
i]ef(*eation, the grafle of tension in tlie rectum, however, is r*'gistered 
by the aulonomie system, which is resimnsible for the original impulses, 
a/tcr which voluntary and involuntary activities are operative. The 
spituil uutonoinic center is located in the lumlnKsacral spirud segments. 
The citrticrtl association connections an- thought by B<'*'hterpw to be 
in the signiiiid g,vnis. Krfintal assiM-iation pathways are also present, 
interference with wliieh causes involuntary defci-ation, as in frontal 
tumor, genenil pan-sis, epileptifonii ei>nvulston, pn»f»und stii|xir. 
emotional loss nf control, etc. 

• Cunrall fiib: Htuit)- of the Enurtfanu. Pliilnd^tiitiui. lOIA. 



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122 



VEGETATiVE OH VISCERAL SEVROtOOY 



Interruption i»f spinal pnlliwiiys uiay t-auaf obstipation or dinrTlica 
(t«bes, poliomyelitis, multiple sclerosis, tumor, syphilis of curd, 
heniatomyclia, syringomyelia, etc.). Here deep sensibility conducting 
filMTS^autonciniif ami cerebrospinal— arc; interfered with and the auto- 
nomic reflexes fail to establish tlie psychical eoniiectiuns either for 
cfinipnisinn (discharge:) or cr>ntm] of sphincter (relention). The anal 
rcHex here i^( of jifreat localizing vaUie, itK positive a])pcHranc-e ruling 



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Fio. 57. — Scheni* o( polvic innorvation: c^. apinsl c^DitMl water; In. first lumbEir; 
», gym pa the tic; cl, roniut; ith. ik<c>bypoKaatnc; i/ini, iiifrriur inc«ffnt«n<.- Ki>(M{li'>n ; pAp. 
h)'pDKB«trin gaiiKliitn; plH, hyt>ri(t&.'(Lrir ptoxud: \fhm.. tiomnirhoiil&l )pknij1ioii: nh (u.bo\'B], 
liy|io](iuitrir nrrvp; nr, siM-rui Herv«; b. eriin>ri»; npr, iv)mm(»n pudorxtnl; nk (twlow), 
hcman'hciidtil luirvr; ndp, dunvilui peuu; n/'jj. ilL>e(t iK^riucol; m, liladdcr; bbt, mroixark. 

out .somatic di^nse of tbe lower sacral and coccygeal segnients. Lesions 
of the cervical or dorsal con! interfere with the voluntary activities 
of the abdominal muscles in ilefccation. while lesions of the lower 
lumbar conl cause changes in the voluntary sphincters. In sacml 
lesions, with involvement of the external sphincter nucleus, ttie auus 
remains wider open, not so sharply corrupitwl, not as vigorous in 
closing and there is loss nf the anal reHex. Notwtthstantling the loss 



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AVTOSOMIC A\r) SYMPATHETIC \EHVOVS SYSTEMS 123 



»tiii 



of the voluntary sphincter, Rntunoriiic closure i^ possible. There is 
tlierefore no single deft'cation center in llie luwer ecir<l. 

Severe constIi)atioii may be of purely autouumic origin. This 
constipation reaetion may occur at physicoehemieal levels, such as 
those fine to excessive absorption of water; at vital levels, r. e., resulting 
from pain from kiihieys. );a II -b lit i liter, peritonitis, elironic apiK-ndieitis, 
hemorrhoid's; tir at purely psyehical levels, where infantile pleasure 
ijliHiitttsics may play a larpe role. i. c, anal erotic in displueemenl of 
ati'ei'ts, birth pliunlasies, etc. Birlh and death phanta.sies which ileal 
with feces, and wliich are eoneealetl behind eiwistipatioiis and diarrheas 
are very frequent among psych4>neurotics and psychoties, particularly 
in schiz4)phrenics, y. v. In sehizophrenics frequent fecoi discharges, 
fecal .smearings, fecal eating are symbolic activities for which the 
psychoanal>'tic technic often reveais the psychical equivalents. The 
anatomical pathways which make ^ucl^ relation-sblps comprehensible 
exist in the autonomic fibers. (!onstipation as a correlate of miserli- 
ness is an inst4inee in puhit, and is mure fully tliseussed in the chapters 
on the Psyehoneuroses. 

\'agotonic manifestations within the gastro-intestinal tract are of 
eonsfderable unportance. althougli us yet far from being definitely 
analyj'.ed. Pilocar|)in and physostipmiu increase them, whereas 

renalin and atn>piri dintinish tliem. In vagotonic intlividuald there 
increased esophageal cardiac spasms, tendency to increased 

livation and to increased secretions from the nose and eyes. There 
is slowness in the peristalsis, as shown by radiosnipic examination, 
due to increased nmscular tonus, 'lliis latter causes the stomach 
form of hy]ierkiiiclie motility gastnHieurosis. It may arise from 
disorder at the physic cK-hemical or psychical levels. HyperseiTetton 
and hyperncidity are accompanimenls with pylorospa.sm. Certain 
eerebrospinai levels seem to be invohed, as sliown by llie Head hy|XT- 
aensitive i*kin areas. Membranous enteritis or colitis with mucus and 
many eosinophile cells in the blood and raucous secretions is associated 
with this condition summarized as vagotonia. Here psychical influ- 
ences are of great moment. The constipation just spoken of may be 
arranged in this vagotonic group. Ilenal and biliary colics, spasmtiitic 
jaundice, reflex anuria, eosinopbilia, and increased glucose tolerance 
are to be found in this vagotonic gronp. 

Diarrheal states in hyperthyrobdisra, in anxiety neurosis anil in 
various systemic toxemias (acidosis in children) are mediated through 
vegetative mechanisms. Involvement of tlie syuipjitlictic lUH-lei in 
the cord by poliomyelitis may cause severe diarrhea and constipation 
symptoms. 

Oenito-urin&ry System. — Here autonomic and cerebrospinal controls 
are in evidence. The former act through the mesenteric, bjiHigastric, 
and hemorrhoidal autonomic sacral ganglia, supplying with non- 
medullated fiWrs the involuntary muscles and the muitats membranes, 
N. hN-pognstrieus to muscles of colon nnH bladder (sphincters), the 




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pli'xus t-avernnsus. ami ncrvus cripens to the genital vasomotors. 
The latter aet ihnm^Ii iiiaiullateit filH'rs to the vohiiitary muscles and 
ndJHceiit skin ureas. 'Ihe nervus pudeiHln.-* ciimmuni.-* supplies the 
external sijhlneter ani. external sphineter vesirte, eompressor urethra', 
deep i>erinei, etc-. 

A series of autonomio reflexes are here met with, the most important 
being: 

1. Scrotal reflex: Stroking of iJerineum or femoral skin; con- 
traction of dartos. 

2. liJaddtT Ffilex: Stretching or stimulus (me<.-hanical, psychical) 
of bladder wall; contraction of bladder (mcchanicat, ().\vchicai). 

3. Itcetal reflex; Stretching or stimuUis of rectum; contraction of 
rectum. 

4. <!enital reflex: I'sychicai or mechanical stimulus; erection and 
hyperemia; corpus caveruosus, 

o. Ulenis reflex: Stretching or irritation of utenis; (i>n traction. 

(>. Anal reflex: Stretching of amis; psychical; contracture of 
sphiiic'lrr ani. 

All of these reflexes act through psychical levels as well as througli 
peripheral, i.e., somatic ones. 

Bhddrr.—'i'hv geiieral mechanisms of the bladder i>atterii after 
those of the rectum and (inite homologous symptoms follow disturl*- 
anees of homologous relationships of the autonomic and spinmerehral 
pathways. The chief autonomic s<n-ies travel in the sjicral ve.sical 
nerves to ami fmm the inferior mesenteric and lupoga-strie ganglia. 
Sympatlielic filx-rs are also functionating thnnigh tlie hyjHtgastric 
to and fnmi the inferior mesenteric ganglia. Thus the bladder has 
a vegetative mechanism comparable to tliat of the pupils. 

Kniptyiiig f)f the hladder follows similar lines to that of emptying 
of the rectuHi. Scctictu i>r the cord to alM>ve the ntid-dorsal region 
brings alnrnt automatj*: emptjing. Psychical influences " are here 
active as in the case of the rectum ^urethra I enitic with retention and 
incontinence of purely psychical character, 't'hese are riiscussetl unilcr 
Psychoneurase^, whereas the more mechanical, neurological features 
are taken np umler Diseases of the S]>inal Curd. 

SexiKif (hgmnt. — .Autonomic and sympathetic supplies are present. 
The fornner carry stinndi thniugh the nervl crigentes from the sacral 
e«»rd, producing \asudilutution and erection, turgor in the female, 
nipple erection, etc. The latter carry stimuli through the hy])i>giustrie 
nen'c to cause vasoconstri<-tion and cojitraction of the unstrlped 
musi-ulature of the sexual glands and discharge channels. In the 
act of copulation, desire, erection and ejaculation (orgasm) may show 
separate mfchanisms. \\ the jiliysicochi-mical level the concretization 
of sexual desire usually reaches an active adult stage with the oaset of 
puherty. It is a.ssume<l tlial chemical stimuli — hormones— act at this 
level to cause tension- — tuinesceni'e — within the organs themselvtst, 
and also possibly working up<m higher level nervous structures 



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AUTONOMIC AND SYMPATUETIC NERVOUS SYSTEMS 125 

c^iLse .111 inftease in vital ami psychical tension, therohy causing 

in(T»*a.-M^l sensilizatidn ttt sensfu-y {MntJirts and to mental stimuli. 

ITius the love inipul^^e springs uj) at n tfiueh or iiiuler tlie iniluence of a 
^-Avniholic exi)ressi«n, as in jKietry, or other artistic creation. 
^B The whole impulse of life and of tiie principle of race-preservation, 
^n. e., tmmorlfility. is bouml np in the iiLitinct of repnHlnction. The 
Bcner^' of this inslinct has l)een temieil lihido l>y various writers, by 

otiiers the word is used in a wider sense, as sjiionymous with the life 

■rnerRj' wherein one can distinguish » nutritive or self -preservative and 
U sexual or race-preservHtive aiiniwnrnt, 

rertain hints oMoincI from the study of the processes of reproduc- 
tion ui lower orpinisnis prtitozoa. protopliyUi -tend to show that 
tlie continuance of the life of the indivitlual and of the sjjccii-s has lieen 
obtained through a sacrifii-e of the ego. Purely individual reproilucti<in 
fTflve way to gametic reproduction, (, e., to the principle of fertili7.atinn 
Mby means of budding, etc., by sexual pmeesses. 

H To put the iiiiiItiT in a few wnnis, the process Ims been something 

like this: Tlie original nnicvlhdnr organism was all-sufficienl, the 

H amelMi, for example, performs all of the functions of ingestion, digestion, 

Hegestion, and reprotluction with practically no structural differentiation. 

~ To Ik- sure, there are certain <liffereiiees in dill'erent part.s nf the pnrto- 

plasra, but they are relatively inconsiderable, and after all, all of these 

functions are earned on in the single cell. Correspiuidingly this single 

^■cell is practittdly immortal, that is. it only ilies as a result of accident. 

^pi'be inunorlality is secured at tlieex|K'nse(irdiffen'titiH(ioii of structure. 

Immortality can only Ik' attained in simple, all-sufficient, unicellular 

organisms. In dc^■cIopulg fnmi this primary condition one of the 

first steps U a union of a group of cells, forming a more or le-ss loosely 

integrated organism. As evolution )>rocee4]s, however, this integration 

becomes nmch more definitr and along with it there goes ditferentiatinn 

in the functions iind correspondingly in the structures iif the diH'erent 

eellt, so llmt there U'gin to be cells which are set aside, so ti» s|>eak, 

fiff digestion, others that are set aside for reprmluction, etc. The 

^rells w differentiate*! ore x*ery much more effi<i<*iit in the performance 

^^of their s*-venil fnnctions than the original uhdifferentiatc<l ivll wa,-i, 

but eB<h cell »> differentiate*! has rea<hc<l its excellence at the exi)ense 

^^of giving up (sacrificing) its other functions and developing in this 

^■oiie particular way. The arlvantage gnine<l Ims been that encb cell of 

^■thr gnaip received l>etter service, so far as each function was cinitrmeil, 

^pthan iH'fon*. but eucli cell had to sacrifice soinething of its oun inde- 

pendctHV in onler to get this advantage, aial in nuikiug this sacrifice 

^-IierhapN the most impiirtant thing which it gnve up wa.H its practical 

^1 inimnnality. Vieweil from this angle it is maile apparent that death 

^m ilwir has Ixm a<iiuircd h\ rmturHl sek-etion U-eauHe of its arlvan- 

j^ Uei'M. highly complex inilividuuls soon ae<-umtdatesainuu-h piist that 

It IS (listincily advanlageMUs lo MTap tJiem and make a m-w start; 

hen^T. (uii III deatli comes life, u eonlnust eonstuntly met with at the 



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12G VEGtiTATiVB OR VISCERAL NEUROLOGY 

synibolic level. In the hiphest, most rnmplicatcd orjiani/^tions. there- 
fore, each cell, while it has a ctrtain imlivlduality. is highly specialized 
and therefore has only a relatively short siMin of life. It lias given up a 
fCreal deal in order that the community of cells of which it is a part may 
profit. In the prr»KrePS of evolution the protT-SA of selection l-s Winy, 
so to speak, slowly transferred from the single cell to the larger group. 
Each function, therefore, wliether of an organ or only of a single cell, 
may !«; looked at from the double point of view as to whetlier it 
ministers to the preservation of the Individual organ or coll as such, 
or whether it miuisters to the preservation aX the whole organism, 
and therefore it may again be seen that both nutritive and reproductive 
activities are represented at all tliree levels, the phy.sicochcmieal, the 
sensorimotor, and the p«ychic. 

Inasmuch, however, as vital energy* acting solely through physico- 
chemical ]»roc('sses <ioi'.s not afford any adetpuite ex]>liination for nil 
and least of all for the most im|x»rtant <if the jdieiiomenu of evolution, 
an adequate hypothesis must also include similar activities at higher 
levels. /. f., vital and psychical. Tlie out-and-cmt materialist stops 
nt the lowest levels, the vitalLst midway, the evolutionist argues for 
the leadership of the psychical, but needs the interrelationship of ail. 
Psychical impotence with Intact organs, for Instance, is inexplicable 
on materialistic h.>TX>theses. 

.■^een from another angle this vexed subject of interrelationships is 
well illustrate<l in the large disease group of schizophrenia (dementia 
pretax). From the psychical side jilnnc some have endeavoretl to 
explain it as a series of reactions to reitressed and unconscious sexual 
activities — repressed and unconscious Iwcnuse of higher cultural 
demands and inability on the part of the patient t<» subliniatc. t. c, 
emitlny his libido in its mmicrous useful socialized transformations 
arrivcfl at in the course of cultural development. A compromise situa- 
tion adopts the Interrelatory h^TiothesiH. lieasoning in such terms 
the interrelatlonist says that schizophrenia is a disorder occurring 
in certain inferior indivuluflls; inferior because of certain structural 
flefecis of the gonadal or other endocrinous systems (tt^tes, ovaries, 
pituitfiry, etc.). These disorders induce changes &% the metabolic 
(physicochemieal) level and thus bring about the disease, wtuch 
because of inferiority in these endocrinous glands, chiefly gonndal, cause 
a syraptoniatolog\ nliich is hugely tinctured with sexual concepts. 
'Hie Alxlerhalden pregnancy reaction— ovarian, testicular, hormone 
changes— shows, in some cases, a jicculiar activity with schizophrenics 
pointing tu some disturbance at the physicochemieal level, although 
all of the confusing contradictions in technic have not yet permitted 
any positive statements even as t<» these results. To the student of 
(he problem fn»m the psychical siile it Is difTicull to compn*Iieint how 
changes in chemicid reactions will determine a fairly constunt mental 
pii-ture which jjsychoanalysis shows to be largely occupied with sexual 
s^iiibuliKatiou with its con9e<iuent emotional reactions. The increa»-. 



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AUTONOMIC ASD SYMPATHETIC NEnVOVS SYSTISMS 127 

ing evidence showing that emotional reactions can produce somatic 
modifications, as seen in hysterical conversions, compulsive substitu- 
tions, and psychotic projections, teiuls to throw the proof over to the 
))sychical side, with the compromise situation that lioth somatic 
inferiority and i>sychlcul syniholizatiuiis are iiiterrelateil and more 
or less reciprocal phenomena. The student by keeping his mind open 
and thinking in these various terras will certauily gather more real 
information from his patient than if he held to one side only of the 
problem. 

In the phenomenon of crertkm one sees tliese principles at work. 
The cerebral or psychical Is the most frequent soiiri'e of origin for viisii- 
dilation. The pathways are by means of the cnrd to the np[>er luml>ar 
segments and by way of the erector nerves. In severe spinal Injuries 
psychical erection may remain intact; >ievere continuous priapism 
is not infntpiently of pun.'ly <rrel»ral origin, either organic as jn 
encephalitis, non-purulent or purulent, syphilitic (paresis), or possibl}' 
purely psychical as in some manic states, some sdiizophrenics. 

Sensorimotor levels respond to the sensory stimuli of the skin of 
the penis or adjacent organs, and the reflex pathways are made up of 
the spinal sensory nerves, the second sa<Tal segment and the dorsjdis 
penis and pudendls communis nerves acting through synaptic junctures 
In the sympathetic ganglion. Transverse lesions of the i-erviral dorsal 
coni may also induce priapism. Certain i-ases of eneepluilitis just 
mentioned show rervical crinl lesions o-s well. 

The physicoeheniieal levels respond to the tension stinndi fmni the 
bladder, .seminal glands, etc., acting through the hypogastric 
plexus. 

!n rjncuhtiov. sympathetic and cerebrospinal pathways are utilized. 
A suinnintion of stimuli, actinp thn>ugh tlie .s_Mn pathetic. fi>rfes the 
threshold, setting free a peristaltic contracture of the va.sa defercntla 
with the accumulation of genital secretions in the pwistalic portion of 
tlie urethra. A spinal reflex causes the contraction of the bnlbii- and 
ischiocavernous nui«.'les with the ejaculation of the semen. 

SjTiipathetie distiirlmnces are rare, spinal ones not infrequent in 
conus lesiotis, cither In-ltig tranmntit- or dtie to new growth or infiltrating 
disease, tumor, syphilis, etc- Kjaculation In coitus, in masturbation, 
or in ptillutioii dreams is usually accompanied by other autonomic 
signs, such as inydriasis, }i,\-]»Tidrosis, and cardiac palpitation. Pollu- 
tion dreams have <ieterminants at all the levels rnentionotl. They 
are usually not harmful. When fre((uent and evidently pathological 
they may arise from lower level stlmidi (prostatic disease, etc.), 
but are more often of psychical origin— usually acctmiplishiug the 
reiirt^ssetl and nniTinseious wish for euUurally forbidden se.\ual activi- 
ties (masturbiitory. homosexual, Incestuous, or l)estiallty phantasies). 
Hence their great frecpiency In the psychoneu roses, in schixophrcnia. 
or in compulsive states, unless some other type of symbol carries out 
the forbidden and repressed wish. 



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128 



VISGBTATIVB OR M.SVERAL SEVHtJLOOY 



/nrs 



VO!: 




RespirfttotT Appuatoa.— Complete dnla are imt a\ai[iil>jt> fcir ijefinite 
|)lnttirig of thi" vegetittivi' iien'e phj-siiilugj' in tliis region. Autonnraic 
vnj;us filM-rs, Hctiiig tlirough the siiiK'rior iHrvtificjtl, trHchral, and 
hnmc'liiiil ncrvfs, iti<luct' reflex aiu}:hiiig, inHuumiutory rfiu-tutn.s with 
iiuTcas*' of mucus, etc. Somatic HIhts are conccnicd as well. Potteiipcr 
has shown the (fwat imixirtamt* tif the stufly of the vp(:etittive ner\*t>us 
svstetn in tut>i'rciitosi.s.* His puliation sign is one of the proofs uf 
the protective nutnnomie pesponsc Psyehical determiners probably 
play H lar^' part in this liiscH.w in HfTectinn the vegetative resistance 
to the tubercle l*aciUtLS. Hysterical coughing utilises the autonomic 

pathway-i. Astlunatic attacks, with 
-Spasm of the bronchi, difficulty in 
brc4ithiiip, slowingofrespiratorj' phases, 
emphysema, and eosinophilic sputum, 
are illustrations (if incrtyi-sed vagotonia, 
liena' relieveil in part by adreiudin. 
Here the exciting causes may also lie at 
any of the three levels. Physicocheiii- 
ical (parathyroid with tetjiny, calcium 
metiil>olism), sensorimotor (from press- 
ure phenomena on Iar\'ngeal and bron- 
chial nerves, reHexes from niose), or 
psychical (emutions, sexuiil excitenieul, 
rvjiressed sexuality). The problem in 
treating asthma is therefore to find 
wiiich nervuuH systeui level ia chiefly 
implicated. I'sychoaiia lysis would l*e 
folly for those asthmatic attacks which 
are due, for instance, to cheesy, tuber- 
culous deposits pressing upitn nerve 
structures in the posterior me<liaslitiuni. 
while it alone would rcntedy those 
o^^thmas that arc of ])syclucal origin 
solely. Combined therapy — interrcla- 
tional— is of greatest value. 

Cheyne-Stokes respiration is found 
in a great variety of piLthohigical states 
such us high cer\'icfil myelitis, hemorrhage of the imthilla, hem- 
orrhrtgf.' of the Imse, tumors oF the luidbruin region, and occusiuiially in 
certain cortical atrophies or henmrrhages. It is rarely ]>rcscnt in 
certain hysterics. Snorting, barking, coughing, sneezing, hic-c()UghinK 
and yawning are fre<]uent n-spiratory atfe^-tioiis. They are for the 
must part psychical, but not always. 

Vascular Appara.tiLS.— Only a brief outline is possible, altljougli the 
study of the iiirdiac activities lies miistly in the vegetative field. 



1 6h PotioiMRT; CIEnicul Tubprculwu. 3017, Mosby, St. lAUiw, 




Kui. Bs. — iSchpmt' of tunprvation 
of brvntliiiiu; D. dUtphnuttQ ; rv/, 
|ihr\-nic tten'c: A', aonaorj' vapis 
lirmifli-c-'i* to thfi ltinitJ!i; tr, nttpirm- 
inO' iiutViiH ill iiicihiUii; nXa, tmi- 
wir>' mii-loiui of the vamis: nrr, 
mipimtijr>* iTiiIrr in luidltnun 
rvitiiin. (Bechu-rew.) 




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VASCULAH Al'I'AItATVS 



129 



Beut. — SviniMitlictif, autoiioinic, untl iiitra^an^Iionic- iiifrluinisnis 
are present. The sym]>athctu; jMithways ariw fnun I)! ."i. WrisWrg's 
Kuiiplion is the first syiiupsf. the postganglionic AIkts iMissliig to the 
heart inustulature. 'ITie vagus is active through tliixr tiiahi brandies. 



vcs 



K-F 



Th 



kf 



■J^ 



fl-T 
lP-H 



As 



VCI, 



SVC 



Vd 



.«s 



-^4= 



/■ 



Ifiuim 



<T 



yi^ 



Kio. fiO.— Scheme of rxnllar innvn'otioii: A 4. 
lichl Murirlr; Aji, k*ft aurirlr; V.ii. riitliL veii- 

und iiifprkir vniui oiivu; t.t.c, Miiun vimiuvuh; iF.u. 
ffiTKniro ovtOf^: K.F.. Kcilli-Klni'k niniia nudp: 
A.T. ABchofl-Tawoni nurinii'ivi-nlrn-'ilar iiimIw; 
TA. Thoffl'n »u|»ori'tr vena «ivii l>unt)li>; Tho. 
Thon-l'B inteniiediary uodi* Iniudlc; IV, Wi-nok- 
rnlmclt'* aunriilovt'iii)u?< biitirile; k.f.. Keith- 
Hark fibers l>«>tw<»n K.F. .ittil F.a.; «.(., A»(ihoff. 
TnwiiDt l>iintUi> Ijctw-ovii At. itod F.O.: P.H. 
PaliuliiH>-fli» hun<11<? (.Innnwitki.) 



Flo. 00. — Sdicme gf iiuiervalioo 
nf thp viiaonioton: cv, niMin ocntor 
of viuM^molfjn in Uiv luiKlulIn; a, 
»|iituU viuoinoiur roiilcre; s, aynt- 
Itulhetitr: n.V. vh|oi* nurleiw; X. 
Vjutue; hV. tri«oiiiuiUB iiuulcua; ^, 
hrsHitnl |>lexiiit: ph. vcnral plenw; 
pulm. luiica. iUim. fUianvAi; diufd. 
duodenum; hrp, livrr: tjA. nplmt; 
rtn. kidiwy; r. rectum; rr*. btodder; 
«T. nrrcitiitn: jm. |»cni». (After 
LctuKloy ) 




one arising lieUiw th** superior laryngeal, a spcoikI From the retnirrens, 
a tliini fritm the tlioraru- part of the vagus. The dci'iKT layers of tlie 
heart are supplied tliniugli tin- riglit vagus, the superficial cartliae 
plexus supplying (hn)ugli the left- The sym|>uthetiu fibei's which 



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VEOETATIVE Oft VISCERAL NEUROLOGY 



awelcratf the heart's nttion are in relation with the ejctnicardiac 
ganglia, the eml bmndies of tlic vaj»us in cotincction with the intra- 
canlial RniiglioD. i. e., cells. The intraeanlial cells are here assumed 
to be visceromotor, and are thickest at tlie origin of Ilis's bundle, 
Tawara's mxlcs anil tit the urigiti of the Keith-l-'lack Imndle. The 
activity of the vagus upon the muscles seems to manifest itself chiefly 
through the panglion cells. 

The gray matter of the micihrain in the neighborhwKl of the floor 
of the third ventricle \i< thought to he a higher e(»ardinating switch- 
board—the nucleus dnrsalis vap. an end station. Through this portion 
of the incchanistn, psychical inllneiiccs are switclied in, modifying the 
tonus through emotions, pain, and local stimuli. 

IJra(l>canIlH apijcani through a nurnInT of inHuences, chk'Hy follow- 
ing acute infectious intoxications, by incri-ased intTucrnninl pressure. 
in hy[>othyn»idisni, digitalis and nllie«I gUn'<»sidal aetinns. Trigeminal 
reflexes tlirough the nusc, eyes (pressua-) may also cause brady- 
cardia. Tlic various arrh^'tlmiias, dislocations, and blocks cannot be 
discussed here. 

The relation of changes in or due to ITis's bundle cannot be entered 
into here, although they may proiKTly Ik* dlscusse<l in a text-lKmk 
on neurology. 

Angina i>ectoris, in some of its forms at least, is due to autonomic 
Dverstimiilatinn whereby vascular cramp states are brought about; 
vagus ijaralyzing anil \"asiMjilator drugs therefore aid in overciiminj; 
the condition, particularly In the vasomotor types of angina. Canliac 
disctimfort so frequent in visceral heart disease, as well as iniisychieal 
disorders is carried to con.'iciousness chiefly through conmiunicating 
sympathetic branches through the spinal ganglia, or directly to the 
spinal .systems. Hcail's hyperalgesias are explained in Uiis nuinner. 
The vagus (autonomic) fibers are not implieate<l. They are involved 
in the cardiac <'rises of tal)es. 

In the anxiety neurosis, cardiac dLsturbances are extremely freiiuent, 
Pseudnangina pectoris is usually a s>'mptom of this state, the further 
elucidation of H'liich will he found in later cbajiters, Nenmtic rardiacJ 
disturbunci-s are frequent. In the |,ires<-nt HunifX'an war many pros-i 
peetive soldiers developed canliac irregularities. Many showed extra- 
systoles which graphic tracings seijarated from heart -block. A systolic 
murmur at the ap<*x growiiig hauler on exertion with a ])ositive Was.ser- 
mann will likely prove a precursor of angina pectoris. The use of 
a^lrenalin and a study of the l.»lood will aid in the clinical diagnosis of 
organic canliiic difhciilties. Thus increa.«e<l adrenalin mydriasis and 
[Kisitive lj-mphoc,\tosLs with cardiac irregularity is usually organic from 
a dysthyroid state. In determining mihtarj' ra.parity the test is 
valtadtle. 

BloodresMla : Vasomotor Neuroses. — The anatomy, ph>'sfolog>', and 
clinical disturbances of the bl(K>il vessels make u hirgc chapter in con- 
lemjiorary neurology. ("assirer has devotetl a monograph of 1000 



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BLOODVESSELS; VASOMOTOR XEUROSES 



131 



pages alone to their consicieration. Only the briefest sketch is offered 
here. 

The bliKMlvesst'ls of the fat-e art- hmiTvateil rmin the upper eervicftl 
s\'mpathetic filters passing over tdc iiiteniitl larolid plexus to the 
Gasseriati gungHun. jirui with the pathways to the sweat glands pass 
with die sensi>ry filM'rs of the faoe. Those of the upper extremities 
are supplied ciiiefl^* fn«ii ('5 to 1^7, mostly leuviiig hy way of the D'-i to 
R7 root i>egnu'iits. Those of the lower extremities arise frnni r>1.2 
to \M. h\ the spinal axis are loeatcH only tlie local segiiu-ntal funclions. 
Butljar eenters are present in the nucleus (U)rsalLs vagi, wliich is an 
autonoiuie synapse zone for peripheral vessels as well as those of the 
hitestiues. Stimuli in the bulbar renters tend to cause contraction of 
the ixripheral vessels an<i ilJIiitation of the visceral ones. Intracranial 
bloodvessels have vasiHlilator and vasoconstrictor fibers conveyed 
through the (rrvicftl sym|jjitlietics. 

Cortieal centers have been placed in the fruntal areas (I^wandowsky. 
Weber; denie«l by Miillcr and (xla^cr, who claim the midbrain as the 
highest center), from which (he pathways (miss througii tbe iiiteriml 
capsule, caudate nucleus, thalamus, h\[M»dialamus. pi»ns, central gray 
of fourth ventricle, oblongata, Helwcg's triangular bundle, anlernlatern! 
bundle to lateral horns — tbe tilx-rs cnwsJng in the posterior commissure 
(Hclwcg). The autonomic and sympathetic 6bers apparently follow 
different pathways from the (Xird. the viisixlilator autonomic |>atb- 
ways following the course of the senstjry roots, tbe vasoconstrictor 
sympathetic by way of the anterior mots, the motor nerves, and tbe 
sympalU'tic ganglion. Thus irritatidti of the powlcrior rifots eau-ses 
hyperemia (vasiHlilatatiou) with pain; paralysis of the same causes 
anemia with am^sthesia. 

Within the IjUxNclvessels themselves ganglimi eells are found, save 
perhaps in those whi»s«' vasomotors run in the spinal ner\-es {Miiller 
and Cilaser), aiul reflexes iR-cur here exactly as in all of tbe skin and 
tendon reflexes from terminal stimuli. Hence an anal.\"sis «*f vascular 
disturbances must inchule a study of ttie sensory, motor and (.T'ntral 
portions of the rellcx arc— the last including Imth medullary and 
corticospinal reflex pathways. 

Disturban(*s of the peripheral mechanisms of the va.somotor 
pathways have been more completely analyzed than those resulting 
from lesioiL-i in the s])inal, bulbar, thalamic, or cortical portions of the 
same. (Jf these, more rlcfaikfl mention may he maiie of the: (1) tonic 
hypenrmias (erytlinimelalgia), (2) spastic anemias (jweudosclennus, 
Uayiiaud's disease, migraine, intermittent claudication), and (3) vaso- 
motor irritability, as in acute ungioncurutic edema, uudtiple gangrene 
of the skin, etc. 

I'hysiologieal alterations in the tonus of the peripheral veascls arc 
seen in sleep, emotional states, active digestion, overexercise. over- 
heating, in collapse, and in fatigue states. 



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VE<;STATn 



T. Tonic Hyperemias. 

Tliese consist in prolunped irrita5>ility of the peripheral vasomttlors. 
In certain indiviciiials (sympathicDtoiiic) » dimiiiisliti! alkalinity (if the 
blood is thoii(?ht to hrinjj about such a stinmlation of the Minpathetits. 
These tonic hyp4*remias are seen more particularly in neuralpijis, npu- 
ritides, in infections, or toxic erythemas, and roach a pronuurK-tKl grade 
in the sjTidrome known as er\-thr(inaelnl^ft. 

Erythromelalgia. — 'Wo mn'iu tn-iulh inay he distiiiKuisheil — those 
with piiiti SIS described by Weir Mitclu-ll, and those without pJiiii liut 
with hypiTidnisis anil hyiKTulnesia (Hess). 

Weir Mitfhell, in ISTS, dcwribed n pamxysinal disorder of the 
extremities which was marked by a painful redness and swelliiift of 
the feet. Luiuiuts, in IHSii, wrote an important monograph on the 
subject, and < 'a.ssirer. in the scwaul edition of his I 'tmniintori^trh- 
trophinchcn yeumsen, UM2, has given a complete description of the 
general Kr<Hip to which the name erUhromelalfiias may be given, lie 
wa.s able to gather re))orts of almut VM) cases. One may conclude it 
to be rare. Only 2 in Oppenheini's •2.'),(I(XI iti?ipt^nsary ]«itients are 
reported, while in JeUiO'e's statistics <if Starr's dispensary ser\'iee 
of IS.fKlO patients 21 were obser^'ec^, 15 in males and Ti in females. 
It is nion- often observed in the later years of life, idtlioiigli six- to 
ten-yeur-uid (Haginsky) patients are recor'ieil. 

Causes are difficult to run down. Thermic infhicutrs apparently 
play some role as exciting agents at must. Psychical factor* may 
determine an attack. 

HyiH)thetically erythnnnelalgia is a pure sympathetic atTeetitm. 
an angionenrosis. due to prolongerl sympathetic stimulation. I'rac- 
tically it shows it.self in combined forms. l>eing an aecompanimerit 
of spinal disonler (involving the sxTiipathetlc cell groups) in multiple 
sderoais, and in talies ; it may occasionally be seen in cerebral disorders, 
hemiplegia, thidamii- iinolvemetit, or may lie a part of a [H-ripheral 
nerve disonler. acconnwni\ing a neiirtlis, or it m«y be a cause f>f or a 
part of a chronic vascular disease of an obliterating or spasnuwhc type. 
In each of these the chief action is din-ctcd upon the symijatheties. 
Thus a numl»er of gradations and \ariants exi^^t which are discussed iu 
the works aln-ady cited, particularly in Tassirer antl Oppenheim. 

Symptoma. The chief symjitoins are heat, redness, and pain in the 
extremities, either ImaliKc^l along a definite nerve distribution, often 
following a root area, or peripheral. It Is usually intermittent, worse 
Bt night, and tlie patient snITers ti>rlnres. Heat usually makes it 
worse, so also does movement, es|jecially walking, whereas any position 
re<lueitig pas.si\r (iingestion. thus overcoming the tonic hyi«'remia. 
affortls relief. Severe grades iif the disonler show ii purple eyanotle 
skin, with erytlienia, usually due to transiidatitni following stasis from 
slowed eirculatton in the area of vasodilatation. Hyix-ridrosLs may l»c 
present. 





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SPAJiTtC ASEMtC GROVf 



133 



Apwssory sympt<>m.s, stirli iis Iteadaii-ho. iMtlpitatitin. unH fainting, 
art* n>a4.-tioiis to tlin pain, hihI in part to tht- fi-ar. nr may Im* aciutlier 
fmft nf a psychoncu roses in wliit-h the crytliniiiu'lalniji is also a symp- 
tom. Trtiphif chaiiKcs in tlie ^kiii, hair aial nail:s may take pliur, 
which are either a part of tlie sympathetic ilislurbanee itself or are 
results common tn the anjr"*''*'"^"*'!^, and a produclnd or accompanying 
h-sion- - tal>ps. nniltipic sclerosis, pan^is, etc. 

Course and Therapy. — The outcome derM-nils much upon the causa- 
tion. An er\-throinelaljiia ilue to spinal changes may get better if 
these do (syphilis) or not (tumor, multiple .■sclerosis). Thv therapy 
will l>e (leterminei! hy tl»e caiLse. I^illiatives, stieh as the use of high- 
fretiueney current, violet rays, (T»l(i, autipyrin, are valuable as well. 

.\ neunttii- erythnnnelalgia will improve or not as the neuriti.s il<ics; 
similarly an arteriosclerotic one; but it usually gets worse. The 
therapy is for the more fundamental cnmlition. A ps>'chically deter- 
minetl enthnimelalgia, possibly a hysteria, needs psychoanalysis. 

'2. Spastic Anemic Group. 

Mere the rhief results are due to persistent or intermittent vaso- 
i-onslricti<in. The syiidn>mes are numerous and confusing, but among 
them a few are sufficiently distinct or ciinstant to be given diagnostic 
titles sucli as Haynnuirs disi-ase. ititcnnittent claudication, nero- 
paresthesia. migraine, pseudosclerosis, asph^ gmia alternans, ete. Only 
tlie chief t>'pe8 can be takeu up: the purely tentative nature (.»f the 
classiBcatiiin must l>e em|>hnsize<). 

.Certain of these cases are unquestionably related to underlying 
rndocrinopathies (thyroid, adrenai.i. others are primary am! seeomlary 
neuritic syndromes, or are relateil to anatomical changes involving 
the it>i»patlietie s>*napses in the lateral horns of the coni (syringo- 
myelia, ]Kiliomyeliti>.) (often overlrMiked if slight attm-k), mnlliple 
si-lrro^is. spinal spliilis, etc., othere are exclusively psyeliogcnic. cliiejly 
h>stcri«"al conversions, or s<-hlzoplirenie defensse suKstitutious. 

Bftyxutad's Disease. Uaynaud's disease is also known as sym- 
metrical gangrene, local a>ph\-xia. This syndrome, like the prece<ling 
ja\v. may Ih* of many origins. It may Im- ps\chical (sliock. hysteria. 

lizoiihrenia), rerehral, or spinal organic (capsular ithalanil*) hemor- 
rhage, trauma, paresis, nuiltiplesclenjsis, taltes, syringomyelia, tumors), 
or p«'ripheral in nerve or bl*M)dves,sels, neuritis of all various etiologies, 
mild nwlcMTtnopathies, arteriosclerosis either ix-riplieral or of the large 
vessels (aorta). 

It may n'aflily be seen that from .such a polyetlologieal viewi>oint 
there is no true Ka.Miaud's di9f.r(Ier. Hence Cassirer's attempt to 
make true s\n)|Nit])etic twites and those due to complicating disonlers, 
sueh iLH the ](K-al gangrenes due to diabetic neuritis, or to arterio- 
.•lelero^ts. etc. Kvcn this i%iliHicult to acitituplish. Thus a sjilnal glitisia 
(Kyrihgttinyrloliulbia) may invade the '•ynijuithetic i-ejls in u givcii 



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Plus, ai iind G:^.^ — Uayoaud'a diaeM«, ahowius Huperficial K«ttgrane. 



Symptoms. — The attacks are pamxysmal. The fingers or toes l>e^n 
to get L-ukl, 1111(1 have tlie feelinR of prickliii^ txnd of "(tolrijiaslepp." They 
l)ecome pale an<l wuxy from llie vasoamstrictiou. Pain is franieiitly 
felt and local co]diies.s is present. An attack of this kind may come aiid 
go in a few hours. 

More persistent attacks lead to more marked grades of local a.sph>Tcia» 
with cyanosis, or hliilsh-n-d (lisctiioratioii uf the extn'niities. Pain is 
extreme. Vesicles may form— the fingers may eveu gel htuish-bli 




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IS'TERMITTENT CLAVOlCATtOS 



135 



And gradually dlsai>i>eiir after u few days, or leave slowly healing, 
broken ve^cles, or more deeply lying trophic ulcers (protopatbic 
nerve fiW-r injury). Other tyi>e3 of sciisihility al^o suffer. Epicntic 
touch und tliernial a.s well a.s protopalhic pain, thermal and deep 
sensihility, may also be involved, (langrene is a severe grade with 
l(»ss of fingers or finger-tips. 

Accessor>' symptoms (such as tn)])hic changes in the nails, in hair, 
in the hones, etc.), which are due tn the ditTt-rent ctiuliigical fartorn, 
syringomyelia, neuritis, arterioselerosis, etc., need not lie enlereil into. 
Attacks, with recovery, may pi^rsUt as kmg as three or four mouths. 

Treatment. — The therapy is often without avail, as the underlying 
condition is uiunodi6ablc (syriugoniyclin, multiple sclerosis, etc.). 
As a rule, however, the attack subsides, Hithough lu wppeur again, 
llien attention should Iw addresswi to the general health of the 
jMiticnt, especially to emotional features which produce vascular 
instability. Mild massage, loiid warmth and IJier's hyiwremic treat- 
ment are of value during the attack, .strong analgesias being iiect'asary 
for the paui at the time. lOndoerinopathic cases do well with thjToid, 
In [isychtiKcnic eases psychotlierapy is ahmc available. 

Intermittent Claadication. — This is an angiospastic syndrome anti 
tv^Xs u|Hiii a uuiulwr of foundations, f'liuieally it consist* of a spa.stic 
vHscular state wUb weakness. pai?i, and cxildriess in the affecte<l region. 
In the majority of cases it appears in the leg or Icg^. .\ftcr the ptiticut 
has walked, jH-rbups rapidly, the leg or legs Ix'giu to Ix* fatigued, and 
(xnnmcncc to feel numl) and painful until it is impossible to keep up 
the pace or walk at all. ;\fter a rest the patient may resume his walk 
for a time free from distress, but the state of pain and fatigue recurs to 
be again relievwl fullowiiig rest. There is a later tendency for the 
state to recur when the limbs are at rest. Cyanosis, coldness, paleness 
are aecomjianylng phenomena. There Is mild hyperesthesia of the 
alfwled part but no other sensory signs. The diief ves.s,els may l»e 
pulseless. These should be teslcil by toueii »nd tlie eye aidwl by the 
sphygmograph. 

The chief sites arc the vessels of the legs but the anus may be 
involve4l. Any muscular group may .show the symptoms. I.umbago- 
like forms occur in the back muscles. The ^■essels of tin- iutcslincs, 
internal organs, hniin, and spinal conl may he involved. 

'i'he chief lesion i.s artcrinsclenisis, but others are oixrative. The 
arteriosclerosis itself mny be secondary to syphilis, aleuholism, to 
chronic nicotine jKiisoning.' 

Oppcnheim has called attention to the frequency with which these 
arterial chanj^-s art? found In Hus-sian Jews. This disorder is mostly 
otmfincil to the men of this [icople. Mere Hat-foot pmbably plays h 
role— excess in walking (pi-ddlcrs) niny aid. iXvchoncurotic factors 
also may play a part in the causation of these arterial cramps iiide- 

■ FnuikUUiHiwurt, Dmitach. Zuil. i. NorvonbeiUc.. 1913, voU. xlvii aiul xlv!ii. 



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136 



VEGETATIVK OH VfSrEHAl S'BVaOLOGY 



pemlent r»f any definite artcrioMlernsis. Tlie complicated question 
(if jiliennl cliPinism within the vessel walls caitnut Ih- ciitfrt'fl into. 
Ilt-rrclitarih' iiifcriitr vasrular sy.stfiiis aiv faclorM. 

Therapy.— lU-st, warm applicattiais to the iiarts, aiiij high-frequency 
(iim-iit aiipliration are ttf valitt- in treatitif; the attack in its acutr 
sta^e. Tn'atniciit "f the (imditinn rests u|Kni the pn>per ixmceptiim 
of the inihvi^hial provm-ative disonliT. Arteriosclerotic eases need 
tn'atinent for this; psychoneuroties require psyehotherapv'. Of the 
more fiuulaineiital therap>' uf tite vegetative system which permits tile 
spasticities as well as modifies the c-aleium metaholism in the vascular 
wjin> iii.lhin;; j<s >ct cnn he jali} dnwn. 

Ophth&Imic Migraine. -Tliis is als<i known as siek hemlachc; 
megrims; heiuicrunia; bilious hcndaclie. 

This protean afTcction is difficult to defiite. It may he a simple 
or an extreiuely couiplex condition. Migraine may, however. l>e 
defined as a jM-riodieal abnormal state in which the [Mtient sutfers 
From a |)eculiar oppre.ssive pain in the head, uniljiteral or bilateral, 
londized or Reneral, which develops very gradually from heaviness to 
dulness, t<) jmin that is splitting, and is aceianpanletl or nuire often 
precede*! by charm -t eristic visiud signs, such as scoloniata. fIjiTig specks, 
or parlia! blindness, ('hlllincss. dqjrcssiun, and sensory distiirljauees, 
IMirticularly in the stomach, atiil which may lend to nausea or vomiting, 
are also usually present. An attack may l>e terminated, after a few 
minntes, by vomiting, or it may persist hours or even daj^s. After a 
variable length of time, usually following a heavy sleep, the jiatient 
rcKains his pn'vious condition of wcll-beinj*. Nearly everj'onc has an 
attack or attiicks of nugraine during his life-time, hence its extended 
ileseriptinii here. 

Hlatory. A licritage of the rich and tlie poor, the great and the small 
alike, it has munbered among its sufferers many of the master minds of 
all times, and no disorder can vie with it in nehness of description from 
medical writers who have been themselves suhjcet to its vagaries.' 
Aretaeus is credited with having given the first description of migraine, 
(^elsus gave a description whieh, while not eorpi'si«tnding in many 
details with what is now understwul to he migraine, Is nevertheless 
very suggt'stlvc. C'aelius Aureliainis noted for the first time that the 
Greeks called it hcmicraiiia. l>e(K>is. in the seventeenth century, 
ga%*c his personal experiences tlunmgh fourteen years, and called atten- 
tion to the fact tiiat the usual after-enVcls of vomiting and .sopor might 
come on without the presenc-e uf the headache. Wcpfer in the same 
century seems to have mon- clearly aiipreeiatcfl the eye sjTiijiIoins. 

Tissot's description, 17S-1, remained authoritative up to the appear- 
ance of LIveing's monograph. On Megrim, Sirk Headache, and 
Strme Atliffl fiisirnh'TH tlS73), although in the interim the symp- 
tomatolog.v wjis In'coming richer and the case analy.ses more exhauntlve. 

' See uruHo l>y Julliffp: Onlir. MijiUtti Mt>ilii'iiip. 





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OPHTnALMtC MIGRAISE 



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Thus. Vater. lleimicki'. »iul Hobt-nlt-n made obsen'alions upon the 
Hcntnmata. Plenck, l'arr>", Wollaaton drew from pcn»»>nal experiences 
the picture nf half-si(ie<i hliinlness. Sehonlein ainl Itombprj; introfJuced 
the neiiralnic theories, while Duhitis-Ueynnnul, iiiHiienceii l>y the newer 
wiirli nf Ciiiiifle Urniiinl, lievelupeil tin- hypothesis uf arteriiil spiisni 
whieh MoIIeniiorf eoiitnjverted. untl ])nstula(i.nl a syinpallietie paraly- 
sis, both of which views were roneiliatetl hy Jaceoiid am! hy KuJentK'rj: 
(]8ti7), who (le>CTil»e<l angintoiiic and aiiKioparalytif c<jnditioiis. 

Etiology.-- Mijiraiiie is n vasomotor ilisturhaiitT due to a preat variety 
of iiossihU- stiinuh a*-liiin up«ni the vi-(jetati\e itcrvdus system. The«; 
stimuli may he physical, as seen in attacks following severe blows, 
falls, fast movements, sudden alteration in tem{)eniture. of pres- 
sure— hiph mountains, caisson, deep divinjj. lumbar piuicture, etc. 
They may l>e of chemical orijiin. nici)tLne. tobaccvi. endiH-rinolofrieal 
(adrenalin, th\n)id), morphin, protrin sensitization toxic sijbstimces 
from various sources. They are i[ifretpicntl\' of somatic reflex char- 
acter, fati|i;ue, neuritic, tinnor formatiims, meningitis, etc. They 
may Ih- emotioiLal, great anger, fear fwhich may act by prtKliicing 
metahi>lisin disonlers - acidosis), <lisjtppoiritineiit, chagrin, which 
psychical stimuli may Ik- coiisciiius i)r unconscious. One or more 
exciting factors may ctWiperate. Those mediating in the cereliral 
g.XTnpathetie nervous system cause va.somi»tnr spasms and paralyses 
■with h\^>e^emia and pressure in the brain substance and cerebral 
vesicles usually of a temporary and transient nature. .At times the 
pressure pnMluces persistent or more or less persistent setjueUe, sucit 
as ophthalmoplegia, heminnopsift, hemiplegia, aphasia, optic nerve 
lesions, etc. 

Abortive Attacks. — Incomplete or abortive attacks may be said to he 
the rule rather than tlic cvwption and attempts to classify the disorder 
according to the numl>er of symptoms present offer no help in the under- 
standing of the complete piciurc. 

Mobius suggests that the parents of putient:^ suffering from migraine 
with scotomara often have suffered fniin migraine without scotomata, 
but he also speaks of the reverse as happening. The extreme preva- 
ieiiee of migraine makes many of the {^Miceptions regarding its neces- 
sary hereilitary nature very dubious, and the extreme variability of 
the inrti\'iilnal attacks in the same patient makes general hei'editnry 
features extremely iniprubablc. It is by no means infretpient to 
find patients that show at om- time or another almost every swnptom 
mentioncii in the vnluminous liicniiurc nf migraine. Thus one patient 
umler |)ersonal olxserxation liad about two attacks weekly for a year. 
He then went two years without a single attack, and he then had 
several ^^evere ones with aphasia and psychical symptoms. inters])ersed 
with alxirtive attacks, with hardly any two alike. He wa.s a veritable 
museum of niigmine attacks in the fifteen years that he was under 
oh?er\'ation. 

■Many families are known in whieh l»oth |mrents have l>pen sufferers 




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l:W VEGETATIVE OR VISCERAL NEUROLOGY 

from chronic migraine for years, and yet none of the children, now in 
some instances over forty years of age, have ever had more than one 
or two attacks. The high percentage of incidence makes it abnost 
impossible to calculate an hereditary factor. Again, it may be borne 
in mind that as there are many kinds of epilepsies, so also there are 
undoubtedly many migraines. Some are due to hereditary anomalies, 
wiiile others have nothing to do with an^lhing of an hereditary char- 
acter. Thus, one can speak of migraines that are possibly hereditarj' 
and others that are not. 

The commonest abortive attacks are those that begin in the classical 
manner, vnth chilliness, perhaps with pinched face, and cold extrem- 
ities. The patient then has the scotomata and wretchedness, depres- 
sion and apprehension, and then while waiting for the headache he 
notices that it does not come, and, although he may still have heavi- 
ness and a sense of discomfort, the feeling of relief is sufficient to 
make him feel well. 

Others have added the sensation of prickling in the fingers, numbness 
in the han<l or arm, or other sensorj- disturbances without the headache. 
In some the entire attack will consist of a disturbed painful sense of 
discomfort, without sensory s>Tnptoms, scotomata, or headache, but 
they feel sick at tlie stomach, and have an attack of what they 
term "biliousness," which clears up after vomiting. This feeling mil 
recur witli sufficient frequency, and at times be combined with such 
other s,\m])tonis of a migraine attack, in its varying aspects, as to 
stamp the whole process as a variant of a true attack. Isolated attacks 
of vomiting us the S()Ie expression of a migraine are known. 

Attatrks of scotomata occur alone, without antecedent distress, and 
IK) aftcr-attatrks are noted. These are not uncommon. Histor- 
ically it may be noted that Panv- and Airy had such attacks. It is 
liighly probable that the majority of patients who have had many 
migraine attacks will ha\e had some of this natm«. Attacks of scoto- 
mata and \omiting occm- without headache. In many on the contrary 
hcadaclie is the only symptom. 

Some patients have attacks of hemiparesthesia with no other 
symptoms of migraine. These generally occur at night, and usually 
follow severe mental exertion; in one patient under observation a 
severe ordeal in playing a difficult piece of music mil bring on such an 
attack without other signs. This patient's severe attacks are very 
extreme, being associated with hemiedema, hemiparesis, hemianesthesia, 
and marked liysteromaniacal outbursts. 

Under the heading of equivalents, Liveing speaks of stomach attacks 
associated with some of the vascular phenomena of migraine; glossal 
spasms are also mentioned by him. Attacks of giddiness, vertigo, 
intestinal colic, mental anxiety and depression which occur period- 
ically in partial association with migraine sjTnptoms, are also noted 
as equivalents. There is need of fiulher stmly of these isolated 
phenomena associated with vasomotor disturbances. 



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OPHTHALMIC MIGRAINE 



139 



Attempts have Jkcu iiwtU' td (ii'tiTiniiR' thi- relittivt* frcf|iieiuy of 
inigrainc attncks witli aiui without, the visual sign.s. These are not 
overreliable, bcc.iii.se of the vast preponderance of abortive attacks 
over those of the miiipli-te elassieal type. 

Mohius expresses the opinion that the pereentage of visual acfom- 
paiiinients of the attacks is iisunSly overstated. His statistics show 
I.1I> (uses, witli U visiwl aiini. In I^iveing's (jU patii'iits, 37 siifferecj 
from si*utnmatB. Gowtrsi says tliat tlie eases are about half and Imlf, 
with aii<) without eye sipis. (iulrzou'ski maiiitaius that the vii^ual 
aura migraines aplx^ar later in lift', thirty to fifty years, than ordinarj' 
lui^aines. 

It is (hfficutt to state an infli\ndual position, the results of personal 
iin|ii)ries having been so diverse. Close questioning hn-s revealed 
the fact that at some time or other in the eoiirs*; of the disease the 
majority uf patients have had visual sympt-oms, and it is not improb- 
able tliat the usual statistics are largely ilerivcd from studies of t<M> 
few attai'ks, r. r.. larj^ely from the severer attjieks onh'. Sfrtne notes 
on individual histories are of interest. Sevend |Kitients have kept 
fairly aeciirate records of tlicir migraine attacks for several years. 
One shows llvS attacks in a ]x-riod of about ten years; of these, alK>ut 
KX) wcTc al>(»rtive attacks, the vast majority of which, i'A) ikt cent.. 
cotisisteil of scotomata alone. Of the (iS n-nmiiiinK atta<'ks, about 50 
per cent, were ordinary hemicrania. lateral or bilateral, without sctJ- 
tomatA, the others ophtbahnic migraine, usually unilateral and nith 
seotomatn. \i>t oni- of tin- attacks was ever aoc(»nii)aiiipil by vomit- 
ing. Two were assiiciated with aphasia, fifteen with sensory tactile 
associations; tiicn- were five or six attncks of hcmiparesthesia, one in 
tlie daytime, the rest at night. Spasms of the orbicularis were a 
common aecompiuiiment. Kvery attack suKieieiitly severe to require 
an analgesic was promjiily relieved by from a to Ul grains of eitlier 
antipyrin, aictiinilid, or phenmrtin. 

Clusical Migraine. - /u(r/j/ SympUmts.—'VXw^. may be termed pre- 
<-ursors of a fiill attack of migraine, or tlwy ma>' constitute the sjinp^ 
tons of anVbortivc attack. The most striking are a sense nf heaviness, 
with yaxuiing, chilliness, dizziness, or rlepressioii. motor twitching, 
even sharp spasmodic closure of the eyelids, si'iLst)ry plienumeiia, 
eliiefly paresthesia', occasionally anesthesia, and afTections of the 
eyes or other sensory organs, ringing In the ears, blowing, whistllag, 
modirieations of taste, of sinell, of touch, etc. There may be failure 
of apiK^tite, constipation, diarrhea, vascidar instiibility. hot fla^shes 
ehu.'iing here and there over tin- Ixxly. lhn)hbing in the canrtiils. ete. 
The temporal arterit^ arc often smaller, the saliva diminishci:!, and 
the pupils iiarrowrd. 

The preniuciitory .signs which show a great deal of variability in 
different individuals, and also in different attacks in the sjmfce imli- 
vidnal, may Ix- felt several minutes Ijcfore the attack, in some rare 
instiiuces even days. This is frequently the ca.se in women in whom 



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)R I'tSCi 



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tlie unwt uf till* iiH'iistnml fiiiiftion stK-nis to bear some rfUtion to the 
attack. The t>nlinar.v tk-prt-iisioii felt at this time is a thing apart 
tnaa this special t^Tje of ilpprcssion that jxrvailes tlicni. At times; 
t<ticli attacks iif depres.'Uut) anil anxiety, cimiliined nilh a sense of 
chilliness and ilizxiitess, will ciinMitiite the ciitin' pictuiv uf the ahor-' 
tivr utiaek. Many attacks cniiie apparently without the slightest; 
warning. 

Many |>atients having attack:* at night find themselves heavy, 
and tired, with sore spots on the scaij) in the innrnirig. Mobiiia 
relates a case in which tlie patient fin-nmed of having swallowed a 
rabbit, which ate its way itut tliroii^h the stomach wall. After thia 
unpleasant dream the juitient had a severe migraine nn awakening. 

In all prolHil)ilit\ pn-innnitory s>nnptonis of siutic type are invariably 
pre.^'nt : when tlmnglit to Im- absent it is beciiuse tlie {Kitient haa 
overlooked them, either by reason of their mild cJmracter, because the 
symptoms appeared in a dream, as in Mobius's patient, or beiause 
of naturally poor powers of ol>servution. Man,\' patients, wlm have 
had ht-adachcs for years, have never noticed their one-sided lnK-alization, 
or the well-known furtifitvttion sixftnt. until their alU-titimi has Ih-cii' 
directed sijeeiiicaUy To them. Many patient's will deny ever liaviag 
had zig-zags of liglit, etc., until sIiomti Airy's piftures, when they 
rt-nicinljer having seen such phen<iniena. It U because of such poor 
observation that many eases of true migraine Hre o\erlc)uke<i, which: 
fad lends further snppttrt to the Wief that this disorder is \'cry much| 
more prevalent than is usually sup]}<>.sed. i| 

Setutory Sj/inpfnmx.- \n the more classical attacks the patient had 
preliminary .sensory syniptcmis. These are spoken of by Mtibius in! 
the seiiNC of an aura. If the term aura lie used as, for instance, the 
tiTm "fever" is used, tlirn' can be no objection, but if by an aura is 
nieant a restricted phenomenon essentially related to an ejMlcptic 
aura, the term shouhl Ix^ ehmlnatcd. 

A sense of coldness an<l {-liiHiness is one of the ei>mnionest sensations. 
This is usually gencnd, and is associated with a pale countenance, 
goos4'Hesh, perhaps clammy hands, and a sense of miser>'. Cases 
are kn((Wn, anil are by nu means uncommon, in which the chilliness 
has been one-sided, and is acirompanieil by other phenomena Jnvolvingj 
nne-liulf of the bod\ , including. the face, of the smie side. Yawning iaj 
a i-oinmon early sign. j 

I'nilaterul paresthesia is not nn iiiiiiimmon early sign. Manyi 
patients note a tingling nr nninhne-ss in the fingers of one Imnd; this' 
may .'spread up the arm, and in rare instances general uiiilatend i»ares-i 
thesia of a very uncomfortable nature may be pres^'nt. In some' 
instances su<*h unilateral paresthesiie have con^1,itutell tla' sole symp- 
tom of an attack, save for the heaviness and usual dis<-onifort. (Vcur- 
ri[ig at night, such attacks are often e.xlremely wearing, keeping the 
patient awake. Photophobia, flow of teais. strange sounds tinnitus, 
peculiar odors, queer peppery or ilai tastes, may be noted. 



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141 



Am'sllii'sia is less often uKstTvitl, largely Ik-chum- nf tin* inxHlive 



1pT4 



>Vli 



tiie faiv 



>uth it 



I 



» 



rimrarter of llii* 

complaincil of. Ancstltesia Ireqm'iitly lolIow> the ttiiKling o\ the ewrly 
]w.rv.stlH"tif ilisturbaiHTs. Fnine' has sliowni tliat tlK-rc is n very 
c\i(lcnt dctTcase in the pain threshold, especially after the Iteuilache 
has sft in. 

The rminl phnmmetin are the most Ktrikiiijr. and heiiw held to be 
of the most frequent occurrenee. The ease of observation in part 
arooiints for the ustially aotvpted opinion that the>' are the commonest 
of tin- early sviiiptoiiis. \'ery ft-w iiidivifluiiK have iHt-n snhji-fted in a 
earefnl sensory exiiminatlMii. If nmre were invesltgate)!, it is pmlmhle 
that other slight seiisorj signs would be found Uy \yv equally prevalent 
and as evanescent. The visual signs have been described b>' many 
fliTiters. and many illustrations have lut-n made showing their chief 
characteristics. The extreme uniformity of their general character is 
Htriking. as wtII as the variations of the same pattern. 

As a nde the |mtient notices a alight blurring of his vision if reading, 
or a slight flicker of light located in one eye. to one side of the I'enter. 
CliMier observation n-veals i-ither a slight cIiMidy sjKrt, which seems 
to follow the eye in reaiMng, eiittlirg mit the after-images, or a letter 
or s«i from the center of clear vision. The slight suhjettive sen.se 
of difficulty in reading may preirde the discover^.' of a scintillating 
s|)ot which tjecomes visible on closing the eyes. IJttle by little this 
»p*)t spreads out. usually in a eresivnt-like fashion. CJeiieral statistit-s 
are thus far unavailable, hut n siJecisil study has shown that the 
majority of these scotuniuta have begun in the left eye, are sitnateil 
to the left of the middle line, with the convexity of the crescentic 
border to the left. As the crescent gradually grows larger, the difficulty 
in st-eing clearly becomes more marked, esiiecially mi the periphery 
of the visual firld. l-'nr most, the seutomata is in constant motion, 
flashing in its spectral zig-yjtg fashion, thus causing the classical 
name "fortification s]x*ctrnm" from the play tif t-olors, and the fortress- 
like "in.'* and outs" of the outline. 

After a variable time, from five to twenty minutes, the scotomatA 
lually subsides, or suddenly ilisa[)iK-ars, to Ite followed by the 
ndaehe. Not infre<]ucntly the headache never comes, and the pre- 
liminary sensory phenomena of chilliness, heavint^s, and se*)tomata 
i-on-stitutc an abortive attack. A dewription of the scotomata of 
migraine might hll a volume. The classic of Liveing reprtKhiivs the 
exei'llent illustration of .Mrys, whirli i> lu-n- n'jiroihiccd. 

Oeca-^innaily the right half of the (ich) is involved. Sometimes it Is 
tl»e up[M'r half, one of Mfibius's patients saying that everybody seemed 
hea<lle3s; occasionally, it is the lowrr. In rare instance-* the patients 
complain of total blinthiess, i. /•., central scotomata. Iicrl>ez reports 
an interesting ca.s4' of a ring-like sc()t<ima — the patient, on looking 



Amur. Jour. Plijrsiul., 11)06. 




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VKaETATIVE OR M8CEHAI NSfROLOGY 



at his waU-li. could at*- mily the ctiitral piti wlwro the luimls wvrv 
united; the figitrtt* on the ilial wen- nil (ihscured hy the snnlillatiiiR 

THE DEVKLOI-MKNT OF SC;OTOMATA IN MIGRAINE WUII^ RKADING. 



btve oot rtudied imiDiiinil 
an inta wKick iminlirati 
OMN Mr {upr sppvUnk] 
>)*V« « tiw pnm tot 

« tiiy iqpibon of lunip 
in for the lelcctMB of huT 
' dninble it k to ipprada 
nlonlutioa uti to nunii 
■to place io the muti h 



'ikerr hu ft<*n no sue 
llie L'nit«j St»ta at till 
teorri^fpr lilwrtj- indB 
lor l»ifl^nuiiijir*iwjn at 
jJ A Ajiirmf» : I 

ud thMbtUmaii c^ 
jMt • vwy btfi iiiuDbe 
niwd by paitly mumbuo 
nifata, nuqr imniynutts 



Fw. 63.— Si««e of UurriiiK Uinw miuuhw. Ra. 64— Rwi uutlitiw of *^iittilaiioS 



ineMnoi b iwully iunduM 
w y to ^purti iod the di 
'WTO* OaOIMftr ptriod 
lUr Uumflthtt iiuaipu 
*J ™«rt JRBit we an in^ 

^^ iii iftj dffinil 

nnd. It ewo «t il,c PMt rfdt 
P«rt of the civilJutJoEi of the 
period tad in the yt»n followi 



i ^HalUDaita that our farcfkthcn 



y' BMK fcnrra 

e Udt tht ] 
cdy lo imnig: 

For the 
RtUc the d 
a very trn 
cODtlnuation 

14] hT>frly Bii 

d privBtJOD, _.. 
wkl to the New .„ 
Snalutionary Vlti 



m to Me 

peopfed 

<r ow pTMnit 

tfaafsttte-' 

ihUcaiuitty 

^ OMOcivf 

It aenmelit. 

NOA ta 

red t 

lunial 



Fw. W.— Fivo lo U-ti iiunutce er«*iog BKrtflm*. Fio. «1.--Tcu t« fifteen iainul«». 



of arrivkli at Ellis li 
. IV additinn 
lie r»d>l or 
ihoMwholMd 

If the 
of 
ia 
t illiutntioi 

I9L1 in Hum 
Amenca. It 
'eloped by 
Mnite rrluii 

the cumber ini 
n EuiDpf . Tlii' 
on on ftuoiuiiX 
«tOdenbie aild 



inclc moal 

■lieu 

igw, Ne*rlj- 

e wid OBAoy i 

witfaiAontl 

tlterewHttlM 

the Ittter p«rt of 

iddeoly utued 

tmporCADt fww 

m\\i- rrlntinn 1 

>'ye«n later tbiOH 

i — thu eeoaomir t 

vblume or JmRiixn 

thin poijTitfy who r 

loui IreSuid wfti 

if tl r potato C 

ihropic iwfir 



hwh\ 

D of 



■'U net. j 
olloni'n 



out, tb« En^lith. l>i 
praetically 4ii utivali i 
iluntioD&ry Wu- were doa 
one Germanic nee la tl 
y culoDiird tlw AtUntif 
llie thja line nf dvi-iliut 
of the Hinr race. The "iinn 
m«ay yean after tha B««at< 
these «tko btd pi«0(d«d tha 
ve erinaidered u tluit of omliD 
;v-;i Wu. Dtumiitiiatpeiiodati 
* llisiLOt pOKiiblc to lean tfaai 
coimte>' )>elcre 1S20 tor ta t 
10 record their aiusber and to at 
Jtnow, however th»l the popt 
i' iacmjKl by immifratit 
ohitiontry War, DunoC 



.'.tL^ 



It it araiiiifliii7naf<l, Xoi:' 



Bine uioUr 



Fw. 67. — Fillrvn to twenty ftiinutM. 



k Fm. 

H scotoma. These seotomata arc ustia 



Fiii. 88. — JtxaE Iwfore diiuippttarinit, 
tK^iily lo lliirty miuutrH, and bef^* | 
nine of hPadaflio. (JelUff; ponKiul J 
olxMjri'utiuti.) ^^k 

W biliiteriil phenomena. The^^ 
ig ill the other, ami Ije sumo 



:3 



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OPUTHALMIC miohai.se 



113 



what different in the tiA-o eyes, and may disappear in one ejT sooner 
than the other. Seot-omnla limited to one eye are prnhubly rare. 

The retinal ocpurrences during the time of tliese seottimata are 
uncertain. Rlanching of the jMipilla* has been observed by some 
(GalezoHski); pulsjition of the retinal arteries, with diliitatitm by 
others. Personal expericiiee has shown similar dilatation In a few 
cases, but, as a rule, a normal fundus [a found. The picture seen 
will depend upon the stage of the attack and its severity. 

Fupillar>' dilatation occurs late. Slight irregularity of the pupik 
during a severe attack of an ophthalmic migraine, dilatation being 
usual on the affected side, is not unusual. Bilateral piipillan' con- 
traction is the rule in the heailache stage. 

During the onset of the fortifieatiiiii spectra it not infrequently 
happens that mihl motor pliennmena occur in tlie eyelid of the side 
to be niTet'ted. The eyelid rlroops a little, am! (inwers and others 
report double vision, interpretuble as a sign of [Hiresis in an ocular muscle. 

Motor Duturbnncf^. — Spefch. — This may be considered as both a 
motor and s<rn.si)r\' phenomenon, tor the most freetucnt tyjw of change 
is a transitory sensory aphasia. Anarthrias are known, especially in 
the ophthalmoplegic variety, but for ophthalmic migraine the tspc 
of aphasia found is very diarai'teristie. As descrilied by ("harcot, 
it is an intermittent, halting apha.sia. At one moment the patient can 
get the right word, at the next he cannot, lie stumbles cm a word; 
uses madauie for nuHisienr. etc. In Li\eing's vnsen 1.5 nut uf 20 had 
speech disturhjinees; om- on hearing clock bells was unable to inquire 
what they were. FhC' cites the case of a coachman wiio forgot where 
he was going to drive his passengers; Berbez a like case In wluclt a 
pedestrian lost his way, as he could not read the street signs under- 
slandingly. flowers s|K*aks of a case of wonl-<leafness. Cases of 
agraphia are also knovni. Mobius repons a case with ty]Hcal scintillat- 
ing scotoniata at one time on the right side, at another on the left. 
When the patient suffered from n right-sided scotoma he had wnsorj* 
aphasic signs, but tbey were not present when the scotoma was on 
the left side. 

Other olxscrvers have noted the Nime phenomena, while ciuitrn- 
di(i.ory observations are also recorded. The speech disturbance 
Sometimes resembles a parapbusia, tlie patient using a jum^ble uf 
words. In a i)ers«nal case the {Mitient could not sing a well-known 
tune correctly, liis sense of musical \alucs luiving !)cen interft-rcd with. 

The onset of the aphasic disturbance may vary greatly. It is 
usually tcmporar>-, persisting at times for only a few minutes, again 
persisting a few hours. It frequently antedates the headache, <ir ia 
coincident with it. In a ease reported hy Meige the aphasia i»er.sisted 
as long as the headache, arti disjippeared, as a ruli-, when tliat dis- 
apl)eared. The patient slwuArd a Kiss of ability t« say certain words 
and a tendency to the employment of ineorretrt words. There was no 
anartlu'ia. 



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144 VEGETATIVE OR VISCERAL NEUROLOGY 

Cerebellar Symptoms. — Oppenheira has called attention to a cere- 
Ix-llar hemifTania in a patient in whom every attack of migraine was 
accompanied by typical cerebellar symptoms. The patient was un- 
certain in his gait, walked like a drunken man, was dizzy, and had 
the sensation that hia body, or individual parts of it were doubled. 
The sense of equilibrium was disturbed in each attack. Dizziness 
and loss of the sense of equilibrium are not infrequent but such a 
(t>mplete syndrome has been described only by Oppenheim. 

Paralytic Phenomena. — Attention has already been called to the 
rare occurrence of hemiparesis, which may even involve the facial 
muscles. I'p to the present time no instances of crossed hemii)Iegie 
ty(>es ha^■e been found in the literature. This is of interest in con- 
nection with the hypothesis of the bulbar origin of migraine, especially 
of the ophthalmoplegic variety. Other palsies are known, monoplegias 
of the extremities, ophthalmoplegias, etc. Topical and minute brain 
swellings may pn>duc? a great variety of paralytic phenomena usually 
of a tnmsitory nature but at times persisting.' 

Ilrndnche. — This is the most common feature and exhibits a 
great amount of variability as to location, quality, intensity, and 
duration. In the more classical attacks the headache begins on 
the average about fifteen to thirty minutes after the appearance of 
tlie scotomatA or trther seiLSorv- phenomena. It frequently begins 
on one side, and may remain so or become bilateral. As a rale 
it is frontal, or oc(rupios the vertex, but may involve the temporal 
regions, the occiput, sometimes as low down as the neck. Gowers's 
exiKTicncc i^dnts to tlie i)arietal region as being oftenest affected, 
and usually over a small area. Henschen, in 123 patients, shows 
the pain to have l)een located 110 times in the forehead, 100 times in 
tlie parietal region, and .>4 times in the occiput. There is usually pain 
over the eyes, and the eyeballs are usually painful to pressure. In a 
few instances pressure over the malar bones is painful, and occasionally 
there is a well-marked jawache. 

Statistics of the percentage of different locations are uncertain since 
one individual will have ail the different varieties. Thus, in a case 
already cited, in wliich the alwrtive attacks were so frequent, the 
headaches comparatively rare, the strit1:Iy unilateral headaches were 
only ,j (XT cent, of the entire number. In others the hemicranic 
type runs nuich higlier. In Ilenschen's records of 128 cases, 56 had 
one-sided attacks, in (iT both sides were involved. In Liveing's 
(11 patients. 17 had one-sided attacks, in 7 the attacks were variable, 
while in 'M both ^ides were involve<l. Mohius and others note that 
the headache often apjiears on the side opposite to that affected by 
the sensory aura. Personal studies do not confirm Mobius's statement. 
It dtK's seem, howTver, as first noted by Livcing, that one-sided 
sensory symptoms arc oftener accompanied by one-sided than by 

■ Hiiiil, J. R.: foiilribution to the Paralytic and Olhor Penistent ^luelte of Migraine, 
Am. Jour. Med. Sc, 1915, No. 3. 



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OPIITflALMIC MIGRAISE 



145 



bilateral heatlacrhi's. With hilateral sensorj- pheiiumena, seotoniata, 
etc., bilateral pains are the afmniimiest. 

In many attacks the pains are Hiniteci to the eyes, the feeling nf 
soreitpss of the eyeballs being so very ninrkeil that ii is {ininfiil to move 
ibein. Pain iu the neck may also cause tlie desire (o huld the neck 
rijfid. 

The relationship of these pains to psychical }»ymlmHzaliinis has not 
yet been investigated. In a few eases thus far analyzed, [cft-side<l 
sjinptoms are apt to symlwdize the unconscious love conflicts, right- 
hamied ones, the mitrilivr. \*ah\^ in tlie bark tff the head are fre- 
quently assm-iatfd with iiiir-iinscitaisly rei»ressc'd hute conipk-xe.s. iiii artt 
alsc» jau' iwins, 

The ehiiractcr of the pain defies analysis, since descriptive phrases arc 
usied iu such various ways by dilferent obser^ ers. In some attacks, the 
betui simply feels slightly sore, or hea\'>', or dull, or thick; "Ukc a 
block of wood," is a frequent exiircssion. "Killed with sawdust." 
one patient .say.s. Again, the pain is agonizing, impossible to describe. 
Some patients shriek uith the pain, become hysterical, and roll abairt 
the fltKtr, gnisplng the head lietween the hands, wistiin^ to l)eat thetr 
brains nut. lietween these extremes niiinlierless variants are found 
umimg different individuals, and in dirt'erent attacks in the same 
individual. Nearly all patients will say that the severe pains are 
throbbing or thumping, usually indicating great pressure from within 
or without; as Miibius has said, ''sonic patients think the head will 
burst, others that it is being sftueczetl in a vise." Ik-scriptions 
of bursting are more common. The pain is an al[-i)ervading one, 
gradually mounting to a maximum, then running along continuously 
without any let-up. with, at all times, sudden accessions, e^iwcially 
on movement, if mie lejins over, nr i> fiiR-ed tu sndilen exertion. In 
but the rarest iiist;iiires is it ileserilx-d as htncinaliiig in fpiidity. It is 
the t>-pe of pain ap|>arently seen in cerebnd tumor, in acute hydro- 
eephahut, in eerebnispinal meningitis, and is allied to the pait) of 
opium pi>isuning. or of sea-siekness; all pointing in the direc-tion of a 
modification of intracvrcbral pressure, at times an increase*, or it may 
Ik! h decrejLse, either of which may cau-si- seveit* pain. Occasionally 
the plienomenon of a l>ilateral headache uith marked predominarce 
of one-sided pain will l»e oI)scrved. 

The severity of the f)ain may 1h- eonditiiaied l>y a numlwr of factors. 
Movement uniformly irtereases it. Jieiiding over beeomes ini|Hisslblr. 
The first movement mi lying ilown is usnalty }ieci»rii[uitiied by a suihlen 
rise in severity, but this gradually subsides. The taking of alei>hol, 
usually intTcasps the severity of the \m'm, as (hn-s also the use of tobai-io. 
Eatuig, if [Kissihle, may help somewbat, but usually augincnbt lite 
pain, and is avoided. Strong sen.sor\' inipicssions invariably increase 
tlie pain. Noises of various kinds often aggravate the pain tremen- 
dously and cause certain patients marked distress. The *' Fourth of 
July" invariably drives many migrainous patients to some quiet spot 



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VKCKTATnE OK VISCERAL SKVROIOOY 



the 




(■oimtn-, frw' from crackors and Iwrnba. Mobius notes 
the rnpi »f niigrai tutus parents riirerteH towanl their noisy eJiildrfn 
often resembles a iMitholugit-al hatred. Strong light is invariable 
avoideil, beraiise nf it-s tendeney in increase the ]jaiii. The movements* 
(if the eyeljall and attemirts at visual mi-oinniodatiun eause an increase 
in the pain. 

Psychical effort is often impossible; in milder attacks the awakening 
of a strong mental Rttmuhis may make one forget the pain. Mobitis 
saj-s that his attacks, usually light ones, are frequently forgotten during 
an interesting visit To the Polycliiiik, to be once more prominent 
after^varlj. One uf lus luul frequently begun it lecture with a severe 
migraine to Jind it ahniK^t forgotten until the close, when it rcappears^^ 
usually with renewed vigor. ■ 

The niovcnu'nts of straining at stool, and vomiting, coughing', etc., 
invariably cause a rapid and sharp rise in the severity of the jMiin. 
Sensory stiniuli may liave an unpleasant effect on the psyche. Thus, 
certain odors tause distress; the smell of cooking acts much as it does 
on shiplKMird; it aet-elerates vomiting. Certain skin phenomena, such 
as sore s|x>ts, are fre([uent after the headaches. 

In certuui personal exijcrinients with drugs the following have 
invariably increased the headache within a few minutes: A few 
wliiffs of chlonifonn or of ether, adrenalin by mouth, digitalis, stro-_ 
phantin, and ergot. Drugs that rai.se the btood-prcssiire, in general^ 
increiuse the pain when taken, especially at the beginning of the head- 
ac'he. The headache may clear away very suddenly after an attad 
of vomiting, nr it may pass without vomiting; in some it fades awaj 
gradually. It may la-st a few minutes, a few hotirs, i>r a few days^ 
Some cases of what Mobius chooses to call status hemicranicus ui 
recorded. 

Vamnnaior DisturbanceJi. — Pra<rtically all sttarka of mignnnc ai 
accompanied by visible vasomotor disturbances. In most cases 
vasoeonstri(!tor phenomena (coldness, jmleness, goti.seHesh, cte.) 
preceile, to Ijc fullnwcd later by vasudilator chaitges. Thomas ant 
Comii both point this nut as a result of their c)!|X!rieuces. Thomi 
contributes a stiitistiwil study of 107 cases in support uf the earl/ 
pallor, small pulse and coldnes.-*, which pass over to the i)henomen» 
of warm, red. flushed face and skin, and fiJl pulse. The periofl oj 
initial c«)nstriction may be unnoticed by reason of its transitory 
character. In some instances this initial vasi)ii>nstri*rtit»n may be 
very marked and give ris<' to the phennmeTia of Ifx-rdlzctl i-yaiiosia, 
even advancing to the pic-ture of the constriction jihase 
Kai,'nau<l disease type. (Vagotonic.) 

In the same manner the secondary ^■asc)moto^ dilatation niaj 
pa.ss the bounds ordinarily observed and lead to localized edema 
to the crjihromelalgic tjpe, or, exceptionally, to hemorrhapu 
phenomena in the conjunctiva, ocular tissues, or even in the walhj 
of the stomach. (Sj-mpat-hicotonic.) 



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Secretions. — Alteration tn seerTtcirj' fuiictions are frequently obsen'cd 
early t»r late in the attacks. Hefereiiee has Ikh-ii made to the exeess 
of secTctioii of tears as a frequent pretnirsor. Vomiting of frothy 
mucus, serous diarrhea, iiicreasc of sweat, cory/ji (Cahncil), or inces- 
sant salivation (Lixeiii^;, 'J'issut) are «>mmon ijhenomenii. 

The changes in urinarj- secretion have attracted careful attention. 
The early vasoconstriction of the periphery*, coldness, lack of se<-retion 
of perspiration, etc., account in a purely mechanical w-ay for the in- 
cren^ie of urinary sccrelitm in the early staRes. Metabolic studies show 
no fundamental disturbances. Biogllo was iniable to show c<»tistant 
changes. Although it is not ixi^ssible to exchitie nietalMilic disturbance 
as causing changes in vegetative control, probably it is more true 
that psychical influences cause the metabolic disturbance. 

Tropbw DLtturhatict's. — These have Ir-ch re|)orted by several 
observers. Comu sjiys that nearly all rtf his eases of migraine show 
facial aajinmetry, and facial atrophy is recorded. These instances 
are nearlj* always «»lncidences and are not necessarily attributes 
of the migraine. A facial atrophy which ran be interpreted only on 
the basis tiF u inigrainous disturlwiKt' nf tlw viisomotor apparatus is 
very prohJeniatic, and certainly ("<)riiu's results are not (tinfimied 
by others. I.^»ss of weight in the severe mpidly ivcurrent cases is due 
to disturbBuw in general nutrition due to gastric, rather tlian to other 
cau-tes. Heri)es is a not infR'quent accompaniment in some patients. 

Pryclimi! iiijtttfrbunrrs. — These lja\'e )x-en noted by many observers, 
Liveing being one of the first to point out the relationship of disturbed 
psychical states to the attacks of migraine. 

In the majority of migraine attacks there are few conscious mental 
changes before, during, or after the attacks. Mild depression, ho[)e- 
lessness, ilc-S]MiniIem'y with clear consfTinnsness, are frecptetit mental 
states. With very severe pains Miibius admiU clouding of coti.^-ious- 
iiess, and is not sure tlint severe stuporous states arc not due to pain 
as unpll. Mingnzxini, on the other hand, believes there is justification 
for erecting a 3|x'ciid group, which he has termed the hemienmic 
dys])hrenias, an<l distinguishes a transitory and a more permanent 
variety. Recent obsiTvers arv practically in aceorrl, in showing that 
severe mentid disturbances varjing in character and intensity may 
be part of a migraine attack. 

(iiiidi has anipliiled thesi* ohwrvations by repiirting the history of 
a numlier i»f cases in whii-h the patients MilYered during the day 
licfdrc the finsi't. in a nuu-h mon- decided manner than liy ftrlings 
of anxiety or depression as destrilxd by Liveing. Thus Gui<li calls 
attention tn grave alterations in the i»sychieal state of a numlHT of his 
|jatients. In one the entire <'haracter of the personality would change 
preceding the attack. A ])aticnt who had always Ixren cahn, reserved. 
quiet, and modest, suddenly iM-ciime much agitated, was fom-arri, 
iK)isy. an<l lnf|uaciou.'i. and told sjilacious stories, which was far from 
liis usiuil Itehanor. While in health a spare eater, preceding an 



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148 VEGETATIVE OR VISCERAL NEUROLOGY 

attack he suddenly became hungry, and hankered especially for 
starchy foods. During the attack the patient had glycosuria, which 
disappeared later. 

With the onset of pain the picture is less dear, yet there is little 
doubt that many patients suffer from profound psychical disturb- 
ances, which arise independently of the pain. One such case, under 
personal observation, would be interpreted by Mobius, and rightly 
so, as one in which the pain is the first link in an hysterical reac- 
tion. But there are other cases which do not belong to this group. 
Mingazzini's hcmicranic dysphrenias may be cited as examples, 
in part, at least. In others severe disturbances have occurred, such 
as states of anxiety, rising to actual anguish (Charcot); phobias of 
inability to perform acts (Cornu-Charcot) ; terror (Liveing, F6r€, 
Kraft-P^bing) ; liallucinations of sight (phosphenes, colored lights, 
animals) and hearing with mental confusion (ForU, Mingazzini); 
maniacal excitement (Mingazzini, Jelliffe) and stupor; unconscious- 
ness (many authors). 

Liveing rejxtrts that 25 per cent, of his cases showed psychical 
Mjmptoms. The Italian obser\ers record fewer, but it appears that 
at least from 10 to 15 per cent, of the cases of grave hemicrania 
sliow some distinct mental disturbance in some one or more of their 
attacks \^-hich is more significant than the usual depression which is 
so iniiversal. These severe tj^pes only emphasize the fact that uncon- 
scious confiict is an important etiological factor in the migraines. 

Symptomatic Migraines. — The occiurence of migraine-like attacks 
acconi])anjing, or due to, definite disease conditions, notably organic 
disease of the brain, is well known. The association of migraine with 
gout and malarial affections has been noted. So far as gout as an 
etiological factor is concerned, Mobius is inclined to see nothing 
more than a coincidence; while, as for malaria, he holds it to cause an 
orljital neuralgia, not a migraine. As for the latter, it seems clear 
that the well-known effects of malarial infection on bloodvessel tonus 
are cntirelj- sufficient to cause a typical migraine attack. It is known 
that attacks of migraine may be very frequent during the contintunce 
of a malarial infection. Such may disappear for months after quinine 
tlierajjy, and then reappear at the time of a later malarial infection. 

Migraine-like attacks are not infrequent in cerebral tumor; they 
may apjx-ar periodically, as in cases fully reported by Abercrombie 
and Mobius, or they may be continuous and distinguishable with 
great difficulty from the pain of tumor, as in cases reported by Wer- 
nicke, who has said that such attacks may be quite readily confused 
with those more typical of tumor. In timiors, however, vomiting 
brings little or no relief; quiet gives less relief, and the fluctuation ir 
intensity of the pain is less prominent. A primary onset of migraine 
like attacks in adult life should always awaken the suspidon of ai 
orgimic brain lesion. 

Oppcnheim has called particular attention to the occurrence c 



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. 



migraine^like attacks at the onset ot tahes.; Mobii)!4 h inclined tn think 
it a rare tiombt nation, and rt^anis it either as a pure coinddence 
or a migraine-like neurnlgio. In general paresis, niigrai Tie-like attacks 
may be an initial syniptam. Migraine attacks tirt* not infrequent 
throughout the early stages of the disease, hut tlie anatomical correla- 
tions an- still hypotlietical. 

Diagnosis.— The difficulties ap{)eur in the consideration of i>rilinary 
headaclK'^ and in neurasthenic headaches; in disgulshing lietwx-en 
the s(«timiaia of migraine and other SMrtomata; the paresthesia of 
migraine and other imresthesias; the aphasia, the vomiting, etc., 
as seen in migraine, and the snne as due to other cavises. In m(»st 
individuals abortive and iiicompiKe attacks are the rule, and it is 
often extremely difficult to determine their precise signifioanee. 

Mijbius has suggested that the problem is not only whether the 
t«sc is one of migraine or not, but whether it is migraine alone, and 
not something additional. This author's contention tliat luigruiue is 
hcrcditarj' and begins in youth, would seem to make it a simple matter, 
but clinical experience shoivs that real migraines do apiiear in later 
years, a[>art fr<im other alfections, anil as for the liere<Iitar.* factor, 
the extreme im-valenc*' of the alTeetion makes it hard to accurately 
weigh this factor. The jjeriodic rccurremv is a diilicult fTiterioii. 
There is usually no difficulty In diagnosing the classical attacks from 
simple lieudache, but at times such ilitTerentiation is iniiK>ssible. Many 
chronic sufferen? from migraine know well their real attacks, are able 
t4> distinguish alxjrtive attacks, and also lune lieadacliis of an entin-ly 
different nature. The simplest test in separating abortive migmines 
from simple headaches is the occurrence of sensory phenomena, other 
than pain, which have their main origin in ^■asomotnr distiu*banoe». 
It is on this account tliat the severe headaches following the iise of 
alctihol. ether, chlonifiinn, opium, or analogous drugs sJuiuld Xte allied 
to the migraines rather than to simple headaches. The headaclien of 
neurasthenia, anemia, syphilis, lead jx>isoning, nasal sinus involvement, 
supraurbitid neuralgia, nephritis, eye-straiu. glaucoma, etc., should 
present little diHiculty. 

Treatment.— The treatment e}f the migraine attack i.s, for the most 
part. fairl>' satisfatrtorj'. There are few patients for whom some 
relief lannot be obtained, lioth with reference to the diminution in 
the numU'r of attacks, ami to the niitigaticui of the severity of the 
attack'i themselves. The migraine habit, ismstitution, or liability — 
mil it what one will— exists in vcrj- varying degrc-**s; in some a verj' 
?tlight disturbance is sufficient to set free those forces which culminate 
in an attack ; for others it re<|uires a very much gn-atcr maladjustment. 
If llie general rellcx vascular hypothesis Iw taken as a tentJitive explan- 
ation it is ver\' readily underst<Mjd why the taking away of various 
forms of iHTJpberal irritation may result in eliminating one or more, 
and in certain instances all, of the cuu.ses which set the migraine 
reaction in operation. 



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VKOKTATIVK OR VISCERAL SEVROLOGY 

It is folly to slnit oiir's i-yes to iIh? very fvidnit dinicHl fut-t tlwt a 
few migraines are n'Hevwi. if not entirely wiiK'<l away, by the eorpt-ction 
nf ^onie |»eri|iheral ilisonler. s<imetimes more than one, which has ha*l 
definite effeet on the nervous system. Just what the: interrflution 
umy \n- l)elween (he wverlly of the irritant aixl the nuliiness of an 
uttnrk it is ini]HiKstl)If to juiJKr, hut w^rlainly the relii-f fnmi eye-l 
stniin, froiTi itiseivscd tnrbinates. fmm ndeimids, fmni nmstipntioii, 
fnnii (lysinenniTheji. from a mnnlHT of minor yet lieiiniti" peripheral 
irritatitHL*!. will relieve a (vrtaiii nnml)er of patients. Perhaps tlwy 
are the very sliglit miKraine.s, jH-rhaps not; onf i,s not yet in a |>i>sitioh^ 
to say. Utie kIioiiM therefore elimiaale at the on.wt such of these] 
stnietiiral defeets as are shown to have some inttuenw* on the iier\'(iua! 
system. In denying any |)ossihility to thesi- inHiieiiees in the eaiisatioii' 
of n nuETaiTie attaek, one err* as hadly as when tnaintaiiiinj; some fine 
of tlieui to be the only and incariabtt element iii the cow, as faUdi^tta 
are doinj; and always have done. 

(Iastro-int(stinal factors are elosely analogous to those just men- 
tioned. In the niimis of most clinieians. and (-ertaiiily as generahzetl 
in the fii-lings nf thosi- most affected, it is In tlie stoniaih, liver. «ir 
intestines that the main seat of the trouble is to Ije sought. The 
gRStni-intestinal factor is undoiibteii in many ea-ses; it may be exclu- 
sively gastric or colonic: ixTverted cheinlsni, perverted bacterial action 
(primary or secondary factors, no one can yet say). The significance 
of chemical features, resulting from altered gastric secretions ttr from 
toxic Iwicterial priHlu('ts, is not known positively. It is tvrtain tiiat 
none of the prodncts which have been held responsible as auto- 
intoxicants are universid causes. M any rate, the general features of 
ga>tni-lntesiiiial hygiene should be carrii'd out. Constipation is to be 
avoid(*tl, and sticli diet taken as expericinr has shown is individually 
applicable. Excesses in certain articles of diet are held by umny as 
exciting causes; such empirical fi-elings should be respected; the 
patient often knows himself better than dt>es the phvsieinn. 

In some, excessive earholiydrate intake acts disastnuisly; in others 
wine, whisky, or gin. The history of inability to eat fatty food, pan 
tieularly sausages, is not infrequent. 

In rarer instances, one notes that certain auditory stimuli maj 
bring on u iiiigiiLine. To attend crrtatn fatiguing and thrilling tipcrai 
is followed in ^ome by migraine attacks. Here psychical mechanism.' 
are at work. 

If the varying elements mcutionc<l have any real relation, it h 
evident why such a variety of measures will be of help to a few. anc 
why so many more will be worthless for many but useful for Mwne 
Medication between attacks is largely useless, save naturally in llu 
symptomatic niigraini*s. General niedii-ation, for no rlefinite purjiosi 
but just in the hope tliat it may do good, as i<Mtides, brtnnideij 
strychnine, etc.. is seiisi'Icss. If definite factors are foun<l that nec< 
oirreetion, and can l>e so modifie<l by drugs in tlie desired direction 



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OPUTHALM/C MIGRAI.WE 



151 



then they will prove us^ul. Thus iodides will un(loubte<lly help 
man^' presenile arteriosclerotic mifcraines; bromides are useful forsleep- 
less and irritable eonditinns whieh provide a gooH fovmdation for the 
nervous in.slability that permits an attack; laxatives arc ^-ulled for 
if persistent rcmstipntion hears any catisal relfltioiiship, and thymid 
is iiivaluahkr in ct-rtairi liypothyroitl states which are very liable to 
affect the tonus of tlie vejfetative nervous s>*steni, particularly in that 
type known as syuipathicotoiiic. Very minute doses are useful in 
eertain mild Infjertliyroid migraines, as is also belludouna. or violet- 
ray treatment (tf the thyroid. In the inin;ruincs nlute*! to menstrual 
disorders in women a careful analysis of psycliieal and gonadal factors 
is essential. 

Complicated systems of diet have been devised. T'sually such are 
more prolific in engendering; semi-invalidism than useful for migraine. 
Here and there a |>atient cierives brneHt from a strict dietary n%ime, 
but unites there are real reasons why ii patient sJiould not eat rwl 
meat, or tomatoes, or sundry other articles, as determhied by actual 
experience and uudiT ri'peated experiuiental trials, in unler to elimi- 
nate faddist's ermrs, the piitierit is better off without a diet ciird. 
The reasons sunght for are not tliose contained in many trcati.ses cm 
dietetics, in which priiiiitive notions conccnuuR differences in red meat 
and white meat, vegetables growing under the ground and those above 
the ground, arc- foolishly per^ietuated. The only satisfactory manner 
to attack the metabolic problem is to carr>' out a complete metiibolism 
analysis. Huphazard attacks here and there lead only to premature 
and insei'ure judgments. 

Complete formuhis for attu<.'king excessive bnctmal putrefaction 
are applicable only when it is pn>vtiti that such excessive bacterial 
action exists and has a reUnioii l« the uiiftraine. The hypothesis 
canimt be excludol i'J" ffithntni, Init it remains unproved for most 
ease:!, au<l of douhtful applicability in u few. The lieUef tlmt tlie 
presence of indicanuria is an infallible imiex of harmful putrefactive 
products Is not well foniKled. 

The avoidance of alcohol and tobac<-o, while ad\'isable, is so only 
relatively. The individual's reaction to all influences should ive 
ripiilly estimated l«'fiire tho.se usually self-evident restritrtions are 
impnstHl in the name of health. 

In certain individuals a change of oi-cupatiou may be ubsohitely 
neeessitri , but hen- again one must Ih* wisely conservative, and not 
consign all migraine [jatienls to an outdoor life. ()utdm>r workers are 
by no means exempt from migraine: such, perhaps, should Ix; clerks. 
The character of tlie work is to be borne in mhid. "Dw elements of 
haste, of pressiu*, and of lack of leisure are to l)e thought of in this 
connection. 

Psychoanalysis should l>e advised for severe recurrent migraines in 
neurotic indiviihials. Chronic headaches are very frequently psycho- 
gt'nic in origin and need psychoanalysis. 



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152 VEGETATIVE OR VISCERAL NEUROLOGY 

VftT the hruimeni nf the attack itself, one finds that a like fitting 
of remcflios to the individual is called for. In the initial phase of 
VHS(X'tnistriction a number of vasodilators are of service, although 
their action is extremely unequal. The nitrites and nitrates have been 
employed for years, and usually with a fair degree of success if the 
ilosajje and individual member of the group bfe correctly chosen with 
reference to the st^verity of the attack. A mixture is of greatest value; 
nitroglycerin and er\throl tetranitrate give the best combination, for 
following the very evanscent and powerful action of the former, the 
raoTv. prolonged and steady acticm of the latter maintains the effect. 
Tlie slower acting nitrites are practically useless. Nature's readjust- 
ment, vastxlilatation by vomiting, etc., has already reduced the cerebral 
pressure, and tiie stage has passed when the dilating remedies might 
Ih- useful. It is practically only in the vasoconstriction stage that the 
nitrites are worth much; and in many they are inefficient, the reasons 
for this being as \ct unappreciated. Given too late, they overdo 
the dilatation and increase the difficulty. 

The analget-ic vaso<lilators have come 'to occupy the front rank. 
The precise ]>harmac(>log\- of each must be appreciated in order to obtain 
the best results. Solubility, time of absorption, slight differences in 
the chemical formula and in action, continuance of effect with minimum 
by-effects, arc all to be studiwl. The list is a long one and is constantly 
on the increase. Anti])yrin, ac-ctanilid, phenacetin, and the related 
salicylic acid (aspirin, etc.) compounds are the chief members. It is 
to be rctncnibcred that while their general action is closely related, 
there arc specific differences in the working of each, and the measure 
nf success tliiit one has in mastering the majority of migraines depends 
upon 11 knowledge of these factors. Antipyrin, by reason of its rapid 
snhibility and quick action, occu])ies an important place, but is not 
always ajiplicable. Acetanilid, alone or in combination with other 
analgesics of related type (salicylic acid derivatives), bromides, and 
caffeine, arc also valuable. The dosage should be graded according 
to the usual severity of the attacks. Tolerance is established in the 
quickly recurring attacks, and changes must be made. It is not yet 
certain what part is played by the n'spective analgesic and vasodila- 
tation action.'; of this group. They have roblied migraine of most of 
its terrors, and tended to diminish the use of morphine and its 
ilcrivatives very markedly. 

Caffeine is a much overrated drug. In the abortive attacks arid in 
the morning remains of a migraine it is useful; but for a full-fiedged 
attack it is not efficient. Similarly, bromides alone, chloral, and other 
widely used drugs are valuable only in mild attacks. They should be 
used ill preference to other more i>otcnt remedies, which should be 
reserved for the severer attacks, in order that one's therapeutic measures 
may more correctly approximate the needs of each individual occasion. 
The use of ac-onite and Cannabis indica is more restricted now that 
really efficient analgesics are kno^^-n. Aconite is rarely called for, 



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PERIODIC PALSfBS 



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while Cannabis imliea or Cannabis iiiiiericana has a limilei!, thnuj^h 
no less tieftiiitc. pliur. In attacks asstKiated wltfi itnicli nieiiUil 
depression the addition of (iuin»his is nften useful. The often experi- 
enced ineffieacy of t}iis liiTter remedy is hirfjely due to its extreme 
variability. Great can.- i^ tlierefnre to be exeretsed in the selertion of a 
proper preparation. Tablet preparation.s arc usually worthles.s. This 
is etpiiilly true of the volatile nitrite preparations. Opium, or its 
main derivative, morphine, should l>e u.-:*^! only as a last resort. It is 
rarely really netxied. 

Lying ilown in a tpiiel, darkeTiet] riKiui — a brisk sjiline laxative taken 
as early as [Missible, the patient Ijeing undressed ami well covered — 
these are essential in the severe exliaustiug atUicks. A \'ery hot bath 
often ai*b very materially in restoring the patient to comparative 
freshness. Cold is to la- avoided. 

The greatest folly of all is to treat all piitieut.s and fvcry attafk alike. 

Periodic Palsies: Ophthalmoplegic, Facioplegic, Hemiplefic Mi- 
graine. — It is known that in the urdinary attack of ophthahnie 
migraine there may occur various •(en.<H>ry or motor phenuntena, 
amonj; whiili ane.sihesia.s or paralyses an* the must niarkeil. Thi-se 
siMisijry aiul motor clmiiKcs are extremely diverse when the entire 
range of the migraine sjTnptoni ate logy is brought into review, but 
there is one symptom gniuplug which, by reason of its comparative 
frequency and close similarity, was set apart from others occurring 
in this alTectioii and uaninl by Charcot ophtlialinoplcgic migraine, 
in order to distinguish it from its mure classical relation. It consists 
in a paresis ur a paralysis of one or more muscles of the eye. inner- 
vated chiefly by the ooulomotorius. which comes on either following 
or during a migraine attack. 

Ina^^lU('ll uh ocidornotor pareses or paralyses may occur from a 
gr*-at diversity of cHtis^-s, iipart from a migraine, mid niny appear 
pcrindically. it ha.s Uvn held by many that the term ophthalmoplegic 
migraine has no particular right to exist, but the evidence Is too great 
to eliminate niigraiiic us a i-ompetent prialueiug cause for these periodic 
<»culonK)lor pnnd,\'se.s. 

rurtliermore, evidence is accuuiulating that indicates that paralyses 
of the oculomotoriu.<i arc not the only paralytic syndrome.^, and it is 
recognized that a number of other muscles suffer from similar affections, 
which are more or less transitory in their charaiter ami which are in 
all prol»abillty due to vegetative nerve disorders chiefly of a vascidar 
character. Tn the.se rhuugejihle un<l (lilting jjalsies tlie name |«erlmlic 
palsies is given. Some are niarkeil in certain families and hence have 
been lermetl familial. Among the ran'r of these migraine etpiivalcnt-'i. 
or periodic palsies arc llic facioplegie and licmiplegic t.s'jjes. Monopleglc 
syndromes arc still rarer. 

Ett<doK7- Whether heredity plays any greater iiart here than in 
migraine in general is difficult to decide. Certain periodic f>al.sics 
not usually classed with migraines show markwl heredity. 



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VEOBrATlVR OR VJRCEHAl. NKUROLOCY 



Syn^toma. Leaving xx^Ativ for tlie luuiiieiit the atypical ami synip- 

(oimitif ihtkhIii- oculomotor paraly:*e3 due to other causra than 
mi(;ruino, one finds in these patients, usually during or after a severe 
attack nf nnllaTrni! mipraine, with headache, nausea, vnmiting, etc., 
a ptosis of the eyelid on tlie siune side. nn<l it la-w, iwirtial or cthmplete, 
of the upwani, cltmnwHn], ami inward nieivements of the eye of the 
same side. Tins eye is usually directed outward ami downwanl. and 
the patient sees donblo. This niay or may tuit Ix* Hef<»nnpanie<l by 
sensory distnrbimtx.'s in the superior l»ranch of the trigeminus, just as 
may l>c ohscrvcd in onliiiary cji>hthalini<- migraine. 

After a \ariable length of time, a few da>'s, a week or more, the 
paralysis disapi>f*ars. usually gradually, and the patient suJTers no incon- 
veuieiu-e frnni the iH-nlar pal^^es or the ptosis. In some iiuUviduals 
sni'h palsies ini-oinj/anying a nngraiiie have eutno on romparatively 
early in life, ahnnst with the beginning of the migraine attacks; 
fi>r the majority, however, they fiillow several years after the estab- 
lishment of a mtgrahie, in some instances us late as sixty years. Jii 
some only a ^■c^y severe attack will be accompanied by the o<-ul4)motor 
signs, or only slight palsies; transitory ptosis may occur frequently. 
But in others the palsies develop with each attack of mi^aine and 
often in intTejisinK severity. The effects may persist longer and longer 
helween the attacks, until in a few they Iwcome jwrniancnt palsies. 
This Xy\M-, however, often permits of other interpretations. 

.\ double lesion can he understood, although it rarely occurs. Iso- 
lated alMlm-cun palsy has been described, also isolate<l trochlearis; 
and amiplete o])hthalmopl^ia ia reported in a single case, but in view 
of the many possible contribult»ry factors it perhaps is preferable to 
view such a case from iiiiother standpoint. 

Ofjhlhuhitniiit'ffic Miifriti in:— I'Wtv Ims \ni-n mucli speculntittn con- 
cerning the i^'iitra! or periplieral nature of this form of third-nerve palsy. 
The present view regarding migraine in general, that it is due to a dis- 
turbance in ivrebral pressure secondary to vascular modifications, is 
sufficient to accoimt for the oculomotor palsies a,*, well, in view of the 
location i>f the peripheral branchp.s of the third nerve in relation to 
the «-erebral vascular jiIcNuses. In fact, the occurrence of the ophthal- 
moplegic type is one of the strong arguments for the general pressure 
hyputhcjds, as S|)it/er has well argued. If, as ha^ Ijecn shown by 
sevcnd autopsies, to these considerati4»ns additional local causes be 
added, wliJch increase or pernmneutly maintain such pressure effects, 
tills inter] ire tation is made mon' a'rtain. Thus, exudates, fibrous 
proces3e.f, swelling in the cavernous sinuses, swelling of the hj-pophysia, 
tumor formatifin, gimimata, etc., have been found in patients sufTering 
fmm periodic oculomotor paralysi-s associated with migraine. 

It is true that some of these are to I)e interpri'ted as syinptomatic 
migraines, in which the foreign Uidy acts primarily as an irritant to 
cause the vascular disturbance which sets free the migraine reaction, 
and secondarily serves as an additional cause of pressure to bring 





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about the palsy. In a per^oniilly olM«T\'ed case, with \ms»\ pummHta, 
thf periodic ociilnmotor palsy hikI miKniitic attacks had iiociirred for 
a (htIikI fxteniliii^ over fuiir or fivt- vi-ars, usually with cvi-ry nu*n- 
striiul iKriml. Merc were three intcrpluyiii^ factors, and the cxjict 
jiart phiywj by cacli can unly l)e iufcrrcil. The slinlil disturbance of 
mcti!>truBtion, usually ndju.stcil, in this case was nut by reason af the 
exudate. A nii^uine was set up. tlie iicnte pressure of whidi, added 
to that f>f the exudate. i-aiiM-d the upluhalniiipie^ia. This ophthal- 
nuiplcKia has l>eeume fairly persistent in the intemiigrainous [MTitKLs 
in rL'Cful years. 

Fariupleyt'c muf lleiritplegiv Types.— Tliv^x are niucli rarer cuiiipiieu- 
ti/>ns. Siiine obsrrvers w(mld rule out the facial type, hut there Ls 
no jfood reastui for tliis. It does m-cur, aiiiJ certain recurrent facial 
palsies which Bernhardt in his vtduminous study has sho^\-n to occur 
in 7 or S jkt cent, of the cases are of this type. Menuplef^ic attacks 
accninpanytnf; migraine are also rare.' Hetniauopsia and optic neuritis 
(prolmhiy edenmttius or licinorrha^i*) are still rarer coin plications. 

.S«'>inf jM-riixiir jKil.tie.1 iH-loiiy in this );ronp. A'asomntor palsies 
nceur in the spinal conl as well and are atxoniimiiitsi by edematous 
infiltrations usually of a mild (frade. They are oc-casione<l by much 
the same ctmibiuation of slinuili as are tlie niiffraines but they are 
apiMirently much rarer. The resulting palsies are knowTi as imrittdic 
pahies and are di^cus-^ed in the next ^ronp. 

Diafnosis.— Kvery [latient shoulil lie re]i,'anlei1 as one sulferinjj from 
wfnielhins more than the migraine, until all arcessory caases are 
e.whuhHl. WImt these may l>e have been Tnetilioneil aln-ady. 

TtfiatmeDt. Little needs to be adde<l to the therapy outline*! under 
rnipvine. S^^hilis as a cause for Ijoth u ini^niinc and an exudate 
sh<»uld Ih* treated, and the Wassermann reaelion utitize<l tn clear up 
the diagnosis and therajteutic indications. 

3. Vasomotor Irritability Group. 

Angionetirotic Edema.— This condition is better described as aciite 
circuni^itTilRil *ilema (<^ncke), since such a name Hix^ not commit 
mil* to its iM^iti)* a vnM-iitar m-unisis, altboufili this is pniluibli'. 

'Hn-NC most striking skin edemas wen* descrilied as carh' as ITT.S 
by Siilpertus. Crichtou, in 1S(>1 , als4) observeil thcin, and (ira%es, wlio 
(Cave such an exeellent outline of exophtludniic goiter in 1J*4X. descrilied 
a patient with liH-alized swellinn of tlw face, forelicad. and eyes, in 
whom tl»e edema persisted! only a few hours. N'arious alnrrant loeal- 
tzations Imve Ixt-n ilescril»ed often under different nami.'s. Natu- 
rally hj-steria bulkeii hirge in tlie diagnosis in the earlier days. (.Hher 
itynonyins iiulieute under what difbTcnt diagnostic gnaqis these cases 
Day be found; urticaria, luiicaria edematosa, epidermolysis bullosa, 

•Mllffv: N<nr Vnrk M»»i. Sour.. Jaaivwy 6. I«(K>, 



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VROBTATIVE OR VISCBRAI. NBVROWGY 



urtirjiria UiW-rosa. urticaria gaii^rrt'iiosa, Hrnl pijiut urticaria. Further, 
oiH' HihIs rhfiiniutic cdeiua, artliritic tilcraa, repeating rhcuiuatic 
edetna, hydrops articiilorum. intermittent rheumatic edt^ma, neunv 
flrthritic edema, in the periwl when ilie eases were f;niuped among 
the "rlieumatisnis." (ijwtrtisuifurrhea periiHlicji is it stuumeh li.H'a]i- 
zatinn. lV>hal»i\' there ari' others iif ohseure nature. Aeiite brain 
swelling, meningitis serosa, spinal swellinji. local trnnsiciit edema, 
intermittent eilenia, and |xTi«»«lic jiiiralysis arc ainung them. 

Quincke, in 1S.N;*. descrilM-'d it \\s acute circunt.scril>p<l skin edema, 
whik- in ii Kiel di^scrtatinn, one of his sludenLs, I )inkelacker, hmiight 
together many of the older dewriptions, and showeii the unity of several 
apparently disnimllar processes. He termed it acute i-derna. 



INHERITANCE IN ANCiO-NEUROTIC CCOEMA 
"T" FAMILY 

X • ■ D 



n 



III 



i~n & 



IV 



6 



4 4 4 4 



[f4 



MALE 



□ MAie y i 

O FEMALE ' S 

Fm. 60.— Tlhiin nhnwiiis h<'rwlity in un iin^otunirulir otloma family. (fJalw.) 



FENAIE > t. 



Occurrence. — The disorder is not frequent, yet it is not rare. Men 
luirl women appt-ar «Ik)uI equally invohe^l. Tt inay he present in 
yoiuijf cliildren — one and a half months (Crowr <jriffitlO; three 
montks (Dinkelacker). After rort> it appears very rarely, as an 
initial devclojfinent, althoufjh iti affected individuals it may persist 
until late in life, (assircr rep(_Ttcd histories of patients of seventy- 
nine and sixty-nine, in which the disease ap(>eared com pa natively late 
in life. Haven rejHirts a case in a woman of eiphty-t^x. 

(Jcrupatinn appan-ritl.s' plays no role. Ilei-edity, on the other hand, 
is e<>nspicuous. Many authors have luenlioneil thi^ feature. Osier's 
fatuily tri'c has been freely cite<l. and is here rejirotiuci-d in ^lightlv 
chan^fcd furm. Ensor rejwrts a fatuily of eighty memlwrs, with 
thirty-three atfected individuals, twelve of whom died of edema of the 
glottis. Similar hereilitary feature.** arc reported by several observers. 
The question of its transmission has not bi«n i-ompletely cleared up. 



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VASOMOTOH IRRITABIUTV GROtP 



lo- 



in Aprpt ami Dt'llIIe's fainilks only tlit' nialt'S wen- aiTi'cted, hut this 
does nut sct'iii In i>c tlic rule. 



.Ii 



faniili 



.f 



the 



in many ranulios similar tyjK-s of localized cilcrna prevail in 
riierniMTSf while in others, apparently more iil'ten, all of tlie piwsihie 
variant?! disappear. Other ner\our> system involvements apj>ear 
associated with many of the families; how much of this is largely 
tTHTicidemv, hnw much j^eiierai neiiniiuitliie cjiuwal relationsliip is 
difficult to determine from the studies at hand. 

The s.Midixime is ass(»eiated iiiifrcr|iieiitly with tuU's. mya^tlieiiia 
gravis, spinal wnl tumor, exophthalmic goiter. m.\*xeclema. periodic 
palsies, while it seems very frequently assodated with many so-called 
functioiml neuropathic states - hysteria, compulsion neuroses, migraine, 
etc. — and in certain ps\chotic individuals with schizophrenia, manic- 
depressive p-sychosis, feeble-mi ndedness. 

Local traumata play a role at times, particularly in detemnininir 
the location of the swelling. Emotional shock bulks large as a direct 
etiological factor, as docs atsti the action of thermal inlhicnces. <'old 
is very frL-qiieiitly an exciting factor in the reaction. Menstrual 
factors sei'm to cuter into the etiology of certain cases. 

A moment's reflection, therefore, will show that under tlie term 
aoutc circumscrilx'd edema, one is dealing with phenomena of great 
variability imd multiform genetic jjathogcuy. lei discussing tlie 
pathology, a retuni will be made to this many-side*! etinlogj'. 

Symptoms.- The original conception of Quincke lias l)een much 
employed, ant! Cassirer in his large monograph shows the present 
da\ trend to include a large numWr of acute edematous -swellings 
within the nosological prmip. Thus one distinguishes localized wiema 
(if the skill, edemas of the nuicous menibraiie, of the eyelids, month, 
glottis, esrtpliagus, stomach, intestines, respiratory tract, cdcnuis of 
(he joints, the meninges, the tendinous aponeuroses, of the spinal 
cor<l. of the brain, of the kidneys, with polyuria, uibuminuria, hemo* 
globiimria, dimiiiiithcd secretions, and edema of other structures. 

'ITic ouset is usually acute, with some initial pmdromal sitjns of 
malaise, fatigue, chilliness, anorexia, nau.seu, ami slight rise in tem- 
perature. The s3Tiiptom.s that develop will depend upon the localiza- 
tion of the pmcess. 

lit ihv Jikiv there are isolateil swellings. These are localized, variable 
in size, at tinus small, resembling urticarial blotches (intermtiliar>* 
forms) hut usually as distinct swellings, with an clastic feci, iuid due 
to local accuuiiilations of dear serum within the skin. The color of 
the swelling is usually that of the skin. c)r iwilcr, rarely red or reddi.sh. 
The swelling coincs on with great rapitlity. in a few moments, and 
remains a few hours, mostly a few days, and then disappears without 
leaving any trace. They are, as a rule, non-jpritating. painless, and 
only cause discomfort a.s a result of the tension. Certain patients 
experience burning, itching, and intense pain. 

The nizf of the edematous patches \ aries greatly. At times verj" 



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VEGETATIVE OR VISCERAL NEUROLOGY 



araaU^one-half inch^they flpe more apt to be three or four iuchcs in 
diameter, or at times involve the larper part of a Miiib. 'I'lic scrotum 
may at times swell up to the size of a foot-hall. The penis, in rases 
reported by Uorner, has swollen to double its diameter. The entire 
body was swollen also in a remarkable cnse reported by Diethelm. 
At times the swellings are numerous, potyniorpluiiis, stTJiicnntlneut. 
They rarely rise niore than one-tiuarter to oiie-lmlf centimeter, but 
itwellinpt two to four inehes above tlie skin otrur. Tlic niarjcins 
of the swellings are usvially sharply circunismKc<l, but at times may 
shade off imperceptibly Into normal areas. The swellings are tisually 
deaeriheil as eireular nr sjinsn^i'-shnped. The swellinKs invade aJmoat 
any layer in the skin, the must-nlature, or they may even invade 
the periiisteum. Some have l>eeri termed pseudDlipumata. 

The cftn-aiskncy is semisolid, non-pitting, or slightly sn. Thi^ whr 
as stated is usually that of the normal skin, or it may Ix* paler, or have a 
cadaveric hue. Again it is ]iinkisli to red, or even deep red. Often 
the color tlisappears on pressure. The color may change during the 
rise of the swelling. 

Local tfKijirruttirr varies. At times ihe skin is colder, again it is 
warmer than that of the ne)ii-iitrectefl parts. Kxact stiuties are wiint- 
ing. It seems not unlikely that there is an initial increase in tlie 
local tem])ernture. 

Scnsorp chariffrs are not present as a rule. Certain cases luivx 
shouTi pn'liininary neuralgic twinges, no definite .sensory {lefect 
has been noted, but refined methods of examination, such as those 
dtmanileil by IleaH, have not yet been made. There is frequently 
the subjective sense of great discomfort, e,sixt-iall>' in marked swellings 
about the fare. 

There are rarely any rmdimi.s, although occasionally scaling or 
pecliiig has been obser\e{|, proliHbly for the more sTi])erfie tally lying 
edemas. 

Scrrftory ^yni/j^rmwhave not Inrn carefully recorded. Lo<*al li\*peri- 
dntsis, dermatographifl, iucrease<l tear secretion have been noted. 

'fill' li'Caflon ijf the swelling may be almost anjn^-here, it caimot 
be said thiit «tnc place more than anoihtT is a. favorite site (statistically), 
Kxpose<l jKirtioris nf the budy serin to Ik' nmre often involve*!, hut 
wlien on the hand or hands, the distribution is not of the glove type, 
nor are the swellings apt to Ite symmetrical, nor do tliey seem to follow 
railicnlar or peripheral distnbutioas. There is a distinct tendency 
for a recurring ctJema to tHTUpy the position involved rhiring a 
fitrmcr tittaek. 

IVriiirticular swelling constitutes a peculiar tjiw, so also ilo pui-otid 
and salivary gland edemas. 

Mfif^mn .U»"»(ftm»ic*.— These are frequently involved. The lips 
mouth, s()ft palate, tongue, phjiryngeal pillars, nasal membrane, 
larynx arc all sites of election. The last is jmrticularly frequent 
and is dangcroiLs to life. In these cases other structures than the 




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159 



larynx are implicated, especially the epiglottis and closely associated 
stnictures. In llit- larynx tlif iiiueous membrane is swollfu and 
tense; the edema infiltrates throufihout. 

When the lar^Tix is involved, the symptoms arc apt to be very 
niarke<l. There is iH-KidninK ticklin};. and rapidly oni-ominK difticiilty 
in breathing, until marked dyspnea may supervene, with death. uni(.*ss 
hituhatinn nr trachpiitomy is performed. Some of thrse patients 
die witliin a few hours. Many cases, on the other hand, dear op in 
an hour, after severe dyspneic sjTiiptoms. Aeute eonjumtival edema 
is not infn-queiit. 

Edemas within the bronchi occur in perhaps 20 per cent, of the 
rases. They make up a certain |x'reeiita};e of the cast's of astluna. 
Certain liay fevers ])C)ssibly belong in tills in'uup. Luii^ edemas have 
l)cen described. 

In edemas of the stomach (j;a.strosuccorrhea i>erin<li(ra) extenial sijrns 
are also usually pre.sent. There may be intermittent voniitiiiK< or 
sudden arute pains and arorexia. The attack may last a few lionrs 
with severe pain, atid finally mort* or Ii-ss a>ntinu()us voniitioK of clear or 
bile-colored watery masses, marker) thirst, and Rrathial disap|>earanre 
of all of the symptoms. Bits of tjastric mucosa have been accidentally 
dislodged which showed marked edematous Hwelliug. 

In inte,ttiua! lacalizalirm^ profuse diarrheas are present, with colicky 
pains, metforism, tenderness of the abdomen, dhnuiished urination, 
great thirst, and collapse. The diarrliea.s arc purely neurotic diarrheas, 
so-called, and occtir in asiweiation with other signs of a circumscribed 
edema. 

Jlarer UtcalizaiUma present in the tendons have been deseribeil, 
partictdarly by Schlesinger. Muscle edenuis are ako rarely described, 
although it is probable that they are of fn^iuent iK-currence. Lumbago 
ispossibly i»f thist>T>c. .VrticidaredeinHshaM' been nienlionw). They 
are fre<]uenlly of psychical origin, as for Instanc** in the classical ass^ici- 
ation of attacks of gout and of anger. 

Optic-iier\'c edema is one of the rarer localizations, as Is also an 
edema in the labyrinth leading to a Meniere syiidnmie. 

The bladder, kidney, and heart structures are among the rarest 
Iwalixations. Meningitis serosa, aphasia, hemiplegia and monoplegias 
are among some of the more problematical occurrences reported and 
periodic paralyser arc inclnde*! here as well as in the previous group 
alJietl to the niigraities, 

Tmttitition formti are cninnioii, es|M*cially ui*tirnria-like eniptitais. 
Acroparesthesias. Haynaud-like attacks, local asphyxias of tlie extrem- 
ities, paroxysmal hemoglobinuria, acroasphvTcia chronica, crjlliro- 
melalgia, iicriodic paralysis, cpidennolysis bullosa liere^litaria, synovial 
serositis. fibrous serositis. iierpes zoster are all affections with which 
attacks have \icpn combinw), singly or in gnmps ()f two or thretr. Dcca- 
sioiially edema, acroparestliesia, and eriltiromelalgia may alternate 
in one and the same patient. 




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VBGBTATIVK OR VtSCKIiM. SEVROLOGV 



Prognosia.^Iii k*''!**™! tl'is i^ ""' |?<)0(l. Tlic triiiiency lo laryiij^ai 
IwaliziUioii imist always Ix" viewed .with gravity. A gn-at many 
iii()ivL(luaU liave died from etjeina of the fflottis. Kemissions are to 
be expected, ^'onie (Mitients sutler mauy years, others, but the min- 
ority it would ap|X'ar. have but few attacks. There is some general 
temleiiw for the disonler to become milder a.s the affected individual 
grows older. 

- Pathogenesis. — Iteoent ixmceptiidis conccmiiiK edenm are undergoing 
such mdicul iniKlificatiotis that it is prnctieiilly itiijxiKsible to interpret 
the fiiuhnf^ here outlined along those Jincs that regard all fxlemns as 
cell ]ihen»nu'na solely. inde]H'ntleiit of the action of the ^■egetative 
ner\*ou.s sy.^itpm acting on the hl(K)dvcs.seI.'*. The studies of edema made 
by Fi.scher and others emphjisize only the physionchemical side of tlie 
prohU-m. They iieglei't the role of tlie vegetjitive iier\'ons sy!<tem in 
regulating tijwue tension and celhilar chemism. Tlie statement that the 
disiinler is an ahglinieunwis by n*» means cleiirs the situation, although 
it is (TPtain that the sympatheties are media from cause to elTect. 
The study of anaphylactic phenomena, especially as seen in the so-called 
anaphylactic serum rPHction.t, or serum diwjises, has offentl suggestive 
glimpse.^ indicating certain anah)gies with the wries of changes here 
outlined. Wherein are the proteids suppose^;! to cau.se these related 
to the endticrinous luinnones? It can only he stated that precisely 
similar proces.ses and ajjpcaranres are found in the senmi rea4.-tians, 
and that it is not witliout profit to en<|uire more into the mechanism 
of their production in an attempt to nu'Icrstand acute circnmscrilted 
eiiema. (nfortunatcly the mechanisms of the changes in the ana- 
phylactic reactions are still much in the dark. There is a distinct 
tendency to include the anaphylactic reactions under the phenomena 
ivgidatrd by the vegetative iicrvmis siyslcm.' 

.\cnite circunisiribed edema, hus also been iiiteri)i'eteil ns a motjified 
colloid absorption reaction, due to toxic iiiHiiejiccs bn>ught to the cells 
of the deeper layers of skin, mus<-k' or mucous nicMibniiic. The view 
licre teutativciy adopted is tliat it is a neural reaction brought about 
tlirough the vegetati^'e ne^^■ous system,, which controls reciprocal 
tension relations, or cellular ehemical composition rclation.s. 

It is not improbable that there are a series of reactions represente<l 
in the acute circuniscribeil oh-rnHs. It Is tu»t a tmicum, and analysis 
will show that a imnihcr of difTcrent pathological processes may underlie 
prwiscty siiniliir phenomena, Ix' they in any vascular area of the 
btwly. 

( "a-ssircr adopts this viewpoint, but consents to make only two gnmps 
of case-s: («) a tcj.\ic, autoto-^ie gnjup, in which the poison works in 
some mysterious way, which a wealth of language can conceal, better 
than it can rcveid, anri {l>) a herctlofamilial or co7i>titntional neuro- 
jjalliic gnuip. which be regards as iutinmtely assoeiati-rl with instability 

' Rouvcruui: Entvbtiiiw d. Neurotoicic u. P»(>cliiiitriB. vi>L ii. No. 1. Alao «*o NoOl 
Patuti: NcTvoiia Iti^ululora <if MetaboliMu. Baytiw: PrioHptoe a( Giuiunil Flijsiolagy. 



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rAmmrroR fitmrAniUTY ctenup 

ill rrrtoin parts of tl«* wpinaiivc nervous syslrm. This may be, he 
siiys, u-vMH-iatif} in H<ime mnnnrr with mi)difit'ation.s in the internal 
f^land sptTetions. Here nnnthiir flark portJil is entered. At all events, 
CV'v'^irvr is hmth to jKTinlt -so-callwl aiintoiieurotic cdorau tu wander 
from the neunilopital fold, and concludes timt the disease Is am- 
ditinnwl— at lea^t his pmiip (6) — by the lability of the vegetative 
ner\mis system. Onr own view is to emphasize the importanee of 
paychopenic comjxinents in ihe eliulogy, 

Treatment.^'l"Iii>i is pnn-ly einpiriml. It eoiisists first in avoiding 
all those tilings whieh exijerieiice has shown to lie hazanlons, 

If one of the mtyrv pronouneed tnxi<'-anaphylaxi^like t^pes be 
present, careful study niu-st lie niiule of all of the patient's pnttein 
reaetion.-*, and attempts made ealrulated to repiihite the diet iieeord- 
ingly. It ?>eems possible that it is thmiiph the jjastro-intestina! canal 
that such pHxIucts gain entry, particularly in food, yet some may 
enter the respiratorj- tnu-t, ns seems to hf tlie ease in the relate<l hay- 
fever reactions which are thought Ut follow cerlnin contaet-s, such as 
raijwtrd. rose. hay. and otlier [>nllens. or even the emaniitions from 
lower aninmls. 

Krom specific exclusion of certain prftteins one passes to tlie (jreneral 
hygiene of the intestine. This meaas a sort of search in tlic dark 
for etTrctivr iiRencies by cheniiral means. One is justified notwith- 
!<tJin<linf> in trying to bring about altered bowel Minditions, which 
rmpiriciilly may do some k'x"!. when n laisser-fuire attituile seems to 
lKT|)etuale tlu- disturlKince. Xatnndly one should avoid intestinal 
theinpy. should the patient W of an entiri-ly ilifferent t\Tw, say the 
tntrnNely neurotic fonns with familial hcretlitary Knrdens, and emo- 
tional shiK'k reactions. 'I'hese patients neerl a psychoanalysis. 

Of the ga.str<>-intestiiud antiseptics so-<-alk-<l, few art' of value. 
Menthol, saline laxatives, carlHiimtefl waters, careful dieting it) may 
b(> found amon>; the conventional remedies in the Ujoks. The taking 
of a milk-vej^talile iliet has liei'ii coincident witli Ijettenneiit in some 
indiviiluals and iiHTu-idrnt with gi'tting worse in others. 

In iiTtain cases with assix'iatiHJ toxemias, such as malaria, etc.. a 
sfKcilic therapy Is indicated. 

Cn the supposition that the h|oodve»tels need bracing up to pre> 
vrni trurisudalion through their walls, also a liy|>othctiral postulate, 
Apparently inad4-4)uiile, such drugs as slrvchnine, ergot, arsenic, 
Htropine, morphine Iwve been rei-oninicndeil. While all of these will 
liring about va-vrn-onslriction It is nut ap|>Hrent whether they can alter 
a hy{iothrtii-]il lra^^1udldulily or not. <*a)(-iiun lactate is the mtMleni 
weniMHi fur this latter. 'Hie aulhors hitvc not seen it nv-onimenilc^l, 
but it may t>e of service in previ-niing transudates, as such arc thought 
to Ite 4fiitditione<l by a dimiuutton in the calcium content of tlie body 
pliLsma. rn.ssin'r mentitPiLs calcium chlorate. .\t all events the vnso- 
coniitricting <)rugs have not t>een of any pmliciilar ser\'ice clinically. 
Now juid then they ttecm uf i^ervicc; none have been proved of pro- 
11 



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NATIVE 01 



phylartic value which i.s a strifter test oF their iisefuhiess, since the 
disease is so self-limited. Almpiiie is of preat vahie at times. It 
should ftlwjiys be tried in the cBses which seem to show s\'ni pathetic 
Iet-<lown — h\'])tTth.\ rnid tv-jK's. 

Ill eaM's Mssoeiiiteii with laryiim-al symptoms, inliiliHtion may be 
neeessary— even traeheotomy. There are recordit of certain patient^} 
condenineH to the persistent use at the tracheotomy tube. 

In the more strictly iieiirotic type— ("iissirer's proup (6)— it is impor- 
tJint tliat the jjatient Ih' taiiglit a healthy morale. 'J'he substitution 
iif reasonable and intelligent actions for pnrely instinctive and cmn- 
tional reaetioiiK must Ur Hcxiiiirt^l hy thrnir if tliey eiin hope to hi any 
way control their hair-trigger vegetative nervous system. Perhaps 
it was s<» fiiven to them, defective and badly (iMJrdiiiiited; even then a 
nitioEut] |K'rhigogy will prove cif -wrvice. Many will he helped hy the 
mctliods uutliucd hy I>uboiM or iJejerine;' others will need a [wycho- 
analysis. Incrensinij experience and the literature arc serving to ■ 
establish the fact that psychogenic factors amenahle t^) psycho- 
anal^-sis are responsible fur a niiniher of these phenomena. .Asthma, 
hay fever, nise coMs, protein sensitizations, urtiairiiis, synovial swell- 
ings, nrthritis ilefomjans.migmine and other edematous states causing 
wule, even chronic Jisc>r<iers have been in most instances greatly 
relieved, in others cured, by the altered cmotimial attitude taken by 
analyzed patients. Just hnw the vegetative pathways iH-ivme invttlved 
in their complex neurobim-hcniieal relations has been sho\\ii in the 
|«ige.s preceding, also in the chapters on the neuroses and psyehn- 
neurose.s, under which groniw a!so many of these iwtient't are classified. 

V«ffetatiTfl Skin Syndromes.— The veg»'tutive nervous supply of 
tin- skin is still an uruNriiti-n chapter in meilieine. It is only pos^sihle 
here to sketch rapidly a few skin syndromes wliieh are spoken of in 
clerraat'ilogieal literature as "neumtie," or as "tropliic deramtosc-s." 
€te. The skin is |>eenliarK under the <'ontrol of the vegetative ner\'ous 
.system and a careful stucJy of skiu pheciomena with an eye to their 
neurological signifiianee will y'\f\f\ many fruitful suggestions. The 
field of skin symbolisms in the neuroses, [wychorieii roses, and psychoses 
has hardly been touched by tlie dermatologists.^ To the neurologist 
tJiere are mnnerous fruitful problems. 

Scleroderma. — HipptKTates described an .\theuian who had a hard. 
indurated skin all over his body, and (ralen spoke of patients whose 
skin was hard and leathers, with the pores all stopped up. Thiriai. in 
JS4.'), gave the earliest gtiod descripitioitsof scleroderma, and the French 
school, will) Hall, Charcot, anil llalloiK-au, fjushicjiicd the prescnt-<lay 
ilescriptions of this disonler. trrasset anri firissaud, in liiiW), were 
among the earlier advoeatts that it was a vegetative nerve disorder, 



I 



I I>ubub: Psyrliic TroaUuvul of Nltvoub l>U*irdure. Dtijenue: roychoiieuroeiM oiul 
Pij'rhi»tlii'rii[iy. P1)iln'lrl|ilitN, lOIS. 

■.lr-llifT<>: PannMis aff an Hysterical CnDreninn Mechanism, New York Med. Jonr., 
Decenilxir. lOIQ. 



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SfLEltODEIiMA 



]r>3 



whilf Slniinpfll first ftinvilated s«me of the erdnerinous cases, ohsen*- 
iiig H patient uitli sclcniiiiTiiia h[hI JlcrnlIl(■gHl.^'. 

Its (tescriptinji, iicc-iHTeiice, aiut iliffcrfiitial Hiagnusis. its nnmrniiis 
forms and variations are \-iV^\. to lu* fminil in <U*rmatnIngif'al literature. 
Thf nt'umlopical interest fncHsst-s itself upon tlie (ieterniinatioii of thi* 
ic\ol of the ncrvuuti system involved, for the patlioperiy is extremely 
multiform. I'eriiilieral ner\'e lesions (trapezius palsy) have hi-eii known 
to be followefi by localized sdewKlenna. Spinal cord injurj-, involving 
Jftoiibsohn's sympatbctie nvidei, iwx-asions other cases. Numerous 
easi's are assiM-ijiinl with ntber spinal injuries, as in syringomyelia, 
poliomyelitis, muUlpli'^ siIiTnsis. etc 



Flo. TO. — Sdefwiomui. (Xanmiack.) 

As a poljglanfhilar enHoerinoi»athie wnrlrome. s<'|ercMlenna has 
shown a many-sided chnraeter. Cases are known with assoeiated 
hypophysis, adretml, tliymid, uihI mesenteric pland disease. The 
thyroid (frcfiuently syphilitic th\n>id disease) eorrellations seem 
numerirally to <)Utiiuinher the other in the cases rejjorted.' 

No ;>sychopenic cases have as yet been analyzed, but inasmuch as 
many if not most hyperthyroidisms an' <tistirictly psyi'hogenic, at 
least ill the initiid stajjes, it is nut an tinrensunable hypothesis that a 
iwychogeiiic M-lenMlenua is ii {Hissibility. 

'Hie chief pathological alteration, increased Blirosis. is largely due to 
ail imbalance of the svnvpathetic branch of the vegetative system 

> Marifu%co and Ould«tdo; Nouv. ieonoit. de la Salpeiri&rc, PnTfe,' 1913, ;>. 272. 



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1G4 



VEGETATIVE OR VISCERAL NEUROLOGY 



f.f. 



hf^- 



cf, 






arcs. This increased sjinpathicotropic action may result from a 
number of causes — diminished thyroid secretion, diminished adrenalin 

secretion being among them. The more 
exact pharmacological dynamics has not yet 
been definitely worked out. Timme has 
" attempted toascertain the resultant pathologj' 

of oversympathetic stimulus by cutting off 
the balancing autonomic stimuli in the walls 
J, of the stomach. His experiments throw some 

light on fibrosis in general and should be con- 
sulted in any study of a lesion resulting in a 
chronic fibrosis whether of the skin, the 
stomach, kidnevs, liver, or anv organ of the 
body.' 

Treatment. — The therapj- will depend upon 
the underlying factors. The endocrinous and 
ps>'chogenic cases would seem to offer the 
most opportunity either by carefully balanced 
opotherapy or bj- psychotherapy. 
. Molt^ Nrarotlc Gangrene of Qie SUn. — 
The condition described by this title may be 
mentioned. It is a dermal process in whidi 
the vasomotor constriction is not limited 
solely to the extremities, but to apparently 
unrelated, isolated patches of the skin. 

WTiile exaggerations in neuropaths (hj*- 
teria), or in psychoses (schizophrenia) may 
bring these changes about by artefact, maling- 
ering explains only a small number of them, 
granting that the term is any explanation 
at all. 

The disorder sets in with a burning and 
prickling of the skin. Then after a variable 
length of time (a few minutes to forty-eight 
hours) swellings occur, blisters form, with 
later necrosis. At times only a circumscribed 
edematous bleb forms. 

Sweat Secretory Meckanisms. — ^These are 
closely related to, yet independent of, the 
vasomotor mechanisms. They probably have 
independent ganglion cell representation in 
the lateral horns. In general those pharma- 
cological agents which increase vasodilatation 
(autonomic) increase sweat secretions, yet 
vasodilatation may occur without sweating, 



pd' 



y& 



'Zl 



rv. 



Flo. 71.— Scheme of spinal 
centers of the sweat socre- 
tioni«: /, renter for tho face 
and neck; hr. center of the 
upper extremities; pd, center 
for lower extremities; n, 
superior ner^'icul KanRliuii; 6, 
middle cervical sanidion; c, 
inferior wr^-ical ganKlinn; m, 
medulla. (Bechterew.) 



' Moaenthin: Arch. f. Dcnnntulufpc, cxviii, 613. 



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PJIOMOTOH SYSTEM 



165 



and the latter may {icnir with anemia and vasoconstriction (cold 
sweat of fear, sweating of face in migraine, epileptic aum). 

rer\*ical sympattielie and hii]har-auton4mii<- innervation is pn>hal>le, 
and cortical conne<ii<»ns. thuUKh still tupi>f;raphiratly iinanatyzed are 
certain (unilateral sweating in thalamic legions, hcniipk'gia, hysteria, 
<i)nii>uliduii neuriist-ji, schizuphrenia). (Vrliiin anatomists phuT the 
cortical jiathways anions tiie motor trai-ts in the internal capsule. 
TIk* hypothalamus is made a midbrain wnter by some.^ 

(.'JinicalK', sweatinj; is itu-reastd in certain liemipie^as, and in herpes 
zoster. Diminution of the sweat is seen in eertain {-ases of [}oIii>- 
m>'eliti.s, mnltiple sclerosis, s^Tingomyelia. myelitis and ttimor of tiie 
spinal cord. (Jreiit variability in the sweat activity is seen in many 
psychopathi<- inilividuals, in vaKotimic types and in the psychoneuroses, 
liystcria, anxiety j^tutcs, [■oinpnlsivc states. 

The reactions of the sweat secretion mechanisms are exqxiisitely 
sensitive, as is seen by tlw response to pinn, pistr«»-intestiiial emmp, 
canninativea, nictitine, anxiet> and joy. Veragiith's psychogalvanic 
reflex experiments shnw that a close relationship exists lx-tw<.*en the 
skin secretions and p.sycliicai processes. The tiiieness of wpistration 
and the extreme complexity of the phenoraeiia. however, militate 
against the practical utility of the galvanometer tests. 

Pilomotor Systera.-— 'I'lie smooth mu.si'le fillers of tlie skin are under 
sym)jatlH-tio innervation. The pilomotor fifjers run with the senwiry 
filxTs (lligicr), each sensory nerve carrying fil«'rs fnnii ahoiit live 
sympathetic ganglia (Iligier), and have similar topographical (seg- 
mental) distribntidiis. Mechanical, thennal. and electrical stimuli 
CMUse contractions. The erector pUie irflexes (best observed by side 
light) are particularly responsive to cold. Tlie frequently felt pares- 
thesia', acntparesthesiff, etc.. of psychoneurotics dejiends upon these 
sympathetic reactions, and their exact obser\ation is of much diagnostic 
importance. Mackenzie's observations should lie consulted hy the 
intcrt'.sted student.' 'riic feeling of ciild over the abdomen after 
taking a»M water in the stninach is an example of the relationship 
of the sympathetic innervation of an internal organ and a skin area.'^ 
A large numlter of analogous phenomemi are known. Thus anicnR 
tlicni, mcchani^-al stimuli of the plexus pudendi. as in ostitis, rectal 
exploration, prostatic massage, prostatitis, causes ilistinet goose-flesh 
or paresihesia- in the region of the motor Juinbar plexxjs. Erector 
pihe crises are known to occur in tabes; the>' are at times migraine 
i-quivalents. Psychical stimuli may lead to localized, or more often 
to gi'nerali/.ed reactions. A great variety <if extremely important 
skin lianu<'inatory cxiMTienees are known to (x'cnr in dementia preco.\, 
and in the jwychoncu roses, hysteria, anxiety states, compulsive states, 
(pathological blushing, etc.). Their correlation is only just being 
understood through the results of psj'choanalj'tic research, 

■ 9*v MTiIUt ami GlftM>r^ I>piU. Zcii.. f. Xerven.. vol. xlvii toxlviii. p. 3G&, Tor liu*nitun>. 
'Macfc«iixie: Tbn rtigoa of IMMtwe. * Head's Zofw«, Muckotisic. 



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106 



VtiGKTATIVK OH VISCKItAL SHUROLOGY 



Similarly it is Wfiiimiiip to l>e qiiotionwl. if not affirmed, whetlier a 
wluilt' grniiit of flironic skin ilisordi-rs. imtuhly tvrtain frtrms of <H"/ema 
ami {xsuriasis, und whirh are statetj hy tin* stiiiiilurd (ierumtolngiiits to 
\w "nervous" in nripiii, ar** not hIso tlic n-siil(,.s of cliroiili- emotional 
I'liiillit'ts ill thf uiKtinscioiis, mmliHttv) thnmgh the vt-gctativf nervous 
sy.sleiti, witli or without relaled endnci-iiioputhics. dysth\Toi(ii.sms 
particiiljirly (endocrinosympathetic). If this Iw scj appropriate 
p«yrhutherapy may show the cuu^l relations l>etw't^ii the skin dis- 
ease as a s\inlH)l of a psychaeal eomprciniise niul thus the scape-^oat 
1)0 removed. 

Bony Sjmdronies. — A host of IwnediMirdiT^ an* relnliil to vegetative 
di^iturlmnees. Tlie ln-^t studied are the iitruphies of tal*es (Charcot 
joints) due to interruption of Butonomic stimuli because of the 
syphihtic prixx'ss.' 

Some patients with chronic rheumatoid arthritis recover followinR 
polynhmclular therapy, and the studios of I,evi nud UothsehiUI seem 
ti> itnjiIieaT*- the thvrotd more piirtieiilarly. [See Kiidix-rintfpathies.l 

Blood Syndromes.— Knowleidge is only beginning to dawn n*lati\'e 
to tlie influeiiee of the veif."t«tive nervtms systetn U]ion the hhMNl. 
This is a most promising fiehl. The Ix-st studied an<t apparently 
HHist widely observed blood syndromes of veju;etative disor^ler are 
chlorosis and eosinophiHa.^ 

Chlorosis.— I'Vom the time of the earl>' h>iKitheses of the retentiou 
of menstriml blood as the cause of chhimsis to the present thi.s prob- 
lem of the etiology of chlorosis has Ihhmi extremely obscure, ^'ege- 
tjitive nervous disease hypotheses have not Im-cii neglei-ted, howvver. 
Sydenham (17U5) and GrawitK anion}; modern heniatologists caillwl it 
hysteria. Wliat they understand by hysteria is iiard to envisage. 
Copeland, Iloefcr, Eisenniann, Urintijn llicks, and the modem Genoa 
school ((iiovanni) have conceived it thus. The gtMieral fomnila adopteil 
by lliem Is that elilorosis is an en<liHTino.syrnputhetic dystrophy, and 
exists chiefly In two forms as ii thyroid and a suprarenal eldorosis. 
It Ls originally ovarian, tlie htirniones of the interstitial ovarian cells (?) 
twin); iniplimted. What the real dynamics of the situation ia, is still 
obscure. 

Eosinophilia. — Many forms arc obscrx'cd. The best tj-pes known are 
tlni>e line to various parasites (imcinaria. tfeniee, trichina") and to 
iiuTeased activity of the adrenal glands. Koslnophilia is a frequent 
accompaniment of vagotimie states and is fonnri widely in the agiliited 
depressions of depresstMl niaiiics, anxiety hysterias, and anxious eoin- 
pnlsivc states. Here fear, conscious or unconscious, is the etiologicial 
factor. Fear also induces the increased adrenalin activity. 

■ i^tvrliuK. W.: Dt« tiupltWIicu, vcKetutiwn ErkrHiikutiR^u lim KnorhMuyalcmn, 
?A*r\\r. i. d. K- Ht-ar. u. Ps>'ch. Itefwme. vnl. ir. 

*8cbwnTi: Kusinpliili«>. Liiltuwh u. OeU'rlmt'i EriedmiKiu*. 




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CHAPTER in. 
THE ENDOrniNOrATHIES. 

INTERNAL SECRETIONS. 

MKDirAL iHolo^y has noi yet arrivf'<i iit hyprithpses sufficiently 
rornprehenxive to ptrmit a unitary scheme which can e?(plaln the 
nOaliniis of the vej^tativp nervuu.s \\stem to the (Yintrnl of the viseera. 
Siinie suggestions liave been otTered eTjncemiiij; the aetiiiu uf the vege- 
tative nenous 9,\*steni upon the gustro-intestinal tract, ami also ^tome 
ideas relative to the intricate adjustuieuts of internal and external 
organs hrought aUmt lhn)ugh the hlondvessels have been reviewed. 
Special neurological problems in which direct mmiifieation of the vege- 
tative systems in the eyes, nose and throat, lungs, heart, skin, hlwMl 
oiKans and l)ones have been touched upon, all too hurriedly. The 
pMblems of ivthilar ailjustment now ^lemaiid attention. These 
conceni the vital phenomena of anaboHsm ami kataholi.sni. iind the 
ailjustnient of aJ! of the organs of the ImmIv involve*! in the eltibnration 
of special substances, which are of iinpurtauee to tlie metabuli.sin of 
the rest of the organism. 

Thu'*, what part is playe<! by the ner\ous sj-stem in the carbohydrate 
oxidations of the body, acting chieHy through the lungs, the liver, 
the (Nincreus, and supran*nals? The substance of the hypophysis, 
its hormones or active i>rineipl(s, what an'; they: and what is the 
interrelationship between them and growth as seen in the clinical 
])hriiomena tif infantile ilystnijihies, of aiToniegaly, and a numU'r of 
relatol conditions? .SiniiJar questitnw arise for discussion conceniing 
the thyn)td, the thymus, and the adrenals. The pineal gland is also 
a rbrumafiin forraatiim, likewise the paratb\Toids, witli their problem 
of regulating the calcium metabolism not yet certainly disposefl of. 
Wiat nervous meehanlsnis k(H>p the other c<»astituents of the bixly 
jilastna in a stale of equilibrium, sii that all tvjH-s of fntictinning may 
go (in, physicochemical, sensorimotor, and psycliical? 

This entire gnHip of questions cannot even be aske<l here. It 
can only be said that in their consideration, one sees an entirely new* 
«iuntr>' oiM-ning up whi<h promises to greatly modify the geography 
of our present neurological s*hemes, since Bniwn-^H^)uard in l>vSt) 
itMched mit for immortality by his use of testicular substances. It 
may Im' rr<-allt-il that as early as ITT.'i Hieojihile <le Uonteu foundeil 
the vitaltHlic scIiimi] arid taught that eacli organ of the luMly elalK>ratcfl 
a •'peeiHc substaiur. So far as spatr i>ermits the more essential 
intem*lationshii>s an<l correlations will Ik; brought out in the dls- 
ctiasion of the variniut diaeaaes. They an.' at present grouin-d under 

leir re5pe<tive glands. A shift in the point of \-iew is apt to come 
almost any time. 



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168 THE ENDOCniNOPATHIES 

The chief available literature summaries are Biedl,' Sajous,' Falta,' 
Ijcwandowsky/ Parhon and Goldstein, Lev,>' and Rothschild, Pende, 
Laign^l-Ijavastine, and special monographs to be mentioned under the 
separate diseases, such as Cashing on the Pituitary, Klose and Vogt on 
the Thymus, Morel on the Parathyroid, Sattler on Basedow's Disease, 
etc. 

The glands in question may be grouped acconling to their phylo- 
geny and embryology as follows: 

1. From the buccal cavity: 

(a) ThjToid (phylogenetically gonadal). 

(6) Pituitary (posterior lobe of hypophysis). 

2. From the nervous tissues : 

(a) Hj-pophysis (anterior lobe). 

(b) Chromaffin tissue (suprarenal). 

3. From the branchial arches: 

(a) Parathyroids. 
(6) Thymus. 

4. From the intestine : 

(fl) Parath\Toids. ' 

(b) Mucosa of small intestine. 

5. P'rom the mesothelium of the genital ridge: 

(a) Gonads (sex glands). 
(6) Interrenal bodies. 

Among the earlier attempts at correlation of the group of disorders 
of the blood glands or internal secretory glands were those of Claude 
and Gougerot, and Laignel-Lavastine. 

A recent systematization of this latter author* is suggestive. In the 
first place, one can distinguish (a) neurological symptoms as a part of 
an endocrinopathy; (6) endocrinous disturbances in neurological 
sj'ndromes, and (o) double forms of endocrino-neuro-endocrinopathies 
and neuro-eud<KTino-neuropathies. 

The endocrinopathies, as outlined by Laignel-Lavastine, may thus 
be rapidlj' reviewed. It is questionable how valid certain of these 
conclusions are. They arc suggestive, however, and entitled to be 
tried out. 

I. Uniglandiilar EndocTinopaihies: 

1. Thyroid. 

(1) Myxedema — hypofunction. 

(2) Exophthalmic goiter— hyiierf unction. 
(.3) Th>Toid iasufficiences. 

(4) Th\Toid instabilities. 

2. Parathyroids: 

(1) Tetany. 

(2) Paralysis agitans (?). 

' Intcriinl Secretions. * Tho Interim] SecretionB. 

* Die F.rkniiikunEen der Blutdriisen, oxhauHtive and Biiitgostive. 

* Hnndbuoh c!er Neurologie, vol. iv, Special NeurolnRy, n collection of valiinUe 
monographs. * Kiidocrinologia, 1916. 

* Ke\'uo de m6d., August, 1914; Noveinlier, 11)15. 



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^M 


^^P jstbhs'al sFrRKT/nys ico ^B 


^^^H 


Thytnus: ^^H 


^^^^^H 


(1 ) Vagotonic s>-niptuni» of exuphthaliiiic goiter. ^^H 


^^^^^B 


{'2) Myostlicnia gravLs. ^^^| 


^^^^^H 


(3) Th.NTiioprivuu.s idiocy. ^^H 


^^^H 


Siipraifitat : ^^^| 


^^^^^H 


(1) Addtsoti's dist'iist^- — l)y|K)riincti4iii. ^^^| 


^^^^^1 


(2) Genito-wlreiml ^yndnitnp. ^^H 


^^^r 


Sympathf^tic {Miru^iiiiii^lia. ^^H 


^^^^K 


Pancreait: ^^H 


^^^^^B 


0) Diabetes mellttiL<i. ^^H 


^^^^^^^^B 


1 1 y popl) \ MS ^^^1 


^^^^^H 


(1) Adi|M>so^ctiitiilLs uf KriiliJicti. ^^H 


^^^^^B 


(2) Acrumc>:a[y (hypcrfiiiif'tioiO- ^^^| 


^^^^^H 


(3) Gi>;aiiti.sin. ^^^| 


^^^^^M 


(4) n>'p4jphy>(0A] iiisiiffidcncy. ^^^| 


^^^H 


T^ncat: ^^^| 


^^^^H 


ll) Macrogenitosomia. ^^H 


^^^H 


(toniujs (ovar>', testicle): ^^H 


^^^^^K 


(1) Iiifiintilbun, ^^H 


^^^^H 


(2) Actiuireil o\'ariati InsiiRicieticy. ^^H 


^^^^^^H 


(X) lIy)x'niVHriauisin. ^^H 


^^^^^^■^ 


(a) Inriintilistn. ^^H 


^^^^^p 


(i) .Acquin.'d testicular imufBcicnoy ^castrntion). S 


^^^^^v 


(r) Kuiiiirlii.sni. ^^fl 


^^f 


iVostate: ^^H 


^^f 


(1) H.vpo-aiul liypcrprostiitic syndromes. ^^H 


^^^^ II. FdiygUtmlulnr Etuiitcrinoputbirn: ^^^| 


^^B 


Thymiil prci luminances. ^^H 


^^^^^ 


(1) Kxoplidialuiic giiiUT widi tliynuc hypertrophy. ^^H 


^^^^^1 


(2) M>T(edema with thymic hyjwrtTnphy. ^^H 


^^^^^H 


(3) Acromegalics with ovjiriari insufficiency, at times ^^H 


^^^^^P 


rescmliling cxophthahnic goiter, at times ^^H 


^^^^^H 


Diyxedema. ^^| 


^^^H 


Ovarian pretlomiimiicp: ^^H 


^^^^^H 


(1) Thyniid reactions nith uvariiin insntficiency. ^^^| 


^^^^^B 


(2) Dyshyperovarianiran of hypothynadism. ^^^| 


^^^^^H 


(3) Thyn>ovuriunisni. ^^H 


^^^H 


\Vith liyimphyseal predonihiance: ■ 


^^^^^1 


(1) Infantile giant><. Feminism. eunuchUm,cr>'|}ton-h- H 


^^^^^H 


Ism, pscnddhcrmaphrrHlitiMni. H 


^^^^^H 


(2) AeTr»niegulies with defect svinptnnt-. Infantilism, H 


^^^^^H 


nnierinrrhi-a, oltesity, asthenia. H 


^^^^H 


(3) AtTomegalics witlt hj-peracti^ity tiymptoms. extiph- H 


^^^^^V 


thalniiis, arterial hypertension, atheroma. ^^H 


^^^1 


With :%upran*iml pretlomiiiunce; ^^H 


^^^^^H 


(1) A^ldlsonians with anu-iiorrhca, frilosity, tetany, or V 


^^^^^B 


goiter. ^^H 


^^^^^B 


(2) (>oiter, acromegnlie.s giants with dial>etct. ^^H 


^^^^^^H 5. \Vfthoilt titHrkci'l predoiiiiiiaiiei', ^^^| 



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171) 



TltK ItXIX)CajSOt*ATHIES 



Till- Kmirli whiHiI has cnrnVid (Iicm' ilediiriion.s tn preat Ifn^rflis, 
and Imvc lifvrlopecl an organotherapy of starilinj; t-oniplcxiiy, bul one 
whi<-li shimld In.' cure-fully n-viewcd and checked u|). Here we piirfHiae 
to discuss those disitrdcrs of the internal secretions with pronounced 
disturbance of the nervons system, beginning with those best known. 
The student is reminded that a text-tw»ok enii mily rleal with the 
ntost pronounced typi-s, and those i-oricennng which there i> a ttTtain 
unariiinily of npinlon, hence for furtlter study of the mass of material 
Reference sh«ndd I»e made to the literature here quoted. 

We shall therefore take up: (I) the thyreopatliies, (2) llic hxi^iiphy- 
seal disonlers, and (li) the. dLsonlers nf the parath\Toid. thymus, 
adrenals, and sex glands. Finally, some suggestive re]ati(>nships 
between diseases of certain \'iseera, liver, kidneys, spleen, etc., and the 
nervous system. 

Hefure passing to the detailed study of these forms a worfl may be 
said cuiuvrniii^ the interrelationship of tliest* viirious endocrinous 
glands. It is highly prohiihle tlmt these glands work in unison and 
that sudi regulatory synchronism is mostly brought about through 
the vegetative nervons system, I'nre chemical regtdntioii may take 
place, but it is l>ecumirig more and more evident that the reactions 
which bring more or less hormime lo the blemd aie nicdisitinl by the 
syinpathelic liliers more particularly. These hormones in turn modify 
the ekK^ical carrj'ing capacity of the fibers and the rcsistaupes at the 
synapse and thus uuHlify fiUietUm. The whole series of processes are 
highly (x>ni|>lex un<l the student is referred to special works' with the 
express warning tluit while all science U <lependcnt upon h\-i»othese3 
as to its growth, medicine owes no debt of gratitude to tUcfae who 
teach her theories without priMif (Klliot). 

The iriterrelatiitnships t)f the varlcMis endfK'rinous glanils has lieen 
well illu-striitcfl by Noel l*alcui, a repn>diiction of certain of bis charts 
or diaigrHns being given Iicr-. 

As Patou well remarks, tliese umy well lie a grotesque parody of 
what will ultimately he found to l)e tiK' relatioiLship of the activities 
nf these organs. "They arc yirobahly as near the tnith a.s those quaint 
ancient maps of the Inrlies with their 'here Ix* much goltl' scrawled 
across them, which servtnl as the charts of our forefathers, but if, like 
thern, they uiert-ly iiidiciite the direction which fntlicr investigation 
should take and suggest lines of attack, they will have ser\ed their 
pur|MJse." 

Tlie direct and profound action of the secretions of the sexual glands 
(goniuls) upon the body is seen in every tissue of the body. How far 
their action is facilitated arid how far checke<I by other endocrinous 
organs Ls not yet entirely workcij out. The th\inus supplements the 
action of tlie testes strrctiim. Its relatiotis to the ovaries i.s not so 



HyxlOin. Jmir. Serv. niid \tfUt. Ilia., liUO, 1917. 



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171 



certain. It exercises u chrtkiiiff Hclinii on the mnle gonadal netivity 
which in its turn acts reciprocally on the thymus. (.See Fi^. '- to 75.) 
The removal of the thyroid cheeks tlie growth of the gonads. Cas- 
tration acts less on the thyroid, altlioiigh menstniati<m, childbirth, 
and the menopause cauM' nmrkt-il thyroid activity. (.S-e Thyroid, 
Fi^. 72 and 75.) 



HtpTT 



put 



lln. 



711.1 



o- 

Thm. 



tVi. 72. — To ilKtw th*- [irotiaWf iiifliii-ii(H> nf thi- viiriniis fiidocTinou* atjijrturva oa 
(wtK ■iiotluT. The fi>Uun-ui)( KSiilniiutioiut aviiiy ti> diin uml !■> tlw thnw (mrif«dil)|; 

lisum. Biiniulntioo; inhibiti'W. Thi- arrow indicau** tlw ilin>oti6n 

vi Mtum. Hyp.. hyp<i|ihy«fai: Par., panttto'ruid; Cft.. ChronuiUiti Hy.HU'in; Art., nrtery; 
/*tl.. (liluiury; Thm., Th>iniu; TM.. ih>Tuiit; O.-'cunula; B., tioiw; In., iiilOTmial; Pnn„ 
pnnmMfl: M . muwHc. (I'siton.) 

The destruction of the pituitarj- leads to j^uiail atrophy and n-'<np- 
roeally castration causes liypcrtnjpliy of the pituitar>'. The .s<'cn'tion 
of both stimulate the prowth of the loiip Imhics, the uncontrolled 
activity of the fnmicr Icndinp to ^igantUin anfl acromegaly. The 






'::> 



ICk 



+... 



Tfc. 



C.H.O, 



"O- 



Flu. 73.— Tn nhow ihi* priilinUo tiKulr <4 ni U<iit iif Uic* rnriiitu iuirmal opifrtinint im 
iJw rniiUlUnliiMi li Micir in thn liwr. (Patnn.) 

artion of the ^madal seeretionK \s to cheek the pituitary activity 
itnd ihr iiirrcii-^r in **iz*' of the eunucit is p»>ssib]y a rcs|Minse to 
this luichei'keil hyiHiphyM-al aetivily. The pi>iiads are not alone iti 
liiiiderinK the pjluiliiry aelion. 

Siiprarrnnl and ^nniulal nKivity art' clnscly n'li)t<'<l ami stipran'tial 



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THE B N DOC RINOPAT HIES 



loss is usually accompanie<l by genital aplasias or anomalies. Paton 
has suggested the identity of certain elements of these tissues and that 
the sui>rarenals constitute a sf)rt ot bridge or intermediary between 
the bodily and the sexual cells. 




4BQiiimmiimi||n 



Fid. 71- — To show the itmlialilp mode of nction of ocrtiiin of the internal actTctinna upon 
the spinnl roHox arc. (Paton.) 

The thyroids and pituitary are closely related. Hemoval of one 
causes hypertrophy of the other. (Fig. 08.) They thus mutually 
check each other in part and are also cooperative, the pituitary needing 
the thyroid to complete its activities. Hj-perthjToiil activity does not 
lead to hyperplasias of connective or bony tissues as does hyperpituitary 
actipn; the reciprocal autonomic and sympathetic nerve activity ia 
not exactly similar; althougii (iiniinishefl activity of both substances 
ma\' lead to diminished bony growth — atrophj'. The vegetative 
mechanism of this, however, has not yet In-en elucidated. 




Fio, 7.i. — To show the probable modo of luition of tho iutcnial spcrctions oa the 
KTowth of muscle and of one and other connective tiMUes. The posnibility of this being 
a vjiHomoUir reflex meirhanicim i» indicated by lines marked? (Paton.) 

The action of thjTiius on th>Toid is far from clear, but the tendency 
is to show a reciprocal checking action esi>ecially on the neuromuscular 
apparatus. The problem of myasthenia gravis has l>een thought to 
lie Whlnd this reaction. 



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TUH TUYRHOVArUIES. TlIYltEOHES 



IZl 



The thyitiiHs aiul iwratliyruids have distinctly diffemit ami even 
nntafionistic activities: The former S4?cms to Im* related inorctlistlnetly 
to the iodine, the later to the caleiuui metabolism of the iKxIy. Jiist 
how thry are nttulated thnnifih the vt'sctutive nervous system Is 
iinkiiirni). Calciiitii is of prdtuniiicetl value in ncu mm uvular activity 
d.-* the phenomena of tetany show. Mvasthenie states in (feneral and 
myasthenia prans in particular are more directly relates) to disr»rdcred 
thyTfud and Uuthiks activities. I.inidlMirK luus sn^nested that the p;ira- 
thjT»ti<l function plays some part in the reaction. 

Tlie th\Toid acts on the paiicn-a:s chieH\ llirtiujch its action on the 
liver sympathetic fibers. Sugar mobiltzution and release are hnnight 
ohont through modified thyroid and pancreatic action, which latter 
pri'vents the mohilixation of su^ar in the liver. Thus glycosuria is 
frequent in hyi>erthyroid states. (See Ki(f. <i9.) 

The coniplieatcd interrejatioaships cannot he entered into more 
fully. The chief available literature has l»een tnilicateil. One point 
hnwever. should Ik- empfmsizeil and that is that the activities of tUe 
internal secretion orptii-s a«' nit under vegetative nervous system 
fontntl. The active substances, honnones, if one wishes, are not 
etitirt'ly indejjendent chemical activators, they are under sympatlKftic 
Hn<l t*"nisym pathetic (autonomic) control. The output of iodine, of 
cah-iuui. of adn^-nalin. nf hvpophysiti aiui of all of the siilwtances 
thus far known or named is rontrollerl almost exclusively by the 
nervons sy^tenl. The internal swretions act thnm^'h the nervous 
SN'Stem. While it may be >hoM-n that within an organ itself pnmar>' 
chemical regulators may Ih* effective- thus one must explain the posi- 
tive and negative tnipisms xvithin the cells of an organ in its initial 
resptnwe to a disturbance of cellular adjustmenl yet the chief activ- 
ities itf the internal secretioiw are bnnight alujut by neurttclteniical 
regulators, as Paton terms them. 

Jiist ^ the complicated sensorimotor integrations are cfTectivc 
in governing the uniscular activities of the human Ixttjy, so tlie inte- 
gnition nf iirnnicJiernix-al regulnt(ir>, taking place at the physiwi- 
i4ieniical level, is effective in adjusting the irM-taboilsm of the lnjily 
wlls. Honnones are not the activators primarily: lliey are the ser- 
VHQt:} uf iJk- vegctativf nervouii system. All of the endiKTinopothies 
are really ^mly glandular syndromes and markedly nmler psychical 
influencrs. This as a fact ha- l)ceti known for centuries but is just 
being worked <»ut ex(M'rimentally in the physiolitgical laljoratories. 
U'awluw, <*annon, etc.). 

THE THTBEOPATHIES; THYREOSES. 

TllK TllYHOII). 

In the lowest vortebratrs the thyn>id was intimately coniiecle<l with 
ihe i^'nitttl ducts, thry werr uterine glandt^, but fnnn Pctr>.rtny««>n 



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upwiinl it has lost thai connet'tiiHi. altlinuxh it is kttDwn that nn 
intirimtr {ixily^lHiiihilHr) iiss(K'iHtH>ii stilJ [K-n<tsts (ineii.-itnmtiuii, 
pregiiaticy ant) swelling «>f K'utMi, genital excitement and lij-per- 
fiinctioniiif; and other rclaticiiiships to be iliseiissed). In tiie human 
einbry<» it swras to !>e cut iifl' from the furegut. It t? intenwly vasmlar 
and its chemistrj- is unique. It contains a comparatively high por- 
<*ntage of irwltne, also phosphorus, arsPuic, hromine an<I sulphur. The 
chief hormone KeiKhill names the alpha io<Iiiie eoinjMMUKl. It is usually 
aHsociutcd with inlloid nmterin], the presence of which i:s a general though 
not II wTtain index of its uctivity. 

The nerve .su]i])|y, thyroid nerves, arise from the wrvic-id symptithetie, 
the fiWrs. mostly non-mcdullated, passing from the middle <inferiur) 
cenical ganglion from the thyroid plexuses whose fibers |H*uetrate 
the gland. Itt chief visible supply is luitonomic (vagus) but .sym- 
jiathetic fibers also aiv present. 'I he fillers go t^i the bloodvessels and 
also to the glandular cells. The eharacter of the reee]»tor unil elfcctor 
eelU of the glandular irlls is not yet kiiovni luil there is evidence to 
show that the seerctory reUcNes pass by means of tlie syni|>athetie 
fillers and not by the cranial luitonomie ones.' Sympathetic acctiun 
causes m.-irkcd atn)ipli\' (jf tlie gland. vaguH section none. 

The chief cndi>crino|>athies proiluced by thyroid disease are those 
due t<t lessened function, hypothyreoses. and those due to an excess of 
function hyJ^e^thyrc«^^*■^. While the iodiii is the most striking inn iu 
the si'cretion it is prubably not the only one in prcMlueing the striking 
uu'tabolie disturbuiKv^ of thymid disctrder, 

Hypothyreoses: Myxedema.— The chief pronounced hyjHithyreoses 
an- grtiU[H-d under the symbols vt\i.redevm and crvtinl^m. There is 
an inijMirtant group of cases in which less marked insufficiencies are 
found ami which need elose study. Three main ty|>es of the former. 
congenital, idio|»athic, and ojH'rative, are dcscribe{l. while siKiradie, 
endemic, and' irregular types of tTCtiriism are distinguishefl. The 
whole gniup may be eonsitlercd as one, /. c, liyiio- and athyreoses. 
The various subgroujw ha\e gro«'n up eliiiiciilly since Gull, in 1873, 
first called attention to myxedema. They arc still in gi^cut need of 
clearer differentiation and description, especially the milder and tiic 
the variable types. 

Operative myxedema (carhexia thyreopriva) has been the best 
studied ty|H' since Koi-her, iu ISWi, <-alled altentiou to it, tme year 
after Ibulclon had shown the relationship Ijetween myTtedema ami the 
thymid. 

Symptoms. — The chief symptoms are present in the skin, nervous 
system. th\TC)id, circulntory apparatus, temtx'ratiire, digestive tracts 
blood, urine, bones, and general mctalxilism. 

^At'h.— Here there occurs n general gradually increasing swelling. 
most marked in the Imnds and head. It seems edematous and yel 

' Caaoon aati CattcU: Am. Juur. Phyaol., 1910. 



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175 



»l(ifs not pit on prt'ssiirt'. The thirkiicss nf thr lips muses nil evcrsion 
or hanging down of the same. The. fuMs (ff the skin, esperially of the 
forehead, are more distinct than is iisiiaI. Irregular, Hattish, fat- 
like dei»iisit-s art- pn'sent in different parts of the body, often being 
must marked in tlie snprui-lavicular n-gion. 

'nielianiisiireapttobe dunisyand thiek, tlic skin of iIh' bark of the 
hiind Wing much thit-kencd. The feet m«y show similar ehanges. 
The whok skin is wliitish and dr>'; it scak^ readily and rarely shovs 
any |>erspiratiori. Diaphon-llc drngs even are unable to bring al>out 
any inarkeil iXTspiratiun, and tlte mueous membranes are apt to l>e 



t 



Aiiicu^t :(. I'JU. AuKUMt IT. IUI4. NuvnnbM 27. lUU. 

FW(. "0. — liilnnillc ni)i(«iemii. Tpd >■<?»» uld. Treated by latar di»w t.f iliytvid 
UlinUk. (A. Ju*Hm>ii.) 

dr>' and not easily irritated to eause exudates. Yellowisb pigmenta- 
tion may iKi-ur. The liuir breaks easily and is apt to lie l>adly and 
sjiarsely dc\-eloi>ed. The nails are brittle, develop sluwly, and show 
irregular markings. The te<'th also develop l>adly. 

There is a sense of tension in the skin, and coldness of the exiremiries 
ifl universal. Thin !» mixle mueh worsr in uinter. uitli marked 
tendetH'V to eliapf^ng ami fntsl -bites. 

The nervous system shows a mrndxT of defcf-ts varj'ing with the 
gratle of h\[)olhyre<i>is. .\jiy of the eninijd iwrven may ^how defeetive 
development. The cerebrospliud nerven may lir defitnent. 1 he 



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FlO. 8(1.— Jnnuffliy fi. 191a. 
io8. 77,78.79 aoil SO. — Hypothyroiduiin. KffcctBol thyi^Wio iKrgvdoemuockHvton.' 
12 (A Joacfdou.) 



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178 



ntE EN DOC Ri NOP AT in BS 



motility as well ns the sensibility is dimiiiislicil holJi us a irsiilt 
peripheral and centra! maldevelopmcnt. The ehanges in sensihilitj* 
are furtliermore aujcnnentcd by the loealizeii skin changes. The reflexes 
are not markedly t-lmnped. The ^ait is u.siially witle-Wiw^l and 
chinisy and duo in jjart to the mental dulness, Oefeetive th>T<iid 
substaiiiv Mfms to binrier the refteiicrutlon of cut »r injured pcr- 
ipiuTal iiervfs. 

Mentally a great ^'ariety of changes may be observed, llicy 
are ii-snully in the imture *»f deftx-t. There is defei-t nf nieinnry, atten- 
tion is diminished, thinking goes on more sk»w]\', but may Ik* of fair 
cajiarity. There is nsiiiiEly a loss of initiative, and emotioiiid dniness 
(loes alonji with the -srnsury kis-ses and inittor rehielariL-e. Tlie sjKfeb 
is apt to lie slow, as are other motor acts. It is monotonous and the 
thickened lips further euntribute to make it at times unintelligible. 
The wliole ii])jH'arance of the [wtient is one of gradually advancing 
stupidity which, if there is no relief, goes on to more profound defect 
states— dementia. 

Tile tliifrt/id itself Is usuAlly much dimlnishe<l in size, or not at all 
palpable. Thnngh |)al|mble, its active secretory substance is usually 
defective. 

Tlie nrculiitur;/ ji[)|)arntns sljdws little nbimnnaltt}'. The heart 
action is usually normal the larger vessels may Ik* felt. Vasiw 
constrietor action is prfimitient and is rcs]K>nsiblo f«ir the ttold exlremi- 
ties and prtssibly some of the d^>■ne.'^s of the skin. 

'I'lic co/f/ sensjitious are not Mibjeetivc alone, as there seems to be a 
fairly cimstant diminution in the bndily heat, as is also seen in 1i>.ikj- 
pitiiitarisni. Digestive discomforts fnim dry mouth and enlarged 
tongue are frequent. There is not infn*quently diminished muscular 
toiie and deficient sicretioiis in the entirv digestive apparatus with 
obstinate constipation. 

(imital anomalies arc fpeqnent, eonsi.sting of irregular or suppre.ssed 
men.struation or diminislie<l [«>tenry. The organs ihenisL-lves — testejs, 
ovaries — muy l)e dinlini^hed in .size ami infaiitik^; tlicn' is defective 
hairy develnpmcnt. 

Tlif blood sho\\'s fairly constant eosinophilia, the clotting time is 
increased, and the fibrin content above the average. 

The xtrine is not characteristically altered, save that its quantity is 
usually decreased. 

Mftfilnili.wi is .slowerl down in many directions. Oxygen exchange 
is redutvd, the calories consumed being markedly ilirnimshed. The 
nitrogen output is less, as well as that of the purin derivatives. The 
calciurn-magni'siuni metalM)lism is not modified save in those operated 
upon antl in wlii»ni the parathyroids are also disturlx'd. Carbohydrate 
tolerancv is high. 

The huny sj-stem is variously altered. Here the amount (jf cluinge 
and its diversity dejwnds largely upon the age of the pattent at the 
onset of the disorder. The long bones fail to grow nonnally and those 



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179 



^ 



wilb late usslficatioii centers fail to miderffo coinpltte development. 
The ?kuli is apt to be macroeephalic, but the thickness of the bone may 
diminish the interior nipacity a prent deal. In hypothyroid oises 
fractures are apt to heid slowly. The fontanelle in young patients is 
apt to reniitiii open. The ehanpes in niyxodema are not those seen in 
rachitis or clioiidmstrnphia. 

Types. — The uliopathic form usually begins ftith changes in the 
skin, and is ufti.'ii aceonipanted by iieuralKic paiiis, A patient recently 
seen was diagnosed as a talietic. The skin of the face is often first 
affected and usually the extn-niitics arc implicated very unidtiully. 
The sjTnptoms may all come on within a few weeks, but usually their 
develojjment occupies months. Women are much more frequently 
affected, and usually about the 
menopause period. I ii these 
cases the hyixithyrensis may be 
diagnosed as a " menopause neu- 
rof«s." A not unusual result of 
the cessation of the mciistruid 
function is an overactive thyroid, 
but in other cases the recipriH-iil 
stimulation which is pronounced 
between ovarj' and thyroid suf- 
fers with the dimimition of the 
ovarian function. 

(fjHriitmr 7»ifTe(!riHa is now 
comparatively rare, since the 
essential relationships have been 
pointed out. ITic tetJiiiy symp- 
toms often seen in the earlier and 
Ijudly iipcnited fa«es were due to 
the parathyroid removal. 

Cvtigriiitnt farm:*, thyrci>(iplfl- 
sias. ntrur In children ii.siiflll\' of 
nurniHl birth mid avenige de- 
velopment np to aljout the time of \veaning — if not breast-fed 
usually earlier (tliyroid in mother's milk). The symptoms tlien 
tievelop rapidly, and, as a rule, are very extreme. The irn-gular, 
imjxTfcctly dcvclojK'd. cretinoid pictures are not the usual ones in 
congenital nij-xedema; as Kppiuger has R*uiarkcd, thcrv arc few "half- 
way" congenital thyrcoaplasias. The female sex ])repon derates am\ 
there are no geographical limitations as in ctidemic cretinisn». Neither 
is there, as a nile, any goitrous family historj* as is often found in 
cretinism. 

Thesi- little patients forget to suckle and to swallow. The skin 
Ijcctinies foide<l, the uosc broad, the eyes deejily sunken, the nasal 
wings widely spn-ad apart. They are mouth-brejitheis, with swollen, 
not infrequently protruding, cyanotic tongues. Halivury intTease is 



Fw. SI. — Myxoiiciuu bIiowIuic TuilurE^ nf 
oMlirntiMi in ■vi['h)f<v of tin- hotim nl the 
biiind. (Sienert.) 



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ISO 



TtlE ENDOCniNOPATHiBS 



nftrii present. Thi* Imir Is badly (Icvflti[wil, t\w face tlmt of nn oT 
lunn. The hcnil griws in size, hut the rest of the bntly stays bchiml 
witli marked disproportioa in leiijijlh and brvftdtli tliruiigliout. Tlie 
epiphyifcs do not ossify, and the centers of ossifiaition, especially in the 
Imiiiis. fail t() develop. The fontanelles remain oix-n perhaps until the 
twelfth nr fifteenth year, and the teeth are slow in appearance. 'ITie 
Imdy is apt to l»e fnt and the abdomen es|>ecially swollen, in part 
from gas and obstinate fec»l Aceimmlations. I'mbilienl Iternia is 
frequent. Other defects nre often present in lieart, i«dale, and other 
struHures, and they die early with tlie jceneral nicntiil .symptoms 
in purt des<Til»ed. 

Z>iapio8is.^N'epliritic edema and other skin edemas must at first 
be ruled out, especially ovarian pseiidocdema of the menopause and 
rare forms of s\philltic or familial neurotrophic edema. Chondro- 
strophia niu>it Im* .separated frcmi the cretindici eompUaitinns. The 
rehitiniis tii cretinism are close. There an- ililTerences in the skin 
and {xTsiHration. Deaf-mutism is rare in mjTcedcma. frequent lu 
cretinism. 

Cretijiisin. — This is a ljn>ad. general term applitxj to a ajmhination 
of physical and mental changes which, in the young, result from loss 
or diminution of the thyroid functinn.s. Such a l(»s.s may m-cur s[K>rad- 
ically, itf'toradic crHt/tiitm, from causes to t>e enumerated, where the 
pi<;ture is anulogovis to that seen in the adult fniin removal of the 
thyroid, cachexia thyreopriva aduUornm. or it may occur as a locali/A'd 
or endemic dejtenenition. nlTet'ting the th.\Toids of ii larjje number of 
indivi(hials, causing a liypothyreosis which may show a number of 
lendencies. When the.se are pronounced they arc spoken of as goiter, 
goitrtms heart, antl endemic cretini-sm. 

These three fairly well-separated conditions may be discussed to 
advatitage under the head of cretinism. In the first place to call 
cretinism a type of idiocy is misleading. There are numerous very 
intelligent cretins. Cretinism, as here used, is solely a complex of dif- 
ferent conditions due to a lack of development of one or more elements 
in the l>od\' and due to defect or loss of the thyroid hormones. 

The hist<tric.il chapters on cretinism are full <»f interest. The dis- 
orders were known in early days. Pliny has left indubitable evideni«- 
of tlicir presence in early Itomaii times. \'ogt, in his admirable nioiiu- 
graph in the Ix^wandows^ky Ilandhuvh dcr Nniroloffie, tells of Marco 
Polo's descriptions of tTTtain types he had seen in his iVsiatic travels. 
During the pa.st two centuries the disorders here includc<l under this 
term have been observed throughout the world. In (t- rtain lands the 
disease is very widely distributed, certain mountainous districts of 
Switzerland, Nortliern Italy, etc.^endemic cretinism — while in other 
regions it occurs rarely — sixirndic cases. In the L'nitcd States it is not 
frequent. It has been obsen'ed in California, among our native 
Indians of the Southwest, ui Vermont, and such patients }iave been seen, 
in New Vork State (Adironducks). In certain regions it has been a 



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181 



veritable plagiic. llius in Swit'/erlanfl bctwwn the years 1S75-I8S4 

7 per tfiit. of the rtcruits in iIk* nnny shovned some form of cretiiuiiil 
LdcgeneratioiL In ten years l.*5U0 men u^ere lost to the Swiss urmy 

from this i^tuse aloiie. Certain val- 
leys, especially those of Heme ami 

Wailis ort* nverthickly populated 

vnth iiiilivi<luals .showing rretutoiil 

degeneration. In the sehtxil years 

Isyj^lUOl. of ;i:iG.)KK) elnldn-n (it 

for school, 15,(HK) luwl one or 

Knotlier type of eretinism. Similar 

ronditions existed in Styria, Austria. 

and in (t-rtain Italian provinces. 

!•'. Birclter has eontrihiiteil an iniixir- 

tant study to the distribution uf 

cretinoid degeiHration. 

^■ofB^ as tlie etiologj' iacwncenied, 

it seem.H (vrtaiii that the eontfitioiis 

are fundamentally Hue to a defect 

of the thyroid substance — the thy- 
roid hormones. Thu* is set«ndarj' to 

various tyjies of InHummation or of 

aplasias of the th\Toid. There are 

certain liruicutious which mast be 

discussed in their respective para- 
graphs. 
Sporadic Cr«tim8in.—/rt/i'i»/f7iT Myj"- 

tiiftun vf xome Anihurs. — The clinical 

pictnn* in an cjctreme oi.sb — u p., 

fully develo|)t'il - ill contrast to the 

many irregular or intvmplete forms 

' is thai of a normally Ixirti child 

who alM>ut the end of the first or 

the beginning of the second year 

I»egin.'< to sIkiw the eluiracteristic 

changes in development. Hie little 

patient UvWf. U-hind In his nurititd 

bony development. Tliis i.s due tn a 

defect in the devclopiiKiit uf the long 

bone^. The epiph>'M-s fail to lay down 

bone even after twenty to thirty-five 
Lyeart. and in twenty -year-old cretins 
'the anterior fontanelle may still rc- 

umiii o|>i'n. There is a pro|K»rtionutj' hiss in I)ouy sulistauM* thmtigh- 

out ; thus a chamcteri.-itic dwarfi^im results save |KTlm|>s in the deVe)o|>- 

mentuf (lie skull, which gn»W8 larger in prt>portion to the rest of the 

body giving rise to (he "fuU-aiotm" factr. OLlter eraniid botie defects. 



Vut. .VJ. — Cr.aiiiiiiiu. Wi.m^u, 
K^tMl thirtv-fi>iir ytvira: mottlrUly, 
•rvrti ymrn l>y lUnet-Simnn \c*t; 
livitftit, W{ iudiM. prill ■ilii'mnt 
■luloinpti. tyinifiil fiiruw, Mi|inu-|»- 
vicuJar pi»ta ut fitt. 



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SNDOCRIi 

sphenoiti, nasal, etc., give rise to the widely .se]>arate(l eyes, the pug- 
iHisc. The eyelifis are thickened, the earis have a waxy apftearance. 
Tlie bony dt^ffct is in the nature of a selerosis and the Ixiny tissue is 
umisiuilly lijird, whicli is the reverse ttf that se<'n in radiitis. 

Dental deficieneies (diminished ealcitientitin) go hiiiid in hand with 
the bony defect. In severe athyroid cretins tlie teeth do not develop 
for a number of years, and the first or milk teeth may persist far 
beyond the normal period. Other defects ap|>ear in n high luilatine 
arch, which with large adenoiils and tonsils and a i-hnmic hypertniphic 
rhinitis eause the eliihl tu snore and sniffle, often with copious 
excretions from the nose. 





Km. Si. — (';i-'' 1.1 -[uiiitlh' >Ti'liTii!iiii, \nceil 
twonly-ofn- Mi.r- lt-'r>>i<- iri.-»t(iM»it. 



Km. M. — ('(WO of dporatiif' ^rptiniim. 
After four nioiitliii' Iri'jilioctil.. (H. 



There is usually a short, thick neck. A fairly wnstant finiling is that 
of umbilical heniia. The abdomen is usually puffy, the navel sunken 
(frog-lH-lly). Tlie skin is myxedemalous in tin* young, but lK-c(>nies 
atrophic in later years, the supraclaviLnilar and fueiid swellings remaining 
for many ycais. 

The facial habitus is charactiTistic. The hair line Wgins low. The 
nose is sunken, the zygomatic arches prt>minent, the eyelids swollen, 

' Sanderton: SporiMtU- CiwinUm. with Roport of Thro* Cues in Orn- Family, 
Michigan SlitU) MixUi^ JtHirnni, A)irii, IDOd. 



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183 



the fot-c puffy, the tongue enlarge*! and often prnlruiiing between the 
swollen lijxs. in tlic mild oiiics giving nne the impression of a cluld 
whone whole countenance is puffed up with crying. 

Thirr is usually an enlargement of the liver. Respiration is 
unusually slow in lh<' severe alhyreoses. The genital organs show 
marked clmnges. Tlie lahia are small, the external U(H coveriug the 
inteniid ones. The uterus and ovaries are usually small, and the 
mammarj- glands are atrophic or h.\-]Miplastic. The penis is apt to 
lie nmull. the testi<'tes tin(ieseeiHle<l and HUiall. (lenltnl and axillary* 
hair is al>sent or sanity. In Uiys the puliertal changes in the voice are 
larkinf;. 



flu. !»o Viuv ol »j>or.i"lii: i n'lmijfii. 
miPmI futir ytmn. Ilofanninx tJ thyrnid 
UiwIniMii. 



five* y«in> ul<l. Th>'ruid trMtttnpiit for 
oat yoitr. 



Blood elmnges are present. TJie hemoglohiii is re<liic-e)l and is 
out of pniiN'nion to the eruhmcytes. The Uiikocytrs »n- iiK'n,*ased, 
llic |)ohinnq>hir neutrophiles being niarke<ily diniinishcd and tlte 
l\iupii«->i*-s (tirrespondingly in<>reused. Ijirgi' numbers nf granular 
eellfl jire ohsc^^■ed. These changes apfienr as a result of deferti\*c 
thyniid sub^Tiince. 

The metalMilism of micium is markeilly dimini.-iird (one-third of 
it« nonnal amount in the studie>t made by llauganly and Ijing?ttein) 
and the rf<piin-<I cnlorirs an* far lielow that of the noriiud child's 



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THE BNIX>CRINOrATinKS 



need. TIk* awiniilHtion of carbohydrates seems high, and adrenalin 
injections, withniil uuTcasccl supir intiike, do not result In a glyrasuria. 
Then' is a definite hypothermia. In many cirtins there is a widemnR 
of tl*e selhi turcii-a. I[y[i«plasia of the thymus is alwi not infrequent. 

Nervous system (U'frcts an* pre.s*'nt with the others and np|»urently 
ttjnditioned by the endocrinou.s gltind insufficiencies. These show 
at i«n.-iuriinotor levels in tiefecta of sensory and motor-nerve structures, 
and at psychical levels in various grades of stupidity, mental weakness 
(moron), imbecility or even idiocy. These words are here used in 
accordance with the arbitrary scale of the IJinct -Simon testft. 

Thus .imcll is at times liefcirtive; the eyesij;ht piJ4)r; hearing is 
frequently disturU-d. and with it sjicci-h, so tluit many patient.s are 
deaf and dumb. Tlie vestibular function is fretiiiently involved, 
so that tliese jjatients bidance biidly, often showing unsteady gait, 
with wobbling of the head, and nystagmus. 

Some s[)oradie cretins may shon- little involvement of nervous 
structures. 

Cretiikoid Degeneration. — Mention has )>een made of the widespread 
character of this t.>'pe nf degfiH'ralion relatwl to defective or absent 
thymid secretions. The statistical study of the conditions, particularly 
in Switzerland, in France and in Ilidy (BIr-Iut) has shown that 
goitwr, goitrous lu'art, emleniic; cretinisni, endemic deaf-mutism, and 
endemic feeble-mimlcdne.'*s are clo.sely allied. The cretins are almost 
all goitrous, or nearly always have goitmus parents. Kxophthalmic 
goiter (hyperfurietion) is rare with en^tinisui, but very frwpicnt witli 
goitrous heart eonditimis. 

The causes of this partic-ular tyjtc of hyi»i»thyroidism are not 
definitely settled but there seems to be a c-cwistant relation between it 
and certain elements in the water supply, and goitrous springs are 
known. Just what the noxious <rlfmciit may be is still conjix-tural, but 
it apparently is relatcfl to minera! eonstitucnt.s found in lertain geo- 
logical frjrmations. notably in the trias and tertiarv'. The disease is 
absent iti n'gionsfcd friiiri Maters flowing through crystjiHinc formations. 
As a result of Hirrher's suggestion of supplying a goitrous region in Kup- 
perwill from Jura water amiing from an adjacvnt valley, the disease 
disap|>eared. Similar results followed in the town of .\sp. Animals 
may be made goitrous from drinking water from certain springs. They 
also develop goitrous hearts, and are delayed in their development. 
The thyroid shows degenerative changes. The agent passes through a 
Hcrkcfeld filter, hut is modified and made non-active by being heated 
to 70* C. It does not ilialy/e and is thought not to be an organized 
plant or animal substance, but to be of colloid nature. An h^i.'pothesis 
which had the authority of Hirclicr behind it was that the disease 
was of an infectious nature. 

Goiter. — Here Kalta describes those enlarged h.\-pcrplastic, non- 
inflamniator>- th>Toid formations, with degenerative clumges in the 
struma. The byperphisja invades the parench>'raa awl the vessels. 



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TtiB THYRBOPATHieS; THYRBOSgS 

Not withstanding histological hyperplasia there is phj-siological clim- 

linutioii in function. Functionating parcntlivTua, however, docs not 

r«xbt. Histologically one finds parfnciij-raatous, va-scular, or fibrous 

hj"perplasias. with circumscribed or diffuse goiters. A relationship 

betwpttn goiter and uterine myomata exists, and with a diminution 

of one there ta a decrease of the other at the menopause. 

Goiter Heart. — See Kxophtlialmic fioitcr. 

Ejidemic Cretinism. — Here there is a richer and much more variabit: 

picture than obtains for sporadic cretinism. Whereas a typical 

habitus is describetl, there are many anomalies and variations. The 

heiul is usually broad, but may he .<4mall and Hat iiisteatl of large 

laod broad, at times very large. The nose is usually wide-spreading 

^and flat, the eyes wide apart. The neck is short and thick, the features 

swollen, the early impression, especially due to the prognathism, one of 

monk!4cuess or stolidity. The Ixtuey arc shortened, various annniiilies 

us scoliosis, ankyloses, etc., hc'iuR present. Great Miriation in dwarfism 

tjs ol»scrved. <_'crtain cretins are under three feet six inches, but full 

jretins have Iteen observe<l seven feet in height. As a rule tliey die 

young, but Kocher reports cretins seventy and e\'en one hundreil 

years of age. 

The general coordination of these iwticnts is poor. They arc 
iwually short, chnnsy. inelastic with badly develoixHl musculature. 
The skin is hxcs**, lax, anemic, markiNl with fuld.s and wrinkles, giving 
a [teculiar ap[>eamnce of okl age. The lips are swollen, the tungiie 
eidargc<l, and not infrequently protruding. The breasts are flat 
or badly develoi>ed, the alMlcimen flat or [lendulous. Slu>rt, stumpy 
fingers and toes give an ugly ap[>earan{^ to the extremities and con- 
tribute to rhimsiness. The entire activity is apt to lie heavy ami 
awkwanj, although a few atliletes and acrobats may be found among 
them. 

The changes in the bones liave been mentioned in the paragntplis 
on si>ora<lii* cretinism. Here, however, the variatioits are' more 
marked and Weygamlt's study of \"irehow"s material shows tliat many 
l)ony anomalies exlit among cretiiu* not mentioned in \irchow'8 
classic which has remained a standani for wTiters for many years. 

Till* skin has a {K-eidiar cachexia. It is swollen and flabby, whitish 
or yelliiwish, folde«! and s<»gg>'. The general iipjK-nnincc of old age 
Is striking. The hair and nails are* badly develupe^l, both hn'aking 
eaMily. Thick, underlying, fatty masses arc unevenly distributed, 
usually in the neck, back, upper chest regions, occasionally over the 
hands. Variable states of tension occur in these fatty masses; at 
timiM (hey are hard, again like empty sacks. The muecHis membranes 
are* also |wle and gray, often folded but look difTexeut from a typical 
aiieniiju 

Tlic sexual organ changes have been touched upon in the description 
of sporadic cretinism. They on; charactcristioilly infantile. Men- 
itniation is scant}*, wanting, or develops ver>' btc. Fecundation 



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THE EXDOCRJS'OPATIIJES 



may taVe place, hut tlif results avr niistarriap's, tlwid rhildrcn, 
monsters, etc. The secumlury sexual rhanieters ure all (lelayoil in 
their tU'vt'iu|)iiieat. 

Tlie miijority H>1 per cent., KwakI) of cretins show a swollen thyroid, 
bill it is not an overfunttiauutj: one, nor ihi lliey all show uthyrc(»sis, 
or hypothyreosis. Schoneinann has rei)ortrd the finrJinKs of strumous 
ehaupes In the jtlandular |)ortion of the hypophysis. In 1 12 autopsies 
on piidcmip eretins he* foiiml a noi-mal hy[K>physis in only (wenty-eev'cti 
instances. Those iniiivichuils hjul no goiter, lie states that in indivi- 
duals with stninm of the thvruitl almost inxarinMx' there was an increase 



Flu. 87.— Two ca.-i«d of hyiKiiliyrnidisiiL. KImi, ttxoX friurto^n .voitrs: Liiui. ajk^ sistecD 

years. (A. JoaefaiHi.) 

in the fonnective tisaue, also the clironiaQiu irlls, struma of the vessels, 
hyaline defeneration and swellinj; of the cell strands and Hnally poiters 
with colloid formation. It is higiily probable therefore that the Roiter 
pois4in work.H Heletcriousty U|K>ti the liypoplysis (Kalta). The para- 
thjToirls show no changes. 

Most of the internal orj,caiis show reduction in activity. Digestion 
is usually .slow, constipation is marked. Tlie metabolism is miHlificd 
as already iudicatwl. The urina^' secretions arc apt to be diminibhc^l, 
&n<l of high specific gravity. 

Mentally cretin.s show marked variability. A few are practically 



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is; 



normal, but most show a chflrnctcristic combinution of mental traits, 
which is in marke*! contrast with many other defec-tivf mental states. 
(Sec chapters on I'>('ble-miTiiletlnes.s.) 

As noted, the fujcai majority sulfer from impairmeut of the chief 
sensory tracts. Hearing seems to suffer most. The defect in hr-nrin^ 
is associated with speech defects. Taste and amcll are also defective. 
They take little interest in their food or drink. The fccblc-niiniledncss 
Is acconipanii^l by gn-at slmvncss of all reactions, wiili nmrkcd retar- 
dation of motion, witli apathy, and indolence. This indolence is a 
marked feature. Many cretins will tie in the sun all day long, and in 
the hoHpital or otlicr institution will sit around and do nothinj; for 
weeks or m<mtlis. in the milder grades thert* is often preat ^llyne3S 
whii'h makes them uTia]>pr«)achable and serves to make tliem api>ear 
more feeble-minded thuii they really are. It is witli the Kn*at«!st 
difficulty that they can l>e trainwi to the simplest of ]^rforniances. 
With many, in spite of the niarkcfl general stolidity of tln*ir avi-ra^e 
miMMl. they may show great exciteiricnt and eniotional outbreaks. 

The sense of sijjht is fretpieiitly diniinlshed. It is Inphly probable 
that the receptors and ct)nduction paths are K-ss invul\eit than the 
perception areas In thU diminution in sensory intake. The hearinff 
seems to Ik? affected both as to its receptors and the cotuluction 
paths. Pain, touch and thermal sensibilities arc alt dulled. Motility 
Ls extremely retarded. The reflexes are adive (IK) per cent.). The 
field of \ision is reduced in many, although the fundus is u.^ually 
normal (ilitschmann). 

.'Mierraiit iuul nbortive t\pes art' tft be expe<terl. In the former 
one may find piitients with srrikinj; development of one or more 
fetttures, in the latter a very ureal sbailing off to almost normal states, 
I. f.. entlemic j-oitcr with miUl mental sijjns. 

Endemic Deal-mutism.— This injudii nation is extremely frequent 
wliere endemic cretinism is present (20 per wnt., Scholz}, It may 
constitute one of the aU-rraut tyi>es just mentioned with striking 
development of single features, or it may be associatctl with all the 
grades of a complete cretin picture. .Awording to the studies of 
Kocher, the loss of hearing is due to a bony defect wluch has destroyed 
the possibility of normal cochlear development. Had hearing is 
reporteil at li'2 per cent, among cretins in Scholz's investigations. 

The changes fnnnrl in the brain which may account for tlte feeble- 
mindedness have been variable. Meningeal iidlamntation ami milil 
grades of hydrotTphalus have been found by Schcilz awl Zangcrle. 
Tlw brHin is nfteii a.M'iiunctricnl, small, or single EoIh-s are diniinished 
in .si/vC. Often the brain's development is arrested at an infantile 
stage, the jwiHium or the ganRlia being involve<l ahjne or tt^ethcr. 
The cen-'lK-llum is often imperfectly developed, wliidi fact stands in 
correlation with the marked incoordination and i>o.s3ibly in relation 
with defective labyrinthine development. 

Theeardinicultie»are tmmcrous. Peripheral, conducting and central 




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THK HSDOCRISOPATHIER 



iiicclutiiisnis arc fuuixl tu In; nt fault, but at all events -scftm »et»iid- 
ar\' to the (levelopiiicntal niiikinnlie^ induced by tiie action of the 
poisonous substance on the th>Toid. The speech defects usually go 
hand in hand with thiise of hearinp. but this is not universal. The 
cortical developniental tiefert is sii(fi(ieiilly explanatory for most of 
the cases. 

Mild &nd Mixed Hypothjroid States. — I nder tin* ^'ucral title of 
iibni"tivi' or mild liypnthyruidism may Ik' grruifwil a very birfje nunilx-r 
of individuals, rarely cvnsidered sicli. but who nevertheless are not up 
to eorurrt piteli. 'i'liey show one or more syinpt4>ms which are due in 



Flo. S8. — LaJiuio hair. 



Hyp»tbyrutd duturtmixie. (A. JowfaOD.) 



pjtrt solely to a mild tliyroi<l defieiencj*. or to a polyglandular syndrome 
with hypotiiyniid preduiniuanee. These show themselves at various 
ages. Thus in the nursing child the absence of appetite. ainsti|)ation, 
obesity, and somnolence have been referred to. In the older, the 
premature loss of the hair, irregularities of dentition, wide sparing, 
iion-emergtmce, etc., precocious graying, siiinnolen(r, eorii^tipation. 
Anorexia lus a syndrome is often conditioned by mild thyroid defect. 
Certain studies of families have shown iu the different memlxTs 
graded series of hypothyroidisms froni myxedema to the mildest 
involvement, and again in others the gamut from the must severe 



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THE TltYREOPATHIES: THYREOSES ISO 

types of inyxetlemH. on tlif utic Imiid to the most severe types of 
exuplithalmic goiter on tlie other may be observed. 

The hypothyroid type is usiuilly smaller thjiii he should t>e, with a 
tendenrj' to obesity. There is a trentl toward faeial piiffiness, the 
eyehds, particularly in the ninrtiing, Ijeinjj swollen. Tlie (toniplcxion 
has a tendency to Ik- shIIow and \nri(ijsities iin- fiiH|uent. The hair is 
apt to lie dry, and the hair line liigh. The hair over the brow's 
is scanty, particularly at their outer edges. The Tnoustaehe may 
be scanty. The eyeball is deep set, often lacking luster and witli- 
out expression or lif^tless. The pali)ebral iia.sure.s are namtwed. 



Flo. 69. — Hypothyroicliam bvfora nod aft«T traattnciit. (A. Jcfsofeon.) 

frecpiently unrmially so; tlie teeth irregularly (levelupetl. Napoleon 
was a (■lB.ssi<*nI illustration. 

(Jingivitis h not niiv. The nails are brittle or frequently vcrj'hard. 
The extremities have a tendency to be cold, the lianils coUI. bluish, 
slightly swollen and moist. Chilblains are not infrequent in winter. 

This is a general schematic summary of the chief minor hyp<ith>>Toid 
signs. These sxinptonis may be found entire or in grniips. Thow mrnrt 
likely to IxTonstiint are the defects in development, the hairy nnnmalies, 
and the coldness nf the extremities, which latter is frc(]uent[y a.^sociatetl 
\nth a hypotlierinia, wttli frilosity and tendency to shivering, goose- 




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THE EXDOCRLVOPATlflBS 



(Icsli, clijittcrinp of the Ufth, vU: A marked hype resthesin to cold is 
often found in these t.v]X!s which leads readily to t-oryzas, to bron- 
cihitides »nd tn nniralgir pains. 

IIy[K>lliyn>iil mnstipalidii 1;* jirtiUdily dcinonstrated to be a fact. 
It is a iniirked ft-atim- of the inyxtnieniatous and its opposite, diarrhea, 
IS rw-ogiiized in exophthalmic goiter. Tiie explanation pmlmbly lies 
in tiie lowered tmic of the unstrii>ed muscle filx^rs, as an altered 
autonomir response Ut the diminished th.\Toid. In some mixed types 



Fio. 90. — PapudoepitibyBU. Aii euducrUioua ibyiiutliyu'i^; iJioduct. (Joni'/aoii,) 

where thjToid lubility is marked (chiefly seeundary to inarked emotional 
hd>ility— the so-<Tille(l nervous, neurotic or hysterieal ty|R's") altrrnj)- 
tions of diarrhea and constipation are fn'qtieiit. This is related to an 
cspedftlly signiKciviit tyi>e of intestinal movement syknokeiiosis. i. e., 
increased frequency of movements, not diarrheal, but soft and frequent. 
From the vegetative siile thew uiv n^Iated. jjartieularly by I.evi and 
Molhsrliild, to thyroid instability, from the i>syehical si<lo thry are 
relatal to the symbols of impatience, huste, tenseness, unconscious 
rather tlian conscious. Tliey frequentl} subside on thyroid tlierapy 



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191 






out are eqimlly luiu'iiiihlL- tii rest anil qiiift. A more fumlnnicntal 
psychotherapy is fiilK'il fur In otlu-rs. 

A number uf other Hynilmrnea, much emphasizetl by Levi antl 
Rothschild may be mentione*!. Personal experience has not yet eon- 
finiu'd these completely. They are hemorrhoids, raueoiaeudinuious 
enteritis (umlotihte(31y tliyrojilii! .'^itrndarily. hut i>rimarily emotiimal). 
Bradycardia is frequent. 'IVnnsitory edemas, tendency to eohls, nasal 
asthma, respirator}* oppression arc amonj; the minor signs. 

Certain skin syiidnpnies are ehisely rehited to mild hypothyroid 
states. The skin is usimNy drj*. roiijjli, apt to b*; tlifek. It is frecpiently 
ly, even advaiiiing ttt ichthyosis. The vegetative in.stahility leads 
acrocyanosis, to transitory edemas, at times tu eczemas on the 
flexor surfaces, to |W(»riasis on the extensor surfaces. Urticariie are 
not infrcftuent liypothyroid sijfns and are closely related to gastro- 
intestinal inferiorities (vepetutive) nsually spt>keu of as amiphylactic 
reactions to certain {usually) proteids. .-^cne, hcri)e.s. eczema, ]>3oriasi3, 
sderoderma shonid always be studied with the thjToid in view. 

The bony or joint inferiority which may resutt from defective 
development on a hypnth>roid basis is frctpiently responded to by 
chronic artliritiiles. Sinncliroes the spwitie ovcrtln-owinf; lesion is an 
infeetioii, again metabolic inferiority is registered by a chronic arthritis. 
Cases of rhrmiir rhriimaloii! nrthrifii then should Ix' carefully annly/X'd 
with tlK' ijossibility of hyjiotliyrcjid states in view. 

Pseudocpiphysis, Joscfson has shown tu be a hypothyroid stigma. 
(S'ec Fig. •)()..! 

In the parajfT«!>hs on mjTtedema attention has t>een directed to the 
sense-organ deficits. These may show in benign hypothjToid states 
as cortH'al o|Micities, opacltitrs in the \'itrcous, Jntcr^ti1ial kcmtitis, 
iritis (so-ciilled rheiiTiiiitnid iritis). 

Pathology o( Hypothyroid States. ^'hc study of the changes in the 
thyroid lies outside of the purimses of this work. Tlie most important 
defect stjittw result frttm infections, cnuslng acute and chronic thy- 
roiditis, from syphilis and fnjiii various aplasias. The changes in the 
nervous system rclatcrl to or possibly dut> to hypothyroid states have 
been extensively stnilied. Kojima'.s wi)rk in relation to tluit carrietl 
out l>y Mott is lujteworthy.' 

The nervr-cell changes are most strikingly seen in certain ea-ses of 
myxedema anil if cxpcrinicntul hy]K)thyroidisni. Chroniatolysis, par- 
ticuhirly within thi- v)'gctatt\c nuclei groups, is marked. Vagus and 
glossopharyngeal nucleus ehrumatolysis was extR'mc in certain of 
Mott's cases. In those patient** with marked mental symptoms — 
m}T(cderaatou.s psychoses or in certain manic-ilepressive states 4>f the 
meuoiKiust, probably rclate<l to dysthyroid activities, either due to age 
atrophies or cniolioniiliy indnccil imbalances, there are found extensive 
cortical and bulbar changes. Prccisi- currelatiiuis between the destruc- 

' PniopiKlinjn Itnynl Stwicty nf Medtcitip, PaycbUtric Smiion, vol. viil; Motl, ibid., 
Patfat^Bicnl Svclwn, Fobriwry 13. 1917. 




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THE SSDOCRINOPATHIES 



live le^ioiis found and the symptom atoloRj' are still in too crude a stajje 
to be didactically formiilaurd. 

Therapy for l^pothyroidiam.— Many crmtrad let ions nmy be found in 
the literature coiutniing ll»e use of thjToid substJince in various ty|xrs 
of mj"xfdcnm and i-rctinnid dt-geniTatiun. This is to Ix- cxix'i'ted since 
ao innny observers use their diagnostie terms so lightly. Age ditTerentvs 
are not recorded — stage and intensity of the tilsease — ami grade of defect 
is overl<joked, and hence no unifurni basis for comparisons exists. 

Among the l>cst reported results are those of v. Wagner who obtained 
the futlott'ing results: a diminution in the myxedematous swelling uf 
the skin, the genitals developed rapidly, the tongue diminisheil in size, 
tliere was loss of the umbilical hernia, development of new hair, 
dentition was hasteiieil, closure of the funtiinelles otrurR-d, and there 
was an inerease in bony ilevelopuient. The psyehe vuis less hopt^-fully 
rncidifii'd, but there was i\ diuiinutioti in the npiUhy, and slight increase 
in the intellei-tual ea|Micity was noted. 

Early therapy is luituralty the main feature. Aecordingto v. Wagner 
small doses of iodine in addition seem to stimulate the thyroid 
activities still further. Magnus Levy, v. K.^-ssclt, and others also 
report excellent results, complete cure resulting in some patients 
still in their teens. 

A widespread state experiment was carried out by v. Kirtscheras in 
•Styrta by treating 1011 (TCtlns. Alargi' nnnilHTwcre iiegh'eted by the 
parents, i. p., trratnient was not kept up. In 2.-1 per f-ent. the th,\Toi<l 
tjihlcts could not Ix' well borne. iUl idiots and severe grades of deaf- 
ness and dumbness were left alone. Of 440 of the cases 10.2 per cent, 
showed slight in(Tease in Ixiny development. 4 ix-r cent, showed definite 
change, N") [H-r cent, showvd an increase well above the average. The 
increase in bony growth was marked with the younger individuals, 
but al.so persisted into the third decade. 

A careful revision of (177 cases showed! 42.S per cent, marked im- 
pri)vemerit, 4R ]ht cent, some dcfiiiitc improvement, S.O [H-r cent, no 
iinpniveinciit. 

Scholz's experiences with 100 cretins in an institution were dis- 
appointing. He used as many as eight tablets a ilay. Aon Wagner 
claimif the doses were too extreme, hence the bad results. Kmaciation. 
weakness, lo.ss of appetite, vomiting and diarrhea, and other symptoma, 
of hj-perthyroidism developed. \'on Wagner recommends the use of^ 
imly one-half or one tablet (thyroidinmn sieeum, Merck^gram 0.1); 
0.4 gram corresponds to the activity of an entire gland. (Ilurroughs 
Welcome Co., O.l-fl.3 gram=gr. iss-v.) 

Iixlothyrine has also btrn utlliwd. One gram cntitahis three milli- 
grannnes of active substance representing the loflin content of one 
gram of fresh .sheep's thyroid. It would seem that the iu<dine content 
13 not the only factor in the activity of the th>Toi<l substance and it is 
not as yet definitely demonstrated what the combination is that is 
effective. .Surgical implanting of tl»e thyroid gland itself would be 



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ideal therapy, and ex|)eriments dircrte<! to this end have been 
carried cmt sini-c l.VSit, when HireluT wtus nm* of the first U) attempt 
it. The fEland has been iinplunteil in different iwrtiona of the Iiody— 
the neck, under the breast, in the spleen. e\en in the bony substance. 
As a rule, however, the impljintation has not Ix-en as sueeessful as 
was hopeil. the (Hand itself nnderK'>in(; retn»jrnidc changes. I-'urtiicr- 
Diore. it would api)ear Innn the :<tudies by KnderU-n and Uorst that 
thyroida from other animals )x»ssibly are not the best things to use. as 
the biochemieal eonipc^sition of the huniiiti and aiiiTnaJ ty{>es varies 
so widely a.s to render rlf^neratioii <»f the iniiilaiitcii t^land likely. 
Inijilantation nf human inlands has not iMt-n t>ui-('t»sfnlly bnttit^ht about 
as yet, hut with the newer work on orf^an transplantation as inaugu- 
rate*) tiirough the researches of ( 'arrel it would seein that this techiiintl 
difheulty might Ik* overcome in the ver>' near future. 

One is if>mpillcd, therefore, to resort in most i-ases to the drietl 
or liquid preparations of the th>Toid itself or to such biochemical 
products as tat>onitor>' ri-siarch lias provided thnmjch the utilization 
of the j^lundular sulistanee itself nr that portion of it which pre.sents 
its chief homutne activity. 

The general results of thyroid medication in tjinod cases is fairly 
crjiistant. Rspi-cially is il i»f value in the aberrant and minor forms 
of tlie dLscjisc of whieh one of the most chronic of symptoms is the 
persistent anemia. This may bo in part nvcrtvmc by the simultaneous 
ase of small doses of arsenic, winch have l)een recommendeil by jt 
number of investiKutors. .Vlcohol and nsorphiu work disadvantape- 
ously. and shonki lie carefully avoided. The use of small dos«.'s of 
sodium bicarbt>natc and bismuUk work a(l\'antai;eously in diarrheal 
states. 

Th>Toid medication for the .sporadic ca.ses varies somewhat fmm 
its use in the endemic ca.se-s. In t}ie sporadic cas«»s of the light or 
milrl iy[*f the action is quite similar to that seen in the endemic ones, 
but as a rule sporadic cii.'+'s by reason of their longer involvement 
an<l the less rapid dcvelupment of the symptoms, their more hidden 
c»r ohrtcnrv nature with their gn.-at niixTure of synilnnues make (hem 
les.-* respon.si^e to the therapy. Nevertheless*, many of them res]»ond 
verj- kindly to it. the same dosage In-ing utilis'.e<l. 

Id the l>enign hyp»ithynml states c«ref\illy selected thyroid therapy 
has been of excrllent service. Massive duses are at timei require*! 
t(t bring about the desired elfects; again very minute dosage is 
sufficient, 'the u.-^ of the endo<-ritir)us glands at the jiresent time 
stems to be going through the chara<teristic cycle of all enthu- 
siasms. ThxToifi is mm a universal paiiac"ea. (hit of this hv-per- 
theraix'Utie activity careful dis<Timi nut ions will come and proper 
means adapted to liel]i llie syndnimcs wliieli have U'cn here rather 
hastily snniinarizeil. Hormone Ihempy has its platv, the limits of 
wliidi are being outlined by n careful scrutiny of the vegetative 
reactions and their relations to the endotriuous honiioues. 
13 




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THE ENDOCRlNOPATHtBS 



Hyperthyreosea : Exophthalmic Goiter.— rira\'es describe*! the con- 
dition ill is:ij, IJasi-diiw in IMO. Miihius ii] 1S.S(> iiisistttl im tlie 
relation of the dtstirdtT tu chaiiK*^ in the thymitl gland. 

KTcophtlinlmie goiter is a disorfler coruIitioneJ by a moJificiition of 
tlip iK'tivity (»f tliyn)id glatid suhstaiitr which in turn It-a^ls to an 
increased activity of tlie vegetative nervous system witli a series of 
cuniiovast-uhir sipns, tachycardia, exophthalmos, tremor and increased 
raetal>i>lic activity. I'nder some circtinislHiifcs the incrcasi^ in the 
glandular activity is prbnary, the vegetative symptom atolopy, second- 
ary, under ulhers tlw reverst^ In every rase the cause for the liyi»er- 
artU'ity sliould be ascertained Ijcfore tlierapy is inaugurated. To 



Vto, 91 ,— Exophltmliiiji: Ki)itpr, etrnw- 
iiig markod csrjphtlialmuH and cnluritMl 
thyroid. (Coiirwsy of Dr. Gwru* W. 



l-'lu. 92. — SniTir putit'iit ffmr nifnithji 
afU'c u|x;ra1.i<ju (<>x<.iriKiti>>u}. Gitallj' 
dimiiiLshtrd rxuplithiJui'iE niid chnngp ol 
facial i'Xi>m*«i(ni. ( CoiirWsy of Dr. 



ojK'rate for an acutely distuHied thyroid due to a severe mental shock 
is hiLsty and mostly meddlesome therapy. To attempt a psychoanalysis 
for a septic thyroiditis is equully farcicnl. 

The ilisiinlcr is widespread and presents many varintion.s. Indeed 
abortive and irregular forms arc among the commonest of the mani- 
festatious of hyperthyroidism. Women much more often than men 
show this particular tj-pc of disturbance. In Sattler's ^trtat monograph 
320(1 (tf .'isiM) cases rcjmrtcd were females. Hereditary types arc known. 

Symptoms. The chief symptoms are found in tlie thyroid, eye, 
heart and bloodvessels, skin, and muscles. Psychical, f^astro-intestinal, 
respiratory, genital, anil metabolic changes occur a-s well. 



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195 



It must be einphai^ized that the sjTnptom groups whidi are here 
described apply tn the mnre evident hyiterthyrnid states. It shouKI 
constantly be bonic in mind that a jireat many |>ersons, women 
particularly, as a result of eniotiniial disturbance, often unconscious, 
sufFer from mild luxic lliyn»l<l slates. The Htrratun^ is euormniis. 
Sattler's nmiiograph is the lunst cuniplete to date. 

An cidnrjied thyroid is fairly constani, although occasionally alwent. 
It is soft and clastic, rich iii new hl(X)dvfss*'Is, pulsates, and varies in 
volume (often very rapiilly). It-s variations in volume nre fairly com- 
mensurate with the intensity of the synii)ton]s. Auscnltation of the 
enlarged th%Toid often gives a marked bruit. 

The heart action is rapid (Tachy<-aniia), and the pulse is very 
variable, reactiiij; excessively, particularly to psyt^hical inHuenres. The 
heart sounds are increased in force, the bealinj; heLnj; felt in the neck, 
an<l the whole c-hcst wjiil is at times moved by the cardiac tumult. 
The lilnfKl-pn's.sun.! is ran-[y nusi-d and the radial and other ve?tsels 
sliow markeii h>'iKrtonus with reddening of the face, ears, and finger 
extremities. 

T\iv rye symjitoms consist of a marker! and variable protrusion of 
the e>el>all, with witlened orbital fissure, sometimes itreatcr on one 
side tJian the other, and felt as a clisanrcenble pressure and tension by 
the patient. The eyelid.s are at times swollen, and the upper, and 
possibly- the lower lids lar^Iy retracted (DalrxTnplc, Stellwag) in<le- 
pendently of anil often precrdinji the ]irotriisiiin of the eyeballs. The 
upper lid also does not move synch roiuMisly with the loweriiip or the 
raising ()f the eyeball (vnu (iraefe's sign), fnllowing more slowly 
or receding more rapi^liy (spasticity) than the moving eyel»all, in the 
presence or absence of protrusion. lioth signs may be unequally 
present. The relative infrwiueriey of winking (Stcllwag) is a fretpient 
sign. Kpjjinger shows in tabular form the relative frequency of these 
ocular phenomena. 



Symttloin. Per emt. 

Pnitnwton, wldo. V. GnusfB 23,0 

frolnuion. v.Crwefo . SRU 

Protnuinii , . . , , .10.4 

No eye aJsns , . . . . IS. 3 

Wide, protru^inti 

V. Oracle, widv 2.6 

Wide S.l 

V. Gr«e(e 7,6 



Number of caM* 



39.0 



Pnr t*ni. 
37.3 
19-8 
17 a 
13.3 
2.2 
5.4 
I.I 
3.3 

Bl.O 



Rnpingrr 
fV* cell I. 



101.0 



Lowi's sign (dilatation frtvm adrenalin) is frecpient. Occasion- 
ally mydriasis is present, less frequently miosis. Irregular or still 
pupils may be observed as well as lo.ss of the accommodation reflexes. 
Optic nerve atrophy is infrequent. Increased tear .secretion is often 
observe<l early, dryness late in the disease. MecJianical complications 
—pus, ulcerations — are met with. 



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THE ESDOCRINOPATHfES 



IiLsufRciem y of ciwverRt'ncT, without drmble Wsion (Mobius's sign), 
is frequent and is independent of pnjtrusioii. 

Cardiovascular symptomji are among the most ronstAnt and eariy 
signs of exophthalmic Roitor, and are dne to the action of the tli>Toid 
secretion. Tuchycanlia (occiisinnally paroxysmal) is the most promi- 
nent yiiigle sij<n. THl- piilsi^ may beat from 1(10 to 160 times a minute 
—even 2(Kl hius been reconle<l. rndoubted cases may show no rise 
above 100, and jrreat variability is the rule, especially in re»|)on9e to 
psychical stimuli. During sleep, luul also on lying do^\'n, the pulse 
frequency slows down. 

Angina-like attacks, with hyperalge;<ia in the left ulnaris region 
are not infrequent, and in most patients the feeling of dijitress and 
anxiety over an increased .sense of heart oppression (apart from the 
tftchyeaniia) is one of the nmst anruiying s\'n\pttmis. Canliac dilata- 
tiem, witin later hyjK'rtrophy, without valvular defect, may or may not 
(50 j»er c-ent.) aci'om[miiy tin* d^seu^4'. and disapjieiir at its termination. 
On au^eultation the first .s<nuid is usually accentuated, and systolic 
murmurs at the base are frequent. Valvular insufficiencies occur 
under special eireurnstantrs, and an- often of serious moment in 
operative cjises. 

Strong pulsation of the t-jirotids is frequent, and though the large 
vessels are often pniminent, and apparently arteriosclerotic, the 
mdls are usiwlly soft and yielding. \'Hsnmotor instability is frequent. 
Marked retldrning niternates with i*nleness. Irregular mlheniata 
also iiTv not infretpK'iil iitid niaiiy [witients futiiplain of surfatv iK'at, 
se<'k cold places and light clothing, even in w-intcr, and yet show no 
teui|XTature anomalies, dermographism is also u frequent vasomotor 
phenomenon, and epistaxis is not infrequent, Ilarer urticariie, irregular 
cireumscrilu'd edemas, pruritus, etc., are to be exjH'cted. 

Skin symptoms are frequent. Inerea.ted jxT-spi ration is not rare 
and the skin is always moist with Minie {Kitienis, possibly only on 
one side, or in isolated (head) areas or .smaller siKits. 

The plwtrical resistauc-e t)f the skin (Veraguth-N'igoureux) is dimin- 
isheil as a re.snlt of this increased .sti-n^tory acti\ity. floose-flesh 
(lc\cIo|>s rcttdily with these jwitients, and changing pigmeiitjin.' anom- 
alies, chiefly chlfwsma si)ots, are present on the skin, not on mucous 
mnubrunes, more esix'cially on the eyelids, ueek. iiippK'S. armpits, 
and genitals. In many patients (23 per cent.. Sattk-r), there is a 
tendcnc\' for the liair to fall out (sometimes unilaterally) xvith the 
development of the <lisease, und usually there is renewed growth 
of the hair with improvement. 

TIte nails not infrecpiently show deformities and dystrophies. 

Tremor is an early and frequent sjinptom, and may involve the 
entiri' body. It is usually fine, varies from seven to forty vibra- 
tions per second, and occasionally is intermingled with wider, irreg- 
ular choreic-like movements. Psychical rather than ])hysic»l stimuli 
increase tlie tremor greatly; lying down temls to diminish it. It 



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TTIE TnYREOPATlIIBS; THYREOSES 



197 



. 



IS niiirv apiMit'nt in the upper tlmn in the lower extremities ami 
is marked in the eyelids (Rosenlxic'h), in the tongue, and n-hen in the 
vochI conis produces a peculiar staecnto breathing (Minor). 

l>igtstiK disturbanws are frequent. Hry innuth may alternate 
with excessive sahvation. There is a marked tendency to elironic 
alvine discharges (.'l[t i>er ctait.) and to voiuitiiig without anorexia 
(15 per cent.). Both occur in paroxj'sms, somewhat resembling 
tabetic crises. IIour-Rbss enntra<-tion of the .stomach may Im; demon- 
st-Tat^nl by the r-mys. Iloilj the vomiting ami iliarrhea are ithstiiiate. 
are aeeoinpanied by mucus or colloid, at times hloody material and 
the movements may n(?ciir as often as four or five times a day. Fatty 
stools without diarriiea nmy ticeur. With bntb diarrliea and vuiiiitiiig 
the patient* arc in grave danger. Obstipation of spastic type may also 
occur. In many patients then* are enlarged lyinphalies. tonsils, 
tongue follicles, thymus, and lymphatic-s uf the intestines. 

iUsfiirtttory sjTnptrmis, dyspnelc in chanieter are usual. Normal 
breathing is frequently irregidar in depth and rhythm, and seems 
fitraii>ed. The swollen gland may cause relative stenosis. Asthmatic 
tendencies are present, and the general sense of air hunger is striking 
with nervous |>seudohysterieal ct>ughinK. 

Menstrua! irregularities are common. The flow is usually small 
in amount and infretpa'iit in iH-enrrence, with ocfasinrijilly the 4lIiTet 
reverse condition. Thinning nf the breasts, niiil other atrophies 
(testicles) have lnt'ii recurdeil. and seem to he coordinated with 
thymus anomalies. 

Mffahoiic anomalies arc characteristic. The |>atients become 
markedly emaciated and get verj- weak. This is related to a definite 
nitrogen lo.s.s. juul aUo to a nmrki-d o\'eroxidation of carbohydrates 
and fats (see fatty stoids). This sutldeii loss of Hesh and strength 
may ttjme on in attjiek.'^, antl then a di.stinct iniprovetnent takes 
place. Eppinger s|>e4iks of these patients as individuals who, not 
doing any work, iieeil all the calories (tf a ha^d-w(^^kirlg individual. 
Thus in mIKl eases an increase in calories keeps the patient at a nonnal 
weight. The increasi'd oxidation also sbt)ws in a mild hyperthermia. 
Alimentary glycosuria is frt-queut. and gradually disappears on re- 
covery; hyperglycemia, 0.1 per cent, and over, is a common accom- 
paniment, and not infrctpiently the blood-sugar findings may be utilized 
as a test for the severity of the disnnler. True dialwtes is an infrequent 
onmplieatinn. Polyuria is frequent (13 per cent., i^attler), less so 
Hlhumimiria (1 1 p*"!" '■<'nt., Sattler). 

The Uixid shows anemic changes frequently at the verj' outset. 
Tlie num^KT of red ei-lls is not markedly lowered, as a rule, save in 
those patients with marked cachexia. The leukocyte count is usually 
low; die percentage of cells is altered. Lymphocytosis is marked 
(60 |>er cent.). The pulynuelear neutrophiles arc markedly diminished. 
The eosinophilc cells are increased (S to 20 per cent.). The large mono- 
nuclears are nonnal. Thyroidectomy changes the entire blood picture 



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TltElENDOCRIKOPA THIES 

more towanl normal, as does aluio ligation uf tbe tliyruid arteries 
and according to Kocher the blood picture is a valuable proffnostic 
index. The eoagidation time is increased. In the young, hjpcr- 
th.\Tet)sis leads to increase<l growth of the bones, and young exophthal- 
mic patients arv apt to Im> very larger. 

The mrnial syiiiplomalolngy of hyiHTthyrcosia is of great importance, 
since from the studies of Parhon and others it seems possible tliat like 
otiiers of tlie symptoms tlie mental signs may develop almost exclu- 
sively. Ill many cases the psychical signs are mild. The tendency is to 
both psychomotor and emotional irritability. Mowlincss and sudden 
changes are frequent. In marked cases distinctly manic pha.ses may 



riHj. 'J4. -K'H'i'liihjJinn' ni.>ii>-r. 
(Hammond.} 



Fni. 'JL i^xi'i^htliJilmic goiter. 
(Uaminoad.) 



develop; again acute and deep depressions (often suicidal) take their 
place. Thns the picture approaches very closely at times to the tj-pe 
of|Kraepelin's mixed manic-depressives, or the more t>*pical circular 
fonns of this psychosis. Toxic epiphenomcna may take i)Iftcc with 
ideas of reference, of iwraecution, even hallucinatlims, ])rincipally of 
sight. The general picture of an acute delirium is a gra\e sign. 

Tbe analysis of the psychical pictures in exophthalmic goiter is 
far from complete. .Sattler advocates a catliolic attitude, saying 
there is no one t.vpical hi,7>erth\Toid psychosis. The present tendency 
is to ally the mctital plienonicna of the hytXTtbyreoses with the manic- 
deprcsslve groiii». and to separate certain manic-depressive cases as 
I largely conditioned by hyperthyroid activity. 



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199 



General Etiolocy and Pathology.— General con sidt rations relative to 
the athyn'i):^t*s, dy.stliyn'o.scs, juhI lij^jprthyrcoses jis .seen in the elinieal 
pictures of conji^nital and ai-qiiir*s^i ]i.\^jofiinctioning as in c-retiiii-ira 
and myxedema, and in hypprfimctinning as seen in exophthalmic 
goiter |Hiiiit U* jHiralytic and irritati\'f plienumeiiu of the sympathetic 
and ])arasyni pathetic (autoiujinic) nervmis systems. 

The hItxKl eliaiiges iii cxuplithahiiic goiter acid in myxedema are 
similar, f. r., there is a relative lymphocytosis witli diminution of the 
neiitriiphile leukiK-ytes. In exophthahiiie xtiiter the euiifjnlaiioti time 
in iiitreu.sed. in myxedema dbuintslied. In exophthalmic fjfiiter the 
symptttlietic irritation explains the exophthalmois. tachycaniia, loss of 
weight, and tlie alimentary plycusuria. Autonomic irritability causes 
the von tiracfe, the lymphocyto.sis. the diarrhea, the increased secre- 
tions. The intlnence of the thyroids on the earh(jh>'drate metahoUsm, 
as seen in the rapid euiaeiatioii and alimeiitary jjlyci>suria, possibly 
acta throujih the pancreatic retantution or thrnugh a relative Increase 
in adrenalin action. That the thyinns is invulvcd in ibe bliHid picture 
fonnatioii ^ems eertain. 

Thus one comes to a condjijied neurochemical theory in that exoph- 
thalmic goiter is dependent upon liypcractivity of the thyroid secre- 
tions, which increased secretions act tliroujih the visceral or veRctative 
nervous system. Both autonomic and sympathetic systems are thus 
in a state of h>pcrc\'citability — a condition the anatomical foundations 
for wliieh are fifund In a certain tyjje of indivitUial termed vagotonic by 
Kppinjiier. 

The detoxication hypothesis of IJIuni, Ostwald, Kocher, Klose and 
others, in whieli a dysthyreosis is assumed with a type of Iodine 
poisoning from insutlieient lU'toxicatiun is ingenious, but not yet 
satisfactory. 

The full etiology is still very dark. Many apparently healthy 
individuals suddenly develop the disorder following a shock. Tlus 
shock frequently iuvolves the complex of the fear of death or the loss 
of money. Tlierc is a chara<-teristic fear reaction. Minute analyses 
from the psychoanalytic school are not yet available to permit generali- 
sation, but the psychical import of shock is undoubted. In certain 
personal experiences chronically increaseii thyroid activity and certain 
definite unconscious trciuls ha\'e been uniformly JLssociatcd. 

Infections and tuxit- types are also rcr-rignized — acute thymlditis, etc., 
and also a form of iodine intoxication in Individutda who have taken 
potassium or other iodides. 

The changes in the gland itself are of little moment for the inter- 
pretation of the disonk'rs. A gn'at variety of variati))»s from the 
normal have been described, chiefly of hyperplastic tyix'. Apparently 
perfectly normal glands are at times assoclatwl with severe tj-pes 
of the disease. The gland is usually enlarged, elastic, tlie vessels 
dihitetl, and new pn)liferating hloiMlvessels are ftnnid. Kocher has 
descril»ed the goitroas type us pareneh^Tnatous hyperplastic struma, 



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THE KNtifyCHISOPATfllES 



|)oor in ctilloul iind in iiKlinc; utlwr <'1ihii|ws are lan?ely due to 
L'ompiications. 

Forms and Diaenosis.— If the rla^u^ii-a) triad, exoplitlmlmos, tachy- 
cardia, aiifi piittT U- prfsriit, there J? little (jiicstioii as to diagnosis,, 
hut still all may l>e absent uml yt-t the patient he siifTerinp from sever 
hjiHTthyroiiiisin. Hence great VHriahility umy he i-xptrtiMl, I''i)pinj?er 
and Hess distinguish two chief groups acconling to the precloiniimtice 
of the s>inpftthctic or autonomic irritative phenomena. These deserve 
niort; detaikd study. 'Hie aiitoiioniicr group, in purticuliir. is often 
i)verl<Kiked. 'rhese show von (rraefe's .sign, diarrhea, lymphoryt(vsis 
and increased perspiration nnd nuirked anxiety. They are not infre- 
quently taken for auses of anxiety iieunisis or other iieijrii:^then[»id 
hybrids. Severe gastric or enteric crises have led to a mistaken 
diagnosis of taln-s. r]nIcve]ii|XTl forms niay Ik- n-iidily overliMiked, 
espceiidly when the nion* clu.s.si(al triad just noted is not present. 

Particular iittt-iitiun siioiild he fm-ussed on the tliyroid it:jelf. Its 
rich and in<Teu.sed va.scularity tends to give it a pe<'i]liar consistency, 
even when not markwily enlarged, which is very chariicteriHtic. Kocher 
has cnmiMired it to the general fulness of the breii.it of a prcgniint or 
mn>iiig wMman. 

In a very large numlK'r of patients, espcciafly those showing the 
pjirasynipatlK-tic irritation (vagotonic) signs disciLs.sed, hyjjcr- 
trojshy of otiier lymphatics is to Iw observe*!. These are chiefly 
to be sought in the thymu.", tonsils, tongue and reetal lymphatics. 
'n«Tr is ii tendency to elongated extn-niities, scanty lieanls in men 
and badly developed genitals in women. Marked lyinphocjlosis is 
also present. This relati\'e l\-mphatism (wissihly plays a very im- 
portant etHnpcnsHtory role in (lie disease. 

The patients with niarked psyehlcal signs art- »i>t to show both auto- 
nomie ami sympathetic symptoms. Certain patients sliow only cariliiv 
vasculnr signs. These are those described as goitrous heart. They 
show tachycardia, dilated heart, some respiratory arrhytlinuK. The 
eyes are often shiny, pu])ils dibited, and striking even if not protnid«l. 
l>ennographia is frequent nnd diK/.ine.>JS is nflen complained of. Other 
closely related forms suffer from dyspnea and bronchial catarrh, bleed- 
ing from the nose and (rongestioit of the upijcr air imssjiges. Neurtitic 
goitrous heart from prc.s.sure is another sjiccial tyjM' often ovcrloctked. 
Tlicre is also unilatend mydriasis, at times tachycardia, and the eye 
on the pressure side protrudes nn«l recede:^. Itarer cases arc disguised 
under mild diabetics, and F. Miilicr has described a group of pseudo- 
sclerosis cjises (»f hyperth\Toidism. 

The iodine toxic eases form another group. Running from the 
nose, hnineliia] catiirrb, salivation, stoniachie distress, nausea, tliarrlM-a. 
.sleeplessness, licndache, and skin eruptions are tlie more frequently 
found s\iiiptoms which may develop with but small doses of iodides. 

That the blood uf patients with exophthalmic goiter contains an 
increased adrenalin content which in some cii.ses may be cxiK'rimcntidly 



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THE TIIYJiEOPATKlES: TUYItSOSES 

demonstrated in animals, is a point of h>'pothetical diagnostic value. 
It also points to the possible relation between this disorder and uncoD> 
scions "fight or flight." 

Oeeurrence and Course.— The disease is comparatively rare. The 
proportiun of men to women i& I to 6 on the average. Betweea fifteen 
and thiny are the most frequent years of incidence. 

The eonrec is usually chronic with ups and downi.s and many varia- 
tions. Kmotional shcM-ks, behind which simple term there may lie the 
profonnilest and nnwl tragic events of life, almost invariably lirins on 
an attack or increase an existing one. Acute infwtions frequently 
bring on exacerljatioiis, while pregnancy frcqiiciitly acts advunUig**- 
ously. The length nf time that the disease (M-rsists is extremely 
variable — from tlin-c months to thirty years. The prognosis also 
varies ttilii the severity of the hj-perthyroidism. With healthy indi- 
\'iduals the prognosis is relatively go<Kl, with ilistinctly nervous (espe- 
cially vagotonic) individuals it is less ho|>efnl. 

L\inph(K'>'tosis, nnth normal numliers of white cells, is a better 
prognostic sign than lynipluK-ytosis with Ieuko|HMiiH. 

Treatment. — This may be surgical, by internal remedies ur by psycho- 
therapy. Surgical treatment is the most radical. The statistics of 
various o[x_Tators have shown improvement in fn)m fi to Tti i)er cent., 
death in fn*m '2 to 22 per cent.' Kochcr has rciHirted 7fi per c**nt. good 
results. These figures are pnihalily high, if ultimale results are meant. 
'ITie operation of choice is the suwessive elimination of thjToid sub- 
stance, with minimal handling of the gland. This is advocated par- 
ticularly by Kwhcr, whos<.- lethal results have Wvn fnini 3 to 7 per trnt. 
Death frcfpiently is preceded by narciwis, with a vcrj" charactcri.'^tic 
symptom-complex. The face gets red, the whole body becomes tremulous 
and breaks out in perspiration, diarrhea supervenes, the tcmperalnre 
rises and the heart action becomes excessively rapid, and death with 
cyamisis anil dyspnea takes pinw. Stiitus thynHil>ni[(lia!iciis is 
possibly resjMinwble for these results. 

The operations on the cer\'ical sympathetic are not to be reconi- 
metide<l. They help the eye s>*mpto[ns posiubly, but the disease is 
not one of tlte cervitnl .\vmpathetics alone. 

Internal theraiiy is jstill nasatisfactory. Kest in bed ia primary 
and essential. .-Viiy remedy increasing the lh\Toid secretion is bad, 
hencf thyroids and ifMiinc are to i»e avoided. ThynuLS has been 
tried, with beat results in tlie sympathetic types. Tlie fresh gland 
i.i given by mouth. Heliotherapies, .r-niys. violet rays, as »t present 
ilevelojMil arc justified in a limited nunilHT of carefully cbosi-u taises. 
The chronic infectious, hyperplastic goiters do bc^^t with light therapy. 

I'hjtnnaeological agents which a<t to diminish tlie th>Tr»id sciTetion 
have hern UM'd. Chief of these is lielladoniUL. It Is tlte most reliable 
of the internal remedies and can be given in fairly large doses. Adren- 

* Eppiofw, loc. dL, u, 70. 



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nlin in solution hy rcotum is of service at times. Vagotonic cases 
reiiel best to its iiiflueiiiL', t}ie tachycardiii and diwrrliea being well 
influencpfl by it. The digitalis grfuip (if glycosides Jirc not to be rcconi- 
lueadcd, nrithcr is iron uf any servtw. An^.'nic and bromides maj be uf 
passing service, csixx-ially the latu'r, in aiding sleep. Certain cases 
react ver>' advantageously to extremely minute doses of thjToid ; whether 
this is a blind p.'^ychotherapy or not is an open question. 

Psychotherapy is above all of great value, esiiecinily as applied 
towanl an cducatiini of tlie piitieiit coiiceniiiig his fears, in tlie sense of 
I )uboi». This is a combined rest and rec<liK-«tion therapy wliich Ihibois 
claims has Ikth succe.ssful in the vast majority of eases. Psycho- 
analysis Ls of the most signal sen'ice in a large group of ca.ses. es]R'ciaIly 
in readjusting the patient to his iinconseitjus wishes, revolts an<i rttM.'!- 
lioius. It is iwirticularly valuable as a follow-up of a surgical o|jerHtion 
which has l>een iK'rfonned to save life. 

•Scnuii tn-atnients aiming to exert a lytic action upon tlie secretory 
cells of the tliyroid have been devised. The most promising are those 
of Kogcis and Bccbe. 

PAKATHTROID SYNDROMES. 

The iNirathyroid glands iirise in man from epithelial outgrowths 
on the third and fourth bran<-liijil clefts. That from the third cleft 
usually lies free froin the thyroid in mo.st smimals save in man. Acces- 
sory parathyroids are iiresent in ditferent neek structures and para* 
thyroid tissue is frequently found in the ihynuis gbiTid. In man the 
chief jMiriithyroid masses aw Imbeihled in iind blended with the thyroid 
tissue, although distinct from it. In gi-neral the reninval of two or 
more of the parathyroids* gives ri.se to the disorder termt'd tetany. . 

Tetany. — ('orvisart first used this term "tetanic" in lSn'2. Frankl- 
Hcicliwart, in 1.SS7. clarified the conception, and since his striking 
descrijilion the term tetany ha-s had universid reciignitiuii. 

'J'etany is nio.st satisfacturily iiiterpivtiil jis a disonlcr of the vegi-ta- 
tive control of the calcium nietalxdism of the body, alterations of which 
mtwiify the elcctricsil i>erincability of the neuron membrane of the 
synapse, causing marked hyjierfunt tinning of the sensory and motor 
spinal mechanisms. ,\s the parathyroitis arc possibly the chief regu- 
lators of the calcium ions in the bctdily fluids tetany i.s pn-iinincntly 
a result of parathyroid liyiMifunetioning.' 

Symptoms. — Tctan\ has. as its main sympttims, tonic, intcnuittcnt, 
bilateral, often painful criitTiiw, wlueh, without, for the mi»st part, any 
loss of consciousness, iiwobc the nmsclcs of the upi)er extremities, 
particularly the hand, which is held in the obstretrical position. The 
muscles of the lower extremities may also be involved, those of the 
larjTix, of the face, and of the jaw, seldom those of the chest, abdomen, 

' Sec Ostprlifml: BmtaninJ Gatctt*. 1015. I'l soi)., lur vnluaMc stmlii-n uit \)ic nltvra* 
liaat at oieclncal [icrmi-iiliility uf rdl rniiniliniiHM, tlua h> bivalent kaLioas. 



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neck, diaphragm, or tongue. In rarer cases the eyeball musHes are 
implicated, as is alst> the bladder. In tlio sensory spbrre parestliesise 
and pains are present, while hyperesthesia? oocur now and tlien. 
Pressure ii|H>n the braeliial plexus may give rise Ui an atttaek (Trous- 
seau) ; hyperexcitubility to electriod currents is prest-nt (Krb) ; raechaa- 
ical hjiierexeit ability of the raus(Jes and motor nerves is ob^'i'vcd 
(Chvostek), while the sensory hyperaetivjly to mechanical and 
electrical stimuli is also present (HclTmann). The psyche is rarely 
uninvolved. an<l follnwiufc oi»erative removal there has <levelo|>ed 
extreme anxiety with the sense of impending dissolution. 

In chronic and rej)eating forms se4Tetor>' and trophic- disturbances 
occur, such jus increased iwTSjiiration, reildening of the skin, swellings 
of the joints, mild edema, falling out of the hair (alo(»pcia) ami nails, 
discoioratinn nf the skin, urticaria, and herpes. Dyspnea may iiiter- 
vcrif; polyuria and glycosuria an* rare iiceompiuiying symptoms. 
Inconifjletc forms have been designated " tetanoid" by Kriinkl-Hochwart. 

For <lidactic purposes Kriinkl-IIochwHrt divides tetany Into simple 
and acute forms and chnfnic recurring forms. A fui-fher division 
of forms occurring in cliiltb'cn and in adults is made. Tetany of the 
adult he groups into seven classes: (1) Tetany idiojwthica— tetany of 
otherwise healthy iihliviiJuals— wiirknian's tetany. This is the form 
which seems to occur p]Hdemiially as an acute, or acutely recurring 
alfection in (vrtain cities, notably N'ienna, HeidcllxTg, etc., principally 
in the early sjjrlng months, and amonn <*ertiiin linndwiirkers — tiiilora, 
shoemakers, etc. (2} The tetany of gastric and intestinal airections. 
(3) The tetanies of acute infe<.-tious diseases, typhoid fever, cholera, 
nieast'ls. searlel fever, etc. (4) The tetanies of acute poistniing, 
chloniform. morphin. ergot, phosphorus, renal, and gonadal sub- 
tanees. (5) The tetanies of maternity (pregnancy, parturition and 
lactation). (6) The tetanies of parathyroid invnivcrnent. (7) The teta- 
nies accompanying other nervous diseases, exophthalmic goiter, 
brain tumors, cysticerci, .syringomyelia, etc. 

Incideacii. — Tetany in its dilTerent manifestations is very rarely 
seen, and is even less frequently reijorted. In undevelojied phases 
the letjinoid reaction is (.tjiiipunitivel^ frcfjuent in children. Gas- 
tric tetanies are pnilmbly the most frc^inent, while the pure epi- 
demic form has not been encountered in the United titjites. In 
Griffith's study only 77 cases were found recorded, while Howard's 
later rollection brinps tlie American c-a.s<'s to 154 in 1907. 

Etiology.^ — Whether the work of Mactallum and Voeptlin' has solved 
this problem is to be determined, but it would appear that an cs-sential 
factor lias l»ecn found in the relation nf the pjinithyroid to the calcimn 
metabolism of the body. The hyiH'rexcit ability of the neuromuscular 
apparatus is primarily due to n change (chiefly a <leficiency) in the 
amount of the calcium in tlic blood, and tins is thought tu be due to a 

'AmericAii Jounml uf luMiiily, 1009. 




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relative or absolute ijisuflidniey of the pjiratliyroid glands, riijingea 
in tlie miciuin content (bivalent kations) alter the permeability of cell 
membranes to electriral stimuli, and the t<:tany reaction may be due to 
a lowering (if the syiuiptic thresluiid to Reusory stimuli (analo^niis to 
stO'chnin). An inerease In stimuli summation takes place with the 
overmu'tion re.v[Hinse. 

Pathology. — (-'onceniing the liis(f.iU>Kieiil (■llall^Jes, tin* present view 
exeluilfs a si>feifie |M(thc>lii|:^y. The insufKi-iency of the panithyrnids, 
be it relative »ir cumplele. iriay be bruujjlil iibout by a great variety of 
lesions. These in n'ality oiler cvidentv in favor of the [mrnthyroid 
iiisuilifieney liypothesis, but go no further. In the uiiiutr grades of 
tetany In children, particularly in so-ealled s|>iismophile,-i which l-'rankl- 
Hoch'A'art regiirds as tetany, the findings of Vanuse, of Kseheriseh's 
clinic, iire illuminating. Here l»emi»rrhagps in the panithyroid seemed 
fairly con.stunt findings, and offer an explanation of the gahiinic hyixir- 
excitidiility. At the other extn^nie one finds the absolute insufheiencj' 
letjuiies in exiHTinicntal pnraTh>Ti-<ipriva. In acute epidemic fonns 
thyroid (iind probably ponithyrtiid) involvements are known. 
Tumors, tulxTculosis and a liost of otlier cliaiigi-s in the thyroids 
have been descrilM'd. It will probably lye found that in most 
of these the parathyroids arc likewise implicated. Thus, in exoph- 
thalmic goiter a coinbinatiini of thyroid and parathyr(Hd sympt^tms is 
often pre.sent. In many tetJinie.^ i)uri: thyroid s\inptonis ap|>ear. 

Symptoms.— Considpnible variation is to be found, but in general 
four types of symptoms are observable in the fully di'velo|)ed attack. 
These are the muscular spasms, which may go on to an exhaustion 
paralvsis, vr ]»ares[s; the Trousseau phciionicntju; iiicn-asi'd elei-trical 
exdlability, or the Erb symptom; and lueehanical hyjierexcitability 
of the muscles— Chvostek's sign. In some |>atients urn* or more of 
these may be missing. Incomplete fnrm.s. so-called, may present even 
fewer sigtis. On the other hanil. a richer combination of symptoms, 
apparently closely related to the general disorder, may Ih* en<'onntered. 
tJenstjry disturbances, anomalies of circulation with edema, of respira- 
tion with cyanosis, and of temperature arc sometime.*! found. True 
psychoses, ]RTha]«s Indislingtiishiilile from the hyslericjd confusions, 
are ftaiud. Trojiliic ilisi>rders of the skin, hair (ulo|>ecia areata), uiul 
nails occur. In some rare instances, widely dilTused convulsive 
phenomena resembling epileptic seizures occur. 

Couise.- Cliuieiaus have recognized arbitnirily three groups of cases 
in adults, and most mo<lem a\ithors arc inclim'd to follow Trousseau 
in his classical description. In the bejiinn fonn the :*i'n.-*f>ry phenom- 
ena, such as formication or a simple sensation of heat, may prece<Ie 
the spasms. These are confined for titc most part to the hands or 
awasionally to the feet. The contractions may lie fleeting, jiersisting 
from five to fifteen minutes, nr they may ixrsist f(»r an hour or more. 
Often the attack terminates by a recurrence of the sensory symptoms. 
A period of refxtse lasting for a tjuarter of an hour to two or three hours 



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severity of the condition other sviiiptoms may be noted. Headarhc, 
malaise, and a rise in temperature of 1° tu 3* may be noted. The 
afT«cted muscles may show siftna of cotiRestion, and loealized ederaa 
of the hands and feet may be obser\'ed. Other muscles than those 
of the extremities may be Involved. 

Thesp severe attacks are rarer than the benign uncA, Krankl- 
Ilocliwart has shown that there is u distinct tendency for the well- 
marked lighter cases in many ijistances to become graver, and the 
(PmhI pmgno.si.s which most writers have given is seriously doubted by 
this obser\'cr. 

In the grare form there is no addition of symptoms. The attacks 
oivur with preater and (greater frequency and l>ecome more and more 
intense, and the patients die as a direct result. 



PlO. It7 ^Miiiir-ii nj |iMiilLi'iiiij ti'laiiii' Himnii) I'f luiml li>' Mrrti-luriu llii- Umchiiil plexus 
!>>■ Enrriblc nKdurliifn at thettrm. Kote "obntetrioal" hand. (Pool.) 

Diagnosis.— The dinfrnosts of a classical case offers few difHeulties. 
In Kiij'lish-stM'aking ixmntries it is apt to Ijp nvcrlonkcd, although the 
nion- fn-qucnt rei>oi-ts of n-ci'iit years pnint tt> tlie fact that it is bring 
recognizeu more often, especially in its milder forms, 'llie presence 
of cramps in the upper extremities, alone or in conjunction wiO» the 
upper limbs, with the classical obstetrical liand and the additional 
evidence supplied by the (livostek, Trousseau, and Krh signs, is 
usually sufbrient to determine a diagnosis. 

Tetany jftrtimiprim, or, better, iMirathprerrprira, as suggcstcil by 
Erdlieim,^ oiTcrs the most cln.Hsical manifestations of the ilisonler, 
throwing, as well, considerable light upon some of the possible under- 
lying and fundamental features of this peculiar reaction tjpe. InsufRc- 

> Milt. t. d. GmuBob. d. M«J. u. Chir., 1900. vtrf. xvi. 



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iency of the panithjToids results ui coavulsive phciiDmcna of the tetany 
type. 

Proffnosia. — ^The point of view here maintained precludes the possi- 
bility of the statement of a general prognosis. \ery little is known 
definitely of the prognosis in infants and ehildren. Most authors 
agree in giving a fnirly pt)n(l prognosis, HJthoujjli I'>;uikl-IIi>rli\viirt 
says thflt healthy ciiildreiL rarely acquire aniviilsions, ami ttiat the 
prognasis h not good. In many of these children only one tctany- 
like spasm has Ix-en noted. Tn others the spasms may persist for weeks 
and even njoiitli:*. In simple ea.ses tlie prognosis is much better than 
in tho^ complicated csjK-cially witli gastric or intestinal affections. 
Bronchitis, pneumonia, an<I occasionjilly an ascaris infection also 
determine a less favorable pri^nosis. Dangerous sijrns appear with 
glo!<sal cramps, which may cause death. I!ecurrences are frequent 
in those who recover. 

Tetany coining on during pregnancy and childbirth usually has 
a graxl prognosis. The hypercxcitahility of the nervous system may 
|»er^ist for weeks after delivery. In succeeding pregnancies the 
recurrence of the plicnonicnoti may he Linked for. 

In the cases apparentlv* due to (listurbatices uf the stomach surgical 
interference has brought about distinct amelioration. Sudden death 
may occur, and apart from surgical intenention the progru>sis is 
admittedly had (TO to 80 per cent.). The cases are com]>arati\ely 
rare, however. In severe cases associate*! with marked gastric dila- 
tjiticiii, operation, if only ex])l()nltI)r^■, is ad%i.saMe. TEie mortality 
after o|>eration in some dozen or more eases now reported is ns low as 
;^0 per cent. The siilisei|ucnt history uf these patients remains to be 
rt'ijorteil. 

Tetany following infections diseases anil acute or chronic poisoning 
seems to present u fuvuruble prognosis, perhaps the best of the various 
forms. 

The prognosis of tetany thyreopriva depends upon the amount 
of thyroid gland reniovett and whether the jtarathyToids arc inchidetl. 
Total extirpation of the entire thyroid am] })aratlLyroid tissue is 
recognized to have a fatal nuti-ome. Tetany appears after total 
removal of the parathyroids, not only in man, but in lower 
animals. 

Treatment. — I'rom the sland-puhit here outlined it may be readily 
de^luccd that the treatment must In* carcfnily worked out for each 
individual case. The parathyrolilectomizcTl individual would not be 
iH'nefited by a gastric operation. 

With a positive diagnosis established, the organ involved should 
come int« review. Inasmtich as parathyri>id insufficiency is tlie most 
general cause, it is rational to treat those cases, many in children, tlw 
whole group of so-called ieliopfithic tetanies, many tetanies of preg- 
nancy and of thvToid disea.se with thyroid and parathyroid preparations. 
Paratliyroiti preparations seem to fulfil most of tlie conditions, yet 





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THE ENDOCRISOPATHIES 



occasionally tlie combined th\TtiiH and parath>Toifl involvement renders 
the Riving of the rttinbint'd products of more trorvice. 

'I'hp use of fnmi.stufTs rirh in cnlrium and of calcium salts follows as 
a imltifHl (imjilary fnmi the studies enumerated. Such nuNlicntion 
may entirely replace the use of the slandulnr substances themselves. 
In cx[x-n[iiental letaiiics the success of the culcJum salts has 
been ver>- striking, and in tetanies in children calcium therapy 
luLs given almost uniformly good results. Such therapy apparently 
renders the older means uimecessary, .such as nirare, opium, hyoscya- 
mus. the bromides, chloral, bellndouna, ehlorofonn, Ralvanism. sweat 
hatJis, etc. I'p t<i the present time therap«'utic experience U not 
suflicient lo definitely prove the dunibility of calcium medication in 
the cases in which it seems to be indicated. 

The surpical ex[M'dient of transplanting parathxToid tissue has proven 
succe-wful in animal work;' its successful application in persistent 
chronic tetanies in man is clearly foreshadctwed by the experimental 
work on ilogs. The technind ilifliculties dn not seem insuperable in 
view of tlie ready tran.spJantation of these structures in different part^ 
of the body. 

DISEASES or THE HTPOPHTSIS- PITUITARY. 

The Terms hyixtphysis and ])itiiitJiry have been emplnyed synony- 
mously but the pn-sent u.sap' is In reserve the term hypophysis to 
desiRiiate the collective structure made up of two distinct parts with veij* 
different functions. An anterior part (pars anterinr'), the pituitary, 
which is epithelial ant! dcriM-*! fnmi the jiiistnMMiteron. and a posterior 
part, pars nervosa, which is nerxdtis in origin and tenned the infundibular 
process, k pars intermedia separates the two but in reality is a part of 
the pituitary. Fatta is in doubt alKtut this. It is derived fnmi the 
oral cavity and contributes its secretion to the cerebrospinal fluid. 
The whole structure is in^ller^ate^l by the vegetative nervous system. 
Hy reason of its special relatifxn to the ii]itic chiasm, the third and the 
sixth nene.s and to the infuiidibiiliun alterations in the gland produce 
not only syndnimes correlate'l with the internal secretions — pitnitrin 
(anterior l(d>e) and infundibiilin (posterior Iol)e). but also may 
give rise to profound neurological disturbances of these contiguous struc- 
tures. Accessory pituitary strurtures are known: I'arahyjKiphy.sLs, 
hj^Kiphysis pharyngea. The physiology of the gland cannot be 
diseus-sed here; the student is referred to the works given in the 
introcJui-titni to the endocriuopathies: the monographs of Cushing, 
Hinsdale. Falta, Noel Paton, Schaefer, Lewandowsky, and Pcnde are 
the most available and R>liable. 

Two types of hyiwphyseal disorders are thus to be distinguished, 
hypothetically at least, although clinically, disturbances of the true 
endocrinous gland, the pituitary', are the best known. 

• Msrhncr: Arrh. f. klin. Chir.. IIKI?, Uxnv, 1. 208. 



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Clinically three main trends may he rccoRnized wliich are due to 
increased, diniinisheil or irregular functioning of different parts of tl>c 
pituitary structures. The analyses of these syndroineti has only jast 
i>eprm. but in view of (.'u-shiiig's' and Tilney's' fundamental studies on 
the hyjinjihyseal structures a flcfinitc syridromy will j)n>hiilily develop: 

(1) llyjierpituitftrittjii is associiited with gigantism and witii acromegaly; 

(2) hyjtfiiiiluUanMin with varinus grades of infantili.sm, physical and 
mental, with aili[M»sity unci genital dystrophies; (3) lUjifpilniUirixyn 
shows many mlxefl syndromes. Absolute loss of the pituitary occurs 
very rardy. 




Hyperpituitarism: Acromegftly and Gigantism.— These conditions 
are closely relarcd. showing; nvergrowtli in the skeleton and particularly 
in the long bones in gigiintisin; changes in the t^tc-v. fingers and bones 
of the face, more pmniinent in the acrKmegalie tendency. In general 
gigantism occurs when the disonler begins prior to epiphyseal union. 
acromegaly wheji the changes iwur after the uaton of the epiphyses. 
PriKlromala such as fatigue, niusfiilar pain^, apathy and sleepiness are 
frequenl. 

Acrumrgalji is characterized by the gradual cidargenient of the bones 
of the n<ist'. jaw, hands and feet and a hyperplasia of all of the bouy 
structures due to an overactivity of tlic vegetative nervous system. 
This overHxeitabiliTy of the ner\'ou3 regidators of metabolism, from ex- 
cessive pituitrin secretion, also induce.s hvperplasia of other endocrinous 
stnictures, notably the thjTnids, inter.stiti)il gnnarlal colls and the 

• Tb«> PiU^tMr>- Body. PliiladolphU. 1012. 

■Cocnparative lludatosy vS the Hypopliyois. Memoin Wintiu Inst.. I9I1. 
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suprarenal cortex. From these contributory factors arise a medley 
(often cnntradirtory) of th>Toifi, penital and vascular anomalies, some 
in the nature of h.v(>eqilasia5 (see 'I'hyrold). sonic of ft degenerative or 
inhihitive character (sec (Jonads), such as liairy and Renital defects. 
The change in (he jtitnltiiiry itself is most fretjneritly of an iidciiomiitoiLs 
or adennstircomatous type, although this is not invariaMc. In pure 
adenomata tif the pituitary the symptoms tend to he more cleaii-eut 
and classical. ^\s a rule the whole hypophysis is imi)licatc<l which brings 



Pio. 99. — Acramegnly. (Joatfatni.} 

the posterior lobe (infundihiiHn) into increased or diminished activity 
with contnulictnry and miveil synilromes, the minute details of which 
miLst be looked for in the rich and gmwing periodical literature. 

Symptoms. 'Hie ktowiIi in acrtimegaly is vt-ry jinidual, usually 
occurring Ix^twccn tlie ages of twenty and forty. It includes elmnges 
in the skin and hair as well as in the bones. These latter arc all 
h>*pertrophied, causing striking peculiarities in appearance, particularly 
of the face. The nose is greatly tliickened, as are also the supercihary 



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ridges and the maliir Ikhips. 'Ilie eyebrows are heavy, overliaiiKinf; 
ami coarse; the lips are thiekeneil and protruile. with marked 
projeetion nf the nften eimrnioiisly hy|M'rtniphittl lower jaw. This 
hy|wrtriipliy causes the 9pn>a<ling of the teetli. Tlie imitiius nieni- 
brmies share in the hypiTtrophy. This marked cranial bone alteration, 
with the presenee of the tumor causes a greatly enlarged sella turcica. 
Tbe Iiaiid.s and ft«t are notably widened, the firiners and toes stumpy 
ami thick. The skin and hair thrrmphnut, inclusive of the fp^nltaJs, 
show the same IiyiXTtrophies, as do practically all of the Iwnes of 
the skeleton. Amenorrhea is frequent in women and Iosa nf [wtency 
in men, visually ftss».Kiuti*<l wi(h atrophy of thv Koiiads. Glycosuria is 



Fid. IOU. — Chnmrlcnstir hUKJof iw-ronu>mly. NoIl- htutpiniicf liBtivanlxnit nails, "typv 
en Urgi>" nt Mnrii^. CompiuiM wilJi Fl^. lUl. t Frum (-'lulimit'a "FituitAry KcmJ)'.") 

frttpient. f'urbobydrate tolerance may Im* high, however, and an 
incTca-scd fondness for sweets i> frequent. The muscular tis^ues have 
a tendency to atrophy early in the disonlcr following; hyjKTtrophy. 

.\nomalies dependent \i\Mn thyroid alterations are fretpient. Thesei 
coHMst, for the mo.^t part, of inerea-ted sweating, tachycartlia. diarrheafl»| 
exophthalmos at limes. .'>telwafi's s,\Tnptom, irregvdar paliwbral fi.-isunrs, 
variatioiLS in pupillary e(|Uality, tremor, thennal alterations and marked 
irritnliility. .Suprarenal curtex nlteratioit is iipjiurenlly n-lntcil to the 
nrterio»K']erosis fn*quently seen, diabetes mellitat or Klycosurin, and 
•itlicr sipv* of nltcn-(l adn-nalin (7. r.l activity. 

In addhioa to tlie es-sentiai metabolic disturbances, sj-mptom-s due to 



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rrtg RStX)CHrNOPATHI/iS 



the tmtuix' iif the producing k'sions -tiiiiior, }iyptT]>lasia, i. €., iwigh- 
borhood sjinptonis, ore frequently found, but tWse arc not invariable. 

Severe bitemporal Iieadatlies are frequent. This is an intracrauial 
pressure sign. The sella tureica is usually eniarped from tumor forma- 
tion, a.s disclose*! by the j-rny exainiimtitm. 

Pressure n|Min (he nplie nerves at the ehiasni is usual, leading to 
various type-* uf hemianopsia or even blindness. Distorted fields are 
the rule. 

Mental syniptoni.s ranjiing frnm sluggishness to severe (U-terlorn- 
tion occur, but are not inrariable. Kpileptic attaclcs may aectjmpany 
hypophy.seal deficiency. 



FW- 101. — Typical Tai)?nnK h:iin3 of adnlMcent h.vpnpiniirarisni Compare with Fig. 100. 
iFmm Cuithiiut'H " limitary llixlj-. ") 

TxognoiiM. This is always grave. Tlie disorder is prtjgn'ssi\T. usu- 
oll\ very gradual, five tn twenty yearn, but the advance in symptoms 
may Ih* arrested spontaneously. As \ et no positive mode of inHuencing 
slight gra«les of hypM-rpituitarism h known. Polyglandular experi- 
mcnlatidii Is widely eiuploycil. Thyroid jircparattons are useful in 
those cases with accompanying hypothyroidism. Careful analysis of 
the symptoms will afford other suggestive clues. Light therapy has 
been u.scful in .some cases. Wlien pressure syinptonis. enhirged sella, 
vi.sual defect.s develop, operation is advisable. The results have at 
times been brilliiint. 

Hjrpopituitarism.— Deficiency of the pituitary substance gives rise 
to a j;rinip of sviidronics the most classical of which is Frohlich's 
dystrophia adipoaagenitalis. 




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DrffSASBS OF rns nYPOpnrsis-piTUiTARr 

Definition. — The c-liiucal picture is rharacterized by u progressive 
utrurnuliUirtii uf fnt, nften loi-ali7C«l. cliielly ulwut the buttwks iin<l 
brt'usts, as is stTii in the froiuuiul (!i.stiirlMinces of cuuuehs. This is 
I)ossibly CTirrelatcd with defective activity of the interstitial |;lands — 
from atitonomte and sympathetie ac-tion of the defieient pimitriii. with 
the coniie(|ueiit faihire of development of the secondary sexual eharac- 



FiO' 103. — Ciuc o( iHwl-imuiimlic hypopilmlorum iu ■ L-hild, with ettmitv ndipoidt 
hiidi ■ucw toivnuirc. Mid Pjii1i>|wy. Mnrkcd uniunvmnoDl with wbols kIaikI f«edios 
((Mluil&ry). (FWnn Cu»hing"» "Pituilttry Ilody.") 

ters. involving the genitals. The psychosexijal devclojuneut even b 
hinden-d, showing us various grades of conscious and unconscious 
homosexuality. Polyuria is frec|uent and additional pressure siffos 
(luinor) may l»e found (optic nerve clianges). 

Stiolof7 &nd PatboceDNiis. — A no( inrn>(](ient cause for Iiyp4ipitiii- 
tArism is l)yilri>(f|>liiitii.s. Thiit oiTurnug in the ynung fritiii numrntus 
causes — acute inlla inn m lion. hertHiitan syphilis, tuberculo»ii), |X)lif^ 



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THE ENDOCRJNOPATHIES 



eiic-eplialomyelitis, etc. — t^tids to hnug nbout a foinpression of the 
pituitaPr' witli atrophy. Tumors wliieh in the early stages may cause 
acromegalic sjinptoms, may later lead to destnirtiftn n-jth defect 
sjTnptoms. Tumors may also brinfj ahout the syndmme without 
aeromegalie features. KrHiikl-IIoehwart' has made a enllecliori of a 
large uuniber of these. 

The pnthogeneMs is not clear. Loss of pituitary substance itself 
is a jrifw qua non, hut whether this loss acts purely chemically or is 
mediated l>y the vcRetiittve nervous system is still not understood. The 
laTtrr hypothesis is the more favored. 

Symptoms.— The disorder is chieHy devehiiMil in youth. The olx'.sity 
is tlif nin.st striking ffiitiire in the youthful cases.' The hips, hutUH'ks, 
nioris veneris ami rnaiiuiiary glands aif the chief ]«K*alizHtions. The 
lower ahdomen is invnlved in lH>th ynntig and older eases, l-'ntty 
cull's on the umlleoli: ela\'icular eollardike thickening are otlier local 
Mtc3 for the aectunulution. Cases without obesity are kntmTi. 

The .skin is utubaster-Uke. and in the adult tyiies is cold, hard, and 
dry and exfoliates reailiiy. At times it is myxedemaloii.s. The hairy 
[lurts art* much snioothtT or all hair is iibsent. 

The genitals are umlerdeveloped, ]ienis small, and bnried in cushions 
of fut. Tlie scrotujn is small and the testicles may not descend. The 
labia' renmin infantile, the ovaries small and the breast glands defective. 
Mi'iistruation is irregular. 

The voice may rt-main thin and child-like and the tjpe of object] 
fixation remain infantile (asexual or homosexual). 

As a rule there is a fairly jxTsistcnt though slight snbnunnal tempera- 
ture, a marked degree of sugar tolenmce. marked rcilurtion in respira- 
tcvry exchange, sh»Mvd pulse and a tendency to shiggishuess or even 
sleei)iriess. The blooil picture terid.s to sht)W a sHghtly rc<iuee<l red cell 
count, reduction in hemoglobin, the iieutrophiles are <listinctly reduced, 
the mononuclears. Jyniphm-ytes and enwinophiles increased. Taper 
fingers are a contrasting picture to the pudgy ones of acromegaly. 

Tin- patients often ivniain i-liildisli in tlii-ir stature (.the hiwerextirm- 
ities u.sually being much larger proportionately to the upper in direct 
contrast with gonadal infantilLsni), and in their psyche. Lillipuliaii 
divarKsm is jL-isoeiatcd with hypophyseal defect (teratoma).* 

Neigh h4irh CM h1 syTn[ttoins nuiy also Iw nhscrvcd. as with the acro- 
megalic patients. Tin- <>ptic nerve changes, bitempoiiil hemianopsia, 
are among the most important. Other symptoms of a general luiture 
due to pressure, ns Iwailnche, nausea, vtmiiting, cimnges in the s«dl« 
turcica, etc., often iK'ciir. es]»eelally froan tumors whieh destrny the 
hy[niphysi.-v. 'IVlgi-uiinal neuralgia has been observed. 

Djrspituitarism. I'lider this heail. the unijority of the (ronstitutional 
unonmliesduetodistiirbcd pituitary secretions may be gathered. These 

> X\*Ith Int^matiotuil rcmiiTww, Bu'liiiw-trt, l(K1f». 

* ConxuiV l-'tttUt'» discusoi-xi. p. 320, PtiUadsl;)bia. 

* Konne; Deutaeh. mHl. Wdiiutrhr., IDIS. 



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DISEASES OF THE /fYPOPtlYSIS—PITVlTARY 

are incomplete forms of aoromcgftly and f^f^antism, cases of ariipasity, 
aJone or with genital atrophii's, or gt-nital anomalies, showing li.v[>er- 
function or hi.'pofiiiielion. V^arioiis epilepsies, proliabiy conditioned 
by liydmeephalic clianj:i\-i occur with dyspituitari.sm and at times 
are helped by pituitary therapy. Variations in mental capacity are 
frequent, as well as a variety of anomalies such as inereasnl sugar 



Fi'J, Iii3. — ny|>'i[iiiiiit:m'iin )n 
boy. t.V. JtinAtta.1 



Fto. IU4. — Hypopituii!iK-..i i. nuin. 
Tumor hypophysis: Lwpiti> -ikih- yemra. 
(A. Jouofmnn.) 



lolenuH-e or glyeosiiria; slightly sub- or bupmnonnal tpinix-ratiires, 
polyiiriii, wakefuhif^n. irrilitbillty and a group "f churucter unnnndiesMj 
well. Hie ^kin la iisunlly >in(K>(li and soft and free from intii^lure. 
the hair '13 apt to l>e thiti, fine, and w-antj'. A great variation in 
win be found ami. in fact, nearly all the d>'»pituitary syndromes are^ 
polygliuidiiliir ill their nmnif(-stAtioti.s. 
Tlie total absci»ce of pituitary- sulwtance brings about conditions of 



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THK BSOCX^RISOPATIIIESI 



Iflliurjry and imrcnlci>sy, witli marked slowing nf the pulse niuj of the 
n*H[>iruti<m. 'I'hiTi* is iiisfii^iUility tu pHin, marked reduttitin iii tem- 
pfniUire and in bluod-pressure and sluw cieath. 

Sytidrome of Rmoii-IMiile.*'— These authors have d(scribed a 
symlniiiie <»f hyitophN-seal in.siifiicifncy cliamcterized liy Inwerinp of 
the arterial teiwion, tach\Tardia, diniinutiun in the ainmiiit of urine, 
insdmuia, increase in perspiration, and iiiahility to stiiiKi heal. These 
symptoms, often confused with a so-tvlkHl fiinetional myocarditis, clear 
up under hj-pophyseal medication. 



Flo. 106, — AdilMHK^ t^nitnl dystrufihy. HyTvipitiiil'-iri'^in. Tiimikr nf pltMWl. 
(italley iiiid JcllilTo.] 

Treatment. — Acromegalic patients, or those showing pituitary syn- 
dromes due to evident tumor of the h>'popliyseaI region, need surgical 
intervention, wht-ther the signs of hspo- or hl■^1er|litnita^ism be present. 
Hj-popituitary and dyspituitary cases withont ndf^liborhoml syinirtoms, 
of tumor may !«■ given pituitary extract (0.1 gm. of conihined extracts) 
sometimes to advantage. In trrtain refractory cases combined opo- 
therapy, pituitrin and thyroid may be employed to advantage. Certain 
stationary acruniegalic cases are benefited by thb treatment and others 
apparently are reiMicred stationary. 

■ r^ngniaa de MM. Paris, 1007. 
»Thfew d*- I'i\ri«, SU'inlicil, 1903. 



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mSKASBS OF TUB PfSSAl ohoan 

Ratliotlierapy is in general inefficient. 

The <'hier surpieal modes of relief are; (1) sellar decompresaion, for 
h>*p4^physt'a] lieailarhes, or to (KTmit ii tuinnr iriiiss to i-xpan<l (iutAi<le 
of the crania! cavity; (2) [wrtial removal of a hyjK-n'hwtie and over- 
a(-tin){ glaml; (3) partial removal for the sake of saving eyesight; (4) 
subtemporal (le<-om press ion to relieve general brain pressure symptoms; 
{.■>) Anton's rallosal puneture: (6) t'ombine<l ojx' rat ions;' (7) oiieratioiut 
for fflandiilar transplantation. 

Infundibul&r Syndromes.— Little piwitl'.e ooneerning a pure .syn- 
drome of jRtsteriiir IoIk- disease Is established, hs exclusive removal 
seems to Iv well iiorne by animals if the anterior loht* is left intai't. 
Itsaiiiveprineiple, iiifundibulin (bypohpysitO.actHinnrh tike adrenalin 
but apparently iliroujcii other part:* of the vegetative rt^tlex arc than 
doi-s adrenalin, the chemical structure of wliich it dws not resemble. 
In animal.-^ (rat.>«l feeibng experiments have shown that it has a retarding 
effect on the rlevelopnienl nf the sex glantU, in contriLst with a marked 
Mtimnlatiiin fnmi feeding with the initerior lobe e\(nict. 

IJialietes insipidus has been held to U- a symptom of deficit in the 
|Mistcrior IoIk*. but us yet no definite syndniiue Iws \kvu denionslrated. 

DISEASES OF THE PINEAL ORGAN 

Pineal Syndrome.'— By Gaskell the pineal gland (epiphysis) is said 
to api>ear as a vestigial remnant »[ the paired median eyes t>f the 
paleostraccan ancestor of tlie vertebrate stock. As low down in the 
animal phylum as AmuKxxictes (Wily ime of tlicse structures, right, 
IH'rsist-; and it is rudimentary. Through Me\ncrt's bundle connoctitm is 
made with the ganglinn ImU'nuhc, traces nf which >till persist in the 
human brain. Gaskell lx-lievi>s this ganglion hulH-nidft' to U' the 
primitive optic ganglion of the median eye. Rest-arches by Tilncy 
seem to dlspnive thU general assertion and show u si-paralc cmbr>'o- 
IngicAl and probably phyletic origin for the pineal gland an<l tiie pineal 
eye. 

It is .still di.sputed whether the pineal is a gland of intenuil secre- 
tion, Iiut by reason nf its position and because of certain syndromes 
nrlatcil to {|isea.s4- uf this structure Marburg has assiuneil a definite 
pineal syndrome. 

Tumors of ilie pineal, chiefly teratomatu. when they bcttunc about 
4 inch in diameter, cause a striking group of symptoms due chiefly 
to (1) a hydroc-ephalus, wliich causes the ad iposogcni talis synttrome of 
Frohlich, in part; a sexual pre<t>city, in part, and 1-) by pressure' upon 
the quadrigcmina. certain i>eul«r palsies. .\ combination of these is 
tlu> pineal Hvndmme. I'lU-tial pineal syndromes in which fatly and 
muscular anomalies are present seem to sh4>w a relationsliip U-twi-en 



> Stt (Naaliiai. PiluliAiy Bwly. tippfnoolt, lOI'J. 

> Baa«y Mid Mtiffe: Anb. t. lot. MmI., 1012. 



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THE RNDOCRINOPATHJES 



the }iftrtnnnc action of (hl» structun' anil nmsfular dystrophic states. 
(Sec Mustulur Dyintrophics.) 

Operative interference may save a patient with pineal tumor but 
the technical surgical Hiffinilties are extremely great. 

DISEASES OF THE SUPRARENAL BODY. 

Suprarenal Syndromes.— The suprarenal glands are noade up lar^ly 

of cliromafiin tissue, which like the cells of the sjTnjjathetic ganglia, 
arediTivcd fruni iiinirulila^ts iiF thcirntral iHTviiiisnystein. Tlie i-cirtex 
of the :iupmrennls is nuulc up nf entirely tlifTerent types of cells. 
rhroniaffiii cells arc fuLiid also in the sympathetic iMiruifunglia of the 
solar plexus, Zuckerkandl's aortic garifjlia, the cwrdiac parapinglia, the 
Lcoccji'^-at aiul eitrotu] (janyliu of l.usihka, anil the t,\i)ipariic para- 
fganglia. The tissues themselves arc richly supplied with sxinpathetic 
nerve filwrrs. 

The climmaflin tis-sues prmhice a true interna! secretion, adrenalin, 
whnsc chemical composition is known: orllm-diuxy-plR'nyl-cthaiiol- 
methyltimine. 



B 

i 



IT H II 



-LI 



-H 



H 



Its nearest relative is tyrosin, a well-known product of protein deeom- 
pusition. The chief action of adreimlin Is upon the sympathetic nervous 
fibers increasing their reactive capacity, or sensitizing them aa it were. 
The nHitinc fniicfinn (if the ehronmfTinc tis.Mie is to react to mctahdUc 
stimuli lar^-ly in response to desire and fear. Their emergency func- 
tion, us Cannon has termed them, i.s to provide the necessary nver^ 
wsponsc to emotional hyperactivity — (. f., to increase<l or diminished 
desire and fear — which, as their correllates love and hate, are the 
ultimate expressions in the symholii- .sphere nf what are instinctively 
kninvii US ns<'fnl or tiarnifiii H^ciieics ti) the itr;:itiiisni anil to the race. 
This o\er- or under-response linnps about, through widcsprcnd vegtv 
tativc nervous system activities, including thoie upon other endocrinous 
glands, the approximately necessary metabolic adjustment. Tlii.s takes 
>lace chiefly through the regulation of the blood volume and of the 
ForganJc ajid inorganic eonslitiicnts of hs pliLsma. Adrenalin itself is 
present in the pla-sma In proportions of 1 to "20.(HMt,0lMl. Notwithstand- 
ing this extreme dilution it nets njion uiustriped nniscle fiber and on 
sympathetic receptors. Adrensdin then is a typical prtMhict which 
demonstrates the metabolic regulation meehanLsms of the vegetative 



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DISEASES OF TtrS SVPRARENAL BODY 



219 



nervous ny'sti'm. In atldition to this bruad runetion of kecpiiifr the 
sjiHpiithetic nerve filk-rs in nrijnstnicnt it \ms certain sjiecifif fnnrtions, 
over- or uinitTai-tivity, wliich give rise to a typical hypcradrfiialcniia 
and to h^'poadrcnalemias. The latter syndrome when well de^-eluped 
is known as Addison's Hisca.se. 

Furtliermore, very minute amounts produce results antagonistic to 
those from liirpe doses. This l»ears upon the farts known eonc-erning 
the antH^fiiiis.[tis of synipallielir and aulniiuniie impul^e». I'liis idea 
should prove of semoe in the entire range of ojMJtherapy in calling 
attention to the results obtained l>y large aud by small doses. 

Hypoadrenaieinia.^Tbe most acute form which is present in com- 
plete or great loss of the suprarenuls is rare. I'ende' has ilestrilied six 
tyi>es. to which he gives the names impromptu death of ^iipnirennl origin, 
pseudoiferitoneal type, cholera-like or gastro-intestinal adrenalemia, 
aiMiplectifiirm typi-, nieniiigiM-ncephalittc tyjie and myia-anital tyj>e. 
In the first form indiviiluals suddenly die without warning, without 
symptoms save jM-rliaps an epllepiiform cry. or acute d\'spneu or angina. 
Taseou-s degeneration of the suprarenals has been oljscr\-ttl. Tlie 
pscudoperitoneal fomts resemble an inexplicable attack of acute 
peritonitis uith death. The ga.stro-lntestinal form behaves like an 
iwute poisoning. The apople<'tifonn resembles a cerebral hemorrhage, 
but autopsy Ims shown no cerebral defect but suprarenal hemor- 
rliage. 

The ca.se3 are extremely difficult of diagnosis ami are rarities. I.ess 
severe tyiH-s may Im^ met with, among which the uieorrigible attacks of 
vomiting of pregnancy may be con.-vidcrc<l. 

Addison's Disease.— This is a more chronic type due to more or 
leas tiilal invulveiuenl. 

As early its IK.'Wi this disorrler was first described by Thomas Addison 
whoBC outline practlcallj <-overed the t^senlial Mymptiimatolng> . It U 
a disorder of adult life thirty to fnrty years. Its chief features are 
a gradtially developing astlienia, with arterial h>ix>tcnsion. There is 
morning luinsca or vomiting. ItuidHir pains, an atlvancing yellowish 
pigntentalion of the skin and mucous membranes, amyatrophy. depres- 
sion, unwillingness to do anything, nith episo«lic occurrence of myoclonic, 
tetanoid or epjleptifitmi convulsions, with i>erii>«lic i>alsies, confusiutral 
states, delirium, chronic paranoid iileas. omui, death. The chief li-^ion 
found is (ulxTcuIosis of the medulla of tlie supran-iud glands. Tlie 
more complete sjinptom picture may be c«n.'*ultcd in work.s on gt'neral 
medicine. 

Fariial liypuadrrnalemiait. — 'iTiese have been termed thealtortivc or 
Ulent ty|it-s <if .\ddison s <liseasc. The melaiUNlenna is absent, but the 
(itJicr symptoms noteil are observni. Constitutional hy|)oadn'uideinic 
titates no douhi are very numenius aiul show themselves as rare and 
difficult fonns of lowere«l vascular tonus, cardiac instability, mtiscular 

■ pHiol<«a d«ll aiifAnitu lumnaW. Miluw. 1909. 



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TUB EHl 



ustlienia, visceral and li^amfntoiis ptoses. These are often corrplftted 
with a rhroiiic srlrritsinjj mirciial. 

Hyperadrenalemia— Several ty|>es are known, tlie most striking of 
wliirli lilt-: iiJj geiiitu-itdrenal syrifiriniK" nf iiwudohfriimpIiiiKiitism, 
(/') virilLsni, (r) ])re('ot'ious mncroKfiiito:^omiu. The fac^t ih;it these 
syndromes occur only in women, as well as the pathological data, 
point to a simultaneously invoked ovarian disturbance. These are 
feminine hemia])itrfKlitif fonns t-xternally uilh virile secondary male 
sexvml fharacters. Tlic earliest case n'portrd wjis liy ('M'echid in 18G5, 
of a woman of fifty-two, taken to be a man. Slie hati a large |>eni.s-like 
clitoris with hyposfrndias, no »crotimi nor te.stieles. a uterus with two 
tubes, two ovaries wiUiont a trace of <-i)rpora hitei. and an enlar(fe<) ami 
voluminous suprarenal. She had lK<'n niarkc<lly asthenic, dyitij; in a 
syncoj>al attack «ith vomiting and iMr^i>teiit iliiirrliea. Oher cases 
show other oomliinutions such as amcnorrhcu, gyneconuLstia, adiposity, 
hypertrophied chlnris, h\']HTtrichosis, niaseuline voice, muscular 
Hctivitv, iii'r\fius ami agitated, even nvenictive. Others only show 
continued liyiH-i-teiision and secondary artcriosclenxsis possibly with 
glycosuria. Some ]>atients piws through a nervous, agitwtcd crisis with 
all the signs of markc*! hy|>ertension, approaching a manic episotie. 

The virilism types are maile up of those intensely masculine females, 
wilh traces nf licanls ht»! often with markedly hnntnscMial trait-*. 

Tlie third type consists of the "infant hcrcnies" armnuilies, who at the 
ages of from four to eleven years develop genital hair, In-ards, general 
liypertrichusis and markedly older skeletons. Sometimes the intelli- 
gunec is pn'cocious, again they are imbeciles. 

Therapy.— l'oIygl.Tn<lular opotherapy with careful analysis nf each 
type may gi\e relief in certain cases. The iiulicutions are slowly 
cryHl«lli/ing but caruiol be even summarizetl in a text-book. 



DISEASE or THE GONADAL SYSTEMS. 

Genital Syndromes.— Agenitatistn, Hypergenitalism.and Hypogenital- 
ism.'— (ieniial >\ndri)ines arise fnmi iliMinlers in (1) the gonads !in<l 
(2) the iritcrrriial tissues nf (he aib-ciial cortex. 

()f all of the glauils of internal secretinn the goinids have best and 
curliest been known to possess definite cuniml of metaboli.sm. The 
ancient practice of castration called attention early to this intimate 
relationship. 

hi t tie male the testi.<iis formed of (1) true gametic cells, which develop 
spermatozoa, ami arc- not known to possess any hnnncme ailivity. {2) 
the interstitial (.rlls of I.eydig which are probably the true cells of 
internal secretion. 

'Coiitiull. Hiinn!<: Iiiiicn> Spkreiion dot K«imdniM», Fw^hcr, 1914. TaiuUvr ii. 
Gnwi-. BioloKm-bv Grundlnicpn d. !u>kiitMlAn>n (l<7ic>i)1i>rhl«<'hiiriiktoro, Berliii, UUH, and 
tho mutHJtfniplis moiitiuncd, portiouljirlj' Biedl. 




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nrHKASK OF THK GONADAL SYRTEMS 



221 



In the female one Buds (1) the Graafian folliele containing the o\'um 
and (2) Interstitial rrlls, holwwn tho follicles, which clfKScly rcsomhlc 
thoite of the testis, litith interstitial cell t> pes ap])ear tti Ite nuHiified 
ganietf cells ami l«tih nrc the hominnc prmliipors. 

Tliut inter:slitial hnrniunc acts as a eoniiec-ting link l)etwe«n the soma 
and the gonads and thmugh this spec-iHe action, particularly marker! in 
the male, exercises a tlirect and specific sthnulus uiwn the soumtic 
structurt^ ttf the ImkIv, thus incrcasinj; gn»wth activity, causing definite 
lines of development, varj'ing in the sexes, and so affecting the whole 
muscle and nerve metabulism as to produce profound and far-reaching 
altcratioas. 

The gonafis an' snpplieil both h\ aulnnnmie and synipiithctlc IiIkts. 
The chief genital or gonadiil syndromes result from aplasias or mal- 
formations, giving rise to various henna itUrti^Uh- syndromes; fn>m agent- 
talism or hNixigcnitalUm with eunuchs, eunuchoids, and their many 
transitional forms and. fnmi hy[H-rgcnitulisni with the syndromes of 
ili/tthmirrtimrintiism , titjukyjirrduuitcmatti, and cliturtvii:! {t). The genital 
like the other syndromes are usually polygl(unhiIar. 

Bemupbioditism.^Truc herniaphnidites are prohahly niui-existant 
so far (is the male sex is concerneil. Tna* eases of ovotestis are ex- 
tremely rare. PseudohermaphrtKliti^m, while urmsual, is nevertheless 
m>t infrc<iuentl\' nl)servc4i. A great variety i)f finliiigs are recordetl. 
Females uith enlarge<l clitoris. \'aginal <-ul-<]e-.sac, ovaries, uterus, and 
hilaterat It^tes. In certain patients primary- and secondary sexual 
characters airrespond, in others there an' male gonails with female 
hair distrihution, [H'K'is fornuttion, fatty de|H>sit.s, hij^h voice and 
enlarK<'d inannn<e. It is liiphly jintlwUc that the ailreual c-ortex 
interstitial tvlls piny the Iniportttnt role in these various ndmixtures of 
hermaphroditic primary ami sweondary traits. 

Acenit&lism: Eunuchs.— The symptoms varj-conwderahly. depending 

upon the a^r of the individual when the lusually surgieal) loss of the 
(gonads takes phnv. In early htss in the male (rastratimi U-furc pulierty, 
destructive orchitkles) the petus, prostate and M.-minul vesicles remuin 
small, erotic dr^ire fails to show itself, and potency is lost. In the 
female a similar failure of <leveh)pment lakes place. The girl is apt to 
grow tall, btiyish in type, with infantile sec«jndar\' characters. 

Later l(>ss, after puberty, tends to increase the siw of the skeleton — 
a tall, tliin, ty|>e snd a short, fat, dumpy t^ike with broa<l hi|>s. female 
fat ilistrihntton on the hrea.st.*i, buttocks and iliac crests. 'I'he lower 
extmnities devi-lop dLspro^mrtimiately more than the upi»er, or vice 
trrm. The head h ilatlemii U-hind. the sella turcica widened, the 
superciliary ndge h apt tu 1k' pmmincnt. The skin is usually smooth, 
cool, marble-like, |MK)r in pigment and color; the hair of the head usually 
thick while that of the face is absent or only downyi that of the piibes 
follows the female ty|K* of di.slribution — horixontal. ."^niall thyroids, 
thymus, larynx, and wide (x'lvis ai-e tin* rule. 

Tlie average i-astrate is upathclic, H-ith shambling gait, bent in his 



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THE Sh'DOCRI} 



jMisturt* and a sleepy or imiolrnt mental attitude The face is usually 
fat, with puffy eyelids. The voice is high and thin. ICrotic desires are 
not iilwiiys absent nor is intercourse iirijHissible. even though the penis 
is »]>t til he smnH. 

The female — artifieial menopause — lemb to grow stout aud irritable, 
autunomte tonus is lewered. plases are frequent, vasomotor instability, 
with hot and cold flashes, with darting, jumping; pains, anxiety, nervnus- 
ness and ihuhtiness develop. Alcohol, bromides and other drup habits 
not infrequently develop as attempts at relief of the annoyinj; symp- 
toms. The praze for ovariectomy having spent its force, fewer of these 
cases are seen. 

Kumtchoida. — These result from less marked disturbance in the 
developiiicut uf tlie gonads, A great ^■a^iatioIl also exists Iiere follow- 
ing various accidents to tlie testes i\\u\ ovaries, iuflamnunions, tumors, 
infections (tnberctiiosis. parotitis, gonorrhea), etc. Two trends are 
prominent, the tall and the fat types. The changes are thase found 
in eunuchs, ttltliough for the most T)art less pronounced or monosvrap- 
tnniiitir in their appearance. Kverj' grariiant may he enconiiterfil, 
hence difficulty in di-seribiiig a ver>' variable mosaie. (.'ryptoretiism is 
a frequent eomplicatuin. 

The skin changes are pri'sc-nt in lx»th forms. It is usually thin, jmle, 
anemic, and apt to be slightly wnxy, fine lines or wrinkles develop 
readily, giving an appearance of old age with youth. Tfie hair anomalies 
are as already discuased. Atrichia, irregularities in development, lanugo 
substitutions, alopecias, are not infrequent. The eyelids and eyebrows 
are sjMirae. Single long hairs develop on the chin, the moustache is 
scnnty and wiry. Sterility is the usual result In bntli cases. Many of 
these patients are potciit, some even h>i)erexcital)le. but the n.-verse is 
the rule. Meritorious jjsycbical achieveuiciits are frequently found 
but as a rule the mental activities arc below the average. 

A late tyiw of eunuchoidism following disturbances of the testes 
(sj'philis, trauma, alcohol, gonorrhea, tuber c-uiosis, etc.) develops, 
somewhat similar signs. 

Info lit His III. — Various txpes have been describeil which have Ix-eii, 
keenly dlscusseif. More than in any other group perha[)s does tlie 
polyglandular hypothesis seem necessary to comprehend tiie many 
major and minor variations. LasL-gue gave the name to the group. 
Lorain then described his types as: (1) Those small, graceful and finely 
built, (2) thase that remained more or less infantile and (."i) a feminine 
type with broad hips, small genitals, scanty facial hair, long and thin 
hair of the head, large breasts and prolonged primarj' dentition — failure 
of second tcetfi, etc. Hrissaud then showeti that certain of Lorain's 
t jTies were myxedematous and I lertoghe took them out of the gonadal 
group and classed them as thyreoijathics. Later students pointed out 
hypophyseal anomalies, others pancreatic, still others implicated the 
spleen. Hypotheses ran riot throughout this entire field but soimd 
relationships are slowly crystallizing out. 



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DysKenitaUsm. - -Chlorosifl. — Without committing oneself to the 
definite position that chlonwis is an nnomaly Hue to Heft^tive f^onita) 
hormone acti\'ity yet the e\'i(Ience now ^-eins to point in Uiat direttion. 
Its ocTurrenee in pirls at the time nf puberty is one of the factors aeceii- 
tuatiiig this relationship. \'nti Noonlen was aitinng the fipit tu aM-Tibe 
chlorosis to a defective setretion of the ovarian interstitial cells. In 
this syndrome other endocrinous glands, notably the thyroid, sliow 
alterations. 

Symptoms. Tlie symptoms are not recorded h<;rc, as they arc better 
fouml in wiirks on general medicine and the vegetative paths involved 
in control of the bl(M>d-nmking orgaas and of the tonus ten-^ions of the 
hloixlvessels and the bli»od itself liave not been sufficiently workei! out 
to bf stated definitely in this place. The chief factor to ln' empliasiKcd 
here is that chlorosis is largely cnnditiont-d by an excessive plasma 
plethora in the bloodvessels. The Iwne marrow ts ovcrstimulatcd to 
create an increase of re(3 «'lls. which because of the great <Iilutioii from 
the surpUis of plasma volume are correspondingly poor in hemoglobin. 
It may he assumed provisionally that this plasma retentinn is made 
possible by dinUTiUhed transudahillty of the vascular walls C.synipiithicii- 
tonic) and is an opposing pietun' to that which is s«'eii tn the disunlered 
tnuisudability in the various tyjicsof angioneurotic edema which have 
been discussctl (vagi)tonic). 



_ rfoiM M>iiultty. PrpciMriiMw iiitelU^-iire 
•otiw, briKhl. icay aud jollj'. Pranx-ioiut 
ptibrrty. Mrii'<rrhnKi». tnctrorrhaciBft. 
iiincrtiirrlioit nf local l«non. Oonceallve 
ilyH(ii('n<irrhi-»s, twnrouB dyvmeixMThBBB. 
Hfiniiony •<( fcinu. cood nnutitution. 
TvmkiniU aiicinii- palenesB. Tbynid uor- 
itinl, nith [n(-(>niiUtiiry. Moflcvd fecunrtiiy. 
(rumi)|miuN> n-lanlml. Vervous type. 
fon*it[k4iinn not mnrk«d. 



Wii)»'>-o»ar»a" Sign'. RcUriJW linliitu*. 
K^wniliivc) or lorvlisml. Varir>uii typn 
of infuntUiarQ. moroDo. LaU) nMualru- 
■tiiin. HtthttiiKl nmrauTrhiNi, nivtrur- 
rhMiin. N#rvoii'i 'lyanwDorrlic* fmni 
flnstiH) or Tiihi-r iiiidfumwUfm. Pnle, 
piilTy, pMUdoniyxodi'niiitQii*. ■di|>nel(y, 
acntryunoma. cold pxtreniiiieft. ThjTcwd 
MilftTitnd. mQd otoiihlhaltnie *\tenn, in- 
reriiiidit}' more ufteo, early itK^uopaUNe. 
\<Tvr>\i<, rnni>li|>*tinn rnarknl. 



Treatment— Various t>'pes of testicular and ovarian therapy have 
been used. In certain h>T>o-ovarian cases moderate doses of dried 
ovar>* (0.10-0.20 gm.) twice a day, over a fairly prolonged period have 
Iktii reported to be of some service. The glycerin extrai-t byp<Kler- 
micaily has )x'cn abandoned. Corpus luteum preparations are now 
being exteasively cmpU)yed with results as yet not readily interpreted. 
Combinations with th>*roid, pituitary, and suprarenal extracts Arc 
recommended. Thus in simple ovarian insufficienc>- ovarian cachets 
may be eniployeil solely a-'^ substitutive. For the headaches and the 
hot Hashes pituitar>' or adrenalin preparatiims may be ui^cd as regula- 
tory or as hornnvstimulatory. Suprarenal therapy is contra- indicated in 
the hypertensive states, whereas in myasthenic, constipated, and wake- 
ful nervoas patients with lumbar pains, headaches, digestive disturb- 
anres and oth<'r dysovarian signs it has provc<l serviceable. 

Opotherapy for gonadal syndromes is still in an experimental period 



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THE BNDOCRINOPATHtBS 



of development. IVrsonnl cxpcriemTs point to it ns larpcly sup- 
gi-wtive. hut in (Trtuiii carefully analyzed cases excellent results have 
seemtHJ to depend directly iip+m the opotherapy. In obstetriofti and 
jt,vm'colo>:ii.-nl work the iiclioii of pituilriii tipim llie iinstriped fillers of 
the uterus an«l bladder is very niHrkeil and i*aii hv made servieeiLhle. 

Ovarian and thyroid extmc-ts may Ix- added with advantage to iron 
and arsenic in the treatment of cWorosis. 

There is a frequent type of compensat<wy 
h>'peradrenalemia following the menopause 
which is often very a<lvanta^eously handled 
by imxlcmte dcwcs of ovarian substance. 
ThisliyiKTudn'naleinia is often a precursor 
of markfil artcriosclci'otic state;*, atheroma, 
headaches, angina and evtm cerebral hcmor- 
rliaj;e. Its unconscious psychic atrompani- 
ments are greatly in need of careful investi- 
pations. 

Status Thymolymphaticus.— Tlie thymus 
has very close relationships to the ^miads, 
and it has been thought that the thymus 
and testes ai-e reciprocnlly acting organs. 
This does not st»em to be true for the thy- 
mus and the ovaries. 

Certain individuals have exi-css of thy- 
mus Ijnnph ti.ssue throughout the body. 
In recent years the researches of liurtel,' 
Wtcsel and A. IVItauf have shown that 
this conflition is very frequent. Notwith- 
standing the fact that a pathological diag- 
nosis p()stmortem is easily' arrived at the 
dinical diagnosis during life presents many 
ditticulties. 'I'his latter is largely due to 
the circumstance that the disoasul organs 
are difficult to nxaniiiie anil, furtheruuire, 
the signs of ilefeetive development which 
result from the condition are often very 
slight. 

The recognition of status th>Tnol\Tnphat- 
iais often requires exhaustive chemical, 
physical. J'-ray. and other forms »)f examination. Such recognition 
is highly important, howe\'er, since these individuals, if they may 
be grnuiM'd. arc pnuie U* react very uiarki-dly io aiR-sthelii-s, bodily 
shm-k-H, iufccliims rliseases, and to drugs, particularly salvarsan, 
sera, and mercury. A large mwlley of conditions accompanying and 
partly due to status thymolymphaticus, have been described. These 
may be summarized as foUoivs; 

■ StniuK thymkolymphaticDs. Dcuticko. 1012. 



Fiu. IDl). I II ii: !ji>iil, 

BypurcfauuiUB ia buy. {A. 
: Josi>f9nu.) 



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THE EMXKRJNOPATlltKS 



of tlip Imdy Hud of the extremities i* aHovo the averflfje. Tlie nrraiifte- 
mciit of fatty tissue temls to make the male resemble tlie female type, 
and rirf mm. The mental status is inelined toward the infantile. 
Alcohol resistance Ls very slight. 

2. Fact. — The under jaw and the mastoid prot'essea are unrier- 
developerl and the former results in faulty bite, anonialies of dentition 
liy ilispla<'ement and liy crowding. The ])alatal ari-h is high; the 
tonsils and tonyxie {mpilhe are increased iu size. ITie epiglottis is 
inclined to be infantile in type. Kpicantbus. eccentric pupils, irregu- 
larly pigmented irides, adherent ear h)bule.'* and narrow external 
au<litory meatus may be present. 

3. .VrcA-. — The th.\Toi(l, cervical, and other glands are enlarge*!, 

4. Skeletim.— The tlu>rax is long and narrow, rprvical floating 
ribs ar»^ present. Tompensjitory Innlosis of the spine is lacking., 
ITic scapulic arc wing-shapi-d. The pelvis ilevelops heternsexually;! 
the biLcnun is small, the pulse high. Ilypenlactyly, flat-foot, and 
hyperexten:ji»ju uf the elViows may be looked for. 

5. Hair. — Axillarj- and pubic hair arc diminished; the extremities 
may be hairy. 

<). The tfiyniiu-i is enlarged, the breast-s resemble those of the 
opposite sex; iii>lyiiiastia may be riHserved. The aorta is narrow, 
the heart small, the bhK«l-pressure iuw. Palpitation is frequent and 
there is cardiac dilatation with weakness. 

7. In the abdomnx ptoses are frequent. The juguhtpubic dis- 
tance is increased, the abdominal circumference diniinisjicd. The 
spleen is enlarged, the kidneys prolapsed. There is a tendency to 
orthostatic albuminuria and to alimentary glycosuria. 

8. The hliiofl picture shows a neutropenia, tyniphoc^'tosia, and 
eoslnophilia. 

ft. Tlie geniUii anomalies are in the nature of crj-ptorc-hism, hypo- 
plasia, flisturbaiices of menstruation and secondary sextial characters 
of the opposite sex. 

10. There is a marked disposition to other disease and usually a 
tendency to an increase in the severity of the dis(»r<ler. Thus, tuber- 
culosis shows more often in other organs than the lungs; infectious 
diseases of childhood are severe; there is a tendency* to tetany, glio- 
mata, syrjiigoses, hydrocephalus, tabes, paresis, myasthenia. Dia- 
betes, excessive fat and gout occur. Pernicious anemia, leukemia 
and chlorosis, exophthalmic goiter, Addison's disease, osteoninlacia, 
nephritis, eclampsia, asthnui, iufautile emphyseuia, eczema, heiuan- 
gionutta, appendicitis and tumor formation are among other accom- 
panying di-sorders. 

Observation of many cases of status thjTnolymphaticus shows that 
littlr weight is to he given to the occurrence of isolateil sxTnptoms. 
The ilia^iiosis consists in the accumulation of the auomfllies. 'I'he 
differences in body dimensions are of universal iinportance, whereas 
the increjisc in the tongue follicles and the infantile character of the 



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DISEASES OF THE PANCREAS 



227 



epiglottis and its frequent omega shape, are more characteristic. 
Genital hypoplasias are frequently associated with eosinophilia and 
lymphocytosis is to be expected. 




Flu. KW. — iS<'ln'iii(' 'if iiuiorvutiiin of the livfr. wjilivri, and kiiliicy. n.V. iiucIpum of the 
rami"; A", vumix; nr. v:L-<i>tiiiiI<ir jiiirlcuH in niedulla; k, symtJitthotir; re, rami ronimu- 
nirantt; upl. nplaiirhiao tirrvc: pg, aolar plexutt; gx, tiemiluiiiir k»>ik1><»); spl, Hploen. 
(Bccht«rcw.) 

DISEASES OF THE FANCKEAS. 

Pancreatic Syndromes.— Fa It a liolds that the chief activity of the 
pancTeas is subserved through an assimilatory lutmione, which controls 
the gly<-ogcnesis of the liver and muscles. In mild grades of pancreatic 
insufficiency disturbances of earbohy<lratc metalMilism appear only 
when great demands are made upon the glycogeuie function of the 
liver through excessive alimentary earlKiliydrate intake. In graver 
disturbances in addition to the mcHlification of anabotisni a high grade 
of catabolic destruction takes plate with a failure to form higher and 
lower fatty acids (ketonuria). 



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TUB ESDOCRISOPATUIES 



I'flncreatic -tjinlromes oocur as a result of gross anatomical disorder, 
acute paiuTentif licniorrhHKi', ami rlirotiic pancrcHtitis. syphilitic 
pancreatitis, etc.; all of wliich are discussed fully in works on internal 
medicine. Those of JntcR'st here, however, are diabetes mellilus, 
(true diabetes) and pancreatic infantilism, all closely rclate<J to dis- 
order of the chmniaffin tis.siies of the pancrea.s — its Internal secretorj' 
part. Although the pancreas .seems primarily a digestive gland it also 
prothices an internal secretion wliicli holds in t-hei-k the niobilizutioii of 
sugar, thus actinp in a Imlancerl relation with the th>Toid and hypo- 
pliyseal secrctitiiLs wliieli tt-uil to fucilitnlc llic usr of sugar a.s an 
energizing material by the uuiselcs. This mobilization may he con- 
sidered to Ix" made effective by the terminals of the vegetative hcpvous 
system in the Hver cells; just how it is not known. Pancreatic in- 
fantilism shows jMtlyglandular disturbanct^s through arrested bodily 
growth and arrested sexual development. \'agotonic symptoms such 
as exce8»ive diarrhea and llatulent distetiilon are also present. 

DISEASES OF THE MUSCLES. 

Muscle Syndromes. — My&sthenia GraTis.^The clinical position of 
this disonler* is very uncertain. \\y S4>me it is Ui be n-garded as a| 
pontrast picture tii tetany and due to vcnetative nervous disturbance 
conditioned in part hy disturbed parathyroid activity. It has of 
late been sh«>wii that the striped muscular system is provided with 
vegetative nerve libers which undoubtedly regulate the muscular 
metabolism. Hy others It is grouped with the nuiscular atrophies. 

The disorder is Infrequent. It was separated from the progressive 
bulbar palsies of nr^anlc nature by Krb (IS7S) anil later studied by 
(Ippenlieim (1SS7), who tcrmeil it a myasthenic ]Hiralysis without 
amitomii-Hl fouodntioii. In ISOl Jolly described the characteristic 
electrical reactions occurring in the muscles, termed the myasthenic 
reaction.' 

The early s\Tiiptoins which usually wane on between fifteen and 
thirty years of ape, usually involve the fa<'Ial muscles, particidnrly 
those of the upper liil, causing ptosis. Diplopia from paresis of an 
ocular muscle also may be an initial sjTnptotn. The two often occur 
together (asthenic ophthahnoplegia). The patients note the beginning 
fatigue of the muscles, which (H-rbajis intact In the morning on awaken- 
ing, show fatigue signs at ni^ht. This nmscular asthenia then pro- 
gresses slowly to distinct ])arcsis. Other erauiul nerve innervations 
then show a similar asthenia. DifTieulties In chewing or of swallowing, 
or of speakinR develo]). The muscles of the neck may also be involved, 
Whatever group is involved the ehief feature is the great fatigue which 
develops very rapidly after the use of the museles. 

Any muscle or muscle group of the body may be affected. Dyspnea 

'Oppeabeiin, l>io iDya»tlicMiUcb« I'U-u1}-m. 1901. 



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DISEASES OF THE MUSCLES 

and tachycardia are amoiif; the rarities of iinplioation oF the respira- 
tor)' and cardiac muscles. Sensory disturbances are not characteristic 
Pains may occur. 

leukocytosis^ is usually present. The rcHexes are not implicated. 
In some instances fatigue of the tendon reHexes has been recorded. 

The chief feature is the rapidly deveJoping fatigue of the muscle. 
This is best demonstrated by faradic stimuli. These cause a rapid 
loss in the excitability uf the muscle until it no hmger reacts to the 
iritennittent faradic currt'til. lIitfTiriRnti has shown tluit this is largely 
influenced by ilic rate of the interruptions. With seventy interrup- 
tions per second the myasthenic reaction develops promptly, with 
fifteen it dues not. Continuous faradic stimulation produces a similar 
myasthenic fatigue curve. This myastheni;- reaction s4-cms to seiMiratt- 
the disiinier from other forms of muscular fatigue such as occur in 
bulbar palsy, medullary syphilis, multiple sclerosis, Addison's disease, 
exophthalmic goiter and the fatigue of intermittent clauilicatiun. 
There are certain anulugies with this last disorder which are not yet 
cleared up. 

.'Vtropbies develop in the affected muscles, but there are no definite 
indications of the reaction of degeneration. ( ertain traiLsitimnal 
cases which show relationships to distinct organic (nuclear) cases may 
evidenrt* electrical changes approaching li. I). Fibrillary twitches in 
tlie affeotfd nius«'lps are not the rule, hut iliey have been itbserveil. 

Myasthenia gravis run> a chmnic njui>e with iil times marked 
reaiis.siuns. It has Wen known to develop rapidly in three or four 
months with fatal issue m from one to three years and. on the other 
hand, it ha.s been known to extend over fifteen to twenty years. The 
outcome is usually fatal, but certain cases cease to progress. 

Little is knomi of the underlying causes. Status thyniicnlymph ali- 
ens Ls frequent. Many cases are asswiated with disunler of other 
endocrinous glands, chiefly with hyperthyroid states. Conslitutionat 
Hnimialic^, also often rcijanled as uf lymphogctnc origin are described. 
Nothing is known eoncerninf; the psychical states. 

The pathological lesions are nut constant. In the greater numlier 
of cases the muscles are swollen, edematous and infiltrated with I^th- 
phoid cells. These changes have not I)een interjireted. It is possilile 
that ihey are edemas due to disturbance of the vegetative nervous 
system contrt>l, in which ca.se myasthenia gravis is to l>e allied with 
tl»e circumscrilMHl tnlemas. To know this does not help very much, 
but it docs indicate tliat search nuisl be directed towan) all causes 
for vegelativf nervous system (lislurlmui'e, toxic and psydiic. 

The fir>t hn|K>rtant tbcrai>eutic agent is rc^it; abs4)lute and pro- 
longeil. The sei-oud is psychotherapy. (Irgam»therapy has l>een 
tried, with as yet Httlc results, hut it probably has \Kcn entirely too 
empirically applitii. Can-ful attention should W given to a complete 
survey of the fun(*tiotLH of nil of the endocrinous glanils, and if a lack 
of balance lie fouiul an attempt should be made to restore the ItaluncF. 



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TttB BffTiOCRINOPATlitBS 

Artificial fcwllng is at times nca.'ssary. Atropine lias been of service 
ocfii-siimally lus lias also calcium. Alwiholic prepnratiDns are to be 
avoided, as arc also mecJianical form? of stimuli, prtrticularly severe 
maKsafie. 

Thomsen's Disease.' — Myotonia Concenita. — Tliis is a very rare dis- 
order first describeil by J. Thomsen in lS7fi. Its relationsliips to other 
iitTvoiis ijisrascs is very obsciiri'. It is herinlitary, anil is probably 
conditioned by a constitutionally inferior tlu)racir autonomic control of 
the mu-sclc metabolism.- This results in an increa.'i^'d threshold of the 
synapse preventing iinme<liate pa->4.sage of the voluntary stimulus. 
Thw is often a.ssoeiatei:l in the affected families with other signs of 
inferiority; neuroses, psychoses. Tetany, etc 

The chief iinfiuialy Is one affw-tinE the muscles. At the begitinin^ 
of any vciluiilary movement the patient finds it diRicnlt to overcome 
tt muscle hypertonus. This makes the mustlcs stiff and unyielding. 
After repeated efforts the resi.stancc gradually disappears and in ii 
few minutes or more the mu-scular activity becomes normal. This 
limberinR up etfect is htst after a cessation of the movements. .Any 
group of muscles may beaffectwl, hut the lower extremities are ofteiiest 
involved. This makes the be^iriniii^ of walking diflicult. la the 
upper extremities a similar cnndition makes manual movements 
dilTicult. A patient cannot readily lix)si'n his yrusp of an object. 
Talkini: and eating, etc., may be similarly affected. ChanKing the 
tempo of a movement increases the diffi<-ulty and emotional stimuli 
invariably augment the stiffness and awkwardneiw. Merhanical 
stimuli cansi- welt.s to appear which subside slowly. At.NTsical cases 
are reported, in some of which the disonler ap|>ears intermittently. 
(Cuiiipure ttidi peritHht' paralysis.) 

The pathological changes are slight. Muscle-cell hypertrophy, 
analogous to that seen ui myasthcuia gravis, Ls describe*!. 

The disorder begins early, is very chronic, is not fata! in it.self, nor 
does it seem to get well s]x>ntaneoiisly. 

No therapy has been shown to be etfectix'e. Strychnine Is tempo- 
rarily valuable. If the present hypothesis is of value some results 
shouhl follow fn^m polyglandular therapy, particularly from the n.se 
of siicli substHiu-es as influence the bivalent kati»tns, ('a, Mg, etc., to 
regulate the clcctritid resistances in the motor sv7iai>3es.''' 

Myatonift Atrophica. — This rare disorder* is possibly a definite dis- 
ease entity or a variant of Thoinsen's di3ease, as Pels-, (1007) iirat 
annmnieetl. It is characterized by late oaset. twenty to thirty years, 
limilution of myotonic reaction chiefly to the closing of the fist, the 



' ThotEWcn: Arohiv f. Pnychuilrio, 1893. Knch: Umtior Thom«cn*rIi(» Krnnkhdt, 
Lrijing, 1014. 

* S. de Boer, 2«iUchnft f. BiolofDc, 1914, Ixv. 

* JohuscNi nud Mnrxlinll: Qiinrt.. Jinir. Mill., 1015. 

* Batt«D and Gibbi Brain. lOOO. CunHmuuin. DeuUch. Zum-hr. f. NVrvenheHk., \!*, 
Maiiptniiinn: lUd., 5A. HM(ior: Zeit. (. d. g. N. u. P.. April, lOlfi. 



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232 



THE SNDOCRINOPATHIBS 



The Muscular Dystrophies or Myopathies. 

Tills very large auc! extrvim-ly motley group has also Infii built 
up of a variety of forms since Duehenne, in 1849, first deseribed the 
fatty pseu*lohy|KTtrophies, and later, in I80S, spoke of them us utyo- 
srlera'ies. 1 .eyden' ( 1 srti) and Mobius" ( I S7SI described eertain here<li- 
tary forms, while Krb,* in IS&3, first brought some order into the eon- 
fusion of the atrophies and dystrophies by showing that in owlain 
fonns the lesion was predominantly nmseular and not nervous. 
I!e made the first praetieul synthesis. Landoiizy and I >fjerini',* in 
ISS4, descriln-'d their well-kticvttn form, and sepiirated it frnm Krb's 
juvenile type. Since that time the group has been Ix'tter iinifief), 
its limits better reeogmzed, and the various forms within it more 
thoroughly stiutieil." 

The myopathies make a fairly coasistent Rrfmp- although the forms 
may not resemble one another rhniealty at different periods of their 
development, yet they have a uutnber of common factors. 

Heredity is a common feature; they usually oecur at an early age; 
the muscles beei>nie weak gnuhially and atrophy in a iieentiar niainier, 
in tliat true hypertroplued fibers are uiinnled with atrophied fiWrs. 
The muscular atrophy umy involve all of die muscles equally, or may 
be irregularly distributed both as to the body in general or within the 
museie itself. Heaetion of degeneration an<i fihrillary eontractions 
are usually wanting, although a gradual loss of electrieal exeitahility 
goes on eo incident ly with the atrophy. 

Certain museles, peetorolis major, rhomboid, serrutus mugnus, 
arc ofteuest the seat of earl> atrophy, Tliese are also eharaeterized 
as congenital aplasias (Bing). The muscle electrical reaction curve is 
striking. 

The tendon reHexes gradually disappear, but tiie Achilles ia apt lo 
persist, or occasionally be increased, cspeeially with much pi^eudo- 
hypertrophy. Sensory <Iisturbanees are usually absent, likewise 
bladderaiid visceral di^tnrlwnees. I'seudoeontractures with limitation 
of movement are frequent, causing i>eeiiliiir positions. The patients 
hop like frogs. Uuny dystrophies are also frequent, mostly showing 
in tliinntng of the long bones, with craniid deformities, deformed 
hands, short hands and short feet. A number of accessory lesions have 
also been des(Tibed such us acromegaly, gigatitism, idiocy of tliyroid 
tj-pc, leukoplakias, vitiligo, <lifieased pineals, etc., all indicating endo- 
crinopathie affiliations of a iM)lyghLndulMr trend.^ 

Pathology and Pathogeny. — Krb based his synthesis uiioii tiie changes 
he found in the muscles, but at the same time was inclined tt> attribute 



< Klinikdo K. II. l«7b. 

« Neurol. Cttil.. iUta, p. 452. 



> t'niuii Mm)., 1So3. 
* Volkmnuii'!! Kliuik. No. 171. 

► Coniplett rpndii*, l>yM. p. fi3- 
' BiitU'ii. TliR Myiiimtlum or Muiu-ulHr Dy«trutfitgt>n, Qu&rt- -Imir. Mvd., April, lUlO. 

Ixireriit. KrBnkhoit<'ti A. Muskolti, HKM; JcmrlriviMiik, Ilandlmch <!. NciiivJ,, Iflll. 
' Tiiiinit-: Arr:h. nl Iuli>rrml MtHlit-'iiii;. 11M7. 



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DISEASES OP THE .WVSChES 

Uicm to lesions in the sjinpallietic pells of thc^ cord. Tlie*^' musrlp 
changes consist in the main in hyiHTtrophy an<l atrophy aiul !>pUtting 
of the innsflc fibers, prolifenition of the niielei, new connective-tissue 
proliferation with liyperplasia of the viiscuhir tissues and fatty dcposi- 





Pmi. Ill.^I'MniiUih3|«>rtrtiiihii- iiijr- 



Flu. 113. - l'fviiili>hytMTUn|>liitr myopnUiV. 
flusv of ntmithy. lS.'p lll.l JvixIniMik.) 



tioM. Marnwiopirully t!ie nuLsrles have hrtt their mirniul eoUir. vary- 
ing from pale pink to dark rfd. In places where the nmscU- ^uhstam-e 
has entirely disappejirt-*! white cimnectivt: (i:isue is apparent. The 
nttiwle platrM art- fre<[uently niLsning. 
LcKw (if wll-H ill the vf iitrDi Iinnis luis Iwcn dcscriU'<l by 1 lolmes' and 

' Rev. Nnir. mad y»yek^ IWJA, v{, p. 130. 



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DISEASES OP THE MUSCLES 



235 



trophic niyatonia congenita (Oppeuheim). 

5. Distal (Gowprs). 

6. Mixed and traiisitiuual forms. 

1. Pseuihkffpertropln Type (Duchenne, 1849). — Semraoln, in J854, 
and Costa and Gioja, in 1S;W, antedated Dudieiinc in describiag 
these cases, but pictures of earlier centuries give evidence of its pres- 
ence. It is the tj-pe ni<wt frequently oh.-5erved It is more common 
in males {'<i to 1) and usually begins during childhood. An hereditary 
history is very frequent. The parents first notice a certain clumsiness 
in the gait of the child, then the position of the body is peculiar, 
the head hciii^ hrnt forwanl, and the ccrvicnl vcrlcbne sire particularly 
prominent. Tliere is an early Wginning lumbar lordosis. The patient 
waddles then commences to find it hanl to ^o up stairs^^>ften trips and 
falls. On rising from a recumbent position the arms are called in to 



Fm. 114.— I^udoh>-pcriroplilR myopathy. Later tuce. Comp«re 111, IIS. U3. 

' ( Jcad nunik.) 

aid, and the mode of rising is unique. The patient climbs up his 
legs, i\s it were, with his arms. In the final stages the patient is unable 
to raise himself at all. 

The slmidder- blades are freely movable and rise with the rise of the 
arms. Atrophies are apparent. 

The Halt varies somewhat, according to the mu.'^cles chiefly involved. 
It is often wahhly. like a pregnant woman; at times it lias a high step 
character; again the piiticnt walks on his toes. The lower limbs often 
show murked h\^)p^t^)phy in the early stages, the calves are plump 
and firm. 

The atrophy advances \mequally. The nniscles most aRectetl in 
the lower extrctnitics are the psoas, glutei, quiidrieeps, siirtorius, 
adductors, gastrucneiuiiis and soleus; in the trunk the rectus ab- 
dominis, latissimus dorsi, erector spime, rhomboidel, infraspinatus, 



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DISSASBS OF TffB MVSChSl 



serratiis, trajMJziiis. and iK^ftorHlis major, wliilo in the uppt'r extremities 
tlie mii^ck's mintly implicated iire the deltoid, biceps, Inwhialis, and 
hrncliiura'iiniis. 

In advaiuiiip cases all of tlie muscles p>. save jjerlmps those of the 
face. In rare cases the face Ls involved (myopathic facies), and 
in a few cases the vagus is implicnted. In the less advanced caaea 
many df the iJLstal muscles can he utilised. The patients usually die 
of iritiTcurrent ilisordcrs after many years of illnesi^. 

2. Jueniih' Form (KrS). — Thus usii,<illy develops aluuit tlic ap^ of 
pulK-rty. with weakness and atrophy in the shoulder girdle. The 
deltoid may show hypertrophies. The arm us usually thinner and more 
atrophic than the forearm, and typical \viiij:cd scapulw develop. 



F(a. I IS. -Prf-uil'ilixn-rifiiiiliii- i[j\ii]i.'iili.t . i' 1, Ilnniniond.) 

In nalktiig ihf patients not infrequently bend forwani fnnn weakness 
of the trunk and ^support the hack hy holding the thiph.s. Pseudo- 
hypcrtntphy of the calves is not uncommon. 

X. h'acw-goapulft-humoral Tifpe (Landnnzy-Hejcrinc). — Here the 
facial atrophies usually dev<"Jop early, parlimlarly the orhicularis 
oris. The sphinx-liki- face develops, the patients an* unaMe to whittle, 
tapir month is often (irescnt. and the suiile is tlistnrte^l. The eye- 
lids hnng and cannot Im' closeil coniplntely. The shnulder-girdle atrophy 
then advances, tlic waist is small and wasp-like and iW chest flatteneri; 
finally the dystrophic process l>c<'<Mn(*s universal. 

4. Amt/Dioiiifi ('(tngeniia- Myatonia * "onpeiilta <^)ppenlicim' (Wil- 
son). — It is not certain whether this dbsonler sliould i»e inclutled 

1 MmiaU. (. N«urok«fo lu Pivehisui«. 190(1. vui, p. 232. 



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238 



THE EXDOCRIXOFATHIES 



nmoTiK the flystropliics or not. J *at ho topically it seems identiral, 
cliiHtully it is quite at variance. Spiller made tW first autopsy. 'HKr 
number of cases known (aI)out 611—1011) prevents a definite answer 
at tlic present time.' Uothmann is inclined to ally it with the Wcrdnig- 
Iliiiruiami spinal nuclear atrophies as a congenital variety, 

SifJupUnnn. — The disorder is usually couficiutalf hypirtoiiia is ehar- 
actcristic, with loss of tendon reflexes. Active motion is imi>aired by 
rea.sun of weakness, but the limbs are not paralyzed. I'sually the 
lower limbs arc involved, in half of the ca.ses the npiier, and in a few 
those of the trunk and neck. These little patients kaleidoa«)pc a.s it 
were. 'I'lic facial muscles are usually spared. The intercostals are 
but little iilTec-ted. 



I'lu. 1 1',' -J. -|i"ji'rii'(- 

iiti'iniaiiiy. 



Fuf. 120. — IjiqHouxj-DvjeriiM! 
itiyoimthi'. 



Elcctriral reactions are normal, or show quaiitilnti\e rwturtion. 
The knee- and Aehilles-jerka are usually absent; those of the iipprr 
extremity less eonstantly gone. Atmphy is not dc6uite. nor is 
pseudohypertrophy present. Meehanical irritability arid fdtrillary 
contractiiins are absent. 

Contrartures are not uricomnion. The sphincters are intact. Sen- 
sibility is tntaet, also the special senses, and the chiUlren are usually 

■ IfOUmltiU'iHlun': f 'ollk-r KTtH fT'ilniM. Rnun. 1909; Bvtton. lor. ciU; rtuaiiTr. lisnii- 
Uat'h <i. NVur.. 1»1I; flhflitli. Arrb. Kiinlhk., 1910; Griffilh mod gpillcr. Am. Jour. M«d. 
8c., Augiul, lUII. 



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DISEASES OF THE UUSCLE.S 



239 



!>right mentally. ITie general condition is good, and vasomutor 
disturbances are absent. 

The disorder has s«rae lendeiiey to improve, although Hatten 
claims that not vuv !ms jfotteu well. Some of the patients leurn to 
stand, but rarely unaided. 

Intercurrent (lisorders. particularly respiratory, cause deulh in the 
majority, 

5. Distal Type. — (lowers-tipiller,' andSpiller^ first deiiiiitcly separated 
this mytJimthy frcim the apparently related Charcot-Marie-Tooth 
atropliy. It varies little from this latter save in the absence of 
sensory disturbances. 

rrrafmrn/.^'liis has been very unsatisfactory thus far in this entire 
group. The pathugenesis is still to \v^ workwl out. The most hopeful 
of the newer suggestions, as yet only tried <mt in n few cases, is (lie use 
of muscle substuiiec preparations. Carnnt has experimrntcd with fetal 
rausfle substances trying to find possible regenemtiug element-s. Ti*stic- 
ular and suprarenal lipoids at times stimulate muscle growth. These 
are purely empirically useil remedies. A careful study of the heredity 
for end(Mriiio]Kilhic organ inferiority may help in the use nf the 
glandular products. In all jirohably a mixture nuiy be iLsed. I'ntil 
the activities of the sympathetic and vagu.s fiJjers in their c<mtrol 
of muscle metabolism is hotter studietl mcflieine will remain in the 
dark respecting this group. These patients should be systematically 
stii'iud by the vr^'tati\r uietliofls 

^mtty Syndromes. - Obesity. —The exact mechanisms underlying fat 
metabolism are not completely umlerstooil.* From a chemical pninl of 
view the synthesis seetos to start with glucose wliieh on oxldatinii funns 
pyruvic acid. A honnone action then converts this into acctaldehyd 
and carbon dioxide. * 'ondcnsaliou pnHiucea higher ketone acids which 
finally by further ctmdensation and polymerize ti^m build up fatty 
acids. The whole process is reversible. What the lutrmonc is and how 
controller] is unknown. The vegetative nenous sy.steni is probably in 
action but how is a» yet purely conjectural. Kndocrinous disorders — 
gonads, h>-pophysis. possibly pineal, art* known tomiMlify the oxidalioiut 
and |)crmit fat .^^toragr. These take place in very characteristic fashion 
and some have been discussed under the heads of adiposis genitalis of 
pituitary and of gonailal origin, eunmhism and eunuchoidism. Other 
sj-ndronies will U' taken n\t here. 

[^ranfl rlescribiil an exogenous— possibly pancreatic — t>i>c, occur- 
ring in big eaters and develni»ing dialx'tes from ovenvork of the oxydiz- 
ingmpchanisiiis— pancreatic suprarenal (?), and an endogenous tj-pe of 
endiKTiiious origin. Ilius von Noorden diifcrentiated a pancrcatogenic 
obesity and a thjTogcnic obesity. I'Vohlich separated his h>Twphy.seal 
type. Kraus has described a variety of this, pilous cerebral adiposity. 



Brit Med. Jour.. Ifl02. 
'Oayliw: l'rind|JoB of Gflnwnil PhyMuluity- 



* Jour. NcTV. and Mcnt,. Du>., IMM. 



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10 



riiK KNiHKiu>'*vt'iTa/irs 



In n'Idition n proupof locolizwi tip 

,Bn' tlic vurioiis types of lipomato;. i i 
Percuni h an extreme furm rather timn r i 

'many of the milkier types of s.\TnnietnoaI nnii lircLiiii^rrjiivii 
pains, psyrhic ami neurotic disturhanet-s are s*'eii. 

L Adiposis Dolorosa. — Dercum (ISSS) first iiaiiuii *_nii 

PByniinmics. It is cliariirtrrizeil Iiy aili|>it>>ity, pain:?, gt'iicr;: 
weakness and psyehical changes. The patients, mostly won 
averaifiiiK hetwcen tliirty and fifty years, witli a tcndcruy lu ijimdj 
ohcsity, slowly develop fatty deposits, often enormous in size. Tin 
iidi]K»)ty may show as mxhilar de]M>sit!j Isyininetrioal lipomatosis)} 
varying in size from a hean to an apple. Th^y may be cirt:nmscribw| 
or the adijKWc driKwits rnay In- perierally diiTiLSfd ihruuKlKUit tin 
entire body. The liip.^, shoulders, upper arm and abdomen are pr 
dileeliuii ^ii(^■s. TIu* skin is tiMise. Tlic fatty deposits In the weUi 
developed types arc often painful to prepare, esi>ecially at noduh 

.points, and even at times before there i^ much fatty infiltration, llypei 



/4i^^ 



L Via. 121- — Adipoai* cU)1oro«A. (I)cT(-uin.) 

dtthe^ia* and jmri-sthcsite in the form of tin^lin;;, hiiriiii||[, itumti< 

etc.. iin* frequent, .'^puiitancous pjilris oL-eur with some. T!)e>- 

sharp and intennitteTit, locuHzcd in the skin or more deeply, aixt iJtfi.l 

increase with inotion Asthenia is a marked sifjn and psy<-hieal altera-l 

tions are the rule. These latter are mostly in the nature of depressions! 

with, at times, suicidal i<leas. irritability, capriciousness and other sijjnsf 

cli>srly tc-seniblin^ ni a, nic-^fep revive states {7. r.) with Hifibt of idoa.<i| 

,and confusions. Other patients how marked detcriuratlous. 

I Various annmulovis condition.-* have been obscrveil with differentl 

'patients, such as vasomotor signs with edemas, ecchymiksc^, hemor-| 

rhages. and pigmentation. ITytJcridrosis. anidrosis, and trophic cWngea 

also are ret-ordwl. Various coiiiplicatLoiis with other uiemlwrs of tUisI 

vast collection of cbcinicAJ metabolism anomalies are numerous. Somcl 

t Uinrohfuld: Zt«chr. t. d. g. N'. u. P., rcf. Ud. vi. 



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DISBASRS OF THE SfUSCLES 



241 



*f these huve hwn h>^»l'^thyr(>i(lislll, myxedema, selenxirrma. Uay- 
wmrs i]i:*ea:*e plurijjiandular dysfunction, etc. 

Tlie di^iinlers usually pmnress slowly an<! var\' greatly in intensity 
fmiii year t<i year. The patients recover spontaiieoti^ily or finally die 
of inU-rnirrt-n! disease. 

The nrgaiw involved have Iteeii the hyjKjphy.sis anil the thyroid 

chiefly. Imt the e\act relation.shi|>s are still uncertain. iIyiJoph>-^eal 

turners are not infrwpienlly found, uvnrian disease is present in some, 

[vasculiir neurotrophic disonlers ibUtod gland disease) are present in 

{till (illiers. 



rn--, 



?fi. 122. — MiofTMUcUa in acbiondroiiliwia, HhoHitiK the tfidoat hand in lwTat>'-oii»-yeitt« 
old patlcoi I A JoAcbMi.) 



Tieatmeot. -(_lpother»py with thyroid has been uf service in th(i\e 
Va'>cs in which a db*eased thjToid has been assoeiate<l. Ovarian extrart 
has helped the DViirian defect types. •" Eleetrieity, hydrotherapy, diet 
^■hmiI general liypienic control has been of service in others. Here a» in 
^Bother of the tndocrinopathie> a careful sur\-ey i>f the hen*dity may give 
^P.useful clues as to the defects and to their partial alleviation by a 
^'propi-rly scleetcd opotherapy. 

I Bony and Ligamentous Syndromes; Osteopathies, Arthropathies. — 
l^itone disnnlers due to disturWnccs of ncr\nus fuin-tiuniiic iin- l>y no 
^Hjmejin.s infrrfpicnt. The nervous nie<'hnnisnis iinderl\ inp Ixine develop- 
^Btnent lire nut clear but at least two large gruup^i of netirolr.>gical bone 
^HdtAturiiance^ may U* scparateil. Thevarc: ihow deiJen'Ienl upon dish 

I 



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242 



TUE ENDOCRISOrATIIlBS 



ease of the vcKetativc nen'ous system (enflocrinopathics): and those 
accompanying sfiisrjriiiintor disease.' 

T\k chief hoiiy eiulocriiutpathies ar«' nchoiMimplawla, n^teoiimlaeia, 
the bony changes of acTomegaly, gigiititism, infantilisin, Iwrntinsis 

OSSCH, Ctr. 

Achondroplaaia.— This consist chiefly in a defective fetal develops 
ment of the bones of the extremities (micronielia), with eompuratively 
Tioniiid development in all otiier tissues of the body. 



Pto. 123.— \rhi>i|[|n)vtu)!iiit with mirrumoliii, xli'^n-inu •■horti'titil ii)i|>it oxtremily with 
run'Hturea of boriM in Lweutynnni'-year-fJIU |iau«iH. lA. Josefstjn.) 

Symptoms. — The skull is enlarged, often hydrocephalic, with deprea- 
rIoii of the nose and prognathism. Shortening of the extremities 
(microtnelia) is t-hnraefcristif, with exaggerated ciirvatnre of the 
shortened hones. The fingers are nearly all (tf the same length uiiH 
nidiate slightly, spoke-likc. frutn the inotiiearjini jnints with a tendency 
to form the trident hand. The thumb, first and second, fourth and 
little finger, respectively, arc arranged in groups. Lumbar lordosis 
with prominent abdomen ia usual. 

* Btcrling. loi?. eit. 




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244 TBS END0CBIN0PATHIE8 

and forces it into a conical shape. Optic atrophy, with hnpainnent d 
vision And headache and mental failure axe the chid symptoms. 

Rheumatoid ArthrUia. — Certain hypothyroidisms {q. t.) pezmtt the 
development of a rhemnatoid arthritis, possibly by the reduced capacity 
of the individual to react normally to minimal subinfections, aSten ci 
cryptogenic ori^n, teeth, the frontal, malar, and ethmoid sinuses, 
tonsils, intestines, old vesiculitides, etc. 

Neurogenic Arthrop€Uhiea.—Tbe3e are frequent in tabes, paresis^ 
syringomyelic (Raynaud) neuritis, leprous neuritis. 

Psychogenic arthropathiea and arthritidee are as yet not definitely 
established. Hioe is some evidence from the psychoanalytic school to 
show that unconscious complex reactions may show themselves as 
bony syndromes. The classical relationship between excessive anger and 
gout is a case in point. Unconscious anger states produce transitory 
and even chronic arthritic changes. 



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Olfactory.— In man the olfactor>- apparatus has swminply lost much 
of the importance it p<jssf.sses in tlie lower animals, (ithcr sensory 
zones, notably those for the eye and ear and language have taken 
the lead in the program of evolution and have left smell, important 
though it he, in the vanguanl. 

The rts^eptors for smell are lucuted in a limiteil pt>rtion of the 
Sihneiderlan mucous nictnliranes. They react to very uiinute chem- 
ical stimuli, l)cliig for some suhstancirs from \ to "iH.OtWI per cent, more 
sensitive than the receptors for taste. One part in S.dtlO.nilO of imisk 
is capable of being couseiously detected. There is markivl variahjHty 
in individual tlireshold capacity as determined by Zwuardcinaker's 
olfactometer. Thu.s many smell reactiijns are practically non-appre- 
hen.sible to consciousness, yet minimal unconscious stimuli nevertheli'ss 
may pro<luce widespread reactions. Horse anri cat a.stlirra. hay fever, 
etc.. may thus liave psychogenic etiological factors from unconscious 
odor as.sneiations. 

Changes in that portion of the mendiranc. sucli as occur in any acute 
inflammatory di.'*ease. coryza, iuHucnza, diiilithcria, etc., cause diminu- 
tion or loss of ability to suicll. Albinism ih usually associated witb loss 
of smell. Chronic inflammatory processes, often accompanied by fetid 
odur», polj-ps, frontal or maxillary sinusitis, lead poisoning, usually 
bring about unilateral or bilateral loss of smell. Most of the cau.se3 
for this mostly peripheral loss of smell may be estimated by direct 
iiLspection. Certain drugs acting locally, OK-ain, etc., influence 
smell. 

From the receptors, unmyelinated fibers traverse the cribriform plate 
and enter the olfactory liull>. forming synai>ses witli the nutral cells. 
The axones of the mitral i-ells eomjKise the olfactory tract, f()riuing 



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CRANIAL NERVES 



higher synapses in the olfactory area. Lesions in and about the 
cribriform plate from fractures, meningitis, syphilis, pressure of frontal 
tumor, may determine a diminution or loss of smell; possibly lesions in 
this portion of the olfactory pathway may cause hallucinatory odors, 
but this is still debatable. Certain tumors l>ing upon the orbital plate 
of the sphenoid and compressing the lobus olfactonus have seemed to 
give rise to unilateral and bilateral hallucinations of smell. (See 
Fig. 126.) 




Fia. 125. — Extent of true olfactory receptors on the mucous membrane, (v. Brunn.) 

Disease of, or pressure upon, the olfactory nerve in its peripheral, 
thalamic, or cortical portions results in either diminution (hyposmia) 
or loss (anosmia) of smell; hallucinations, illusions (paro.-mia, ismosmia 
or cacosmla), or hyperesthesite, causing excessive sneezing. Odor 
influences taste directly and by association involves the entire vege- 
tative nervous system. The different parts of the olfactory pathways 
need to be taken into consideration. The study of olfactory hallucina- 
tions, particularly in certain psychoses, and in certain tumors in or 
about the frontal lobes, and the uncinate gyrus, renders this of value. 

It is known that certain sneezing crises have been determined by 
tabetic lesions. Just which parts of the olfactory tracts are involved 
is not certain.' 

' Klippel and L'Hermitte: Sem. M*d., February 17, 1909. 



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DISEASES OF THE OLFACTORY TRACT 



247 






:L 



^ 



Tertiary, reflpx and mllateral neunuLs ims^ to tlie thalamus, hypo- 
thalainu.-4, inidbraiii. am! to the <^»rlex. (See Fig. 127.) 

(liiiifal torrcia lions with disonlcr uf this ixirlioii of thv olfactory 
pathway are not tifrtain. Certain overaffLftive reactions to <«]ors, 
disf^ust^, naii.'iea, e\'en vomitiitg:^ from odor:^ need to be more earefidly 
sifted in this connection, especially in relation to brain tumor locali'/ji- 
tions. One personally observed pat ent with ctionloma of the base 

cr>mplained of the smell of " burning 

TDateriai"; another with a frontal fibroma 
was anoamic to test and yet had a constant 
hallucinatory projection uf smelling; d's- 
ajtreeable tluufis. feces, etc. They should 
not be viewed as whims or fancies of 
hysterical patients. Ixws of smell may 
result fnim thalamic lesions, usually 
homolateral. The crossing of the olfac- 
tory pathways is incomplete, and takes 
plat-e principally in the anterior cerebral 
conunissure iFig. 127). 

The cortical neurons end in the ixirnu 
ammonis. which Is a large olfactory asso- 
ciation field connected with all other parts 
of the cortex. (See standard works of 
Edinger. Ilamon y Cajal, ^'an (lehuchten 
and llerrick. IntnKluction t<i Nenniloj^v, 
for the <letails of the anatomy of the ol- 
factory iipparatus.) Irf-si<iiis hen.* often 
rcsidt in jjeculinr olfactory auriLs, as seen 
in certain hippocampal epilepsies (uncin- 
ate St:* of llughlitigs Jaclcstm). Such fits 
CKTCur from tennKirosplienoidal tumors 
also Olfactory- agnosias also result from 
lesioiL^ in this general region. Some of 
congenital origin, with agenesis of the 
rornu auunonls have t«f*n described. 
Anosmias or olfjictory Hgnosias are fre- F,y lao— Illii»tra«on of flnt 
quent in general paresU, and in abscess ■'«! »e«.Dd ufurom of Uie <4liic- 

vi, IT , , . iJ** in ^J"" ri^iwraU (iniual 

The enerent pathways and sxaiaptic cr\\%\. lEdinirr.) 
reflex patlis of the olfactory are ex- 
tremely numerous. The most common motor reHex is tlmt of snifT- 
iug. with ililatutiun of the nostrils. This is occasionally seen as the 
result uf a central somatic lesion IparcTsis), or as a purely synd>ulic 
automatic or uncoiLscious act (Ducnpulsion neurosis, h}'steria, schizo- 
phrenia). The relation Iwtween odors and the vomiting reflex is to be 
I»onH' in mind in hy-'lcrical vinniting, furthermore the ver>' primitive 
L>t.<UK'iationd Wtween ndur and sexua' comple:ces. Hysterical anr)sm)a 



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CBANIAL NERVES 



may be an Isolated phenomenon and is usually classical of the mechan- 
ism of conversion in a narrow Freudian sense The psychology of smell 
and its complicated relationships to infantile phantasies of disgust, to 
childbirth from intestinal canal, to the identification of feces and money, 
make the study of nasal disorders of great import in the psychoneuroses 
and psychoses. Hay fever, rose colds, etc., in many instances, are 
psychogenic conversion phenomena, others may be reactions to stimuli 




Flo, 127.— Sohemc of olfactory paths. X, vagUH nml tibcra; f«. anterior commisBurp; 
cm. mammillary body; cp. fibers from nudeus halieiiulK to posterior c-ommiBSure; fG, 
traet from manimUlary Ixniy to Gudden's iiudeus; /i, fasiriruliis manmiillo-thalamictu; 
fi, fasciculus long, mediaiiuit; fr, fornix; ful, fibers of fornix; gti, nucle\is habenulie; 
at. interpeduncular ganglion; gp, Kyrus pyriformiti; t, median lemniscuH; m, fibent from 
Gudden's nucleus to mibstantia reticularis; rwi, anterior thalamic nucleus; nG, Guddcn'e 
nucleus: nt, lefcntental nucleus; nA', vagus motor nucleux; j>eE, ped. corp. niammilaris 
from fillet; ga, quadrigemina ; r, fibers from n-tegmenti to cranial ner\'e nuclei; re, radix 
lateralis tractus olfactorii; rf, fibers of olfactory tract to trigonuni olfact«rii; ro, median 
olfactorj' tract root; h, fibers from interpeduncular ganglion to tegmental nuclei; «i, 
olfactory trigone; th, optic thalamus; fro, olfactory tract; tt, tenia thalami; x, fasdculus 
relroflexus. (Bechterew.) 

(pollen, horse odor, etc.). Many of the so-called anaphylactic reactions 
probably rest ujwn a psychogenic basis. In <-ertain i)sy<-hogenic 
epilepsies the olfactory symbolisms are highly de\'eloped. What rela- 
tions these have, either as cause or result, to the cornu amnionis lesions 
found in these epilepsies (Alzheimer) has not yet been determined.' ' 

Treatment. — The underlying cause of the changed olfactorj' state 
needs treatment, not the state. Local applications of cocain, mor^ 

' Bailey, P., Flaulwrt's Epilepsy, Proceedings of Charaka Society, New York, vol. iii. 
' Clark, L. P., The Epilepsy of Dostoiewsky, Medical Recortl, New York. 1915, 



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DISEASES OF THE OLFACTORY TRACT 



249 



phin, etc., are usually unjustified. The psychogenic olfactory dis- 
orders should be treated by psychotherapy. Hay fever is preeminently 
psychogenic. 



Etioloot, 
I. CoMawnTAbDcrBiTntor ()i,FACT<)ifT. 



II. Sknilr iNrnbimuN. 



III. MkOIA^OAL iNITLtlSNCBa 

Ciimprmsioii l>y TncninicUiti . 



Trarinii of tilnTSi rrarture. 



IV, FuNtrrtONAL OVERDBE 



V. Toxic iMrLUKNCM 
InflueDxu 

C'orain 

Stryphnini? 

Nirotine , 

Ali-ohol 



VI. S«CO:tDAST TO OthBH iNFLUBNCtn 

I.mion of V nnd VII . . 



CuNtCAL SldNB. 




aiuil4 



FoToamli. 



nfperfwmla 



PBychosenic (hyateria. preooi) . 
Fia. 128. — General summary of olfactory diaturh uncos. (VcraKUtb ) 



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250 



DISEASES OF THE VISUAL APPARATUS. 



The course of the light pnthways mid the topographical urraugeTiient 
of its synapses arc txlrciucly roinplex, since slfrht has become almost 
the principal tool ol ndvance in the evohttioit of man's mental powers. 
In many preverteb rates a pair of median ami a pair of liitfral eyes were 
known. The pineal f\iiui\ with it.s liaheruilar cininectioiis seems to he 
the only remnant of this early median |iair. 

The ranj;e of rLj:ht n-sponse of the human retinal receiiturs is very 
great, yet it docs not include the entire pr*)Up of vibratory phenomena. 
What transforms the ight etierg.v into nirvc energy electrical — is not 
positively known. Mechanical and ])hot<Jrhpmical (thronph the visual 
purple of the rods) hypotheses art? at i>resent in the ascendant. The 
human eye resolves points separated by 0.()tl2 mm. at the fovea but 
this visual acnity rapidly fades otT tnwani the periphery. It varies 
grt-atly for different colors. (Hee Tests by Snellen Type in Methods 
of I-'xainination.) The thresholil of the sttinnlus carles also and is 
very distinct in different individuals in whom enormous Viirialioais in 
color values exist. Tlic best-known classical form of this tlitTen.'ncc 
is culor-lilindness. The hnnnin eye is sensitive only to vibrations 
approximately D.lHHls to (HXKH mm. in leuffth vibratinKat a rate of 
4(Kt.(KH),(XK),()(N1.0;i(( to ,m)(),l)()(t.iM«).<HKM«K) per second. This makes 
up about iiiie-lentli of the entire rariKc fnmi the sh>west lactile iheat) 
stimuli to the highest vibratioiis of the j-rays. N'n human st-nse orj^an 
is yet known that responds to the Hertzian electrical waves, the ultra- 
violet or the x-rays. The solar s(>ec'trum contains about ID octaves 
of this scries. Many vibrations unpcrccived by the human eye seem to 
be respcmded to by the eyes of other animals. \'on K'ries estimated 
that the htimtin eye cttuld distitiHuish between l^O and J."H' pure 
spectral tints, thus making a functional range of between 'ilM^iHlit) to 
OOn.OOfl passible distim'tions. Enormous variability exists winch la 
at the buttom of much of (he variation in perceptii>n of the painter 
t)r color artist. Evolution to wider and more useful ada])lation i.s 
undoubtedly going on constantly. This is chiefly broujrht about 
through the psychic-al stimulus.'^ 

The retina, the mostly decussating optic ner\*e ending in the ex- 
ternal geniculate, the pulvinar of the thalamus anil the anterior 
corponi ([Uiidrigendiia, und lintillx' the optic radiations tenninuting in 
the calcarine region of tlie cortex nnike up the primary, swondary and 
tertiary incoming neurons of this pathway. (See Kig. 129.) 

Tlie intricate and rich symptomatology is dependent upon, and will 
be <riscu.sse<l in accordance with, these anatomical divisions. The chief 
signs to he considered arc tiight-blindness, cohtr-idindness, dimness of 
vision, blindness in one or both eyes, temporarj* or complete seotomata, 

t Compure Adler'a studj' oa the inf*riority of oncana alrendy re/err*d w. 

■ Pliitlio*: Quwtiuiw Itol&tinu to Eyv Truinhiic. faraons. VcAot BlindneM. 1917. 



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nSSASBS Of THE VtSUAt. M'/'ANATUS 



251 



Carl* J 



C<^'^P. jim.t.oW, 



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.-? .v». V .V, 
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// 



Pm. 129. — Diflsmnmstif •obenw of npiio paths ftnd clii«f connwilon* »t four lercb. 
A, IvrH of II ami IH nerves: B, h^vel nl IV iwrvp; (', level of VI aad VII tM>rvefl, tecmen- 
ttiiii of iHi(»; />. spiiul M)nl. Vruron I. n«>fw(>t[ini in roda uul •Nino* of rwUiu ara not 
indirsUMl in llii^ iliaxnuu. Xeurcm 2. 2a, uuintM imamng to pulvinmr of Bune aide: 
ih, jktnnoa [waunK to i:oft*UM i|iiwlnKeniinuin n( asriM mdo: 2r, luonM poMdnc (a MUtrti&l 
VBuiraUle iif muiu> Mtir. all fruui tKuipural nkt* uf rvtina; (mm dbhI miIc 2a. tuumta 
vtiMons in rhiiutn jC'N"lt '" opporil* «xtcni«] itviucnlftW; 3f, kvirwa rrtwwng in Hiiium 
lo lo ta opp«i«>l« nDt«n<ir corpu* quBdriBBtnioun); 20. nxonrs crUMinK ia ctUMuii lo opfkH 
Bile pulvinu. PaplUunkiurulAr bundle &hcn croMcd. partly unmcMMd (aee Fie. IZ7). 
Setroit 3. I*ulvin>r tinmtm tuoiviintAl <^rt«x; 9b, rsUmal Kenitnilat* wiont* t<> <M»4piul 
Inbm; .V, rf, f, rtir^utnt qiuMlrieemiiw fi)>pn. middle Uyrr demi«>ilinc (Meyiiert) to 
iii«(IUd loniitudiniJ luclruliu und lonuiiii tnictua teclolmJbaha cl *pin&lu to to ia 
RMdulla uitil uiitii-iiir njiinirvx, dirtitlii^; itynapaM with third, ffMinh, nxth, and wvemh 
DCrvM uml iriul'-f timlc-i ■:>{ npitud nen'M (apac* orwtiUttiun) ; V. 0. filiMv (rmii inwritilial 
BiielMu(('aifth()i (iMifultial<i»«ilwliiiali«|>n*U(ii»ffirtniitK pnn n( Ifinicituiiinal la.wiruhM. 
PMMiiK to Mttenxrriiliiitim. (urwiiic tyaApnot with III. IV, \ 1 irnitiid hrrve^ ttml itt'>l>ir 
upbaJ iwms. iVnirvM 4. Asonm frtxn orul'imotor. fsrinl, «iid npiiuil nurlei- iSinMif.J 



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252 CRANIAL NERVES 

temporary or permanent hemianopsia, hemichromatopsia, mind-blind- 
ness or optic agnosia, photophobia, hallucinations and illusions of 
sight, hysterical and other forms of symbolic blindness, malingering of 
blindness, unilateral or bilateral. 

Betiiuti8.~Involvement of the first neuron is termed retinitis. 
It may result from the extension of an inflammation or may be due 
to toxic or to hidden constitutional factors. The chief indications are 
ocular discomfort or photophobia, diminution of the visual acuity, 
appearance of scotomata, general contraction of the visual fields, 
micropsia, megalopsia or metamorphopsia. 

Diiferent grades of retinitis are distinguished ophthalmoscopically. 
The chief tj'pes are simple, albuminuric, syphilitic, diabetic, hemor- 
rhagic and anemic retinitis. 

In simple retlmtis there is clouding particularly of the superficial 
layers, in patches or in larger portions at the posterior pole. The 
veins are dull and dark and full, and seem imbedded in the swollen 
or hazy retina. Sight is dim and worse in spots (scotomata). The 
disorder usually involves first one eye and then the other. 

Alhiminvric retinitis is frequent in nephritis (25 to 40 per cent.). 
Headache and loss of vision in a middle-aged to older person are 
the usual signs. There are characteristic changes In the retina and 
albumin and casts in the urine. Cirrhotic kidney is the most fre- 
quently accompanying somatic lesion. The chief change is an arterio- 
sclerosis of the retinal vessels. They are unduly tortuous and show 
contractions and widenings, often being beaded. There is also a trans- 
lucency in the retina, white strips accompany the vessels. The veira 
are likewise tortuous, and disturbances of circulation show particularly 
at venous-arterial crossings. Retinal etlema with grayish opacity 
shows. Hemorrhages are frequent. The margins of the disk liecome 
obscured, the nerve expanding into the retina without sharp lines of 
demarcation. The disk may be muth swollen, woolly in appearance, 
and much extra vasated. Fatty degenerations with "snow bank" 
appearances occur. 

Blindness, scotomata, dimness of vision appear as in simple neuritis, 
but chronic cases of albuminuric retinitis may be present with little 
loss of visual acuity in the early stages. Permanent impairment of 
vision is the rule. Albuminuric retinitis accompanied by hemorrhages, 
and fatty degeneration of the retina, in a patient over thirty-five to 
forty years usually portends a fatal issue within comparatively few years. 

Syphilitic retinitis is probably much more frequent than has been 
supposed. It may result from hereditary or acquired syphilis, in the 
latter case appearing soon after infection. Clinically there is contrac- 
tion of visual fields, dimness of vision, maybe night-blindness, or 
marked dimness of vision with poor illumination. Shimmering lights 
which are persistent and annoying occur, with micropsia and at times 
metamorphopsia. Central, partial or complete scotomata are fairly 
constant. 



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niSBASES OF TRB VISUAL APPARATUS 

TIip o))lithn[niostiii>e shows hyperi'iuia witli serous exudation much 
rei>embling the nlhummuric variety but in milder degree. Hemor- 
rhuges iirt^ inurh rarer, and tlic "snow bunk" xlisteiiings umeh less 
pronouneed. ()|>aeity aiwiut tlie disk is a variant feature, with 
ioEammation o^ the uveal tract. 

nemorrhagic rrtinitU is of importance, but the student must iw 
referred to works on nphthalmolntjy with the olht-r types. 

fietinitiit pigim-ntam is un hcrcilitary variety of priuiary retinal 
degenerntinn showing lught-blltidness with striking fre(|Ueney. Nettle- 
ship's fanioiis ritu<ly of a Kreiieli family showed this to be a striking 
instance of Mendelian dominance. (Plate V.) 



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Fm. mo. — Scbnm« iti ti»|ilD<MnacuUr hutwlle. (WUliraad «ii<l fl&n«M'.) 

Optic Nerve.- The disonlers alTecting the second optic neurons fall 
intu tw(t (troups: those alTecting (A) the optic nerve. m<»rphoIogicaIIy 
a true brain tract, (B» iU terminations in the midbrain structures. 

A. Diseases of the Optic Kerve- -Here three situations need t<i l>c 
distin^'iiislicd: ii\ whether thv atfwliim lies anterior to the ebia.-^m, 
(2) whether it involves the ehia:i>ni, or ('A) lies behind the chiasm in the 
path of the optic iicur«>iis (if the thin! order. 

0) niieases of the Ojxic Nerve Ijefore reaehinf; the chiaNm: Optic 
Sruritif, in general ?senM'. Tliree t.vpes are distinguishable with 
pronounced Hymptoniatology. They are: («) :\xinl Neuritis, (h) 
Interstitial IVriphend Neuritis, and (r) DitTaw NeuritU. 

(a) Axial N«tnritii.— This is a s>*!itrm disease of the papillomncuJar 
bundle, involving ihe nerve In fnml of the chiasm. It may l)« acute 
or chronic. 



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254 



CRAXIAI. SERVES 



Anitc Axial AV«r//(>.— (Occurs usually in younc rHuUs. twelve to 
twenty-four years, more particularly woiiivn. Tliere appears, ^^uildea 
olouftinf; or dimness of vision, and occasional photnpsias. A frontal or 
tfiiipciral headache, or deep pain in the orbit, made worse by pressure 
or movemotit of the eyeballs, is present. The loss of sipht is rapid, 
reaching a maximum usually in five days, am! often is so severe that the 
patient can just count fingers at lo fe*"t, or is blind. With the loss of 
sight the headache lets up. There may be aft retinal changes. The 
pupil nf the affected eye is larger, and is usually sluggish to direct light 
stimulation, but sliow-s no consensual Hpht reflex loss, 

After the amite stage ts over there is gradual recovery of the sight 
at the p<*riphery with varioiis degree.s of persistent central scotoraata. 
The loss may be unilateral or bilateral and absolute, or unilateral or 
bilateral to color only, f»r various griuhttioiis of these paracentral 
scotoniata. etc. The stvtoniata gradually diminish ami after six to 
«ght weeks, with proi>er therapy, may entirely disapgiear (Fig. 131). 



L. R. 

Fifi. 131. — Cetitnil MotAmsU In atriile &xial ii«uritu. <WilbntQcl and S&mwr.) 

The fundus picture may reniniii normal throughout or show a 
papillitL.s. This will depend upon how far hack of the optic disk the 
lesion, which is usually a vascular one, occurred. When there is a 
pa]>illitis it shows slight paling of the lem]H>raI half <ir halves of the 
fundi iFig. i;n). 

Kthtoffi/. — The most frequently as<Til)cd cause is exp<^su^e to cold. 
This is probably only an incident to other real cau.ses such as infec- 
tious disease — s>*philis, tuberculosis, typhoid, erysipelas, sinusitis, 
influetiza, mumps, pneumonia, tonsillitis, cerebrospinal nteniiigitis, 
malaria, beri Wri, etc., or toxemias, such as those of pregnancy, 
nephritis, bums, CO, poboning, methyl alcohol, quinbe. felix mas, 
morphin, etc. 

Treaime7ii.— Hot baths, and treatment of cause, as anti-iyphilitic in 
s.vphilis. etc. 

The Chronic Form is much more frequent. It is the classical situa- 
tion in chronic alcohol or nicotine poisoning, and affects males more 
often. Here the course is a chronic one, spreading over several 



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ytSKASES 



tE VfSVAL APPARATUS 



255 



months or years. The blitnliu'ss appears slowly, and at first fonslsta 
of a (vntral si-ntonm for ctilors. or of a hriiicralopia, the patient spping 
better iiL the dusk than in the bright light (fatigue). The sTOtomata 
be<-onie more marked if the poi.si)niiig continues (Kig. 132). 

The type iif secttoma varies widely. Bilateral, fairly symnietrical, 
oval scotomata for red and green, lying between the hliml spot and 



L R. 

Ftn. 132. — ftrotom* for rvd and cmMi in toharcu axiul nniritis. (WUhratid and Siofw.) 

the fixation |>oint is the early picture. It ustially Htarts a^ a defect 
for red, stretrhing toward the blind spot (Fig. 133). The chief defeet 
usually lit^ nlH)ut 2° to 8^ fnmi the fixation imint. Alisoluto ventral 
seotomata are rare. 

The ai-uity of vision is usually diitnnislieil, and more on one sitle tlmn 
the other. In munueular rea^Ung the tyjte to the right of the fixation 
point is not eleiir for the right eye, while for the left eye the defect lies 
to the left. The defect in vision bears little direct relation to tlie size 



L. R. 

Fm. 1S3. — B egj nn i u g «<olonui far rvd it the onwl ol m u>b*oi*o or aloobollr nxial neuritk. 

(Wilbraod umI Sftnan-.) 

of the scotomata. Pupillary an()maHes. diminution of Ixith light and 
aceiiinniiMlatioii n*flt*xe-* ami p.«cudotalK'tic pictures are to Ik* found. 

The fumhis picture may Ik- normal with gross defwt in vision and 
Urge scotonmta, or there may he h>-peremia. a. mild neuritis, with 
Miinr lemiHiral pidlor. If marked pallor Ls present it sp«*ak.'* in general 
fw ■ more severe process. 



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WsBAStSS OF THE VISUAL APPAHATUS 



257 



llcreilitary syphilis plays a role in sonic cases. In others there b 
an anomaly in the perm plasm. 

(6) XntdTStitial Peripheral Neuritia. — Here the dueaae involves the 
periphery of the optic nerve rather than the central or eccentrically 
lying paplllomaeular bundle, roneentrie limitation of the field of 
vi:>ion for white and color* is the chief findiiiK rather than central 
scotoQiata. Here there b a peripheral inHninmation nf the nerve 
trunk, startin}; in the pia and prweeiling inward in the septa. 

The concentrie limitation of vision Is rarely observed in the beginning. 
As it slowly advances the patients become uncertain of spaw loculisia- 
tion and need to turn the eyes frequently to get clear pictures of 
the surrounrlings. Central vision is iLsually sharp even for color. 

Tlie fiintli show simple or neuritic atrophy, occasionally choked 
disks. Ver>' variable 6elds are oWrved (I'igs. 128, 129, 130 and 131). 



'^^ 



L. R. 

Fm. 13fi. — Vuninl fiddH iii n iMiliml with herpdiuiry uual Dcuriiu. FJAlda fur whil« 

nortnal, for blu« . nod for nd emwentmally ooairacl«d. Ahaolutc raulral 

■cMwmui wiUi lATVPf bonlertnc ■cotoiDS (or bliM and red. (WUbmnd and SAnjccr.) 

Hysterical limitation of the field Is to be con.sidered here. Nonnal 
fundi are consistent with a true interstitial neuritis, sinit* lesions lying 
far l>ack in the ner\'e trunk may cause little or no ilisk <-hanges. A 
psyehnaiialytic niiHnineMs usually will clear up the diagnosis of a 
possible hysteria. Talx-s with neuritis may liegin as an interstitial 
neuritis. The cytobiological findings will establish t)ie diagnoais. 

FMiilagy. Syphilitic meningitis of the l>ase us the most frequent 
cause. A negative \Vas.sermanii in this group of patients is not a ju.st 
criterion lo deny sin-cific medication. Other etiological facton arc 
measles, diphthcriH, inlluenza, myelitis, gonorrhea, sinusitis, t>i»hoid, 
lead, arsenic, lUabetes, leptomeningitis, cerebrospinal and luberctdous 
meningitis. 

The therapy Is causal, usually specific. Arsenic or salvarsan or similar 
synthetic is less to Im? feared than an active syphilis. Many so-called 
neumrecidive.s causing blindness arc due more to the s>philis than to 
the ftn»enic content of the drug. It must be remembered, however, 
that arsenic Is capable of priNluctug an interstitial optic neuritis. 
17 



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260 



CRANIAL NERVES 



T\\e infections and toxemias mentioned in the prrceding paragraphs 
may al.st> iiidiuf! a total optir neuritU. Malaria, scarlet fever, yellow 
fever, erj'sipelaa may be added to the causes. Orbital sinus disea,** 
is iaiportant, and alyo multiple sclerosis (Fig. 13^). 

Other atrophic states, double, one-sided, total or partial, occur, 
eithcrin the papilla', from pressure of a jjl^njcoma, or maybe descending 
atrophies from higher lying causes such as brain tumor, hydrocephalus. 
Primary proKre^^sive atrophy, arising by it.self. probably does not 
exist. The most suggestive cause of an isolated, bilateral, progressive 
optic atrophy ultbout other tangible neurological signs is tJilies. 
Cjtobiological tests will complete the diagnosis {Figs. 141 and 142). 

B. Disease at or about the ChiBsm.— Tlic anatomical peculiarities, due 
to the cn>sainp of the fibers at the cliiasni, Introduces wrtain definite 
signs which are of value. Scotoniata an<l concentric limitation are 
replwed by hemianopsias of varying tyjie. 



M 



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OS 



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tai 



too ut '" "» "*> 

Flu. 143. — Quatlrant bciiiiauupBia of li^wur cigiil xutuucul iluv w )^vn^^>T^hllfpc cIcelrucUon 
within the cxtrrtinl itniiculat«>. (8ce ft^uwing ti£ur(<#.) 

In legions in front of the chiasm bitemporal hemianopsin v:W] he 
p^«•^ent. This is rare. A lesion liehiiul the duasm, usually in the 
sella tureicn, and not infrequent, as in pituitary disease, causes a 
binasiil hemianopsia, partial or complete. Lesions to the right or 
left of the chiasm will caiLse hicomplete homon\Tiious hemianopsias — 
whereas lesions in the tract back of the chiasm — /. r., in the midbrain 
or optic raiiiatioiLs or oc<'ipita] lobes will cause a nsually more complete 
homonjTnons hemian<ipsta. 

Horizontal hemianopsiiis, either superior or inferior, occur in chiasm 
lesions from pressure above or below. They are readily explained 
from the position of the crossing fibers in the chiasm. Such hemi- 
anopsias may rarely iRrur from retinal causes. 

A common cause for chiasm clianges is hy])ophyseal tumor. .Sj-philis, 
however, is specially frequent in just this situation, most basal syphilitic 



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meningitic processes l>eRiniiinj!; here. The process spreading forward 
to the optic stem produces a multiplicity of field cimnges. Tbu.s one 
mny have partial seotomata, monocular temporal hemianopsia, bitem- 
|Kjral liemianojKiia (the most frequent), temiMtrul ht-miimopsiii with 
bitndiiesa of one. eye, bUndne^Ls in one eye and nasiil hemianopsia 
of the other, blindness in both eyes. This very great irregularity 
and changeability, advancing or receding under trcAtnient, w of 
much importani-c in excluding a hypophyseal tumor. A lois of the 
hemiopic pupillary reaction is of importance in making a definite 
lucalizing diagnosi:;. 

The papillary chaages are variable. Other signs of basal s.\-philitic 
meningitis are discus.se<i in t}ie chapter on Cerelinil Syphilis (7. r.}. 



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Vua. 14(.^-SiU! ol IrMfMi in ext«riiA! iceuinitaifl xivioit riav tu <iuiiijniiit boininnuptin iraa 
in n*. 143 and Ute toicondivrv (loeNicniUuiw in Ki<. 145. C. am. rxl.. «iUinuiJ geiiicutnt«;i| 
Airm. buuorrhac*; C.i., inunul «ipauk: f.S., AMUrt of Sylviiu; li.S.. optie ndiAtli 

Affections of tlie chiasm ore more rarely enaiuntere<l as a result of 
traimta. brain tumor with general pr^'ssure. cavcrnouj* sinus disease,, 
cerebrospinal nn<l tuWrr-uloiH meningitis, bone disciuHc, ancur'ism ai 
artcrios<'lrrosis of the carotitls. 

C Th&luntu ZMseua.— In legions of the optic tract posterior to the 
pulvinar, i. e., in the optic neuron of the fourth order, pupillary dls- 
turlwiruTs an* absent. Tints Willhrand and Wernicke (thn-e years later) 
luivc shown that by careful illiuninatinn of the blind side uf the eye one 
can distinguish between hemianopsia in the optic neumn of the 
thinl unler (by Iusm of pupillary light reflex) and a hennaiinpsia of the 
optic neuron of the fourth order (intact hemiopic pvipillury reflex). 
As a matter of fact this test is extremely difficult to perform, but 



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forttinntcly lesions in the midbrain— cntl-statioii of optic nmron of the 
third ohUt — arc almost invariably actompanied by other sensory signs 
(usually a complete or incomplete thalamic syndrome, q. t.), thus aiding 
in thfdiapiosjs. The distribution of the nptic neurons of tht- third order 
an- multiform. Some fibers end in the corpora quadripemina. Lesions 
htre cause pupillary <'liange.s; others end in the thiilanuis fpulvinar), and 
their involvement ransi-s no tli.Hlurbanees of vision. The majority of 
the fibers form their synapses in the external geniculate bwlies. These 
form ric-li collateral asswiationri with the audii()ry tract, the sensory 
triKts. the three or four oculomotor nuclei and throuph the median 
1onF;itu<linul fasrieulus with the synapses for the cranial and »pinaJ 



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F»i. 1-15. — SlmwiuK iitr'i|fhi'' iJviEvneraliutui in 'f[>lii' nulLilioiix iatr.) (mm titminrTliuKU 
in oxif-mAl Kniii'-iiliito (l-'i|[. \\\), inv'inK rise vi qitunlriint homionnpiuii of Fig- \^Z- Cwn., 
ciuiuur; Vaic. riilc«rine (ueure; fi.i., iulsriur longitiKtiiiiJ fiufcii^liui: i. Iitft hninusphore; 
atr., Btrofiliy. (Hwibi-Iu'ii.) 

nuisrle Hbera. (See Plate VII), Hence lesions of the optic tract in 
the genifulate region cause not only hnmonymous hemianopsias, often 
rvniy (puidranl, but they are also liiibh" to be eoinjilicutcd by the 
involvement <if tlu-se other iiear-lyiii^ strnrturcs. Isobited (piadnint 
hcminnop.'iins mity result from small hemorrhages, thrombi, emboli, 
tumors, or eruTphalitis (poliomyelitis — rare) in .the external geniculate 
as well as from lesions fartber back in the tractus (Kigs. 14^!, \\\ and 

J). Cortex Diseases. — lesions of the end stations of the optie tract or 
its associated areas in the occipital lobe may caiise mind-blindness, 
1. e.y optic* agnosia. Here the patient may have no disturbance of sight. 



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DiSEASRS OF THE OCVWMOTOR KERYKS 

or he may have partial hemianopsia, but i» unable to recognize words 
or objects previously known, s(»eci-h being intact. 

\'isual hallucinations are present in di>iorder of the optic end-stationa 
in the oc(>ipilal lobe. When they show definite j>rojeetions in space 
one can make an approximate lociiliz-atioit of the ]x>rtion of the lobe 
involved. This may be of value in rfetennining the site of a tumor 
or abscess formation. 

The chief arterial supply of the posterittr neurons is drawn from 
the calcarine branch of the posterior cerebral. The moiit oecipital 
porticm is suppUeil by tlie median cerebral. The anterior cerebral 
sends branches which innervate the optic radiations just posterior 
to the coqjus cnllosimi, but lesions of this artery at thi.s place cause no 
definitely recognizable lesions. 

Recent experiences in war surgery are permitting a more compre- 
hensive mapping of the cortical representation of the different parts of 
the retina. That of the macula in particular ha.s bt^en specially studied 
by Ilenschen, Bolton, Inouyc and I^enz. The studies of Lister and 
Holmes' support Ilenschen s and Inouye's view that in lower quad- 
rant hemianopsias of cortical origin from gunshot wounds that the 
upiMT halves of the retina* are repn-scnted iu the upjHT lips of the 
calcarine fissure. (Fig. \Ai\.) In cases of honicmymous hemianop- 
sia with iviitral scotomatu tlie penetrating lesions caused injury to 
the occipital lobes or optic radiatioiLs of one side and passed through 
or near the tip of the occipital ]M)Ie of the opposite hemisphere. 
(Fig. 147.) Central vision w probably represented on either the mesial 
or the lateral surface of the posterior poles of the occipital lobes. The 
macular fibers arc probably not represeiite<l bilaterally and are cortically 
Im'uli'/u'^l in the jKisterior limits of tlie visual areas, probably nn the 
margins and the lateral surfaces of the occipital lobes. It is proliably 
Iwause there is an overlapping of the mi<hlle ami posterior cerebral 
arterial supply in this region that cerebral hemorrhage with visual 
defect so rarely involves ihe macular regions. 

For further distiif^ion of the ci>rtical disturbancefi of vision from 
lesions of the temporal or occipital lobes see chapters on .\phasia, 
S>7ihilis of the Brain (I'aresw), Brain Tumor, Hemiplegia, ThronilMisis, 
Arteriosclerosis, etc.* 

DISEASES OF THE OCULOMOTOB NERVES. 

Ocular Nerves: Third, Fourth. Sixth.- Uisonlers of the functions 
of these nerves are l>est dLscuss<'d under a general head, since the iLsual 
ocular }ml»ies arc often complex syndromes iu which one or mort; of 
these nerves arc involvcil. 

* Sm iMXet mvi Holmni-. DUlurbaiiooa la Vishjii tnun (.'fiivhral I^mods. Proo. Roy. 
Bm., 8ert. oti Ophlhalmnlocy, Miuvh 33. I9]0. nno of %\» many iUununaUns patwn va 
liib lopfo. (Sm aim Bniin. vol. kuu. p«rU I. », Ifllfl. 

■ 8so Wtlhrmnd uid Binanr and Hauiriitta In Lawiindoi«>lcy'» nukdbuek, vol. iU. 



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Thf tlilnl ncn'e is a motor ncrvc for nil of the mu.tclcs of the cye- 
hnll, save tJic cxteriml ri-ctus. ami tlit suix-rior oblique, which hitlCT 
rttvivc tiifir motor fibers from the sixtli ami fourth nerves respectively. 
Tlic tliird nerve also suppUrn the levator palpchnv, the ciliary muscle 
ami the coiitractinjj Hhers of the pupil. The dilating fihcrs of the 
pupil receive a hraiich from the sympathetic. Deep sensibility filient 
al^o puss in the iimtor riMits.' 

Third Nerve Palsies.- These are often ver>' ci«nplicate<l and may 
be central or peripheral, complete or partlitl. Complete paralysis 

of hot h thin! iuT\cs is nire, partial 



palsies are the rule, liiilateral 
palsy of all of the exteriml muscles 
Kuvenieil by the third nerve 
(often termer! oplitlialniopleRia 
externa) is iliie usually mily to 
a lesion involving the se<*or«I or 
peripheral motor neurons of the 
third nerve. Bilateral external 
ophthahnoplejiia may occur also 
from lesions of the mesencephalon 
and cortical oculomotor |)aths. 
The chief causes for central palsies 
are various ty|)es of enwphalitis, 
polioencephalitis, cither infectious 
as in Hcinc-Medin'.s <lisease, or 
toxic as in alcoholism (Weniieke's 
|M)li[)en<;ephalitis superior). 
.Syphilitic thrombosis may cut 
otT the blood sujjply of the 
nuclei. I'ressiire friim the aque- 
duct above, or third ventricle 
may cause pressure palsies, usually of irregular distribution. (Noth- 
nagel's Syndninie. I'irieal Syndrome.) 

Peripheral prtlsies are more frequently due to disease at the base, 
u.sually basal syphilitic meningitis, tumor, tidnrculosis^ heinorrhaRe, 
traumas (rarely) or are occasioned by involvement of the fibers as they 
pass throujjh anil about the red nucleus by tumor, multiple sclerosis, 
or when Implinited in a thponihotic or heniurrha^'ic softening of 
the ccrebrnl peduncle - Millunl-Giiblcr. Benedict, Fnvilles' syndromes, 
red nucleus syndromes. (See chapters on Midltrain for (jescription 
of these syndnimes, also see Fig. IHO.) Infectious disease neuritis 
may also ownsion peripheral palsies. I*re.s.surc from aneurbm of the 
internal ciimtiil, ami throndiosis of the cerebral sinuse-s (sinus caver- 
nosus) may also cause peripheral palsies, A special hfr|H*s znster 
ophthalmicus is known. K^ophthalnnc goiter and diabetes are special 

Sliorrinutoniuicl Toiler: Proc. Royal Soc., 1010. 



FiQ. 149.— Cerphral syphilia plo««. Third 
nerve iiuloy. 



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U.HBS OP THK OCVWMOTOR NRRVEH 

causes. Transitory third norw paUics occur in tbt- disonlfr known as 
Dplitliiiliiiiiplenic Dii^aim' {q. t.). 

Syndromea-^The compouiul character of the nuclei and tlie loosely 
iirranjicd bundles luuking up the nerve explain the jireat range In 
s\nnptomatolofty. OlxTsteiner (oth <-dition. 1012) follows Hcrnlicimcr 
chiefly in his teaching regarding the complicated question of the local- 
ization of the brain stem nuclei.' Thus it will he seon that from before 
bat kward ibe nuclei are arranginl as ftillows: levator paipehni*, nnlus 
9up<;rior, rectus intemus. nblitpius inferior, rectns inferior. trtK-hlcaris. 

A complete unilateral palsy, probably nuclear (ophthalnioplegiii 
eompleta). would then cau»e ptosis, wrinkling of forelieul on same 
side (from effort to overcome ptosis by (Htipit(ifr»>nt«Iis), wide pupil 
from involvement of the FCdinger-Wostphal niK-lcus). irrcsixmsivc to 
light and accommodation, eye turneil outwani and slightly downward. 
Double vision is present and some dizziness in the early stages. A 
variety of individual muscle palsies may also result from either nudear 
or [leripheral involvemeiil as iiuiiejited- iijilitlmlmoplrgiH extrrua, 
when the pupil is not invol vc<l ; ophtluilmoplcgia interna when only the 
internal ninscles are Involved a rare ci>ndition. 

The distinction of nuclear from peripheral palsies is visually made 
on the basis of accompanying symptoms— sensory or motor, due 
to implication of the h.tl tuH-lens, i»r of the i-en-bral ixduncles. In 
tlK- absence of these accessory symptimis (\Ycl»er-(»ubler, Hencdict 
syndromes, nibrospiiial s>iulromes) the distinction may be imiKissible. 
There is no single disease process to which the term ophthalmoplegia 
may be rigidly applied. Hencv tiiere is no general course and no 

Ceral treatment. The various jialsies must l>e interpretetl on the 
is of the d>niamic factors, and the treatment must be founded 
upon the caa-^ation. Syphilis is responsible for the majority of these 
palsies, and calls for verification by the cytobiokigical tests and prompt 
Bntis>']>hititic trea(n»ent. best by salvnrsan and hypotlcmiie injei-tion 
of mercury. (Sei- chapter on Syphilis of the Nervous System.) 

Isolated involvement of the pu]iillary ap[>amtus may be disMUswd 
here. ContractCil pupils, irregular pupils, unequal pupils, dilated 
pupils, etc., have been disnisscd (sec Symptnniatolog>*). .\ filiated 
pupil with loss of acconunodation reflex is infrequently seen in severe 
sUfjholism (Ki>rsakow's syndrome). It may be present also in opiic 
nerve tlisea.se — ix>uiblned with hiss of light reflex as well. A loss «if 
light rcHcx with preservation of the aceommorlation reflex (reflex 
iriduplcgia, Argjll-Holiertson pupil) is a frequent sign i>f syphilid. Its 
mechanism has been dl'^cu^scil. It is often unilateral in the Ix-ginnlng 
of a tal>es or paresis, or other lyi«- ()f cerebrospinal syphilis anil may 
occur in a number of other conditi<ms, though rarely. In wrchral 
s>*pbilis it usually l>ecomes double. 

• Sm Kidd. Rfv. N«ii. uid Pvch., xi. A07. 



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Fiii. 15[), — KwvUKm* nyiidroriHM. with lUJUirior iini] i>r>,iU>rKir pontine ■yndrorani. 
Hcmiplesis. cerehral tyjw, with (a) conjugate deviaiioa of the li&aJ and eyca, (h) by 
Icsioai of the upper pi^rtion of ttiv puus, rijthl side, liirolvina the Bntciiot portion of 
the pon.t and i\w reginn of the tegmentum. On tli» loft sultf tht-7» is a cnntralatcral bemi- 
plefttii cif thip IldiIm, of th» Iowm part of tiw tiico «tkI of tlie totiipi'?. beoauw of tb» involvi^ 
nifitt (if the pontine pymniulnl rilH>n< Py (fvirtJi-oiipiaal pynkmi<lu] filicrii. mrticonucleur 
facial and hypoftlomnl fibers). In ■:, rinht-hand fiouro, thorv is a aiiude Iceioa which 
invrilvcMt.hc IVKmr-rituTtintitKuiit^'ni-inUTiui] iiiigEt! find iliMlmyN l.tu'. httntl' turning (cnpKa- 
loitvrir) and eye tumin* (oculonyTic) filwrs of thr* rialit side wlijcli at thia level aro ntuated 
iu thi) |H>H IvnuuBLiu und tho totvriwl purtiuu <>( tlic luudiun till«l Ki^ini rijn to majuiftta 
deviatioTi of the bend and of the vyca. By rnuum of thr< [irfilomiitaiit action of the antoco* 
niatfiChDhcadisiticliiiod to thnrifiht and thcoyc^lmk tothpriihl, tho pkticrnttooks to tho 
aide of the leatun. In a there are multiple iitotated IcMiona. Fnur lari^ foci in the anterior 
portion doairoy tho pontiuff pyruiuidiil fibers with a rcBultioK croawMl contniUlcral hmni- 
ptr>Kia of tlie rxtn-mitiei, tha fiitns, and the mupiP. Another foPiM nrfiijviM t.hn [nintorinr 
iu(«nial v-JZll'Mi nf the t^ipnonlum and deslrnyit the inUTxiuelvnr oi-'uloiOTie fibers of 
thp iKi»t«'ri(>r loiiKitu'liiiid Hiuudlr' wliii-h din-ctly uniti>?" Hip niiHci iiT iho sixth utid third 
uervc!! and tice itrtu. There letiultd a paralysis of tlio eyeL»alls bj' wtueh th^ (Minuot 
turn pidewiM toward the right — right omiiurotnrj- paralysis — by ronsM) of the prediunii- 
aanco of thi» niitHROniMta lh« palieut loubn U> the left. Th» pnUwtt looks nwny frr.>cii tlie 
Imioo towani thv paralytixl uicmlKm. The cortical oculontary fiben atid the pm lem- 
nuciu arc intact. For deLaLlA of atiucture and iibbroviaiioD*, M« chaptat ou Midbraia 
Lesious. (Dejorine.) 




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ilSEASES OF THl 



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269 



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Fill, l&t.— PonliniF tjiitlnMnc. with vjp palMra Mt c(>ntral urwin nm] a)Tiiiiti>ni>i)ti« i 
cndation. Then ta linv b warned bcmiaiuatluHift with alu^nintinB imralyBiR of the 
Yl aad VU cfsnisl n«r\-M. aoMlhcaU ot Um V uhvo due lo hemorrhftKe in th« lal«nJ 
And lutror pitrtuin of the poaliiic) tegmcnUuii of ttie left udo. The rioMrJutmt fi^ma 
ftlunra the hemJABMUiMi*. dlMoHaUd lU in nipinQomnfiin i hmniRtifllsMda Bnd hemU 
ihnnniuMii ill mill iIub lo loMon nf ihn ctimmmI tienmiry pMthwAy-H mI iIir latonU |)»rUim of 
Ihfi rvLictiliu' fnnnntHin. Thcnt is pnwcrration nf lh« iHctilo nnd [MMliiml aMMiitiililim 
AtuJ of Iho ttervUBiKwtio acame. Lo<muo of the iiiouraiili-M' «sleiu>iuu u( Uie ledun tu tfav 
iii4wltAn lemnurus (ffm). Tb« Uft-hattd figurt showa I'l) aln>phir t>Bnl>-si4 of iho VII 
atrxv vrith rMntiun of tiBCHMraliOD. Iac(>ptilhfilinta. ilnxipins uf Dhi bp«. Uni nf (arial 
uiimtrr. pualyw of the catini left fsdul I VII) in(lii-af«fl (a); (2) »iu>thau of 
th» f«««, f^iUowinx invotmi)«Rl of th« dtMcvculiiut nmt of the Uimuiniu (im V on «') ; 
43) panilyi^ nf the cvtrnml rfx-tiiH vHth winvergcut stnblaonu by rauoa of tlit o«ns 
ftrtloa of tbt> notair^itifU. Kurtbcrmorv. there it s ponljw of the latenl tnovemoata 
of the oychnlU Ui«unl liu' Ml mitwillMtiuiiling thi< liilcicrity nf the p'wtf-mr liHuiiuiiiiuU 
tisoloulua (Flp^. '*l iho iiu<'lcm" »( the VI und of the adj]ir«nl >T'li>nilMr f'>rin>tion- 
Thtf Iniun of Drilpm' nuflciu. anil of ihe Uhyriiilhine oriilnrfilno' (itx^n whlrh unllo 
Dritnn*' inirlens {Sfti l» iho iiiiHri of iho III »ihI VI r«itNn* ihU. By roMnn <>( iJiA 
o^-vrartpiin of Uic nr>(»KiiiiMa th» palinnt I'MiIu Hi the ricltl. (ATlfr I>ej«nti«.) For 
ftbbnvuitionfl of the anutomiMl akfUh mo section on Midbnun. 



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271 



Ilypfniictropia is the tmial i^ndition of the child at birtli. At 
tlin*e cmniftnipic- vision is the ruk*. Pen*isteiHv nf tin- hypcnnt-tnipia 
is B vi'gctative neiirologiral sipn ant! is fn-qiinit in vagotonic individuals. 
It has also a psychir n>ot and tlic hypt-nnetrupic eye always sees the 
world difTcn:nlly from the fnimctro])i(' eye. 

Chronic Progrtt^itf Eye Pahirg.—Thvae niakc up a spitial group, 
occasionally mnjrenital. more often they are a part of a prtigressive 
anterior pll^n^lnyeliti^. (Uulhar palsy, q. r.) 

Fourth Nerve Palsy. ^The fourth (trorhlearis) nerve supplies the 
superior olilique muscle with its motor fiber*. Aiferent fibers carry 
deep sensibility fil)ers from the muscle. The fibers arc crossed and 
uncn)sscd. the latter Iieiiig phylogenetieally IIk* first to Hp|H-ar, hut 
later are ovcrsha<Ioweil by the crossed fibers. Isolated palsy causes 
a marked diplopia, and some dizziness when the patient loolci down- 



KlU. lift ^Plllull -11 iW tin- InllI ( 1 1 ll|-(Vt.- 

luability ui luok down. It will kx tk(it«l 
Uiat a» lliv rv«linll (loo* not turn iluwn- 
wmni ilic pyHiil <Ii>«.>« tint ilMcend; ul Uw 
HUM time the |iuiK>(it cMi clow hU eyoa 
when loll] tn do m. i KusHl.) 



Flu. Iji. — I'limlyrisi 'if ihv (ourlb 
nam. Tb» suov pativnt Ho«ins his 
ftfM at oommuiid. Utuwull.) 



ward ami outward. The false image stands lower and nearer than the 
Inie one, its upj)er eml incline*! toward the true iniaKc- l*<ii'king 
upward or downward causes no diplopia. These imticnt* have 
ditTleulty in dcMt'iiditig stairs, and they incline the head forward 
and toward the ^nind side tn adjust to tln'ir flijilopia. 

The fourth ner\e is frequently involved with the third and sixth 
in ba-^l inf'amniutiuns or new growths, or may Ix! involved inde- 
pendently from pnssure in the posterior fossa (cerebellar tumor). It 
also is involvetl at its nuclear origin from cnccplialitls, poliomyelitis, 
toxemias, etc. iFigs. l'»iiHtiil l.'(7.) 

Sixth Nerve Palsy.— This is |»erhaps the most fre«|ueni of the eye 
imlsics. The peripheral motor neuron is exjiosed for 1 hrei^f ourtlis of 
an inch or more on the Imls*- of the skull, and is therefon- suhjcrted 
to greater jKissiliiUly of local pressure than any other cranial nen'c. 



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When the external rectus muscle is paralyzetl there is an internal 
Btrabisnius and a slightly smaller pupil in the affected eye. 'I'herc is 
also a diplopia. 

Sixth nerve palsy more iisnnlly n^sult.s fmni hastlar disease, fracture 
of bajic, meninjfitis (s>^)hiUtit■ anil othtT tjiics), tumors not only of the 
base hut ab<) of the Ijraiu sulKf.tanix' itself. Nuch-ar iav4)lvt'uient is 
seen in encephalitis, poliomyelitis, toxemias, etc. External rectus 
palsy as a result of a myositis is not unknown. It may also be a 
complication of severe migraine (periodic pal.\v). 

Cetttrol Mofor Xcurons. — Isolated eye palsies are due to nuHear 
or to periphenil invnUemeiit of the third, fourth ami sixth nerves. 
Supranuclear diseuHe of the oL-ulornotor jjatlis dues not result in tlie 



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Fin. 158- — Pomlj'^U of upwunl mok-finont of tho vyv», H|i>>i.vii>t( tW oxcc^vft wrinldlnc 
of thv [oiehcad la the attempt to look up. Sknif dc^'iatiou. CHulnim.) 

loss of fumiion of n single eye, much less of a single eye ntu.'^cle. Such 
lesions between the ocidomotor cortex and the nuclei in the midbrain 
cause complirated disorders of the fUK/riated mmfmriit^ of the eye.-*. 
The ino.si fre<|uent of these are: (a) ciiujugate deviation, (.6) lateral 
assoc-iatrd palsy, (c) vertical as-iociated palsy, (</) loss of convergence, 
(e) central nystagunis, if) irregular ty|>e5. (^ee Plate VII.) 

(n) Conjugate Drviaiu»i. — -Here both of the eyes are directed tn 
the side of the lesion, and cannot be voluntarily moved in an npposite 
direction. Yet, if the eyes are fixed upon an object and the head 
is turned away from the lesion, the eyes will turn in the direction 
which voluntarily is impossible. This is termed conjugate fleviatifm 
of tlie eyes and head. The eye axes may not l»e tnily parallel, but 




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THB OCULOSfOTOn SERVES 



273 



may diverge slightly. In acute apopttixie^ this syiuptoni is <>ccasion- 
ally seen,^. e., forced deviation of tJic head to the side of the lesion. 
(See Kig. 150.) 

Lesions of the inferior parietal, nngular gyrus, and possibly the foot 
of the second frontal gyrus may piiKliK-e or octusiou this type of 
forced position of the eyeball. 

Lesion of the centrum ovale, and of the internal capsule involving 
the projeetiou filjors of tlie oculomotor may cause conjugate deviations, 
here asstK'iated with hemiplegia as a rule. The chief lesions eau.sing 
conjugate ilcviation are: hemor- 
rhage or softening, abs<«ss, enceph- 
alitis, occasionally tumur. 

(6) iMltrnl Afiimcinte<l Vnlxy.— 
Here the eyes are unalile to pass 
the middle line. The altered 
position of the head as seen in 
conjugate de\'iation is absent 
and movements of the head are 
unavailing in bringing the eyes 
past the middle line. Conver- 
gence, however, may remain inta«,'t. 
Certain incomplete conjugate de- 
\'iations are found here. 

I.atenil conjugate paUy is usu- 
ally due to a pontine lesion on 
the s«de of the paUy, and which 
implicates the alKluceiis filx-rs near 
the nucleus, and the synapses of 
the jHrsterior longitudiuHl bundle, 
jHjtwibly lA'wandnwsky's tractus 
pontis asccndens. Pressure at a 
distance may also occasionally 
otusc a lateral conjugate palsy. 

Fractures, pontine tumors, multiple sclerosis, softening (after 
labyrinthine infection) are aiuong the causes of this comparatively 
rare comlition. 

fr) Vertirtit .\jiin>rinlril PaUy. — Mere the motion of both eyes is 
hindered only on looking up or down— all other associate^l movements 
are [Missilile. Wlieu there ii loss of ability to look down usually the 
eyelids do not ilescend as they nonnally do. In some patients the 
palsy is not sjnnmetrical, one eye moving up or <lown more tlian 
tin* other. 

C 'ertain forcwl positions of the eye, one^ being higher than the otlter — 
(Magendie-Mertwig |Ktsition) may lie mentiiine<l hrre. Tills syndrome 
often {Mtints to implication of the middle cerebellar pe*lunele. The 
side involved is indicate*] usually by the lower lying eye. There is also 
nystagmus. 
18 



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KXPLANATION OF PUKTK VII. 

n*e Owilorotary Paths and in I'articular tlie Innervation of Uic 
Muscles which Turn the Head. 

AbhMPiatiaiu.~BT<J't, arms of anterior ivwi>«>rii riuadriRpmiiw; C. the coeWea with 
Bpiral piDiJiun. lliu mH-'Iilcor bmncb uf tbo Vill iinir, Ca. luitcTKir liorii ui tlie n[iiu« 
«)rtl; Cgi; ««it«ni:tl |innirulHt4>; O, i"tta nwliform btxiy; Cio(Rm) iiit«<Jirarj- rrffirm , 
ul tliD njodiillu Dtnt.-iimris ihv iiioJiikii IrRitiiwus: Ctrl, ralrolcuticuUir WKninnl »f tfaaj 
intMtiAl c/kpoulc; CojV, cortironuolcnr continjioiii of iho rynmiidat tmoc. CA'fff, saaitlAli 
view of till' orHiMU)ii>m]>oral loliea; CV. viaiial nrva ul the mUTiml fare of the hemi-j 
tphen, tmiuq^urciit via*'; CI-II, Bwt and nw-oml ovrvKtU itoir; DC. «aitcr uf conjumiMJ 
deviation of the hencl and nf th^ i>ym; />rj-f, richt ritcmni rrotus ntiiKrIe; /Knl. rij^it 
int^iriinJ n>rtu» muM-lo; Fa, nwcndiiiK fniiiuil n>ii\'ulutiun: Fi, Ft, Ft. Ihroo fntntnl 
mn^ilHlinnm; fap, ]w»\cnoT and intrrnn] arruat^ fibers of the medullit; Ftp. pnHlorior 
lirnintiidiiiiU fiwrinilmt; /tg. tovtafjimitl filnpra; zl'i, PCTitnJ or semndary IriceinilUil 
lialbvru)': 00, GaHacriiiii |;niifcliaii ; G. Sc, S«-ur|m'n KiiiiKl>'>iil .Vflr, BL-chWrrm-'n iiuHeuff; 
.V/J, Dfitlers' iii.ii'Iciin: YI'ji, wnwirj' Irijti'inJiiUK iitirliim; .\'] 11, oi'iiLiiitiiilJfr iiLirIi*ii!<: /// 
pair; A'V/, nudciu> <7X(rruiU rectus: W'lIIc, iinU'rW tertnijtiil nudciis <jf the rc»<:hl(Mif; 
A'r///p, trinnitiilfir iiuHniH of l.hc vvatiliulnr: .VA"f. spiiin! ftcrwwar:!- nuH(^im (l.mpiNttitH- 
sli>nic>deidoniu«toid> : On, miperior oHvr; /*). /*». t(U[toruir and itdi>riiir puriclul Udie; 
fffl, nATciidiiiK imriptiil <N)nvuIutJun; Pe. aiiRiilar fOTiut; /'n', inferior rcrctx'Uar pcduncjo; 
Pcm, Rudtlle ran-licllnr |iK)l(iiirlf ; Pul, luiiviiiur; Qa, Qp. iiiilorior niid iMnl^^iiir i»r|)fini 
qundHitctniuu; It, fumurv uf lUilundo: ttoHm, reidou uf DuKJlati Icmniwiu: Rt. lutcral 
li'miiLM'iis; Hm, ihihIihii IrtnniM-ns; SqH. fEvlnllnixw milmtanri' of Itolnndi): Sft. rtrlirulur 
MiljetaJiPe; SRq, uray n'tinilar eiilmliiii'-e; 7'i , Ti. Tu teiiiijorui i-oii volutions. Tr, IrapewMd 
Iwdy: v. vNlihutar iicrve; Vt. Vt. Vi, ihrre linmi^bod of the triKeuiimu. nphtbslmic. 
fiiiieriiir iinri inferior tiinxillnry ; Vnt, duM'riidinit niitt, of l-he tn4!*'iniiiuii; z.W. Ltrjcnietitnt 
trniKniiiK fil Mcynrrt; XII, t>]»lir nhisuim; ff/, ornltmiutor; VJ, oKtemnl n>i'tti»; Vlllc, 
iijclilcvir liririnc.hi's uf \iw umdiluo': VlHv, vmlilmlnr; Xt, Hpinal HeecsMiiy. 

Th« toiaueutiuu iti its medullary, iiniiliiic. pcdimcutKr (.^rlioita aeeu in projection Bt 
the level of iJie aqueduct of .Sylvias and the fuurth veolrtrln, with the retinilor famiation 
(HR), lL« pantvriur loiiRiludiotil fiLneieulua (Flp) aiul llie luvdiitii kiitiilwus {Jimi. It 
b timiUYt iatefnlly l>y the InC-rul IcmTii.iriin iRt). roli>red in ycU'in-. iind the |nii|t Mtmtory 
iiU'Ui'i tif tin- tri|«'iriiniis I V) and of the auditory- [I'llh nerves (.Vl>. S(j}{) wilurod omen, 
nnd in yellnw [Xl'ftte, \'Bf, ?iVtHr, ND) aod showiuK eai'fi side nf llic nutlinn line: 
(I) alKne the mirloi of ilip /// imir (A'///) which iimcrviilo»i by croaHed and hy dirwi. 
Bltcn* th<!iiit«rn»l reiUj-i id tlif eyt-; in liii.- renter. Ijjo nudui of llii> Vt pair (.V|'/j which 
inmTV»U*B t\u' csti'niHl n^Httit nl the eye, iind (3) Ih-Iow, tlie ■■eiiluiliimtary imrtci whlrli 
bpI U> rtilalt' iinil iniltiit- llie liwid nnd neek; npinid tiucl«-i nod niiinal afccsaory .VXI, 
ami omtor cetilcrH nf ibv rrr^-irid eurd {Ctii. 

Xlyeliiiutni early arc the filwra wliieh unite the nuclei of the sixlh uiid uf the thin) 
pair and uf their aiwu'ialed fihen tn coahle the Iftieral oiorenients of the vyo to Inke place 
ill the oariy t>Liiitis< <*[ life. Tlirtte inttmurSrar fiberv. colnrvil in red. lake their orinn 
from small colls in tho niielai in the otulomolor, Ul and nbdueeiui W. and pajiw by meiina 
of iJin poplerinr hniKitudiiirU fa«eli"uliu<: llie niniUl itntkElioii cells of tlie niti'leiin of iJiA 
left Vi pair for example, tan put mbo artioa the crossed and direct rojl flbon ituinjt to 
the left infernal rectus; and ar the same limfi the eiuislinn cells of (ho nueli'us of lJl(i 
IH h'ft |iair. ejiu put into neliim tlie root filieni (if the bouiulslcTAL external rectus of 
rtie sanit- Mde ilcftj. ThuA there i» muhliabed a Btriet ph]nrioIa«ical assfjciation. per- 
niiltioK the action of a dexlrurotary ^>'at«in, turiuoK the o'u toward the hjtlit. or a 
Icvorolary system, luminic the eyes to the left, an assueiatton which con Iw inejled 
wid aotivutt^ iub>'1n> by tiw eortex, or by variuun muisotj' or aeusorial pntlis. labyriutbiae, 
t«(Ttila or (iptie. 

1. The cortieiil oeulorolary pathway (vr;Lon>d dark ml in the riehl, pale red on 
Itw left) bclonOB tu the conieunui-lear piilh (CeA') (nee Plate I, 0) and takes ita 



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CRANIAL KERVBS 



The <-ause for the faihire of the lid In rrs[Mm(i, nnalogous to von 
CrHeft''ss\Tii|>toni in cxuphthalmic^iiHter, is not tliorouphl y uiu]t>r.st()0(l. 

In the majority of the cases lesions have been found implicating the 
coriHira qundriKcmina (pineal) either directly or hy tumor, or by 
direct pressure. So-called liystcncal cases are iisiinlly mistakes in 
diaKHtssis. One such of Ixiwandowsky's proved to be u cysticcreus 
of the corpora quadrigemina. A personal case showed a sarcoma of 
the third ventricle ])ressing ii|xm the anterior corpora quadrigemina. 



Frui. I(Kt, — liit^iualily 
pMpil In we thnii rinlit. 
Itumultiltf. 



Li-h 



I'm. [«)l.- I 



r..l ti 



IJm^rniJ tvciiw pinUiy. 



(irf) PaTolysia uj Cmnwrgence. — As an isolated symptom this is rare, 
it is usually accompanied by other associated palsies. It is found 
most frequently in multiple sclerosis. A closely related phenouienou— 
weakness of the iiitcmus mu-sclcs, Mobius' symptom in exophthalmic 
goiter, Is thus far difficult of explanation. 

(e) Central NjjfitiigmuJi. — 'i'he extremely complicated subject of 
central nystagmus is more fully discus.scd in the section on Vestibular 
Disease. When rliythniic, p. (-..possessing a quick and a slow excursion, 
it is usually vestibular. I'ndulatiiig nystagmus, t. p., with uniform 
backward-and-forward mnvcniciits, is more apt to be due to involve- 
ment of the central or peripheral eye muscle nervous pathways. Pos- 
sibly vestibular associations nnist always Im- involved. Vndulating 
nystagmus is occasionally seen in severe fatigue, in myasthenia, in 
pre^ressive muscular atrophy, alcoholism, hydrocephalus, etc. I'ndu- 
lating nystagmus as well w^ dissociated eye movements are normal in 




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CRANIAL ^lltnVES 

infants. &nd arc frequently seen in congenital defects — (idiots, imbe- 
ciles, congenital hlindnesa). 

(/) hregulur PaUies. — Dissociated eye movements in which the 
eyes move irregularly, each according to its wish, as in criLstacea, 
in the very youiijt infiinl, in coiigenilal tlefective (levelupinent,s, is 
seen coming on in adults from destruction of the associative mechan- 
ism of tlie eye movements, more parli<*ularly from sepunitiuii of the 
nuclei of the ocuhmiotorius. Ivcsloiis which cut the nuclei ajiart 
one from another (multiple sclerosis, tumor) will cause this asyncrgia 
or ataxia of the eye. 

Skew deviations are conditions in which one eye is directed outward 
and downward, the other inward anr! upward. Such a compulsory 
eye ixisition is usually due eitlicr tn u. middle cfreheiliir ]X'dinicIe 
atTecliou or to u (rrchellar lesion elsewhere. 

Eyeball apraxius. so-called, or ideomotor dissnciated movciuenls 
offer certain complex analogies with similar distnrlMinces of the tongue 
muscles in speech, the facial muscles in mimicry, or the arm muscles 
in expression. They are usually due tn lesion of the projei-tion filwrs 
in the iiMitrum ovale or internal capsule. 

Psychogenic (lisHOciatiun of the ocular n^ovcnients frequently 
occurs. It is a most frequent cause of sn-ealled "eye-strain." 

Treatment.— The tn-atment of these various syndromes depends 
entirely niKm the causative factors. These have been discusaed xmder 
the respective syndromes. Also see chapter on Midbrain Disordcra. 



DISEASES OF THE TRIGEMINAL NERVE. 

Fifth or Trigeminal Nerve.— The symptomatology- of lesions of 
tiie fifth nervt- is tiivfrsr, as it has Iwith a sensory and a motor part, 
and liaa many synaptic junctions with cranial, spinal and vegetative 
nerves.' 

Motor Part.^ — The oirtieal origin of the motor part h bilateral, and 
is liK-atwl in the lower third of the central convolution. Krom here 
the til>crft pass through the iron>na ruiliata. enter the internal capsule 
with the pyramidal Traet, and make their first sjiiapsU with the chief 
motor nuclei, in the dorsolateral part of the tegmentum of the jions. 
Most of the filn-rs cn>ss about the level iif the iHisterior corpora 
quiidrigemiiia. l-'rom here the setwnd motor neuron passes with 
the inferior maxillary branch through the foramen ovale, and is dis- 
tributed to tlie masscter, tcmpornl, pterygoi<I^, tensor tympani, tensor 
veli palati, mylohyoid and the anterior hclly uf the dijjastric. 

Aft'ection of the crtriical moU>r neurons occurs in psewlohulbar 
pftby. Here the lesion is bilateral also. Unilateral interruption of 
the tract causes little disorder in mastication, (llirt claims that a 

I Map scJieTae oi th« Renanry DistrilHttion of iSw V Wirvft. L, H. Peglcr, 1914, 



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DtSKASBS OF THE TIUOEMINAL NERVE 



279 



lert-sidwl lesion inny cause bilateml palsy.) Bilateral disorder is 
nearly always n.ss(H"iat«I with tlic ntlicr rcntiiri-s nf |>si-n(li>hiillmr palsy 
{q. r. Kig. 17(1). Tile jmrulytic signs are the hiiH-opcn innuth. with 
iimhility to apprnxiniaU- the teelh. The jiiw cannot be protnidt-d, 
and the lateral movements are impaired. The food is apt tu full out 
of thf mouth, rnniiot be held by the li])^ uiid cheeks or tongue, and 
has to be manipulated by the fingers. FimkI is often pusheil np to 
the pharynx an<l nose. There is no atrophy <)f the muscles of the 
jaw, and no reaetion of degeneration. The jaw-ji-rk w incTeaseil. 



Fia. 103. — Poralytit <•( Unh ih> In xiimr nf the richt 

«yv und liiniation ol the jui^ l*-* tin- |'nrub'*«) ^'iv '•ri <a.<>iiiiiK tbv uouUi. 

Tortical foct may give rise to chattering movements of the jaw. 
(Jrinding inoveiiients of the jaw. sn fntiuent in paresis and wrju-sionally 
present in senility, are due to (t>rti(al irritation. The champing 
movements of the jaw in paralyse agitans are pi>ssibly to 1k' intrrpreteil 
•iimilarly to the general tremor of the other muscles; namely, as an 
interruptiimnf the tniii(-im[)ulsi-s |ULssing thmiigh tlien)iilliraiii{eor|)c»rn 
iitriata) stnictnres. (S«x* l*uralysis Agilaiis) (irindlng of (he jaw is 
not infretpient an a reflex in children, and it n<rasionatly is Mfn »» a 
result of luLsal meningeal irritation of the motor root, as in tubcrculosui, 
s>'philU. or even tumor formation. 

Prolongi-d spasm of the intiselc^ of mastication is seen hi certain 
toxrinttLs. siich as strychnine [Mfisoning. tetanus, tetany, lien- the 
interfiretJition \a not simple, li is a resnit possibly of the mnrkr«) 
lowering of the synaptic threshold in the |>outine motor nuelei, causing 



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CRANIAL NERVES 

oveirespoiise to the cerebral or reflex motor impulses. The violent 
convulsive movements of the epileptic discliarge are cortical in origin. 

IrreRiilar cr auunuilous spasmodic movements of the jaws occur 
in multi])le sclerosis, u^iually from midbrain or pontine localizations 
of the plaques, or they may l>e reflex or psychogenic (hysteria or 
dementia precox). In the latter instances in the few cases analyzed 
the biting s>inho!izes unconscious hate ur sadistic cravings. The 
clenching of tlie jaw in fixid refusal as in scliizophrenia. depressed 
manic-depressives, fever dcliria or confusion, expresses various s.\*m- 
bolizations. Fear of being poisoned is licru a freiiuent motive at the 
conscious level. 

SnclcdT disease of the motor neuron of the tri^minus may 1)e 
unilateral or bilateral, partial or complete. In nnilateral monoplegia 
masticatoria, the latcrul niovcnient.s of the jaw take place to the] 
paralyzed side. Bilateral lesion cnu.'^cs the jaw to fall, and abolishes 
all lateral movements. Tlie floor of the mouth is flaccid from the 
mylohyoid and diga>tric palsy, and there is difficulty of hearing notes 
of low-pitched tuuing-forks. The mu.scles show atrophy, reaction of 
degeneration and the jaw-jerk is absent. 

Peripheral trigt-miiuis motor palsy is usually associateil with seasor>*, 
.sympathetir and taste phenomena. 

Nuclear dist-ast^ of the motor neurons Is comparatively rare. It 
may occur in multiple s<'lerosirt, in syphilis of the pons, hemorrhage, 
poliomyelitis, syringomyelia. Peripheral [>alsies are more frequent, 
and are due to trauma, to pressure of carotid aneurisms, tumors, 
chronic mcniugitis. rarely to an interstitial neuritis. 

Sensory Part. — Affections here are much more intricate and complex, 
and arc often combined with motor symptoms. The sensory rroiptors 
of the trigeniinns are wi<lely distributed over the face, the mucous 
membranes of the suiKrlor and anterior nasal fos.sB, the frontal and 
ethmoid sinuses, Icntorium eerelx'lli, teeth, mucosa of posterior 
inferior nares, the sinuses of the jaw, the durii. muter, the mucous 
membranes of the lips, cheeks, posterior and inferior portion of the 
muutl), aufi anterior two-tbinls of the tongue as taste buds. The 
sensory ganglion is the Classerian. 

(^^llateral synapses occur witli the ciliary gmiglion for the passage 
of impulses from the cornea and sclera receptors. Imi)ulses from 
the ethmoid and sphenoid sinuses, the pharyiix, posterior nares, 
hard and soft palates, maxlllar>' sinus, uvida, pharj'ngeal walls, 
tonsils and related mucous parts pass by way of the sphenopalatine 
ganglion and come into relation with the glossopharyngeal. The 
submaxillary ganglia coimections are intricate and probably pass with 
the vegetative nervous system fibers. 

The chief reflexes arising from these connections are: 

1. Winking reflex. 

2. Pupillarv- (sjTnpnthetic reflex) — pinching the cheek or nock 
causes a dilatation of the pupil on the same side. 




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DISEASES OF THE TRWEMISAl NERVE 



2S1 



3. Jaw reflex. 

4. SneeziiiK reflex. 

5. Pharyn^al refiox — (gaKH'iiR a"*' swallowing). 
The centripetal pathways from the (iHsserian gnii|;lioii join to form 

a lur^e sensory rtwit which is (Hstribuled to two main end-statious: 



.t^ 



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I Nlrf.Bllf. 



Lti.m,<t. 



Tkfort 



Th^l 



S»k. 






Mnf TV. r. 
ritati shV. 



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'■Qi 



Flo. IM- — SrlutnMi of iiitrftrwreltral mjtoniiuiu paUiwii>-!i. C«, Mt hnmUphen*: Cd, 
titUl hemimtbim: Tk^erl., thalamocurtical uicouioiu InicU: Th. a^'iuiiiHfi. of uiitenuriUA 
[q thaUuTWU; tMt, taeaenttptuiUit: Irmriiairiui; nu*l. TnQ., nxiUir tHca-niiniiA nvii niirlci 
in uiUllmuu; mot. Tr. K., motor truiviiituua nudvu* in \>m'u» t-uMiileua; l{>iJ. mot., iitoXiM 
noM; UqI. (hi**,, (iiwniU) BiiiiKUon: J, //. ///. thin* Irtxmiiiinti Imuirtm; mj.. mraMt- 
raplnlio MnKMy inaemUttH noU; ip. Tr. 11'.. npituil Iriifcimnua bnuche*; H. grl. Hi<i.. 
•nlwtanlia mlidiwi Rolaoda. Uollotl linr, motor, mlid linD, moaorj. (Voracuth. 
Bint.) 

a mesencephalic and a spinal one with numerous eollatentls. From 
these nwtj* the second sensory netmin i«isses tlirougli the ineiliuii 
IcmnUcus to the opposite side to end in the thalomtiii. A further 
nenrf^n then piissi*!« to the sens'>ry tirain area. 
The chief sciiHorj- symptoms of tiflh ncr\*e involvement arc h>TKT- 



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DISEASES OF THE TRIGEMINAL NERVE 



283 




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CRANIAL NJtRVSi 



The most frequent of the syndromes is trigem.ii)nf tutur'tis or iic 
(hulournur (tj. t.). Here the Gasseriait ganglion is ofttn involved 
MP the neuralgia may hv due tc pressure upon nnc or all of the rix»Ls. 
The distrihution of the hyjKTesthesia is of value in deterniimng l!ie 
branch or branches involved. It is comparatively rare to find reflex 
neuritio palm from disease of the teeth, hence the hope that removal 
of healthy teeth will cure a tie douloureux is usually doomc<l to dis- 
apix>intment. This is an extremely common error and ne«ds to be 
emphasizwl. 

i.entral or thalamic trigeminal [>ains are possible. Clinically little 
is kuown of tliem. Trigemimil agnosia is a curiosity merely. Anes- 
thesia may be due to interruption 
of peripheral, pontine, thalamic or 
cnrtieal path\va>T*. The diagnosis as 
to localization must be made on the 
hjusis of the accompanying symptoms, 
sensory, secretory, trophic, and 
motor. 

An inflammation of the Gasserian 
ganglion causes a trigeminal herpes 
zoster. Prj'ness of the eyes, ^ith 
hyiK-resthesLa or anesthesia is due to 
11 peripheral lesion of the superior or 
first branch of the nerve. T'nilateral 
niycisis may also point to trigeminal 
irritation here. Rclatetl dryness of 
the mucous membranes of the nose, 
lips, and cheeks with anesthesiie, 
ns\mlly point to pcri]jhcral disease 
of the secnnil branch, while taste 
impainnent of the anterior two- 
thirds of the longiic may be, hut IR 
not iiivariubly.assiH'latcil with lesions 
of botli second and third bninches. 
In root Iesi4)ns, the epicritic loss 
is usually less than the protopathic 
loss, while the reverse is usually true for peripheral lesions. Pontine 
lesions show a more general loss of epicrilie sensibility on tlie side of the 
lesion with mono- or hemihj'ppsthesiie or anesthesia* on the opposite 
side nf the liody, while thalamic lesions are associated often with anes- 
thesia and analgesia tu ])in jiriek, eentrnl pain and alTrclive over- 
respi>nse. (See Thalamus.) 

Trophic disturbances, usually dne to peripheral disease (?), cause 
changes in the gums and mucous membranes, ulcerations, herpetic 
eruptions. Corneal ulceration and loosening of the teetli are often 
present, but whether trophic or not is not certain. 

Dissociation of pain and temperature from epieritic touch sensibility 



Flo. 167. — tSjTiiiK'-ai'iol'i. U*Kiii- 
iiIitK ikM ht'iTiiruchil Hi r»]iliy, I lion 
clovdopiiiK "Morvaxi's dbenw." tiiict 
linnlty ihnuint; cinssii-ii) Hyringomyplic 
vnil Ic-niotu. (Haniuitiud.J 



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DtSBASES OF THE FACIAL NERVB 

may take place in the trigeminus distribution. For lack of spiicclierc 
a complete aniily.sls of sensibility (listurimnees of the trigemliiiLS should 
\te sougiit in special monopraphs. (Sec I-ewandowsky. Ifandbuch der 
NeMTolfigie. for mmplete literature — 191(>-1912.) (Plate VIII.J 

Progressive Facial Hemiatrophy. — This rare cnndition, which sho\\'» at 
its onset a gradual thinning, with wrinkling tif the skin about the orbit 
or jaws, witli later progressive atrophy of the hones, cartilajjes uiid 
niusch*8. also of the tongue ami wft palate, without serLsory signs or 
reaction of degeneration is at times a result of peripheral or pontine 
(nuclear) disease of the fifth nerve. 

DISEASES OF THE FACIAL NERVE. 

Serenth Nerre. — The seventh nerve is a mixed nerve. The cortirn! 
origin of the motor neuron occupies the lower third of the precentral 
convolution, from here the fillers pai» through the knee of the tnternal 
ra]K4uie, through the middle third of the pednnrle and make their 
first junction (|M>ssibly by nicaus of intcrcahitt'd neurons) with the 
homo- and enntrulateral seventh nerve nuclei in ihe tegmentum of 
the pons, just ventrolateral to the aMucens nerve nucleus. From 
theiic nude), four arc usually described, the second motor neuron 
fil»ers make a dorsal upward curve (genu facialis) (see I'ig. l.'il) 
around the abrlueeiL** nucleus, then pass ventrally and emerge at the 
p«»slerior bonier of the pon-s, lateral to the oHve. where they lie in close 
relation to the fifth and eighth nerves in the (vrebelloiKinline angles. 
They are finally distributed (three ventral nuclei) to the muscles of 
expression of the fnee, to the nuiscles of the external ear, the sta|)e<lius, 
the posterior Itelly of the digastric and to the stylohyoid. The frontalis, 
corrugator suiK-rciiii, and orbicularis palpebrantm arc innervated by 
fiU'rs coming fmm the dorsal group. 

In its peripheral distribution the nerve passes through the facial 
canal in the temporal iMjae (aqucthu-t of Fallopius), cimiitig into 
intinutte ri'lutions with other craniHl nerves, eighth, pjirs intcnnedia, 
and also forming collateral a.ssori«tions with vegetative fibers of mure 
Ulan usual ctmiplexity. a study of which is of value in the local diagno^ 
of lesions of this nen-e and contiguous parts. (See Fig. 169.) 

The anatomy of the ])os.sibIe sensory portion of the ner^'e has 
not lH*cn definitely honiolngi/ed. The comiMirative studies of Hrrrick 
an<l Johnson fail a^ yet to show sensor>' comi)onents in forms higher 
tlmn the amphibia.* 

By some its chief gaugliim is coiLsidered to lie the geniculate, which 
is thoujrht to contain the afferent fibers from touch re«.ri>t<trs l<K-utcd 
in the auricle of the car. the Htntr of tlic extcriuil auditor*' canal, the 
t>inpnnum. and from cTrtaiit soft parts of the internal ear. The 
nrr\e of Wrisberg is considered to be the sensory portion of the ncr\*e. 

■ Jour. Comp. Kntnt., 1014. 



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niSKASES OF THE FACIAL SER^. 

tion. Tins is the tj-piral fncial palsy nf the upper neuron fhemiplcgic) 
tyi)c. The fac-c is drawn t« the sound sitle, the an^le of the mouth 
dro«i]»s iin4) the nasolabial fold is Hattened, hut the eyes can he einsed 
and the forehead wrinkli'd. Thert- is paresis or paralysis of the lower 
muscles vbo'IK with tlie severity of the lesion. The soft palate 
may show palsy, pulling to the ^ound side on phonation. Bahinski 
further desrrilx-d a loss of the <'ontraetions of the platysma of the 
affetaetl side un forciiij; tlie mouth o)>eu a^auist slight resiatance. 

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Agimmt 'toMM yitan 



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PUn of the fuUI ntul intcrtnalhu nrrvM and their roroinu n ieatiooi wltlij 
olh«r nerves. (OrKy.J 



In certain widespread mrtlcal iieiirun [mimics; howe%'cr. the upiKT 
hrBiichfs may he involvwl. with iiarrowhiK (at times widening) of 
tlic iMil|H'!>ral fissure, and a dro(»pinp of the outer angle of the eye- 
brows on the iitTe<-trd sid*-. I'ontine syndromes frequently show these 
signs. (Set Miiilirain Section.) 

Apraxin of the fncial musoiilnture U met with in cortical, or 
corpus cnllosum lesions. IUtt the patient loses the power to make 
proper mimetic niovenieiit-s. ITc may not l>e able to close the eye on 
iJie paralyzed side, independently of the other. Furthermore, in eor- 



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CRANIAL NERVES 



tinil neuron jmlsy the tongue protrudes to the paralyzed side or 
aimiot Ix' protruded at all. Speech disturbances are frccjucnt. 

In cortical facial monoplegias— or hemiplegias with faeial involve- 
ment—there are no atrophies, the e]e<-trical rt-actions are not involved, 
and secretory and taste modifieatioiis are absent. 

Cortical and subcortical irritation may give rise to facial convulsive 
movfjiieuts — sp<mtaueou3 laughing or crying jnovemeuts. 

The facial mimetic movements of purely psychogenic origin, tics, 
silly griiaa(r.s of the schizitplirenic, drawn rxprcssinn of the deprefwed 
manic, tenseness of the paranoic! type.s, etc., are numerous. 

Pontine Facial Lesions. — When the nmli-i nf the |>eripheral neurnn-s 
are involved all ul' tlie lirunches may Ijt ulTeeted, but inasrauch a.s there 
are different gronjis of nuclei, occasionally, as in poliomyelitis for 

example, certain muscles are Jn- 
vol\'ed and <:>thers arc not. A gen- 
eral lesion here will cause a total 
palsy of the muscles with atrophy 
and loss of clcftrical reactions. 
TIhtc arc tn) eliangcs in taste, nor 
dl" licaritig in tlic pure nuclear 

CK-SfS, 

liCsions here are apt also to in- 
volve the third nerve, also the py- 
ramidal tract fibers, and the sensory 
fibers of the fillet, hence a variety 
of hciniplepic or hemianesthetlc 
syiidrrHiie^ — crossed or Utwer alter- 
nate hemiplegias (Figs. If>l, 20(), 
and 20]). (See Section on Mid- 
bra in.) 

Suprannclear pontine lesions may 
rarely be duubte (Psendohulbar 
palsy t^-jies). 

Peripheral Facial Palsies.- Thrae are called Hell's palsies since first 
described by IJell. Here a great variety of syndrnmes may occur, 
depending on the exact site of the lesion. These may be conveniently 
divided into five syiulromes (see Figs. 1(59 and 171). I. Most 
peripheral, due Tii ilisease or jiix's-sure at c»r outside of the stylomastoid 
foramen. 'Hiis results In a complete paralysis of the muscles of the 
side of the face. At rest the asymmetry Is marked In prupurlioa to the 
severity of the palsy^ — all grailcs arc foTind. The muscles of the fore- 
head cannot be contractci! horixontatly or vertically, the eye n-mains 
partly or widely open on attempts at closure, closing at night in sleep; 
the na.sal orifice is narrowed, the nasolabial fttld Is oblilcratcd, the angle 
of the mouth droops and shows the teeth, and there is pulling of the 
montli t<i the soniul side. F'ufling the cheek is impossible, holding food 
and saliva are difficult, and on attempting to whistle the air comes out 



['"ii,. lill. — -I'-i'iniuUiilUir |iril-i', 
CTiliioj-.) 




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DISEASES OF TttK FACIAL NERVE 

on the paralyzed side. Tears run down the cheek but the reddening 
of the eye is sc(x)iidary. There is less sweating on the paralyzed si(]c. 
Pressure-pain sensibility is unimpaired. The palate and toupuc may 
be apparently involved, hut rarefiil scrutiny shows otherwise. Ueaction 
of degeneration set.s in as a rule in the severe ca.ses. Slight speech 
disturbance h apparent, especially in the beginning, au<l is very markwl 
willi a (rarelv occurring} double periplieral palsv (see Figs. 172, 173, 
174 and 175). 



/ 









f' /OcnicnUM OaHftUmt 



Mm'«io8hu>«>ittM — 0^^ 



j^r"* 



//il 



FiQ. 171. — Lhnsnm of IncuJ twnre, irfMnrinx eouiM of oDcreuiry and of Uuta fibna. 

(BMwwt.) 

Tliese (taUies are due to trauma or |>n.'ssnrr fnnii a tumor, possibly 
a |KTichotnlritis of or swelling alwut the stylomastoid foramen (ciillc*! 
rheumatic or refrigeration paby). The cITec-t of i-old uikiii the facial 
ner\e itself. »'. r., by exposure in riding with one side exposed to o|>en 
windows, etc, looms large in statistical enquiries. 
10 



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CRANIAL NSRVES 

3. If to this IbsI symlmmc hj-pcrarusis And tinnitus alone bo adiied 
the lesion la slightly farther back in the canal involving the branch 
given ofT to llie stapedius muscle (see Fig. 109). 

4. Ix.siona lying Iwtwecn the geniculate and the stapediUH within 
or at the intcmai entrance lo the Tallopian canal, cause a variety of 
additional symptoms, the exact anatomical relations of which are still 
somewhat obscure. 

(it) Geiupuiate Sipidnnnr. Jhmt'.t Syndrnme.' — Here one meets 
with a herpes of the niiricle and the external auditnry canal. Tliis, 
according to Hunt, is the zoster zone of the geniculate. Kxtensiou 
<^ the initummation or pressure causes a facial palsy plus the herpes. 
In a more extensive process auditory symptoms, tinnitus, diminution 
or loss of hearing are added. In rare instances, from involvement 
of tlie ve-stibularis, naust-a. vomiting, nystagmus and dizzimws are 
present. Tlie cliief causative lesion is an inflammation of the geniculate 
ganglion. Occasionally occipitocollaris herpes is an associated phe- 
nomenon. Severe otalgias with or without tjinpanic herpes are also 
at times the expression of a geniculate hivolveuicnt. 

I'acial palsy of non-geniculate origin from lesions in the same region 
may or may not be accompanied by loss of hearing. The chief addi- 
tional diagnostic feat\ire of lesions here is the lowering of the threshold 
of deep seiLsibility (Muloney). 

lesions of the seventh nerve at its emergence from the pon.s usually 
implicate otlier structures, notably the fifth or eighth nerves, at times 
the sixth, eleventh, twelfth. The facial palsy is of the peripheral tj-pe 
with no loss of taste, clianges in the secretions, or suppression of the 
lachr\*mal secretions. Basal .sj-mptoms such as anorexia, nau.sea, 
headache, and optic disk changes are often pre-sent. The chief puth- 
nlogicfll processes arc basal meningitis, usually sj'pbilitic, or tumor 
formation. 



DISEASES IN THE AUDITORT AND VESTIBTJLAR PATHWAYS. 

The Eighth Pair. — The eighth cranial nerve is in reality two se|)arate 
nerves, with distinctly difTerent structures, pathways and functions. 
It is not a single nerve with two parts. The two nerves are the coch- 
lear or anditorj' proper, and the vestibular — a portion of the cere- 
bellar apparatus. 

The former handles sounds, the latter sen.'es to orient the body in 
space. Their chief receptors lie closely related in the sphenoid bone. 
By reason of this clos(^ topographical ri'tationsbip infections of the 
middle ear arc apt to involve both structures, and by reason of the dose 
associaticiiLs with intracranial structures, brain involvements such as 
meningitis, abscess, etc., may result. Their central stations are wide 
apart in the temporal cortex and cerebellum re.4peclively. 



' J. Raniftpy irtiiit: Jour, of Xcrv. and Mpnl. Di^., 1JH.)(>. 
ScpUiubur. 1014. 



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CRANIAL SERVES 



stimuli of 1 1 octaves, t. e., from 10 to 7H4n double vibrations. Ordinary 
conversational or musical sounds usually lie witliin lf> to ■iOlt2 vibra- 
tions. Spaw orifutation through HOund is purely a.ssociative. The 
chief avoijues for auurid coiiduL-tlon to the receptors is the auditory 
cunat, but sound conduction is also possible by way of tiu- bones 
of the skull iind in part by other bony stnicturcs. From the cochlea 
the braiiches coalesce to form the acoustic ner\-e which, jmssing in the 
nu<litory canal with the facial, enters the medulla at about the cere- 
bclloiiontine auKle. The sensory ganglion is the tiiberculum acusticiun. 
The further course uf the pathways is illustratetJ ia Figs. 178 ami IT'J, 
alsoisee Plate VII. 



ce. 



Thlta* 



A. 



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Ts 






f'/iK 



Ss. 



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Via. 179. — fWirtmr of thr ccntnil ,a<fiii.-(iic puthwiij-ji. Ti. 7'i. firai mnd »Mt>ii<) teiiipond 
lubcw; J, island uX Kcil; o-. cLuuatruni; Li, l«nLinu]Rr iiUi.'loiui,- Ci, iatorual capaulp; 
TkiUam., thnlrmiiui; n.S., im-iliitii UiiidiuKnis; .Sji., xyplv'. ratllMtiontf; V.h., posterior 
gutulHcemiiiu : B.A., middle ccruljellar iMoliincle; e.c.p., cruH oonnlwlU mI |K>riU>ni; r.|7im. 
I'rii.. iiitvmnl crninjlnU-: Coc trstpniiil xviiirulntr: Sia., ninsa aKniatirie; g,ii.j>„ Kurioliou 
ai>irulvi '/'«., wtviuitii- tuliorcle. (v. Mo:uikgvr.> 

The chief dwturbaiiees of the auditory nerve arc: various forms 
of deafness and of timiilus. Pcafiiess may varj- comiderahly and may 
be absolute or partial. ("crtaLu tones may Ik cut out and not uthers, 
upper or lower tones, sometimes intermediate tones drop out (hraring 
seolomalaf analoRous to optic scotomatJL, are not infrequent in hyster- 
ical reaclioits, dementia precox, in multiple sclerosis, paresis, taljcs, 
etc.). These anomalies of hearing arc chiefly piTipheral, either in the 
primary recejrtors or oecusiomdly in the ganglion. Paracusia (buzzing, 
whistling, crackling), arc for the most part periphenil. but nmy also lie^ 
central, as in psychotic or i)sych()ucun)tic syndromes. Psychogenic 
deafness is a fretiucnt complication of traumata. There are frecjufutly 
encountered, particularly in war times — detonation deafness. The 



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206 



CRANIAL NBRVSa 



Chart row DirrsaENTUTioN* or Puiiipukkal and Centbai. Lt^iOKs. 



Speech ttst. 



Air CoDduction fur Tcrks 
c. c". c*. e*. c* uitl fur 
Oklt/tn'B whisLlo. 

Si--liwiU>aeh(o'). 
Riaot (c o>. c^. 



DtMAse ol aauiul-pcrMpttcia 

Deop toiKit tuMu-d wonw or 
bptwr ihftD higtuT on 

HUdi loiM'B h«srd wor 
lliaii diyp onm. Ut>por ' 
binp lhr*«lL>i1[l [owvn<d. 

Modittn or lorntiMHl id 
brtt«r «»r. 

RatrvJy nonnal, mostly 
■horleoed. 

Pbaitivv. 



DH»MI o( lOUIld-IIlIluluDtillC 

apliaralua, 
Doop tODOs hoard wome 

tluM] hiichcr ones. 
thwp tnuM hrnrd wnree 

lluui hiilhpr niios. I.«WGr 

tone llirfA)iiiM ruinwl, 
Mvdiiut or localised in 

worwcttr. 
LenjtlhMwd. 

Naoative. 

Aooordins to Rnde of 

ntardalioQ oidy for c. 

or lor 0. and the highun* 

tODOTtOC*. 

Vestibol&r Nerve. — II has Iwen eatAhlished, almost beyonrl question, 
tiiat ihi- labyrinth is tliat or^an of the IkmIj' which is conceriH'iI with the 
receiving of iniprcssioiLs of its positi(tn in space, particularly fnr the 
head. The uiemiiiin fur the human \»A\ of the physical laws of 
gravity is its chief concern. It is adapted to the mechanical stimuli 
of KTuvity, actiiiK larj^ely through the otolith ornttn, which reacts to 
ehanfics in the incidence and degree of pressure upon its sensi)ry entl- 
orgaiis, due to changes in the specific g^a^■ity «f its Rur rounding liiiids; 
and also through the seniieircular canals whii-h react to changes in 
position in the three planes of space. Ilie sliglitest change uf the 
IxKly in space is felt hy this apparatus, and in the healthy central nerv- 
ous system any such change is automatically reacted to by appropriate 
(proprioceptive) motor response. 

This mf>tor response, however, is a corapUcatHl nieehatiisni, and all 
of Its elements are not thoroughly analyzed. One of its parts is that 
of a reflex muscular tonus, by which the ordinary posture of the IiKMly 
isniaintainetl. It is this function that lias entitled 't to the ap|H'llation 
of the labyrinthine tonus. Sherrington^ hu.s analyzed the eomplicated 
interrelations Ijctwi-cn tlie proprioceptors of the limbs, muscles, joints, 
etc., which carry impressions of movements, strains, tensions, etc.. 
and the receptors in the labyrinth. It Is imi>ossiblc to enter into thera 
here. Suffice it to say timt the re.'^ult is the reflex maintenance of the 
posture of the body, including the compensatory reflexes of the head, 
and those muscles of the head capable of changing the sense of oon- 
aeiousness of position, particularly the muscles of the eyeballs. (See 
PhiteMI.) 

The labyrinth belongs to a series of organs that work in res]>ouse 
to gravity. It Is a part of a great .system of connections — which 
Sherrington has designated as the proprioceptive system— which gives 
animals, human as well as others, a definite attitude toward the 
external world of space. It is the most iniportAnt of these organs. 
It is connected in a system with other nervous structures p*?i-forming 

' Tlie XntegrnUvu -\ctioa of Lhe Nervoiu Sy»t«in. 



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7SEASES IN AUDITORY AND VESTIBULAR PATHWAYS 

their part in the same i^aeral fuDction.and each segment of the body 
is cauglit up in the chain of connections from the lower end of the spinal 
cord to the frontal area of the cortex. 

1'his whole complieateil system of end-organs, fiber connection*, 
long and short lilier trart.s, has its chief crnter, just as every other 
reflex system has its center. The chief center or hea<l Ki^n^linn of 
this whole proprioceptive system is the ccreMlum. The cerebellar 
connections of (he vestibular system, the vestibulospinal, vc-rtibulo- 
bulbar. vestibulowrelwllar, and, finally, the cereljellonibrocortical 



® 



Q 



, JfwcUlU rtlfrfr 



tfwprrfur MrebcUar^, 
ptduncte j 



I Dtntatt 
''fttooj nucUwt 
titir't nurkiu 



K, vtMtUiularU 



fTV. fflno-eerrbcf/aru 



TV. rwtin) ipinalU-- 

TV. wafib«/i>-«piu4iiU-. 1 



Flo. 181 .— DiMim y* Bluitnw Uw ohiaf ipitud ooniwciionii ol th* MratMllum. Od tbt 
risbt tbe Rffmit IntotB an nprnamlad, od tlw loTl Uw eff«nmt oenfaaUar tracu. 

components which carry those fibers whose functioning is recognized 
in the coasciou.sness of space relations, are now fairly well known, 
not in their entirety, but in their main tracts and connections. Hence, 
disease or dis*inler which shows any perturbotii>n of the function of 
orientation in spjice may W more or less accurately lociilized along the 
fiber tracts, carrying iIk* necessary impulses underlying these functions, 
and an appntpriatc therapy adopted (»«■ Plates \\\, IX and \). 

KermB VestibDl&ris. — The fil>ers of the median acoastic root (l^wan- 
dowsky— mixed) conMitute the central pml<mgat)un ot tbe bipolar 



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CRANIAL NERVES 



ganglion cells which make up the vestibular or Scarpa's ganglion. 
The peripheral prolongations of the cells are the receptors (hair cells of 
the ampuUse) in the walls of the semicircular canal. Movement of the 
head or of the body causes a flow of the endolymph which gives rise to 
the specific stimuli in the receptor organs. The thick bundle of the 
median root pushes its way between the spinal trigeminus root and the 
corpus restiform (inferior cerebellar peduncle) lying at first close to the 
median edge of the spinal accessory nucleus, and reaches dorsally like 
the tines of a fork toward the end nuclei. These end-nuclei of the 
vestibular are (1) Deiters's nucleus lateralis, (2) Bechterew's nucleus 
superior, (3) Schwalbe's nucleus medialis or principalis, (4) nucleus 
spinalis. 

F. thatatno-eortiealit 




lfucle\i9 ruber. 

Super iar rvrcUiflar 

pedxiiCte 



Xucleiu 
dvnltit lu 



F- oliw'fc ri'frp 'III r[s- 



F. cortico-pontinut 

I Central Tegmctttal 
( Tract 

iliil'll'f arebrllar pcdancU 
fn/ri-iur Olive 



Fia. 182. — Diaftrnin U> illustrnte tho afferent and efferent connodtiona of the rerebdlmn 

with tho furcbrain. 

Of the connections of the end-nuclei of the vestibularis those of the 
cerebellum are the plainest. Strong, somewhat swollen bundles 
of nerve fibers go from the Deiter and Bechterew nuclei dorsally in 
the cerebellum. Fibers from the nuclei triangularis also join them. 
The acoustic cerebellar tract lies on the medial side of the inferior 
cerebellar peduncle, in the medial lateral portion from the superior 
cerebellar peduncle, in which a portion also goes. The majority of 
the fillers go to the cerebellar worm (vermis) and end, mostly crossed, 
in the nuclei of the roof (tectulis), probably also in the nucleus globosus 
and nucleus emboliformis. 

Vestibular Vertigoes. — At one time loosel>' grouped together under 
the name Meniere's disease, the analyses of later years have shown 
a great variety' of these affections depending upon the anatomical sites 
of the lesions. One must distinguish betwet^u: 



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WirORY AND VESTIBULAR PA{ 



299 



1. Dbfeast- of the jwriplieral end-organ, (a) partial, or (6) complete; 
these are the vertiRoes of partial or t-omplctc labyrintlune disease. 

2. Diseaise of the first neuron, (ri) paresis, [h] paralysis of the 
vestihularis. 

'.\. DisctLscof the priniar>' end-niielei in the medulla and of Deiters's 
nucleus. Lesions of the latter give a special syniptoinatoloju' termeil 
Bonnier's s.'^^ulromc. 

4, IMsease in the iv^on of the posterior lougitudiruil bundle asso- 
ciated with eye-nn>vemcnt vertiRoeH. 

5. Disease of the nurlear rt^gion of the cyc-naiiacles in the corpora 
quadngemina. 

fi. Disease of the pontine eye nuclei. 

7. DiscHiie of (.rnlriil eye paths. 

8. Disease of cereWllurn. 

In disease of all these regions vertigoes are to be expected b>- Impli- 
cation of the vestibular nerve; the cliaracter of the accompanying 
phenomeiui, osi>ecially the nystugmui!. aids in the Itx'idization. 

In partial or (■irtiimscribeil disturbance of the vestibular end-organs 
in the labyrinth the vertigo is assiK-ialed with nysijigiiius. The 
nystagmus is spontaneous and sliows a long slow movement, due to 
the vestibular, and a quick returu movement due to the tegmental 
nuclei, the direction of tlic quick movement naming the ny.^tagmus, 
Vestibular nystagmus usually iucrt'ases when the eyes are direcle<l in 
the direction of the quick movement, and usually diminishes or ccjisea 
on looking in tlie o]>|M>site direction. There is almost always a combi- 
nation of hnrixontal and of nttary nystngmiLs. Ilarany states that every 
other form of sp«)iitaneous nystagmus is of intrai-niiiial urigiii. If the 
nyslagnuLs movement Is rotary and horizontal it must be det4-nnined 
whether it is periplieral or central. A iKTii»hcnd nystagmus to tlie 
right should show on caloric, pressure, and rotation tests that the right 
vestibule is functionally active. Shouhl such test:^ show an inactive 
right vestibular, then the nystagmus must be of central origin. If the 
right vestibular is active, tlien continutnl ol>s<-rvation of the nysUtgnnis 
will alone determine. Shimld the nystagmus continue uninterruptedly 
for twenty-four hours or more, it Is of intnuTaniai origin. If it Umts 
a shorter interval and is nninterruptnl by (juiet inter\'als, it may l)c 
either peripheral or central. When there b* also nystagnms of llie well 
side, which lasts about two weeks, gradually decreaNing, then a per- 
ipheral disturbance seeins certain, hitnuranial n\staguius is not no 
apt to diminish. 

The Menir-re-like attacks are either mild or marked. Hiizzing 
in the ears is rare in milrl attacks. There is no impjiirnu-nt of Iwar- 
ing. Ill tlu' severer attacks thert^ is little buxxiiig, but lieuriiig ts apt 
lo lie iui[mircd. In free intervals the nystagmus diminishes or dis- 
apjM'ars, the Uarany cidoric r<-iiction is diminished on the Atle<-teil side. 

Total dcstnictiun of the labyrinth may \n- acute or chronic; the latter 
may show no KyinplomA. The fomier sets in with violent verl^o. 



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^ 



nniisea, vomitinR. There is marked horizontal and rotary nystagmus 
of the sound side. The slightest mnvemeiit of the head inereases the 
vertigo and ny}^tat;nui» during the 6rst forty-eiKht hours; the latter 
groduully dii«appears in three or four wcelo*. There is marked loss of 
coonliiiation, with tendency to rull to one or the other side. After the 
IH-'ri(Ml of quieseence of tlie n.'k'xtaj^ina-f, caloric and rotation tests show 
tlic defective function. The (talvanic reaction is not usually afliected. 

Disease of tlie ve:<tihular nerve, usually due to tumor of Itase (acous- 
tic, cerebellopontine angle), leads to similar reactioiw. Here, however, 
there seems lo Im- a dillVrerur in that Neuiuaiui has found that the 
fialvanic reaction is re<hiced or lost, according to a partial or complete 
destruction of the vestibular ganglion. Other cranial nerves arc 
here involved as a rule. The cochlearis is frequently implicated. 
Complete deafness does not result. The trigeminus is also often 
involved ami pain, paresthesia', or motor defects api)ear. <'erehellar 
symptoms may also complicate the ])ieture. The nystagmus is apt 
to continue in intensity with tumors, and may W on the sound as 
well as the aft'eeted side. 

Involvement of tlie nuclei (entrphalitis. nbscess, syphilii*. tumor) 
brings about similar attacks of nausea, vomiting, vertigo, and nys- 
tagmus. The symptoms continue and increase, as a rule, beyond the 
three weeks ordinarily seen in labyrinthine disease. 

The method of contiiuions obscrvatinn aids in locating the diseased 
focus. 

Bonjiin'A St/uiirtnne, due to implication of Deitcrs' nucleus and 
contiguous structures, usually causes a marked attack of nausea, 
vomiting, vertigo, and nystagmus with buzzing in cars and deafness 
(Meniere's ^yiulrouie). with irradiations to the nintli and tenth nerves 
causuig anxiety, tachycardia, and hendplegic weakne.s.s. The trigem- 
inus and oculomotor nrv also apt to lie involved. Bonnier has also 
describc<l |>eculiar somnolent attacks accompanying Ins syndrome. 
Little can be done for tliese cases unless the focus Is of syphilitic origin. 

Here vertigo and nystagmus are associated In various wa.V's, but 
the vertigo disupiK'ars cm chwijig the eyes, and forced movements, 
conjugate deviations, and various skew deviatioas afford a clue to 
diagnosis. Caloric and other tests determine the integrity of the 
labyrinthine functions. 

CerelM'llar vertigot's have a number of s|x^ial features. So far as 
tlic vertigo is concerned they may not l>e separable from the laby- 
rinthine or vestibular vertigoes. I Icaring s.vmptoms arc usually absent. 
The nystagmus is less apt to be horizontal and rotary, but may be up 
or down or ohli(iuc, ami is usually directed towanl the alfcctcfl side. 

There are usually also svTnptoms of a tumbling gait toward the side 
of the lesion; there is asynergia and usually adiadokokinesia. No 
real distinction as to the siile of the lesion all'ectetl can be gaineil from 
the fact as to the subjective or objective motion of the objects during a 
vertiginous attack. Closure of tlie eyes haa no marked affect upon the 




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DISEASES IN AUDITORY AND VESTIHVIAR PATHWAYS 301 

vertigo, nor upon the gait. Caloric and other tests determine a normal 
lab\Tinth. 

Trralmeiit. — Here there comes into consideration the surgery of 
the ear and the surgery of the cerelx-IUini and the cerebello]iontine 
ftnglc. The ear specialist should treat tlie labyrinthine cases, not the 



I 



TWm 



law- 



^^ 



l«tf*uni 



y 



bW 



Fut. las. — n«UM«l Mfaenw or tliu iwrvliml |talJu of Uw VMlJImiftr. VU, (aeUU uen-v: 
VIII. uoofUe omm; a, Bwhlcrvw'* iniHoiui: D, TM\i>n'* nuHinw: </. dontata nudmM; 
ff, Durloua ■tobomiB: p, Duchui MutiuUfuTTuu; ra, nuterkir nxrt Bben; «e. ac*. aubmrtMal 
Qbvn uf Uw r«d ouclouf and oC the tholiunu* to the cortvx; I, tesmenutl luideiw. 
(Bccliteraw.) 

neurolc^st, lte:!t in bed, quinin, and the usual medical treatment 
which shuts one's eycH to the danger uf a suppurative lahyrinthitist 
brain abscrss. etc., \» folly. 

In the aiMiplccltc fnnn »jf Meniere's syndrome (hemorrliagic laby- 
rintliitis) often mistaken for n cerebral, or cerebellar hemorrhage, 



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CRASIAL NERVES 

tlie patient must he kept ahsolutciy quiet, the eyes should be kept 
closed, (he room darkrned. and all noises exrhidt-d as far as jmssiblc— 
telephone, Imiise hell, etc., stmt uH". Ir-e slioiilil I>e jipjilied to the 
mastoid. I^'celics are at times nf value. The eotitiiumus vonittiiif; 
may lie in part relieved by swalluwing cracked ice. Surgical inter* 
fcrenec may he called for. 

Ill syiOiilitic eases men-urial injections, salvarsan, or inunctions are 
cnllcil fur. It may Ik- noteil tluil the acute lahyrintliine (tisturhiincc 
which has lieen known to nccnr after the use of salvarsan is probably 
due to the syphilis and not to the arsenic (Bcnario). 

Trcaimetti of Sffutickne^is. — Seasickness is a speiial form of dis- 
tiirhjioie of the Iidiyritith due U* the cuntiinious moveirieiits nf the 
erMliilynijih and irritation of the receptors. As the stomach has little 
or nothing to do with seasickness, diet has little or no direct upon this 
mnlady, and the (x-ean traveller nce<l pay no more attention to the 
question of Uhk\ than that riictatrd by conunon .sense. Kat one should, 
for there is nothing worse than continued retching witli an empty 
stomach. 

If one is predisposed to seasickness. morninK walks nii deck liefopc 
bn-akfasl should Iw disiicnsed with. One should try to breakfast 
inuncdiatcly upon risinfr. and a Uttlc frutt or other light foo<) eaten 
before rising Tray \w found hel])ful. What one eat-s is 4»f small moment; 
the great thing is to eat; hut one should avoid food which one does not 
like. There is no potency In any particular food in t-he prevention of 
seasickness. 

Nor is ak-ohol of any use, unless enough ho taken to anesthetir* 
the patient. Indeed it is far more Hkely to prove an irritant. espL"- 
cinlly if the ineli\idn(il be unaccustomed to its use. ITie value of 
champagne is largely p.sychogenic. 

One should not go to <linncr until it is just about to he .served. thii.s 
avoiding the discornfi>rt. of waiting in a stuffy and i>er}iai)s overheated 
dining roc»ni. AVlien the meal is over it is well In lie dinvn. rather 
than go for a trump nn deck In the hope that it will aid digestion. 

Warm clothing and wraps should be taken on a sea voyage even in 
very warm weather. Told, damp, and foggj- weather is apt to be 
met with <m the ocean at any time of the year, and the consequent 
chilliness, added to that of an unstable va.somotor control, through Uie 
labyrinth, is a great cause of discomfort, which may be removed or 
alleviated Iiy wearing warm outer garments. 

If the sea be at all niugh and the motioti of the vessel appreciable, 
the sensitive traveller should lie down at once, as it is easier to accustom 
oneself to the labyrinthine liyiK'rstiuiululion in a recumbent position, 
es|)ecially if one ailopts tlie position in which the motion is least felt 
in the sujjerior canals, /. c, one should lie down as Hat as possible — 
senitrt'clining diK-s not so jilace the plane of the seuiicireular canal as 
to cause the lea.>>t possible How of Ruiil within it. One Hal pillow Is all 
that aue should use since half-sitting up is »s bad us standing up, 



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mSSASKS /JV AUDITORY ASD VESTJBVIAR PATHWAYS 303 

ChBirs shntild be shifted, if piKt-sihle, according to the pilrh or roll of 
tlie vessel . 

As .Hooti as the tir^t s.xTnptoins of scasickncs.s are feit the patient 
ghotild lie down, if possible, on deck. A.-* eye movements aid in eaiisiiig 
spasiekness, one should close the eyes if there is much motion of the 
ship, so iLs to relieve the museles fmin the enastflnt adjustment necrs- 
sary in wati'hin<; a rising mid f»l!iiig horizon, and in vifrv" bright 
weather, eoloml gliisst*s should be worn to suIkIuc the ghire. It is a 
(;««! plan to face tht* enbiii mtlier than the sea. 

Iteading eontinnously U rather to Ix' avoided, tlicrefore books 
shonid be chosen which will allow one to close one's eyes and meditate. 
Cards or other games whi<'h ilivert the attention an; very helpful. 

In making choice of rooms, one should give preference to those in 
the middle of the boat where the motion is less. To overcome the 
smells and stuffiness incident to ocwin tmvel. one should keep plenty 
of air cirenlating in one's statenxjm. unmindful of drafts, which are 
(»f much less coiuseqncuce tlian one is prone to think them. 

Kuting fruits and salads, drinking plenty of liquids, an<l occasion- 
ally taking a pill of aloes, aloes and mastiche, or similar laxative, is 
generally sidlicicnt to cfiunleract the constipation which is « fretjuent 
ctHLseqnence of the unusual eJiange of hahiLs, especially wlien one cuts 
very little. 



Tails or DimRx^trtAL DtAONoniit or LAtttumum axd Ckrebeu^r 

UutTUnil AN CKA. 



Tofa. 



n. 

Ditatt UkyriMhiUi*. 



fNtub 



bbgrhirtKitk 



latgrrMtliiUik 



fsi^a 



in. 

te potitol MyriMUlii 



^|r£EEi "^^ 



trvtn. 



Xmtam 



sscr 



tVMMBWBt 



UvlealMAi 

bMly I 



U o ■ t ) y n v' 
(nuiiil aiil*,' 
■In bslb 



RaUltfy tmi 
■UnnCMibr 



Wat m <«B 

wd*. or oM 



tttroiKratMonr 
tiloawitiJA 



Botokrr ud 

banwttUi M 



iHiir 



letted b*- wAmJcmt 



DMMMd ur^Umi 









AtMd 

H*ar» atih! 

•UlMfej ud 

kUrtMl 

(M». I 



Vnlian » > 4 
kjrMMMiM <:■ lr?« 

mat of biail 



Ahm 



- Vvrlito, m«(». 






■ ink (tiio, 
•kortn 

Al>«ai 

AlMIt 

Dm/ 



icMLr- 



Abm. 



SlidM TCttin. 



AbraL 
Dm! 



riMB dBtmiuM^ lii«ct iMl 



IbIIv a|n»- BkUoB. If 
doa aytikcaa* 

0v«tinu«(, 



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CRANIAL NBRVBS 



The hcadaolip cif soasicknpsa is best eombatcH by catinf;, by eoffre, 
ami by siimll d(isfs nf bromids and phcnacctin. The widely used 
headache mixtures int-nqmratiiig caffein and aiitipyrin in tlie elixir 
of sodium broinid lire useful. Tlie sodium salt of veronal in doiies of 
from 8 to 10 Rrains. ^ven by rectum in suppository, \s a very useful 
remedy in causing sleep and in relieving excessive irritability of the 
labjTinth. 

DISEASES OF THE LARYNGEAL KERVES. 

Laryngeal Disorders. — The laryngeal rauwles are supplieil by the 
inferior or recurrent laryngeal nerve. The cortical origins are as yet 
not definitely known in spite iif the immense amount of experimenta- 
tion.' That tbey are In the frontal ngiun sterns undoubted but where 
is uncertain. The <'onduetiiin paths pass with other corticomerlullary 
fibers througli the knee of the internal capsule, appan-utly near the 
corticomedullary spinal pathways for voluntary breathing. The 
medullary stations are In-tter known, and eorrespond with the nucleus 
amhignus. I.aryngefil respiratory movements have their bulbar 
nuclei in the nucleus reticularis. Both nuclei are intimately associated. 

An interesting pathological series (NissI) from Ziehen's clinic from a 
patient with tHl)es and complete larjngeal palsy showed degenerative 
changes in the nucleus ambiguus and was the ba^is of an important 
thesis by one of his students.- The ixTHonally seen .series leaves no 
doubt as to the interpretation of the localization of the phonation fibers. 
The iieripheral fibers seem definitely to pa-ss with the vagas rather than 
with the spinal accessory. The larynx also liaa a rich vegetative 
innervation. 

In unilateral paralysis of the vagus, usually peripheral or bntliar, at 
times capsuhir (Avellis synflrome). there is an o-tsociated anesthesia of 
the paralyzed side. In recurrent lar>-ngeal palsy, from neuritis, aortic 
aneurism, inv<ilvement by carcinoma in neck, pnliomyelttis, etc., tlie 
voite is rough or harsh, the vocal eonl is immobile, half-way fixed 
between abduction and addiic-tioci. In dnuhlr-sideil palsy the phona- 
tion is Inst, 

The chief laryngeal palsies arc (1) abductor, unilateral or bilateral, 
(2) adductor, and i'.i) thvToarytcnoid. In unilateral abductor palsy 
the voice is nnatTet-tcd (>r it breaks readily or may be harsh at times, the 
involved vocal con! is immobile during inspiration. In the bilateral 
palsies the voice is unehanged^ inspiration is maile difficult and inspira- 
tion choking and coughing frequent. 

Ailductor palsy is frefjuentiy psychogenic. The patient loses the 
voice and talks in n whisper. The cords can move outward but do 
not come together. 

Thyroar.vtenoid patsy causes hoarseness, the cords are orally 
margined although freely movable. 

I V. H. GralwwcT: Xclwhr. f. "S. n. P., rrf. I. p. 041. 
*Wy»cbvttli)WUfrwa: Bcrliii Tb6n«, 1900 



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fAh NBR\t:i 



DISEASES OF THE SPINAL ACCESSORY AND HYPOGLOSSAL 

NERVES. 

Accessorins. — T\w spinal a«■^■^^ury ihtvc innervates the sterno- 
clritltiriiastnid iiiui the upiKT fillers nf the traiw-zius. Uranehes to the 
vagu^ are known. Us ciirtlcal (trigiii is not (lefiiiitely Incali7.e<). The 
tiupramu'lear jmtliways pass thmugli the internal cuiisule to end in 
part in the medulla near the tjtive and vagus nuclei, in part in the 
nnti'rior horns of the six upper eervieal "spinal" .setrnients. The com- 
bined imiiu-h passes hy way of the jugular roraincn to its museic 
ilistrihution, being combined with vegetjitivo fibers from the cervical 
plexus. 



l-'io. IHfi, — SinunKKlii' tiirli-filli". Ilt-iirl tJrawii 1iia''hward uikI rhin up, dti© to involv©* 
niciit III Ibu ti^ht trii)K-siiif{. iir<>1m1<ly wilh i-i-rtiiin ilvcp iiix^k mtimU^ in tulJilioa U> Uia 
nuinifcflt a|iiwni of the nUnioum^t'iiij. (Masm^RhuKtu G«ncriil H<M)[>ital.) 

Tlie chief lesions eaasiuK ilisurdvr of the spinal awcssory functions 
are tnminata 'bullet'*, (tperations for tulH-rcuKiUi* f^lands), lesions of 
the cervical cord, syringomyelia of the cervical vertebra?, multiple 
sclerosis ncuritidcs, and poliomyelitides. 

Clinic&I. — Cortical dislurbnnccs (first motor neuron] cause irreffular 
and spasmodic actions. These are seen in certain epilepsies, usually 
ct>nclitioned by cerebrni syphilis, multiple sclcrosist or other brain 
disorder. 

llie variuus tics (wrj'-iieck, etc.) are curticul, mostly psychogenic in 



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DISBASKS OF ACCBSSOKY AND HYPOaWSSAl NERVES 307 



orif^in. They represent compulsion tieumsei^ Fur the most part. (See 
Psych ciiieii prises.) 

Niiflvar afTi'ftions of the aecessoriuH are rare. 

IVriphernl palsies are not infrequent and arc Hue to various injuries, 
dircet, through disease of the base of the skull, syphilis, osteitis. They 
cause dej^reesof lossnf |H)Wcr to pull tiie face to one side, with tendency 
tu contrueiion of the opposite side (caput obstipum). !*'leetrical 
chanpes, It. I>., atrophy. loss of reflexe.s, nrtr present in the nuclear and 
IH^riphenil palsies, but a.n' nlj«ent in the ceiitrul palsies or centrally 
induce^I torti<iilIis. Tra|)ezius |>alsy causes an alten'd neck line from 
ppoinliientv of tin* levator hiikuI! scapuhe, tlK'^ scapula is also disi^hiced 
nutwiu^l and downward mid rotated 
outwnnl. IIk' iiHMTlH)rderruiuunt; iip- 
wanl and outward rather than parallel 
with the spiiK-. 

Trraiinnil will vary with cause. It 
should Ik- eniphH>ize«l that the nur- 
gictd Ireittunent of .spa.suii>di(- lortieol- 
tis, which in the overwhelming 
majority of eases is a psyeliiciil re- 
action, usually a <-oinpulstoii neurosis, 
is useless. I 'sych(»ii wlysis and re- 
i-<lueation have liren nuuli mortr 
\nhud>le. 

Hypoglossus. — The hviJoglossal 
nrrvi^, twrlfih [Mur, an.' the chief 
umtornerves of the tonpue. 'I'iiroupli 
etrllaterals they uls«) send motor lilx-rs 
U) the sternohyoid and sternnthyn>id 
musdes. The cortical origins lie in 
the lower jMirtloii of the ivntnil ron- 
volutions. 

The supranuch>ar [wthways are fol- 
lowed with fxitisidcrahle <lilFiculty. 

In the n-rehral |)eduncles they lie in the center somewhat more median 
than the facial; within the internal capsule they lie at the knee. 'I'he 
supmnucU-ar pHlhwa>s decussate frwly and make their medullarj' 
synapse (nucleus of the hypoglossiw) in Uie. lower two-thinls of the 
medulbi, stretching as far down as the pyramidal crossing, ventrally 
fnim the i-enlnil chiuiI to the miilline. At least ten to fifteen r<»ot 
bundles |miss from the hyjK)(rh>ssul nuclei iM-tween the pyramiilal tracts 
and the olive, and join topi-ther for a sliort distance within the h.vpo- 
glossal canal, at the orif.ce of which tlie hypoglotisial vein, which is in 
cunncction with live occipital sinus, surrounds it. The canid is narrow 
and sliort^less tJmn hiilf an inch — lyinp close to the (K-ripilo-jttlanlic 
articulation, at a plaiv where fracture of tlte bade of the skull is very 
apt to alTcct it. 



Fm. 187'— Puraly^ia <jI ri|dtt spinal 
MoorauiT iiervc. 



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CRANIAL NERVES 



At its exit from the skull the hypoglossal lies median to and dorsal 
of the vagiis and of the internal jugular vein, proceeds laterally, passes 
beneath the stylohyoid muscle and the posterior belly of the digastric, 




Fiu. 188. — Pathways of tho taato fibere. I, ophthalmic branch of V, II, maxillary 
branch; ///, mandibular branch; cq, wrtical taate area; So, central aBceadinK taate 
fibers in median lemniscus; fa, subcortical paths; Gg, geoiculate; Q»p, jugular and 
petrosal ganglia of the gloasopharyngeus ; ta, central ascending fibers of trigeminus in 
median lemniscus; fa>, subcortical connectiona of the thalamus with the iDferior posterior 
central gyrus. (Bechtercw.) 



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DISEASES OF ACCESSORY AND HYPOGLOSSAL XEttVES 309 

splits into its various hrHnc-he<«, ami inner\'ate» the miiscJeA already 
montionwl. 

Aiia-stomoses ttitJi the ganfjlinn iKxltKuni, superior wrviral ^aUKlion. 
the ItiiKiial ami first ami stf(nul cervical nerves t«ke plaw. A siiecial 
branch, the ansa hyi>ogIosi:«il is formed by anastomoses of the descend- 
ing branch of the h>'pojtlossal, ami branches from tlic second and 
thini irrvical ner\'es. 

Tlic thief pliysii>l(igiral functions by symmetrical innervation are as 
follows: The Reniogliissns muscle moves the tiinpiit* fi)n\'ani atiil down, 
the hypoglossus muscle moves the tonj^ue back and up, the stylo- 
glossus moves the base of the tongue up and Imck. In as\in metrical 
innervation -that is, loss on one siile-the eoinhincd action of tlicse 
three muscles causes the tongue to deviate in Mv to the paralvzed 
side. 

Affection of the longitudinal muscle by sxTnnietrieal innervation 
causes shortening of tlie tongue, eitlier pulling the top of the tongue 
uji or down. Ily Hsyinmetrical innervation the aiitcriur purtiim of the 
tongue Is pushed to the pandyzid side. Any loss of the funetii>n of 
the braneli whicii innervates the transverse mu-scU-s brings aliout a 
narrowing of the tongue, whereas synmietrical alTeetion of the vertical 
muscles produces a flattening of the tongue. The geuiohyoiti raises 
the hyoid iMine, pulling it forward when the lower jaw Is fixed, )ir pulls 
the lower jaw <lown. When the hyoid bone is fixed the steniohyoitl 
an<i the thvTeohyoid pull on the hyoid bone 

IVripheral lesioiLs of the hyjioglossal arc the result, usually, of mech- 
anical muses, n-sulting citlicr from fracture of the base nf the skull, 
from tiuniirs, dircH injury or tulK-rculosis, or di^locatiun of the up|KT 
ivrvinil vcrtchnc rfrclmwpiiml syphilis, |>articularly of long land- 
ing, in a not infrequent cause of |x-riplicral palsies, while ]K>isoMing from 
lead, arsenic, alcohol, carbon monoxide may cause i>rripjteral Icsi<ms. 

Nuclear and .supranuclear affections of the hy|)ogli»ssjil are due 
to liemnrrhagc within the medulla. Poliomyelitis, tumors, sj-philis, 
and multiple sclerosis— these arc the most frequent cause of nuclear 
or supranuclear li>sions of the.se nerves. 

Isolated cortical lesions cause unarthrias, dysarthrias, tongue ata.xins. 
Psychogenic siH-ech disturbance:* alKiund in vari<ms forms of stuttering, 
stammering, and other c(«npulsive dis4)nlers. 

Qinictl.— Tlic most frequent lesion of the hjiioglostal i.s unilateral. 
There i-s aton>' of the longitudinal muscles of the fmralyKed side, ami 
when the tongue lies (|uiet in the mouth its apex deviates slightly (o 
(Jie non-paralyzed side. The Iiase of the tongue usually ris*'s higher 
on the pandv/cfl sitle tluin tm the sound siile as a result of atony of 
llie hypoglossal mu.scte. 

Movements of tlie tongue arc cHminishe*!; it becomes difficult to 
ri-nu»vc f(MMl whi<h lies lirtwct-n thr teeth and i\w cheek, and it U-ntnint 
difficult for the j»atient to direct the tongue to the tit-th on the par- 
alyxnl side. ( hi thrusting the tnnguc i»ul it deviates to tlie souml side. 



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CRANIAL SBRVE8 



Speech disturbances are present, esperially invoKnng the lahiab ntid 
llugiials. 

Ill lonn-J^tanding diseaso fttrophies develop with fihrillary twltehin^ 
and trenmrs iind promniTuvd irrcgularities; and electrical stimulation 
shows rL-ikdion of »!rj;ciicnitiiin. 

Ill bilateral paralyses spcrrli distiirlmuce;^ art* very marked. Chew- 
in({ awl swallowiiijj arc reudcrctl ditfitult, and the raovemenLt of the 
tonf^uo are markedly diminished in all directions. 

In hysterical lonpiie paralyses, which are by no means uncommon, 
res'i3t«4iee to passive nmtiun of the tongue is .sjhmi. There are no 
electrical I'lmnges mid speech disorder is apt to be ubviuus. 



Kiii. Xva. — -Alrii|»liy iif rixliit Lull nf Uhikih'. CWrlirjil .«y|(liilu( iukI injury. 

In nuclear palsies, atropliy and fibrillan.' twitehinjj are marked, the 
speech dislurliances arc pianounce<^l. the chief characteristic beinp 
wlmt is termed "hot-potato speech." 'Die ]»aTient speaks as though 
he had u hot morsel in his mouth. Ucuctiou of degeneration is also 
present. Supranuclear palsies, such as occur in hemiplegia, involve 
the muscles as a whole, cause ileviutiun of the tongue to the jjaralyzed 
side, au<l other signs of hemiplegia are present. Isolated cortical 
spasm of Uie hypoglossyil may be present. 

Psychogenic hypoglosiial di.sturbanccs are by no means rare. These 
eorLsist of tongue tics, lisping, stammering, stuttering, of constant 
tongue movements, such aa are seen in hysterias, in patients with 




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DISEASED OF ACCBSSORT AND HYPOGLOSSAL NERVES 

dementia precox, compulsion neurosis, and in various paranoid t.NTies 
of thinking. 

Treatment of hypoglossal disturbances varies according to tlie cause 
and is usually pun-ly sjinptomatic. 

Speech Disturbances. — Muinan expression, articulatorj', mimetic, 
tactile, or by UTiting, is a highly (tmiplicated mechanism. It includes 
all of those luuvemeuts resulting from optical, auditory, or tactile 
cuMtacts by which communication Ixtwrcn iiidi\iduiils is brought 
about for social purposes, l^nf^uage as it fully develops is therefore 
a t(Kii with which one may cut into reality and utilize the facti of 
nature for purposes of adaptation. 

All kinetic speci^h disturlwnccs may l>c at first separate*! into those in 
which the a-ceptive (M>asc>ry) side of the pathways are involved and 
into thost; in which the productive (or purely motor) part of the arc is 
implicated. 

On tlic sensory .side one fimis the gradual ac(-uniulation of ex|)erience, 
cliiefly through auditory stirauh (with the gradual evolution of spee<'h), 
Ri>*ml*oIs (language) which stand in the devclopiiig psyche for the 
images of things, idea-s or feeling values. Thought is symlnilie action. 

Optical sttnudi — objects, signs, various glyphs wonls, letters — 
unite to more cwnplex t.vpes of expression in writing (psychieully 
develttpod to cou<)Ucr spatitd limitations). While tactile ^tinnili are 
an integral part of language fr<)ni the more restricte<i side of tactile 
reu4ling of blind and tactile siK>ech of the deaf and dumb to the sensory 
Btimuh of the movements of the mmele-s and tongiic am) lips in .speech. 
A complete analysis of the great complex of sensi»ry factors which 
nllimalcly find nutlet in si>eeeh symlM)lisni with its infinite |j>ychicul 
iniplicHtiun is not ixis-iihlc hen-. It would involve tlic cntirt- pnihji-iii 
of the evolution of civilization niul culture.' 

The productive side of the speech mccliauism h less aimplicateii. 
Originally showing itself in tlic child as a noLsy symbol of crying, there 
lit gradually shajxil by the incrgy nn)rc and nuire accurute sounds of 
expression to meet the needs of hunger and of love. (Iruiits, lauglw, 
gurfflos evolve into more precise formulations, until the rich symlml- 
ixations of speedi are gained, with all their advantages of pm'isinn anil 
cfRciency. 

Here the muscles of the month, lips, larynx, chest, alHlonicn, nrnts, 
and pelvis all come into u gradually refining and orderly scries of 
eoSrdinated ac'tiWtirs, 

As a rt^lcbrutcfi French philosopher lias phrased it;' "If lb*? anta 
have a language, the sigas whirh compose it rau.st be limiti'd 
in numlier, and each of thcrti, onw the sinH-ics is formeil, must 
remain altachetl to a certain object or a tt*rtuin o|ieration. the 
»ign is uilhrreiit to tite thing Mgnifieil. In humnn s<K*iety, on tlie 
contrary, niainifneture and action are of variable form, and, moro 

■ (tiiixiiiiuiti. Hiwat-ti-HlAninievn. Vhti'iim rinnioiEntptMi <■« A|>tuuU- 
' IWrcMw: rrmUvc F.volutinii. IIcnr>' Holt \ Co.. IWl I. 



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over, each iiidtvidual must Ifani his part, because he is not pre- 
ordainetl to it by structure. So a language is reciuired which 
makes it alwa\rs passing from what is known to what is yet to be 
known, 'llicre must be a language whose signs which, cannot be 
infinite in iunnl>er, are extensible i<] an infinity of things. This tendency 
of the sign to transfer itself from one object to another is characteristic 
of liuniun language. It is observable in the Uttle child as stMin aa he 
begins to spi'ak. Iinniediiit*'Iy and naturally he extends the meaning 
of the wurds lie learns, availinphiniself of the most accidental connection 
or the in<»st distant analogy- to detach and irunsfcr elsewhere the sign 
that has been associated in his hearing with a particularobject. "Any- 
thing can designate anything' is the latent principle of infantile lan- 
guage." The truth of this is amply confirmed in the studies of sjtii- 
iwilism in the psychmicnrotic symi>tom, the language of dreants and of 
delusional tliinking. These are disciLS.^ in the chapters dealing with 
disorilers of sixrlal adjustment, Part HI. 



V 



ti 



/ 



uo 



/ 



y 



y 



Fio. 190. — Scheme of ■peecfa oMinecltoni. (Vnasoth.) 

Many schemes linve Iiecn devi:*ed to set forth graiihically some of 
the phases of these kinetic speech disturbances. One of Veroguth's is 
here utilized. 

I lere / r**presents the incoming auditorj' stimuli (tone, sound, words) 
with their more or less sharply defined sensorial perceptions gaine<l 
gradually through experience. They constitute in their totality the 
various audible components of speech and are constit\[ents of organic, 
auditory meinories. The circle / rc]in-sents such a ji^ycbophysio- 
logieal combination^ rather than an anatomical hearing area or zone, 
wiiicli latter is roughly outlined in the first and second temporal 
convolutions. 

Pathway Z represents the optic as well as the tactile, and kinesthetic 
neurciii chain which (y>nvey to the brain centrals graphic symbols 
(pictures, diagrams, graphs^ letters, etc.). The general assembly place 




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of these is represented by tl\e circle. It represents not an antitoinifnily 
ciivum!scribc<l area, hut rather a Eunc-tional capacity. )>iit not unrelated 
to an optical sensory area in the cuneus and precuneus of the oe<-ipitaI 
lohc:^. 

Outgoinff pathways 3 and 4 represent the motor siile of the arcs 
of expression by all those motions hy which the act of articulation 
with infinite vanatiuii, shailcs, nitd iin:inc(*s, niu) tliiise of p'aplilc 
representation are cnrriwl out. Both ])atluvuys are rchited to cortical, 
bulbar, spinal localizations, which make functiomil unity possible 
as si»eth and writing (in widest sense). These urv symlmlizcd hy 
circles /// and IV. All of these are hrouRht to(?cther in an enlarKe<l 
eonrepl (circle I '), which symbolizes the heard, read, spoken, or written 
mtHie of expn-ssion {words, acts, rcpn-scntaliun, mimic, etc.). 

The lines which hind tlicse various centers represent, therefore, a 
scries of possibilities. \Miereas an anutoaiical substratum underlies 
tliese possibilities, no attempt will Iw made to represent them here. 

1. IlciK-tition of words without cucn prehension -Pathways 7, 5, 3. 

2. Heading aloud without compreliension— Pathways 2. 7, 3. 

3. VVritinjj tn dictation— Pathways /, G, 4. 

4. Writing tn dictation without sense — 2, S, 4- 

5. When heard word is comprehended — /, 9. 
0. When remi word is comprelK*nded— .?, IS. 

7. Spontaneous speech of an idea - 10, 3. 

8. Spontaneous graphic expression of an idea — //, 4- 

9. W hen heard word is comprehendeit and reproduced hv speech — 
/. 9, to, 3. 

10. When heanl word Is comprehended and repn»cliiced grnphicallv — 
t.9.U,4. 

11. When read word is comprehcnde<l and repnKlueed hv speech — 
f . 12. 10, 3. 

12. When read word is comprehended and r<'produce<l praphicallv — 

12. n, 4- 

The scheme also attempts to show an internal and external siM^-ch. 

At tlie present time exact correlation between all types of speech 
disturbance and definite' pathways cannot be made. Hut in the main 
certain broad facts have accumulated to iK-rmit certain fairly exact 
(fcneralizations. In the first place the general speech mechanisms are 
lociitcd predominantly in the left hemisphere in right-handed intlivid* 
uals. In the left-handed the localization is predominantly in the right 
hemisphere, .\mbidextrous brains are known and edueabic opposite 
speech ari'as an- known. 

While in t)ie discussion of the apha-sias, one speaks of */i«vA areas, 
auditory (temporal), optic (occipital), motor (Broca's convolution) and 
attempts to localize them, the fact is tluit the arrhitrcture of the 
brain is so complex, the patliwjiy> utilized in the speech mechanisms 
so W)des[»Tail, that it is t>cltcr to sjH-ak of aphasia arras. These arc 
vtus of special preilileetion for the otxiurrcnce of sjieech disturbances 



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314 CRANIAL NERVES . 

which are more or less stereotj-ped. These are areas which are supplied 
more particularly by the 1, 2, 3, 4 branches of the Sylvian artery, dis- 
tributed to the third frontal convolution and operculum of the central 
convolution, Broca's area (motor speech aphasias), the insula (HeschI 
convolution), the posterior part of the first temporal auditory centers 
(amnesic aphasia) and the angular g>Tus, cuneus (optic alexias). 

These areas are well shown in v. Monakow's digram here repro- 
duced. 

Clinical Forms. — These may be subdivided into ertemal and 
internal speech disturbances. 

I. Deafnera brings about a special form of speech disturbance 
(deaf-mutism) Even though the speech apparatus be intact, it 
lacks the dynamic stimuli to be utilized. When speech is acquired, 
it has a peculiar monotonous quality. Certain forms of mutism 
from fault}' hearing are to be distinguished. 

Sulcus centralis 




Kossn Sylvii 
Fin. ISl.^Tho nphosia regioiia in the left homUphere. (Vcroguth.) 

II. Dysarihrma. — ^I'sed in a broad sense, these include disturbances 
in speech due to defect in the productive pathway. 

(a) They may be of purely psychogenic origin, i. e., compulsive 
ideas, hysterical conversions, psychotic sjTnbol distortion, such as 
are evidenced by stammering, stuttering, hysterical speech, katatonic 
speech. 

{b) Peripheral motor palsies; facial, palate (rhinolalia). 

(c) IJulbar palsies (mouthful speech), as seen in progressive muscular 
atrophy (Aran-I)uchenne t.ype, often syphilitic) in amyotrophic lateral 
sclerosis, in acute poliomyelitis, in multiple sclerosis, syringomyelia, 
in tumors of the medulla and pons, and in general paresis. 

(d) In disorders of the static equilibrium mechanism of the midbrain, 
cerebellar paths, corpora striata, as in acute choreas, Huntington's 
chorea, paralysis agitans, multiple sclerosis, one finds incoordination or 
scanning, jerky, or monotonous speech. 



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nraiCASRS of ACCKflfiORY AKD IIYPOOLOSSAL SBTtVBS 315 

The disturhances of inner speech iire termetl aphasia*. They are 
here divided into (.1) ni-ct-ptor, aiid (/i) IViMhictive, which are prac- 
tically synominoiis with sensory' aiid motor aj)hasia re^prt-tively. 

Apbaaiu. Although the separation of all Hphasiu^ into two ^>up», 
receptive and productive, is theoretically possible, praetieally this b 
not the case. The actual clinical pictures seen vary enomiouslj-. 

In view of the fai-t of the millions of years of continuous (jrowih in 
complexity and of cfTwtiveness of this particular series of purjMiseful 
movements, it is no wonder that the many ])njl>leins cnnnecteil with 
si>ecch and the mechanism of its production are still far from being 
clearly rcsolvc<J, nor will this \ye undertaken. 

Arm Cvntrt 



6tnu CorfKJs Catlosufn [t / 4 \ 3 



. 2 



Spl »n< inn Corpus CsIIom i m 



rr»nia|l 

Lobe 



Occipital 
Lot>» 



.^1 



hotor Apkasi* ' 

Sensory Aph«»U 

KlQ. 103. — ^hrin^ of lbi> chiff armu) olid pathwayB invulvod in iiphaaio dittturluuiixia. 
No*. 5. i,&, B. ?, viMrtrvtMilhwayo; No". I.S.R. 0, JO. It. mobir [mthway*. Str., r^rpm 
atriatuin; Li. iL-iitti-uliir nii'leiin; Tkii. (•[rtiv tluilaiiitis . op., <i|x>r(-uluiii: /, iinLb fnmi left 
Uiin|K>rnl Ui riicht UMnpfiniJ i<>* wny ctf thr mrpun rAlI'Mum; 0, piilh from nrripitol Inbo 
U> tlw uiu rPKi'in: J. puth (rum itie arm mi>m b) lh« intenud (-iiiiiule uid poripbsrmlly; 
I. path from t4>ni[M)nil litlw m ami reitkin: 5. piUhs fmtn thr pirJmnuUa to Ft; 8. coanaot- 
ttig iwtli with Dir riitht h<M)iipr>lM5r« by niMiw »f tlir ninxt* f-nltiMmni: 7. [Mtlu from Fi 
tlinni^ the iiiirrnnl rupnitlo ilo«rtnnm): S. tmuux-Una pKth.^ from ft to Tt, openUlmt 
both wny*: 0. imlh fnim th* inunial coniruUl* fi Tr. 10, oiniiociiomi )>M*rM>ii uuniUr 
awl ntpmtnargiiuil g;>-ri anil Ti. tt. imili LrtMreii iM-rigntA] ami T\. (Verapith, sftrr v. 
Mntinknw.) 

What is here attcmptnl is simply a general sketch of <*ertaiii disturli- 
of spirch which have for many years lieen called aphasia. No 
attempt will Ix" made tn detail all of ihe many iiiterpretatinns that have 
been pven to the term. Such may lie found in lar^ and valuable 
works upon the subject, notjd)ly in the monograplis of Klder. Bastian, 
Collins in En^ilish; of Kussmaul. Weniicke, von Monakow. NiesI von 
Mayenddrf in (ierman: and thos*- f»f Dcjerine and Miraille, Marie and 
Montier In French. The a^aIy^i.■^ of the pr<)blcni liari been found to ht 
more ami more complex, successively more tinie-consuminK. money- 
coKting nntl S(.'ientifically difficult. Kach advance has east into the 



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srrap heap many of the classics of a K<*noratinn past and it can he 
aaid that the problems now ™n be solvt-d only by the most exacting 
and rigorous technical methods cciuplcd with mast penetrating and 
comprehensive clinical observations. To completely analyze a :9ing)e 
case of apliasia according to present-day rctjuircnicnLs requires years of 
painstaking obfter\-ation. two or three years of more or less eontinuoun 
microscopic technical manip\ilations, and at the cost of thousands of 
dollars. 

As Adolph Meyer once exprewi-d it, " Xnwilmt the North I'nje and 
the South Pole have been discovered, perliaiis someone will take inter- 
est in that most important tnuliseovered country, the human brain." 
Certainly no better expedition could be fitted out than one tu explore 
the uncharted seas of the human speech areas. 

Uiftury.— '\ he work that the earl>' explorers did is work that cannot 
be thrown away. It outlined the chief landmarks of the country which 
now mnst be left to the skilled pilots uf the State institutions, endowed 
laboratories and univeraily orpniizivlinn-i with their corps nf skilled 
technicians, neophytes to whom a year is hut a day. and to trained 
intcrprt'lers leanicil in the dinUuh cliarls of bruin anatomy. The 
old-time dabblinn in these problems, though dabbling is but a relative 
term, ha-s gone out of fashion. 

To Houillaud, in ISi*), history turns for its first noteworthy find In this 
field. Tinctui"Cil with the notiotis of (tail, liiaiillaud's work was worth 
while, in that hccimtroverted the long-prevailing and nrthodi)X doctrine 
of Flmirens that the brain bail no influence either direct or indirect 
upon the muscles. Boulllaud maintained tliat the brain was indis- 
pensable for movement and he very roughly loc^aUzcd the orpins of 
articulate speech in the antcrif^r IoI)es. As Soury well says, arguing 
from Itouillaud's own writings of 1S47 an<i ISliTi, he was not really a 
Mi-ing pioneer in thisliinitetl field, although his work was full of remark- 
ably clear, valuable muteriul. His work was too much colore<I by the 
conceptions of (bdl, but he was a pn-cursor of Hro4a who In IS^'kt really 
charted tlie first outlines of the aphasia sea. Houillaud, lujwever, 
noted that articulate speech could be abolished without paralysis of 
any of the muscles of phonatiou and separated completely motor 
aphasia from dysarthria. Ihiuihaud also apparently had an idea of 
what is spoken of as internal speech, for he wrote as early as bSi') that 
''the loss (if s|x'e(h deinMiils at times upon the memory of words, at 
times u|>i»n that otf the muscular movements of which six-ccli is com- 
posed, or what is the same thuig, at times upon a lesion of the gniy 
matter and at times of the white substance of the anterior lolres." For 
Houillaml the lesions were bilateral. 

Marc Dax, writing in IHiJli, however, made a rterie.*! of interesting 
observations in which he concluded "that not all diseases of the left 
hennsphertr can alter verljal memory but when this mcmor>- is nltepp<l 
by disease of the bruin It is necessary to se<'k the ciuise of the disunler 
in Uic left hcmisplicrc." Houillaud eontesle<J the notion which Dax 




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nSBASSS OF ACCESSORY ASD HYPOOWSSAL NEnVBS 311 

ooiiUI not support hy autopsy findings. Furthennure, Bnuillaud, fol- 
lowing a custom of the times, offered a prize of 5(X) franca to him who 
would show him a single case of the loss of spow-h dcscrilwd. Tiiis w&s 
in IH4S. and the whole story of the times and liroca's presentation in 
1861 is well told in an admirable eriliral essay by Marie. 

The clinicnl pictures noted by Itoulllaud, (tail, by Dax, father mid 
son, Marce, Jackson, l-elut, I^idat, and others, received their ana- 
tomical explanation by Broea, in 18(U, in bis first autopsy caw.* of 
Ix'borpne. n man fifty-<me years of age whn since the age of twenty-one 
had lust his use of lanjcuafjc. He could pronounce only a single syllabic 
which he repeate<l two or three times in succession, tau. tau, tau. He 
un(lerstoo<l practically everv-thinn said to him. A second case. l^Ion^. 
soon followpil, and Hnx«, then thirty-seven years of age, made the 
<Ieductton that the seat of the Icsiotis of motur aphiLsia (apbemia he 
c-alled it at that time) was in the thini left frontal convolution. These 
two brains were conservwl iii the Dupuylrt^ii museum at Paris and have 
been seen by many. In lsr>:{ UrtH-a reportc*! IL cases in which the 
left tliini frontal Huivobitinn was involved ami in IK)i') he |)resented a 
^nerai thesis upon the subject. He noted the presence of ri}Tht-.sided 
lesitiiis in left-bandeil perstnts. 

Hroca ik-fined his apbemia in the followinR words: "There are indi- 
viduals in whom the general faculty of langmigi- |K'r>ists imnlteml, in 
whom thi- auditory apparatus is intact, and when- all the muscles, not 
excepting those of the voice atid of articulation, olK-y tlie will, and in 
whom as a result of a cerebral lesion the articulate speech is abolished. 
Tliis almlition of siwech, in iiHJividuaLs who are not paralytics, nor iiliotjt, 
constitutes a symptom sufficiently distinctive which it seems to me use- 
ful to ilfsiifiiate under a s|>fciul aanu>. 1 shall call it apbemia Ifi, with- 
out, ami iffjjfii. T speak, 1 pninonnir) for that which these patients lack 
is solely the faculty of articulating words. They hear and understand 
all that is said to ibcm; they have their reasou. they emit sounds with 
faHlity; they can nH)ve the tongue, and the lijw nnurb more energetic- 
ally than is necessary tn articulate s()und and yet, notwithstamling, the 
reiq)onse. while they understand perfectly wliat they would wish to say, 
is reduced to a few artieulatory sounds, alwa>'s the same and alwa>'s 
utten-d in the same manniT. Their viicabulary, if one can call it such, 
bic<ini]M>seil of a shnrt series nf s\llahles, often of a munosyllahle which 
expresses everything, or rather which expresses nothing, for this unique 
word 18 most often a stranger to all vix-abularies. Certain jwticnts 
liave not even a vestige of articulate speech; they make vain efforts 
without pronouncing a syllable." 

(loing into the anatomical correlation Uroca says, ".\phemia, that is 
to say, the loss i>f siieech witliout oilier intellectual disorder, and without 
any paralysis, has been the ciHiS4!quence of a lesion of one of tlie frontal 
IoIm^. In our patients the site of the lesion was in the .second or thinl 
left fnniial n>nvi)lution. most probably in the latter. It is then jMissible 
that the faculty of articulate speech is locatetl in one or the other of 



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318 

tliest* convdiutioris." It is not necessary to pnK-eed further with his 
very temperate statement and his careful wording, in wliich we can see 
his desire to support a superior in the Faeulty, Uonillaud, antl yrt not 
offend him nor the most aetive believers in the localization of (lall. In 
isri2 he saw a imtient with aplunna fnmi a righl-^uled K-sion which 
caused him to Im* cautious. In 18(l;i I'arrol derac«L*'t rated a case of 
extensive destruction of the right third frontal convolution without any 
speech or intellijiencc defect, wliich also contrihutcti much to a very 
active discussion ji^injl "" in I'aris. Finally in istl) Hnn-a came out 
Hat-f4«»tpd and said that the thin! left fnmtal coiivohitinii was the seat 
of his aphemia. Thus, to use Moutier's phrase, the "dogma" was 
createil, althtxigh it was not by any means accepted by all. All of 
the acrimony of a jireat discussion rajrcil but Trousseau j^ave it the 
weight ii\ his great authority and it prevailed for many years and, 
gradually subjetted to certain modiiicutions, prevails at the present 
lime. 

Then l)egan the great period of electrical stimulation of the cortex. 
I.ocalizatinii, u fantastic theani for (iail,, became a scientific reality 
for the English physioUpgists anri when iti Is70 Fritsch and Ilitzig 
published their studies with electrical evcital>ilit\' of the cortex un 
entirely new method of localizing nuiscular movements and the speedi 
mechanism IxH'amc ix).ssiblc. Meanwhile the aphasia question was 
actively studic<l. FIcnry (l^ifi-')) distinguished HrcK-ji's aphemias from 
what he called aphrasics: they could pronounce but did not use the 
right meaning. (Gardner (IN(5(>) separated internal speech trouble from 
intact ideation. Ogle (ISfi?) fell npnn the idea i»f agraphia and Itastian 
(1809) really discovered won) -deafness. Paraphasia, jarg(m njihasin, 
wen* also described by Jackstm and other Knglisli writers. 

The himor has been given to Wernicke, however, for di.sct>vermg 
that the incoming receptive side of the speech mechanism, i. e., the 
auditory understJinding of speech, sepanited from the hearing of sounds, 
was of iinmeiL>ie importance in solviiig the problems of si)eech dis- 
turbances asid he formiilatcil lh;it fornt of iipbasiii which is termed sen- 
sory apliiisia. These patients heard sounds but they might as well have 
been ( hinese or Choctaw. They had lost their meanings. This was 
in IK74, and the defect he then stated was due to a deftH.'t of the first 
left temporal convolution. 

The aphasia problem at first iximparatively simple, and not yet a 
flEenera] problem, began to become e<nnplicatefl. \Venii<'ke deserilwd 
his zone of language. There existed! a mo'tor aphasia, the aphasia of 
HrcK'H and diH' In disturbiiti>ce of (be 1'^ tcri and a sensory aphasia due 
to disease if the first temjioral of the left sirle and jjosterior, in which 
comprehension of s|K)kcii words was lost. This served as a control of 
the motor cTntcr and lesions here produced the various clinical pictures 
descrii>ed particularly by the Knglish as anitiesie apha.sia, paraphasia, 
agraphia, etc. 

A most searching reanalysis of the entire question followed Marie's 



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icnnoclastic uttenincvs in I90(>.' Insufficient corn]»rehensioii of .speech, 
/. <•., as an intellertual Hefevt — n dementia, Marie ratlerl it— was the 
principal fdnwpt that ruled this presentation of aphasia. The whole 
prohleni Is rxtrrmeiy techiiifal and involveil, and the tliscussion oinnot 
lit' entered uito here. At all events the work of Marie cause*] severaJ 
realignments of formor attitudes but did not cswntially modify the 
HCtTpte*! t.v^K-s. a brief rO.sunie nf which is here ftiven: 

C'UNicAi, KoitMs.- Aphasia as here understood consferts in a dis- 
turbance <ir loss of siM-ecli resulting fnim a failure to evoke or crnitrol the 
memory of these auditory or visual syinUils used in s«Hial interchange 
of concepts or ideas. This loss i)f eontn)! or failure to evtike the proper 
symlK)Is is due to a ilefinlte strut'tural rlmnye involving the complex 
brain pathway:*, or it may result fn>ni purely psycliolonical hhK-kii^j. 
It has l>een seen that for speech as for any other volitirmal act. receptor 
and elTwtor ]Kithways must Ik* ii|»en. The receptor pathways, i. ir,, li»e 
.•(en.sor>' part of the process, include the iH'aring and the seeing of word 
sjTnlmls. The memories arc stored in certain are«.s or zones which have 
Ikh^o termed HUilitnr\ and vii^nal word areas, ("enters is hm older term 
but is sonicwhut object innnble. Tlie auditory word zone or area Ls 
jtieatcd about the upinr surface of the tcmpond lobe in the anterior 
transverse g^nis of tleschl ami extending also into the adjacent portiotis 
of the iKKiterior and of the first temporal convolution. The gyrtis 
angularis ser\Ts as a visvml area for those who have learne*! to read. 
I^esionA, which occupy these locations or are in such a position as to cut 
tlie pathways immeiliately retateil lliereto give rise to word-deaf niws — 
auditory aphasia, or word-blindness, visual iiphusia. These are the 
t\"pps of s*i-calletl sensiiry aphasia. 

'Hie productive or clTector side of the speech reflex arc, r . e., the motor 
side wherein motor images are more or less stored up, is, a.-* Ims been 
iminted out, in and about Broca's convolution and the adjacent areas 
of the precentral and insula convolutions. Lesions here result in motor 
apliasia. or, as BrtK-a called it aphemia. It may lie added that Marie's 
siran-hing atlcinpt tii bn'ak di>un the cliLssical motor aphasia, by rntUug 
it anarthria plus a lenticulnr lesion catisingilementia, has not stimd the 
test of cnn'ful investigation. 

The chief lesions causing these aphasias are hemorrhages, abscess, 
emrphalitis, tumors, [hrumlnis<*s, emboli and acute edcma.-«. Func- 
linnal lr>.s.sps are s«H-n rt-sulting from the eiiiltptic dischai^e rmni certain 
hysterical dissociation.s, in uremia or in severe angiospasms, as in 
migraine fur example. 

MoUjt .lpkii^ia.~]n this type of aphasta tlie jiatient has lost the 
capacity tu expn-rts himself tn speech. lie raiuuit read or talk siHin- 
JjMMxnisly. lie umy say a few words, is usually able to say. yes, yes, 
no, is irritated over his loss, fre<|uently saying "damn" or other 

?lctivo in tlie fruitless aiul exa^speruting search for words. Typical^ 

SbbbIm MMImJii, IOM. Ncm. 21, 42, 4^, hm aim, Mmilict'ii TW»da (ur cumt 
[■dto wao a of tb« wfaol* ptvbltcn. 



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expletives are frwiiumt ami are often repeated over and over again. It 
is convenient to distinpuish two types* of motor aphasia. 

Suhmrlictit 'tr Six'dUM Viire Motor Aplutjtia. — Here tlie motor speech 
pathways on the way out tn the medullary mulei are cut ctfT. The 
pjiticiit is usually quite al>k' to understand spoken and written symlwla, 
but cannot sjieak spontaneously, read aloud, or even repeat what is 
spoken to him. He usually is able to writt:. Hysterical dis.4ociation 
may brmp alKUit this type, as well a.s the concrete lesions already 
mentioned. 

CnTtirni Mutiir .IpAiWtm.— This type, less <.i>mmon and theoretically 
more difficiUt of comprehension, suffers a greater loss of internal speech. 
The patient is usually unable to write and usually fails U\ bring together 
long sentences or c-ompUrated word a'liitioiLS. He falls to grasp them 
in tht'ir entirety. The more severe the speech defect, the more pro- 
nouncH-d, as a rule, is the agraphia. 

Auditory Aphuia {Word-deajnexs). — The patient hears without 
diitirulty bnt heretofore known syml>oIs are now as though foreign. 
He is usually nlile tn ri'|iciit the [dirases, Imitate the sounds, but they 
might as well he Chint'se for all hisconi]>rehf'nsii»Tiof them or his ability 
to use them propt-rly is concerned. Here also two trends in the s^inp- 
toma arc capable of fairly sliarp scpuratioiLs. 

SubisMical or Pure Awlitory Aphakia. — The pathways between the 
receptor and their central station are blocked just distal to the auditor>* 
area. S|Hintaneous si)et'i'h does not sulTer but cannot In; countwl upon 
utdess thniiigh visual corrt-etlim. Ity the guidaiiee of the written word 
the patient may express himself iierfectly. Ue|)etition of sound 
symlwls may !« impaired, lience these patients cannot repeat spoken 
phrasi'S. 

Cortical Word-daifrictts. — SjHaitanecms speech is much more involved 
and the patient's talk is usually quite dlsturlx^d whether he att<*mpts 
spontaneous sjx-ech or when reading aUiud. Internal sjk'ccIi is seriously 
disturbed. The patient cannot n']M'at, nor copy to dictation. Mis- 
takes in orthography are frt-quetit. While he may Ix'; fluent tn his 
six-ech it may be fairly clear or a mixed-up jumble. Furthermore, the 
patient is not aware of liis mistakes or only partially aware of them. 

A great variety 4>f j>artial forms are met with. One patient will lose 
the value of names, of nouns, of objects, others are merely confused 
(paraphasia]. 

Auditory aphasics usually clear up but in those patients who are rich 
in auditory forms of memory, In contrast to those whose memory tj'pe 
Is more apt to be visual, the ilisnbillty Is usually greater. 

Visual Aphasia iW on f-b!iminet/s). —This tyjw is also spoken of as 
oh-sia at times. Tlii' patient sees hut dors not tn.ke it in. i'revioiisly 
recognized signs are now as though Kg.\'ptian or cuneiform. Shapes are 
recognized and may even be etipled hut are not oompreheniied. They 
have lost their acquired cuntext. Two types are here to be recognized, 
also. 




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Suhcnrtical itr Purr li'nrd-l'fiii(Inr.t.i. — The arfii or center Wiiig intHti 
the le,Himi involves the ineuming pathways atljai'ent to the «)rtex. 
The patient fails to un<lerstan(l written words, cannot read aloud but 
may write or may ropy fmm dietatitm. Partial hlhidiiess (hemianop- 
sia) tisiialiy accompanies this disturbance. The:**.* i>atients are unable 
to rea<! their own writing even thongh that writing may convey sna^iible 
iiieHiiirigs and lie a fXirn-<-t mnliniii f>f intercommniiitration. 

Cortical HWrf-Zj/inrfrifM.— Spontaneous writing. wTiting from dicta- 
tion, or writing from wipy are lost. The patient is agniphic. He lias 
lost all memories of written or printed ^ivmbob, wortls, de^iga-i. or 
what not. Minor grades of the defect cause "paragraphia" in wiiieh 
the |>atient writes with mistakes in mlaplaring letters, or syllables or 
worils. Such |)aragraphias are very frequent in paresis, for instance. 

In actual prnctic*' the more or les.« sharply cut forms hen- summarily 
(!estTil»ed are les.-* often met with tlian the innnerons mixed forms. 
A frequent tj'pe is a complete or glottal aphasia in which the entire 
bniiii speech mechanisms are wijjwl out. These an' the forms se«'n 
following severe hemorrhage with the middle cerebral syndrome, 
hemiplegia, etc.. accompanying. 

Treatment of the Aphasias.— < >>rtain forms clear up spnntaneimsly. 
No matter what the form, however, immMliate retraining fOiould be 
begun. a.s hhid as the patient has rerovered frnni the shock of the 
original iasult. This retniining shouM U* jHTsistently followed aec«)rd- 
ing to s[)eciHl methiKls for the ^'arious t,ii'pe-s which cannot even be 
outlinetl here. 

Writing Disturbances.— .-\ great variety of disturbances in writing, 
quite analogous to .speech disturbances, arc known, Thm. writer's 
eramp Is analogous to stuttering and stammering. It Ls prob- 
ably psychogenic in origin. In the ]»yeboses, very eha met eristic 
WTiting features and failures are present. The paretic may write just 
Its lie speak-s, slurring, leaving out syllables or wonl-s, etc. The kata- 
toniemay show stilted writing ju.st asheslmws astilte«l atTc<'ted siM-ech. 
'Ilie baste (>f the manic is seen in writing as in speech, lii time a true 
science of clurogniphy may Ik- built up on a itsychtcal hasis, just as a 
true .science of phonetics has been. 

Paralysis agitans, multiple sclerosis, .shou-s analogous features In 
writing and in .speech. 



21 



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CHAPTKU V. 

AKKKCriOXS OF THE PEKIPHEHAL NEHVES: SENSOHY 

AM) MOTOR. 

K£URALOUS. 

TiiK most characterislic feature of disonlerwl ^leripheral sensory 
nerves is pain. In the presence of pain alnne one speaks of neiiralf{ia; 
pain with trnphie disorrlers, tender nerve trunks and altered museular 
function wlien fwriplieral is u.sually tenned ufuritis; rudlculitis if in 
the nnils iir the pli-xns; whereas pain assiK-tntrd witli peeuliar skin 
eruptions due to ganglionic root involvement is railed hcri»es aoster 
or zona. The psychic pain of hysteria, and the central pains of 
thalamic lesions are jiot now oonsidert-d. 

The boundaries i)etween these affections are largely artificial. Thus 
a verj- mild neuritis presents only its neuralgic features; and a zona 
may be so slight as to cause no eruption. From a clinical stand-point 
separation of these processes nmy \w impossible. It is not always 
necessary, ratluilogically speaking, one lomtcs the li-sion of wtster 
in tlie sensory ganglion, yet tie douloureux— or trigeminal neuralgia^ 
is prcemiricnlly a disease uf the seiLsory ganglion, the (Jasscriari, and 
yet there b* rarely any zoster eruption. One Invokes the eticlc^ical 
factor of an acute infection element in herpes zoster yet there are 
zoftter eases <lue to other than bacterial causes. The diiferentiatinn 
lietweeiL n radiculitis and a neuritis is often sf^ely a question of 
terminoingy. 

Too mucli weiglit. therefore, is not to be laid upon the classifications 
given. For practical pur|)oscs these atfections are treated under 
llircc heads, but their fluctuating separations shouh) not be forgotten. 
It is misleading to call neuralgia a functional disorder. 

Like many other conditions in nature, these affections, when seen in 
an acirntiiated anrl pun* form, for practical purjxises, represent different 
entities, yet the partial and iutcrmcdiurit' fonns are so many that the 
clcscrijition of the clear-cut, classic tvpcs does not do justice to the 
whole subject. 

Definition. — A painful affection of the nerve trunk or its branches, 
characteriKed by remittent or intermittent flu.shes of acute pain, with 
free intervals, not usually accompanied by trophic disturbances of the 
muscles, unless its severity limits the activities of an organ, occasionally 
assfK-iated with painful ner\'e trunks and with disturbances in the skin 
structures. 




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Nrumlpas are but the expressiun of tnnny diverse Icsioiu which 
may involve the Ixxly in peiwral, as \u\'u- arui iriFcctioiis state?, a nerve 
tnink iuclf. the scnsfiry paiiglia. <xmtijjiious stnictnres, or they may 
be the reflex expression of a Hisurder in a viscus remote from the 
site of the pain. Tliey may be of purely psyebogenic origin, mostly 
h.N'sterical conversions, oecasionally deUisioiial projeeiions. Neuralgia 
thi'refnre is to lie consideref! soli-ly as a syni]>tiim, a symlrome, or a 
jiainful ^mutie reflex. There arc no idiopathic neuralitias. 

Etiolory.' An extraordinarily wide ranpe of causative factors may 
determine mild or severe neural^iai: in very diverse regions of the body. 
The most frequent causative factors are: 

(a) Am-rnias due Ut hcniorrha^ics. clil()r(t>is, IH■^nicic»u^ aneinia, kid- 
ney disease, endiKrinopathies, nmhiria, syphilis, intestinal parasites, etc. 

(h) ToxuB of exogenous oHfiin. in<irg»nic, and organic or purely 
endoRcnous toxins: thus poisoning by k-ad, mercur\-, ar^nic, and 
copper. AUi>!u)l and tobacco are fretiuenl causes. Morphinism 
causes neuralfjia as an alt^tiiicnce s,i'niptom. The toxins of many 
infectiowi disorders are enpe<-i!illy prone to bring about neuralgias. 
Toa>ullitis and malaria are examples. T>'phoid fever, measles, gonor- 
rhea, possibly syphilis, and strcptociKric infections are frequently 
acfomi»Hnied by neuralgias. The endogenous toxemias of dialM'tcs 
and latent ncpliritis are further examples. 

(c) Inilainniation of the M>nsorji' ga[iglia, which may Ik either of 
infectious or non-infectious nature, gives rise to some of the severest 
forms, as seen in herpes zoster. These posters occur from involvement 
of any ganglion, from the up|»ernu>st to those farthe-st caudail. lliey 
are usually dealt with in lMHik> on dermatology, but tfiey are essentially 
nervous disorders. Ganglion involvements of non-infectious types 
give rise to neuralgiius, such us lie douloureux, while tumors of the 
sensor>' ganglia may txmdition persistent and obstinate neuralgias in 
the affected .sensory ncr%*es. 

(d) Involvements of the nerve tnmk.-. theni.selves, either by mild 
neuritic pr»>oesses, f)erineuritis. pressiuv fmm anatomical structures, 
preswure from lesions, euLs, bullets, wound.s, tears, tumors, periiwtilLs. 
osteitis (often infectious in tyjic). ancurisni. exostoses, fractures, or 
displacements may cause seven* neuralgic pains. If the nerves 
degenerate neuritis results. 

(e) Keflex or assta'iated neuralgias are numerous and puzzling. Pul- 
monary, CArdiac, gastric, hepatic, renal, ureteric, intestinal, vesi<'ttl, 
uterine, ovarian, prostatic, testicular, anrl atfections of other vi.sceni 
may give rise to herjietic eruptions, with painful, st-nsitivc skin areas 
aitd neuralgias: in many instances the neumlgia is not ace)>mpanie<l by 
heqjet.. Ileail's' complete analysis of this class of cases is of para- 
mount imporlauce. Thus a persistent sciatica may be the reflex of a 
prostatic disturlmnce. An anemic woman may not sulTer from pain, 

' Bfmin, xvl, I; zvU, 3»»: lU, 1A3. 



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AhrECTiom of the peripheral nerves 



but on mcnstniation her rcfcrreH neuralgic pains may become very 
severe over the tenth dorsal nerw. and pain and tenderness are frequent 
over the areas of the sixth diirsal (heart), seventh dorsal (st4)maeh), 
and there may he oert]iital and midorhital neuralgia (Head). (See 
Figs. 194 and lOo.) 

(/) Somatie liiseast^ of the ner\'0U3 system. General paresis, tabes 
dorsalis. »pinal or cerebral disease, tlialaiutis dist^ase, sj-philitic mentn- 
Koniyditis, etc.. are often accompanied by neuralpie paias. 

ig) Constitutional Factors: The arthritic, gonty, rheumatic, and 
scrofulous may be said to l>e predisposed to neuralgic disturbances. 
Unknown fartors thought to be relateil to atmiMplierie pressure, 
huniirllty. high electrical tension, etc., play a role in many of tliese 
fa-^es. These are prolmbly psychogenic cases. 

(A) ("lirtwic vascular disease, and fsjKTially arteriosclerosis, is a 
frequent cause, particularly in the agc<l, the .senile, and the presenile. 
Syphilitic vascular disease is a cause. 

(t) Exposure to cold is an important factor. It is not certain that 
all neuralgias causetl by cold are iu>t really mild l\i>es of neuritis or 
pcrineiintis; ihsfussiou of the distinction is fruitless. The older 
writers found colds a prerlisjMisIng cause in from 2."» to 40 |»er cent, of 
the cases. In damp, cold countries this is particularly noticeable. 

{}) Psych4»geuic Factors: T1k!sc play a large |>art in practical 
me<licine in determining neuralgic pains. 

Symptoms.— I'ain is the main feature in neuralgia. For the most 
part it is the only expression of the nerve disturh.iiioe. The character 
of the pain varies considerably, hut in general it may be described as 
unilateral and paroxystnal. It is rharacleristic of most neuralgias 
that tliey arc not primarily localized in the periphery. The jwiin 
seems to begin beneath the surface, and may then shoot out to the 
periphery. It may be described as biting. iHiring, tearing, <larting. 
cutting, like an electrical shock, like a hot iron, etc., each ]>atient 
having his own pet expression. It may rojiie and go in lightning-like 
flashes, or throbbing pnlsatioiLs, iwrsistitig for a shorter or longer 
time, then .stopping for minutes, hours, or days, then recurring. ^Vhen 
continuous, the pain varies considerably in its intensity. 

The painful area usually conforms to the perli^heral distribution of 
the seusor>' nerves. In the herijetic and referred neuralgias the root 
zone area is involved. 

Certain tender poinia seem to be foci from which the pains start. 
These are usually situated along the nerve tninks, and pressure upon 
them is often sufficient to ciuise an exacerbation of a mi!fl attack, or to 
provoke an attack in a period of iivterniission. Valleix attached con- 
siderable importance to these points, 'lliey are found, according 
to him: (1) at the point of emergence of the ncr\'c trunks from bony 
foramina: (2) at .such situations where a nerve trunk traverses a muscle 
to reach the skin; (li) at points where the nerve fiber breaks up into 
branches; (4) at points where the nerve becomes very superficial; 




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325 



(5) at Trousseau's apophyseal points. 
Valleix's points are of diagnostit- impor- 
tance partifularly b separating tlic neu- 
ritir from the neuralgic t\"pes. 

Accompanying phenomena are fre- 
quent. In some pationt.*? a sense of 
apprehension may precede the eouiing 
on of an attack; vague sensations of 
discumfort often antedate the iii-nralKic 
outl>reak. Ripples of pain, like pin- 
pricks, short twinges, etc., announce the 
advent of a more serious attack, or 
may l>e the sole evidence of an alKirtive 
niip, Sueh tnild phenomena are ex- 
tremely frequent in i-ertain of the so- 
called pre<!isp«j«ed or neuralgic indi- 
viduals; some feel that tliey eannut live 
at high altitud(*s; utheni fear rain, or 
an east wind; a thunder storm causes 
others to have iwin(;es; while, again. 
certain dietary' indiseretiniLs make others 
eonijilnin of painrnj twinges for days. 
Just what eonditions are at the basis 
of the*.' features may Ih' didieult to run 
down. They are none the less real. 

Skin hj-persen-sitiveness ia frequent. 
It may pre<'ede or accompany an attack, 
and persist after the pain has ceased. 
Kpieritic sensibility is mostly inifiHcuteil. 
light touch, a pin-prick, or slight degret's 
of heat or cold are uiagnified. Deep 
pressure and extremes of heat and cold 
are usually palliative. 

Anesthesia is not infretiuent following 
an attack of pain, and the exact topo- 
graphical distribution of the sensory 
modifications on the skin throw con- 
siderable light on the po^sibk* etiolt^' 
of the neuralgic pains (Head). 

raresthesise arc very frequent, and 
certain dtstributioiu seem to show them 
more than otheni. Thus, in the cuta- 
neoiia branches of the femoral, they arc 
not infrequent. Here they take on the 
eharatiertif a " meralgia panstltetica." 



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Pill. 1113.— CutaUKKu n>ni'i wmw uI hypanitamk, ■bmrlnt thdlr nUtiona wldi lit* 
tvinti TvA wawMiM and (iMrir vegvutive tiervcp>u»-«3rrt«m ooaoMtiMM. Tli« dottvtl 
■roM AD! to l» watttnmd lu Uic iul*mal mH a em . (After DvjwfawJ 



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326 



AFFECTIONS OF THE PERIPHERAL NERVES 



Motor disturbances, either as cramp-like contractions or as paralyses, 
are not infrequent in accompanying conditions. The painful contrac- 
tions of tic douloureux and the oculomotor paresis of ophthahnopl^ic 
migraine are familiar examples of this. 

Vasomotor and secretor\' symptoms are frequent. The blood- 
vessels are frequently contracted in the early stages of a neuralgic 
attack, with resulting blanching and cooling of the skin. Following 
this a period of warmth, of redness, of free perspiration may result 



^rtICaJU»> 



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OrbitoJ (Di, S 

Jiaiutfrontal (C3,4) 
nmporofronlai {DS.B) 

iiaxillary / - // 

Mtntal 

Superior LuryHoeal "" 
Inferior Luryiif/eal 



[pilaHpfflt 




Fta. 194. — Tutancoufl reflex loiies <i[ hyjKTnlKeuiiL of Ihe head. neck, aud shoulders in 
thpir reliitiftris to vegutative iiorve (soiiiatH^) di!)tiirl>uur(>». (After Dejerine.) 

from the secoiidarj- dilatation of the vessels. In many cases of trigem- 
inal neuralgia other secretions may l>e modified. Crj'ing, coryza, or 
salivation are not infrequent, while in widesjiread neuralgic attacks an 
increase in the amount of urine and of milk secreted is frequently found. 

Premature graying of the hair, loss of liair, thickening of the skin, 
erj^hemata, eczema, i)emi)higus, herpes, thickening of the bones, and, 
occa-sionally, musck^ atrophy are among the rarer trophic by-products. 

During an attack, irregularities of the pulse are not unusual ; slowing 
is the rule. The pupils are frequently dilated. 



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\SVRALf7rAS 



327 



The general pliysk^l am! psyeliiral reactions are extremely impor- 
tant. \ax>s uf sleep ami aiioti-xia i-ausi^ the patient to lose strertfrth 
and flesh; and anxifty. irrituhiiity and petulancr are almost inevitable. 
Mental depression, sulHcicnt to load the patient to make suicidal 
attempts, is not infrei]uent, especially in severe cases of tripeminal 
an<I sciatica neuralf^ia. The contracting of a druf; habit is not una'iual. 

Course. — This depends naturally upon the underlyinj; condition. 
Many are atnte and transiti.»ry, [(ersi-st three nr four days and never 
reapi)ear. Such are the herpetic t>'|>es. Many reflex neuralgia-s run 
an acute recoverable coun>e. but show a marked tendency to recurrtrntv. 
The neuralgias which accompany the clux>nic cachexias of nephritis, 
<-arcinoma, brain or spinal-i-ord disease, usually protrress in a markedly 
chronic manner. In those hpre<litarily disiK»sed individuals the ten- 
dency to ohroniciiy with longer and shorter periods is proverbial. 

Karlier Trench writers attempted to distinguish tx'nign and severe 
forms. Most neuralgias in winch tlie causative factor is imdiseoverable 
(the so-callc<l idiopathic or primary neuralgiasl run a beni^jn course, 
while the neuritic tyjx-s are less auicnahlc to treatment. 

The sulxlivUion of neuralgic neuroses, sulmcute neuritic neuralgia, 
and chronic neuritic neuralgia offer a grouping referable to course 
which has only clinical convenience to warrant it. 

In the first tyjie one finds the disorder more or less limited to the 
nenmpath. The attacks come without appreiiablt* i-ause, or foUnw n 
nervous sliwk. Exposure to cold, or dietary intliseretions are fre- 
quently claimed as causes, but are not. The pain comes on with great 
suddenness and usually goes without gn-at violence; it comes and goes 
apjMirently without rhyme or rea.son. and is not acojnipanietl by ])ninful 
nerve trunk nor trophic disturl>auces. It recovers at times, to recur 
at intervals of a j-ear or years. 

In the subacute neuritic neuralgic type, exposure to cold or pressure, 
especially tn arthritic patients. dctcrniii»*s an attack. The attack 
develops gradually; the pain, at first mild and intermittent, gets 
worse and worse and more continuous. FiImll.^ . after a day or mure, 
the paroxysms become extreme, the intervals being marked hy dull 
pain: h\'])erseiLsitiv e \'alleix's points are characteristic findings. 

When a mixed nerve Is involved, mu.scular atn>phy or other trophic 
signs appear, signalizing the ixvurrcntt' of n neuritic pn>c<*s.s. Iah'»\ 
edema and herpes zoster arc frer|Upnt actxinipuninients. 'ITiis type 
usually commences to rewiver in from two to tlinv weeks, and an 
ultimate rccover>' Is to l>e expected. Recurrences oeair, however, 
and a leap to the third tyiM- of chn>nic neuritic neumlgia is nmde. 
This form is frequent in the agefl. lite history is usually that of 
several .subacute attacks with imTea.sing tendency to chninicity. 
Here the trophic distnrlmn»>s in miL^clr and in skin are inorr marked. 
'Hie paruxysms run it remittent course. 

Diacnosis.—I'jtiiugh lias Imimi sntd to einpluLsizt* tlir neei) for a 
acaMiing analysis of tlie causative factors of every neuralgia. They 



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APFECTWNft or TflS PF.RIPURHAL KKRVRR 

ore many, and presumably the most widesprea<l diagnostic error is 
the ovi-rl(K)king of an early tal>es dorsalis in youn^ to mid(lle-a|;e<l adults. 

Children arc not prone to neuralgias— in the narrower sense— antl 
a neiiralgir affeftinn in cliildliood calls for Hose scrutiny. It is usually 
somatic, hut may U' iisychngenic. 

Since uiiilatertil pain, of s|H"cial localize*! tj-pe, occurring in irregular 
attacks, is almost the sole crilcrinn of ncumlj^ia, il is very frequent tliat 
organic disease of a visciis will show jjrcclsejy similar acpompanying 
features. In the majority of cases the underlying somatic lesion may 
Iw ileterted o<rasi((nally it remain-s ditficnlt to locate. Not infre- 
quently the diagnosis of a persistent neuralgia may be cleared up by 
the finding of malarial organisms in the blood, or more rarely the 
pns*-iioi:' of a nuirked eosiuo|.ilillia will t-all attention to Irifhina as the 
cause of an obstinate neuralgia; or the eggs of an intestinal [wnisite 
in the fccrs (uncinaria) may din-ct attention to an anemia which 
underlies a severe neuralgia. Syphilitic neuralgias, either toxic or 
vascular, are by no means infrecjuent. 

The diagnosis of myalgia from tnie neuralgia is not often difficult, 
but occasioiudly. especially in the intercostal and lumbar regions, 
the (liagnitsis Imhihiics niuvrtain. 'riiest? neuralgic-like myalgias are 
usually isolated in their location, are not, as a rule, accompunietl by 
acute exac'crbntions, nor are the regions usually painful on pressure. 
Motion, on the contrary, usually aggravates myalgias. 

Neuritu of a mild grade offers an csixrially difficult problem. .\s 
already stated, mild neuritis shows itself as a neuralgia. The question 
to be solved concerns the likelihood of a more severe degree of neuritis. 
Ill this i-ase the usual signs of neuritis are painful, swollen nerve 
trunks, trophic dijitiirlmiu-es, mon- eoiitiminus pain, Ijtseguc's phe- 
nomenon, weak, Haliby muscle fibers, and electrical changes. New 
growtlis pressing upon or involving the nerve trunks within or without 
the spiiiid caniil, in the early stages particularly. t>egin as pure neuralgic 
syndromes. Mimite analysis of the sens<»ry phenomena will usually 
clear up the diagnosis early, although at times it may be impossible 
in the earliest stages. 

A neuralgic alTection may lie one of the earliest signs of a multiple 
sclerosis. OpiH-nheiin lias fiiuiul a severe tie doulounnix Ici have lieen 
the earliest sign of tiiis disorder. Syringomyelia may Ix'gin as a 
loc'alt;:cd neuralgia. Minute hemorrliagic lesions of tlie spinal con) of 
traumatic origin give rise to neuralgias. 

In the diagnosis of hysterical neuralgia, great eautinn should be 
exercised. Hysterical neuralgias partaking <»f the nature of a pseiidii- 
neurulgia are extremely diffuse, and react very rujiidly and murke<lly 
to suggestive influences. Hysterical neuralgias are almost invariably 
ttceompanietl by other conversion signs. (See chapters on Psycho- 
ueuroses.) 

Sturwthenic pains need to be differentiated, if not almost entirely 
njle<l out. a.s a common diagnostic pitfall. The many mixed forms of 



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SEURALGfAS 

neurasthenic, h^iKKhondriaoal, and h,v:^tcnca) neuralgic pains should 
I)ear their tharncteristif si<!t-liglits. ilie iliHgiKisis (if tht^' types uf 
ni-ural^ia shoiilij not Ir* tightly nmdr, fur it is not tii bt* furgutlen that 
these syndromes of tlieniselves may be tlie rea^-tion on the part of the 
nervous system to some more fimdamental urgauic lesion. Thus 
patients suffering from severe ao-called neurasthenia nith cat.'hexia, 
and severe intereostal neuralgic pains may have an umliscovercd 
rareinoma nf the stomach, mediastinum, etc. 

In tafteji liorxiilU the neuralgic [Mtiiis have a wide ninge, lire rarely 
localized in a t>eriphcral nerve distrlhution, ami are apt to \v mdiciilur 
in their distribution. Pain on pn'ssure of the nerve trunk is usually 
absent. The objective findings in the pupils and cerebrospinal fluid 
eatablislu's llic diagnosis. 

'Vhv pain.s cramps, and muscular weakness of intermittftit ciaudica- 
tiun sometimes give rise to severe neuralgias. Aortic aneurism gives 
rise to reflex neuralgic pains, which are usually very severe, burning or 
iMiring in eharueter. Aneurisms in other regious ore to be carefully 
exehided. 

In reflex neuralgias the use of cocain or other loctil anesthetic may 
determine, by exclusion, the site of the original lesion. An orthoform 
snp[H>sitor>' pres.sed well against the prostate has U-en known to relieve 
a severe sciati<" neuralgia. Tum<»rs of the [K-ixis fretiuently give rise 
to sciatic ami crural neuralgijL-*, und jH-rsistent neuralgic pains of the 
knee are often a rt'flcx from hip-joint disorder. , 

Neuralgic pidns are a frequent intlieution of disturbed nerve fiber 
metulH>lisni, with a hyiNT- or a hyputhyn>id affection l>ehind it. 

Periostitis and osteitis, often resulting from mendK-rs of the less 
virulent stR-pioeoccus gnjups, M. viridans. etc., are not infrequent 
muses for neuralgic pains whicli are often hx'alizcd. 

For the preci.se localization of the areas involve*! consult Figs. 27, 
28, 21>, 'M), 'M anr! ;i2, wltere both the peripheral and niflit-ular niTve 
distribution are figured. 

Procnosu. — This is conditioned by the pathological process that is 
responsible. The more chronic of the neunilgias, which in years gone 
by tenrle<l to bring about clu^nic invalidism or inveterate drug habits, 
have ceased to have such a sinister import by means of a Ix-tter under- 
standing of the underlying conditions, and by a much more resoiircefid 
therapy. The younger and stronger the individual, and the less the 
tendency to hereditarj' disposition, the la-tter the prtignosis in those 
neunilgias whi<'h npparvntly are idiopathic, as well as ihitse ihte tn 
alcoliol. lead, or other toxic agent. In the more chnniic forms which 
are not due to removable condition the pmgnosis is Iwid. With 
mcreasing insight, however, into tlie many intricate disturbances of 
nerve tnetal>ulLsm many of the intractable forms may be conquered. 

Treatment. — The chief indications are to c|uiet tht- i)ain and ;L'^r^- 
tain thi- iidise. A pninstaking stuily of the history itnd anexliuustive 
[rfi>'sical examination are nceessar)' in all cases. The tiK'nipy will 



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AFFECTtOSS OF THS PF.RIPHF.RAL XRRVBS 



therefore vary widely if the cause be ascertained; quiiiin will cure 
one patient, a surfricul o]X'ratioii uiay be called for in another, fieneral 
rules, therefore, arc largely illusory. One should never treat a neuralgia 
■per Jif, as it is solely a general result of many causes. 

Taking up the Renera! therapeutic indications, the analgesics which 
have proved useful may be discussed first. Phenacetin, aeetanilid, 
antipyrin, aspirin, p\raniiilon, lai'tophenin, and pheiiocoll are among 
those that linvc been valuable. New ones are constantly Wing added, 
and among them some are certain to be of value. The salicylic acid 
group combinations are at times nseful, es|)ecially in the milder eases 
and in patients with arthritic tendencies. In influen?^ and tonsillitis 
neurnlpins the snlicylates are useful. Comhinations of these with 
soporifics, such as ehloral, jmraldehyde, sulplional, trioiial, or viTonal, 
arc useful in procuring sleep, and thus prevent the reduction of the 
patient's resistance. 

If any of the opium group be necessar>* it is letter to give such in 
sufficient doses. I'sually smaller doses may he given when combined 
with the analgesics inentiimecl. .\spirin, gr. vij (l).5 gnini), cinieine, 
gr. i (0.02 gram), and trional, gr. vij {\).ri gram), for instance, is a useful 
cinnbination to be taken at night. Other combinations are etjiially 
effective. In the chronic neuralgic pains morphin is to be avoided as 
long as passible. This docs not apply to a very old patient, or one in 
whom the ncuraliga is simply the expression of some chronic incurable 
dts<trder — cflrcinonia for example. The grHdnally acquired ininiunity, 
with the neefl for larger doses, and the pernicions effects of a habit 
apply to all the members of the opium group. 

All juudgcsics are purely provisionally used. They are meant to 
give tlu- i>atient ease while limking fur the reul cause of the pains. 

If one's inquiry is satisfied by the relief of pain the use of analgesics 
alone is bad therapy. Other (Irugs are (]uinin, which in i-orabuiatiou 
with the salicylates is specially valuable; arsenic which is serviceable 
ill the neuralgias due to anemia, csi«xially in combination with iron. 
Atropine titid aconitine were used widely In-fort^ the d;iys of the antipy- 
retic analgesics. Their definitely pciisoiums qualities have driven, 
them into the tiackgnnind. The unreliability of cannabis int^ica has 
done the same for this otherwise useful analgesic. Tbi: iudidtw are 
called for in the syphilitic neuralgias and are useful in many neuritic 
neuralgias. 

Counter-irritation is of great service in many cases of severe neu- 
ralgia, especially after the acute onset is over. The Paquelin cautery 
is the liest means; inustjird paste, cantharidcs, tnrpentinr, chhtnifomi, 
ether, and acupuncture all liave their i)lace. Local freezing may be 
carried out by ethyl chloride, methyl cldoride, ctlier, or other volatile 
substances. Menthol, or other similar derivatives may be used for 
mild neuralgic pains to advuntagc. 

Direct applications (jf local analgesics, either to the nerve trunk or 
within the spinal canal, are valuable in many deep-seate»l neuralgias, 




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331 



especially of tucdullary origin. Cocain, tropococain, eucain are all 
useful given by the Coming or (jiiincke method. 

IvOCft] appliciitioii^i uf heM are grateful and valu;ible. Ilot-water 
bags, hot saiul, electrioal pads, ote., may bo utilized. (lenoral or Uk-al 
hot-water baths or hut-air baths (huklng) are at time^ desirable. 

General hygienie treatment is imperative. A generous diet, full 
sleep, healthful ueeupation. and freedom from mental worry are 
essential. ("od-Iiveroil. uitrogenoas <!iet, with in)n, iirscuie, strychnine. 
calcium salts, are indicated. V'addy dietaries should be avoide<l. 
FA*en in arthritic neuralgias it is doubtful if meat does; any particular 
liann when not taken tn excess. Alcobollc l)everages are to lie ilenied. 

An alkaline therapy eiften helps many fugacious, persistent nenralglc 
pains. Truits containing the citrates seem to give relief. 

tVeparations of the internal secretions, particularly th\roid uud 
pituitarj' clear up some intractable neuralgias of unknown origin. 
They may be given in doses of from ^n to J grains twice or tluiwr daily. 

dimatic chanpes are rarely ad\ i^able. Ix>w-lying, damp and humid 
atmospheric wmditions seem least desirable for certain patients. The 
general stimulus that ii)mes from a dryer, higher atmnsphere, even if 
it>lder, wtirks to tlie general advantage, even if nut directly valuable 
for the relief of pain. 

Electnitherapy when well managed and properly selected is of great 
value in some neuralgias. It cannot be .-iaid that it is clearly recugnizetl 
just what forms of current arc best utilized in what tyjws of neu- 
ralgia, hem^ most efforts must follow the method of trial ami error. 
In general, however, I^duc's modifications uf d'Arsoiival's rapidly 
interrupted current offer the readitwt and most widely applicable form 
of electrical current for the relief of neuralgic pain. It is doubtful if 
any other form of electrical application is known at tin' prei^ent time 
that is as valuable as this. It is. in facl, a typi^ uf ek-ctricul anesthesia, 
solely palliative, but very grateful. Newer applications are l>eing 
Immght out, and other forms may rcphuv the U^luc currents, but 
ut iiresent these seem to give the nuist reliable results. 

Faradic currents, as heretofore employed, act for the most part 
simply as counter-irritants, and seem to possess little sntx-riority over 
the uctuul cautery. Galvanism with mihl currents is u.^efu] for many 
topulgia^. 

I'sychutherapy is the only rational treatment for the psychogenic 
iieuralgiiLs. These make up at least 25 per cent, of (he neuralgias. 

.Surgical intervention is called for in all cases in which pressure is 
demipnstndile nnil the ennsc rx'movablc. Tiniiop* and new gniwtlis, 
involving or pressing u|j«>n ner\'c structures, if removable slumhl be 
taken away. Surgical interference may Ixr of radical service in many 
of the reflex neuralgias of oliscure origin, probably related to vi.'M.'cral 
ptoses. Such surgiad interfen-rur Is justifiable only in chronic ai.-*cs 
where these visceral ptows have resulted from long-continued psychical 
eaasrs. 1'sychot.herapy is preferable in the cjirly stages. Nerve stretch- 
ing needs mention niiistly tu l>e cumlemncd. 



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332 AFFECTIONS OF THE PERIPHERAL NERVES 



SPECIAL LOCALIZED FORMS OF NEUBAL0U8. 

"While any sensory nerve in the body may become painful, there 
are certain regions which show a greater tendency to involvement 
than others. Bernhardt has collected the statistics of localized 
distribution in some 685 cases, with the following results: sciatic, 303; 
trigemi[ial, 124; brachial, 108; intercostal, 45; occipital, 42; crural, 
25; obturator, 2; lumbo-abdominal, 12; anterior femoral, 11; tarsal|;^, 
4; metatarsalgia, 4; Achilles, 3; and coccygeal, 2. In 616 cases col- 
lected by one of us (J.) during four years (1902 to 1906) the distribu- 
tion was as follows : trigeminal, 315; sciatic, 194; brachial, 31; occipital, 
28; intercostal, 19; lumbo-abdominal, 19; peroneal, 2; crural, 2; ulnar, 
1; coccygeal, 1 ; and plantar 1. 

Trigeniiiial NeursJgia. — Simple neuralgia of the branches of the 
fifth nerve are among the commonest of all the neuralgias. Fother- 
gill's studies on A Painful Affection of ike Face, published in 1773, is a 
classic. Tiie inferior and superior branches preponderate in frequenty 
of involvement. Most frequently these neuralgic pains are due to 
some affection of one of the branches. Inflamed teeth play a pre- 
dominant role. Affections of the ears; the eyes, iritis, cyclitis, iridocy- 
clitis ; the skin of the face or head ; inflammation within the accessory 
sinuses of the n<)se, forehead, antrum, mastoid, all of these may produce 
diffuse neuralgic pains, at times clearly separable from a neuritic 
neuralgia of the fifth, at other times not. 

Cold and wet are important agents in facial neuralgia. In certain 
countries, notably England and the north of Germany, trigeminal 
neuralgias from this cause are extremely common; they seem to be 
much less frequent in the Ignited States, and notably so in southern 
countries. 

Neuralgia t)f the superior branch is seen more commonly by physi- 
cians, although the dental branches are involved much more frequently. 
These patients go to dentists and therefore do not enter into medical 
statistics. This is a reason why it is incorrectly stated by most 
writers that the superior branches of the fifth are most often involved. 
For the most part the milder types of neuralgia are induced by irrita- 
tion of some of the terminal filaments, while in the neuritic form, 
tic douloureux, which is the more classic, a lesion of the Gasserian 
ganglion is u-siially prest^nt. Mild cases of tic douloureux may be indis- 
tinguishable clinically from other types of neuralgic pain. 

Tic Douloureux. — Enough has been said on neuralgia in general to 
indicate the character of the simpler form of neuralgia of the fifth. 
One tji^, however, by reason of its severity and its fairly definite 
pathological anatomy, needs more extended consideration. Avicenna 
knew tic douloureux and described it with great accuracy. It would 
be desinihle to restrict the term tic douloureux to a definite and, if 
possible, limited type of neuritis of the fifth nerve, particularly to the 



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SPECIAL LOCAUZKD FORMS OF S'EURALdAS 

fomi due to changes of a chronir Hepmerative nature occurrinR in the 
Gassemii K-t'iglion. Tljis is nut yet possiljle, and olinicully ihi* iif uritic, 
and pm|ilu>ml ncuraluu' cases arc either not at all sopariihlc from the 
ganglinii cu-tes, or with consiclernhlc difiiciilty. 

Tic doiUouretLx usually allccts one side of the face. In the majority 
of cases some selection occurs anion^ the branches, one or two licitig 
involved, rarely all three; the oplithalniic branch the oftencst, the 
inferior maxillary the least often impiirated. 

The inortr ehissirul tic douloureux neural^iiis are characterizcil by 
the extreme wverity of the pain. iLsually preceded by paresthetic 
prodrouKita, and widely acaiuipanird by symfmthctie or irradiating 
paias in other branrhcs than the one dnefly lnvolve<I. or in other nerves. 
The puin may !»• paroxysnial or continuous, witli market! exaeerlmlioiis. 
Patients compare them to the piercing pains of a sharp knife or the 
burning of a red-hot wire. The patient remains for a shorter or longer 
period, a few mitmles to sfverai htmrs. under the grip of the pain, 
unable to move a niiiNt.*le of the face or fearful of stirring, lent a -.pifun 
mon.' fearfid thnii (he others should ocnir: even tlie air-pressure* of a 
suddenly closed door may bring un an cxaivrlmtion. Tlie hniger 
attack.'* are niri'ly as viHous as the shorter ones. 

MyiM-rseiLsitive Valieix's |>oiut.s are relatively cuiLStant. In opljthal- 
mic involvement the sore points are foiin<l above the supraorbital 
notch, at the external angle of tlie up|>er lid, the upiMT, outer a.-*|:>e<t of 
the mwp, and the gloln- of the e\*e; in the superior maxillary brancli the 
inferior orbital notch is the chief point of pain; the malar bone, and 
opp<isite the liLst upiMT molar are other less frcfpiently found [M>iiits, 
while the outer angle of the mouth, and the roof of (he mouth are rarely 
their site. In tlie inferior maxillary distribution the ]>i>ints arc chicHy 
just in fnnit of the auditor^' <'anal. the side of the tongue, tlie Itonler of 
the chin, and Trousseau's points over the first and aecoml cervical 
vertehne. 

\'asiinnitnr anil secrelor>' disturbmui-s an- usual. The ^kiti is. ».h a 
ride, liot and swcdicn, occasionally jxde and frigid; tears, nasal secre- 
tiniis, and saliva flow in Hl>undan(t\ llie eyelids may be swolirn, 
the conjunctiva re<!demHi to the point of ideeration at times; within 
the nose ami mouth extravasations occur, and ulcers arc not uncfimmon. 
iIer[H*tic attacks are also not infrefjuent. and in .some of these attacks 
grave injiu*y to the eye structures may take place. Glaucoma is one 
of the severe ciimplieation.s. Other trophic disturhftnct-s arc skin 
eniptions, acne, erysipelatous reildening, graying of liair, and blacken- 
ing of the tongue. In long-coniinue<l cases Iiemiatrophy may oecur. 
t hanges in the sciusc of taste, of touch, of hearing, arc at limes pn-sent. 
Photophobia Is frequent, while diminution in tlie visual ReULi and 
aci'ommodation cramps have been notctl. 

Sffverc iiU'Utal disturtian<^>. amounting at times ti» Imlluciimtorv' 
eonfiLsion may Ik- pn-^-nt. Suii-iilal attempts are to beguardetl against 
in tliese excruciating eases. 



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Tlie motor Histiirham-es consist in convulsive movements of the 
fat-ial imiscles (ctniviilsive tit's, spnamoilie, epileptiform netiml^ia, 
Trousseuu), sudden forced closing of the eyelids, drawing of the mouth 
to one side, or sudden turning of (lie head. At times the n)nvulsive 
movpinruts extend to the arms. Paralytic plienomenii in tlic third 
ncn'c have been noted. The general psychical disturbances noted are 
prone to occur in thif* tj-pe. 

Cnurxf. — In the majority of cases the attacks appear in series and 
attain ii prrindieity which comes to he dreaded by the sufferer. The 
fn.*e intervals usually become shorter and shorter; but many patients 
may have only one attack a year, especially in eolil weather, or even 
at longer Intervals. A single attack may last n few days, or in the 
severe fonns* .-several weeks, the patient not lx*ing free from pain day 
or night, save under the influence of morphin. Some patients have a 
few attacks in ii lifetime, others are not free from the disease for yeare. 
The severer convulsive forms are prone to mwir lute in life. 

Diiitfunitin. — Onlinarily the classical form of tic donlunrenx is recog- 
nized without difficulty. Patients have all their teeth extracted, 
however, under the mistjiken dingtiosis of a dental dist-a-se, while 
some intractable trigeminal neuralgias have been cured by proper 
attention to diseased teeth. Aneurism of the carotid, tumors pressing 
upon the ner\'e or upon the CiasAerian ganglion, may be difficult to 
determine as the exciting cause. These, however, are usually accom- 
panie<l by aceesNory symptoms, palsies, eye-groimd changes, aneuria- 
itial murnnirs, pain withiLi the head, eerelicllar snydmnies, eiir pains, 
etc. The otalgias (tNinpanic neuralgias) visually eonsideretl in this 
connection are pi>ssil>ly due to geniculate ganglion disorder, and have 
Wen referred to by Hunt as neuralgias of the seventh nerve. 

Multiple sclerosis has started as a trigeminal neuralgia. 

TtPttimrnt.^X is as essential to entleavor to find and treat the can.se 
for a facial neumlgla as for neuralgia in general. The various remedies 
given under (he bending of neuralgia may 1m? tried, and as malarial 
neuralgias are very frequently trigeminul, energetic (luinin therapy 
may be given; the al>sence of blood finding:^ is not contra-indicative, 
es]]ectally in non-malarial neuralgiius. (iclsemium, the tincture in 10- 
minim doses, gradually ascending, aconite in doses of j^s grain, 
cannabis indica (fresh), in doses of from i to ^ grain, are reputinl as 
esiM'cially valuable in the facial cases, Any of tlie analgesic antipyretics 
may suit individual cases, and avoid the use of morphin, which alone 
is reliable in many severe cases. Local applications of cocain to tlie 
conjunctiva, nasal mucous membranes, buccal surfaces are sufficient 
to repress some mild attacks. 

Injection methods have been tried for years. In the l>eginning the 
peripheral branches were injected by variou.'; analgesic drugs, in early 
days cldoroforni, and in later times particularly eneain and its allies 
or derivatives. The effects wen^ vahmble. but teinpnriiry. Osniic 
acid was used later, but regeneration took place. Pitres and Vaillard, 



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SPSCIAL WCALIZED FORMS OF NBVRALdlAS 

in I8S7, unit SchUisser,' in lOOfl, took up a aenes of experiments with 
nlcohol, niul the latter hos perfected a metlioH of injecting alcohol 
within the siibstauce of the Gasserian pinglion, which ha--* ((iven excel- 
lent results. The chief features in the deep alcohol injection method 
is the introduction of a long, dull, cutting ne«lic into the foramen 
ovale and there injcctinj? in xitu the hranches of the trigeroinue 
Special methotis have heen devised. Narcosis is not necessary; SO' 
j)er cent, alcohnl is uswl. In three or four hours folliiwing the injec- 
tion the pain is relieved, and two or three more injections are given 
within a week to complete the treatment. Immediately following 
the injections, which should be done only after extended practice on 
the cadaver, there h a marked ane.<»thesia on one side of the anterior 
part of the head, including the nostril, palate, and one-half of the 
tongue; a sliglit paralysis of the musck-s of nia.Hticntion. which may 
persist for some time, Init usually disappears in a few hours; a degen- 
erative process is set up iu the nerve trunk, which is recoverable, anil 
general sensibility usually returas, but the pain return^. Relief extend- 
ing over a year iu a nmubcr of cases is reportwl by numerous observers. 
Some patients have l>een relieved for four or fi\*e years. Kdema of the 
posterior eye structures ami liemorrhage are among the diseomFort<4 
HUrl even dangers of the operation, especially in t\w use of the inlra- 
orbital methods deviswl by French oiM-rntors. Itelapsesareapt to!«-cur. 

Three surgical pnMH'dures have been seriously ndvomitcii. The firtl 
and earliest consisted of peripheral section, first said to have lieen 
done by J. ('. Warren of Boston. Sc<*tionof the6fth may lx'employe<l 
to advantage in those cases in which the disease is undoubtedly per- 
iphend. jVs modifie*! by more recent procedures, the older objection 
that regeneration takes place is [lartly done away with, 

Hose. MacKwen, Horsley. Hartley, and Krause iH-rfccttil the opera- 
tion of excision of the ganglion, and the mudified Ilnrtley-lvrnuse 
o|ieration by the temporal mute has Ijcen largely (he metluMl of 
choice. ("iLshing's more recent mo«lif] rati oils are of lasting value. 
Tlie operation still remains one of much difficulty and seriousness. 
Hecurrences are known even with this method, and the efficiency nf 
the newer devices f()r preventing this by capping the ends of the 
tlivided nerve triuiks with metallic lamina' is t(M) recent to proiiouniv 
niMUi. 

Van Gehuchten, in 1903, suggested tearing, Spiller, in 1898, Itad 
sugge:rtcd the surgical expedient of cutting the sensory- root, which 
he claims is safer than the operation of tearing, a procedure tried in 
INHI. The method of division of the sen.sory root, as reported by 
I'Vazer and Spiller, pn)mises to be one of the most valuable surgical 
procwlures thus far iie\ iscil. 

C«rrico-occipital Neuraleta.— This occurs in the distribution of tlie 
sensory nen*es of llie cvr^ical plexus, consisting chicBy of the occip- 

t MQrwh. med. Wduvdir., April .30. |aV7- 



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AFFECTIONS OF THE PRKIPMRRAl. SERVES 



itnlis major, the occipitalis minor, iiuriruians inaf;ntis. i'eni<'ans 
supiTiur, sii|>rarl»viriil!Lris and phrenic. Neuralgia in tliis p-npru) 
region seems lo he rare. In Hemnk'p s\immary of IS.IHHI tTuies only 50 
were in the ferviai-iH-eipitnl reKioiw. \'alleix lm.s given one of the nio^t 
ennipU'te monogrjiplw on ncuralpia In this area and little has Ix-en 
added to his description, save in the finding of rare etiologieal faetors. 

Etiology. The several eanses of neuralgia are operative here and 
nceii iinl Ih- repeated. SjH-fial dftemiining features seem to be the 
etirrying nf heavy weights aw the sh4ndilers (a more fretjuent enusc 
fur hniehiul neuralgias), arthritis deformans of the upper eervical 
vertehne, caries, syphilis, tulxrculosis. tumors, cervical pachymenin- 
gitis, falls ai]d blows wreuchiiip the tvrvic-al vertebra', eiilargenu'nt 
of the eervical lymphatics, and aneurism.^ of the vertebral arten,'. 
Oppenheim refers to the great frequency nf hysterical neuralgia in 
this region aixj ]isychi>gi'nic tieuralgias of the back i»f the neck and 
occiput are extremely common. They ore often found in individuals 
who are eitlicr under great strain nr X\w<*' who are constantly forcing 
lliiinselvcs. 

The pHin.< occupy the regions mentiotu'd. U-ing particularly local- 
ized in the ne<'k, belnw the occiput, and ruiniing up \o the vertex, 
occasionally behind the ears. The N'alleix point found most frequently 
is the (K'cipital point Iwtween the mastoid apophysis and the first 
eervical vertebra; points bclwceu the stcrnoinnstoid ami tra|^H*ziiis 
<eer\'ic»h. the antcri^ir Imrder nf the nuLstoid, and the middle of the 
ear are of less fretiucut weurniiee. 

The pain is fretiuently bilateral. Dull pain on pressure, witli tender 
skin, is usual as a paroxysmal occurrem-e. This tends to make the 
sntFcrrr hold his head in a stitT position, which in time may cause a 
eharucteristic attitude. This tenderness iiuty he so uiiile that ruffling 
nf the hair will start « paroxysm, (jrayiug of the hair, hiss nf hair, 
with other trophic signs may Ih* present. Sudden pulling back of the 
head. t*T other muscuiur irutilvernent, is an iK-casiiMial symptom. 

Diaphragmatic Neuralgia.— This form of neuralgia, also known us 
phrenic neuralgia, is of rare o<'turrcn<t'. Valot and I'eter have written 
U|K)n it. The pain is usually present near the free border of the ril>s, 
occasionally as high as the chin and in the neck, beneath the clavicle, 
and in the scalenus anticus mu.sclc. Trtnisseau's points are located 
over the scvond tn llie fifth ri-rvical vertebra. 'J"he pain frequently 
runs down the arm, especially in certain complex cases of mixed 
braehia! neuralgia. 

IJreathing may be seriously interfered with, the breath coming fast 
and short; longer excursions of the diaphragm are im])ossiblc. It 
\» a common ex|>erieure to have a short, sharp stitch in the side, with 
inability to breathe for fear of pain. This is the type of distress 
emxiuntered in phrenic neuralgia. Iti the majority of eases the pain 
is ill the left side. 

Anemia, affections of the mediastinum, heart and pericardium, and 



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SFECIAl LOCALIZED FORMS OF NEVRALGIAS 



337 



aneurism of the aorta are the most frequent attending features, ka 
intractable phrenic neuralpia may complicate an exophthalmic goiter, 
or be present in carcim>niu ui the ncfk region. 

Idiopathic or pure phrt'iiic neuralKias seem to he unusual, whereas 
tfmporary or more piTmanent t)^^"^ are seen aa symptoms of the 
atTeetions named. In the latter case the prognosis depends on the 
initiiil iliflicuUy. 

Brachial Nearalgi&. — In this general form the com|wncntd of the 
brachial plexus, from the four lower cervical, or sfime of its filaments, 
and first dorsal roots, are those involved. The eliicf ncr\'cs earr\ing 
sensations from the skin an-a of the anns ami slinulders arc the cir- 



FIFTH 

CERVICAL* 



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SIXTH, 



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LOMU* COIVI \, 

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¥ui. 105.— PluD o( llw.' lirarbinJ jilinuii- (fjprrwli.) 



cumflex, radial, internal cutaneous, and miiscuhicnta neons. These 
enter, for tlte niosl part, the upper and middh- cimU of th« plexus. 
In the mnjnrity of cases thf pains of brachial ncunil^iii an* Im-Hleil in 
the upixT anil iind almut the shoulder, ('. c, in the arcii <if tlie cireuniHcx, 
nulial, uinsc-ulmutuiieoiLS. and internal ciitaiicou.-* nerves. 

Bemhardt's statUties show that men are more frequently afrei*ted 
than women, but the reverse shuws true in the hgures of other tibservers 
(UumlK'rK, F.rb). More women have bniclnal neuralgia than men, ami 
in most iustan(r>* it seems that cxcvxmvc .Hwwping is tin* attributed 
caiLvr. In |minn-phiyers, ncurulgia-tiii ihisHreuarffn'tiurtit. iVrliaps 
thciiF should Ik* relcgateal tg tlic uccujiation neuroses with the pains 
23 



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AFFECTIONS OF THE PERIPHERAL NERVES 



of hair-dressing, skirt-carrying, telegraphy, writing, etc. At any rate, 
arm and shoulder pains are frequent, in their mild grades at least, 
and very variable. (i;ee Fig. 203 and Figs. 23, 24, 25, 26, 30 and 31.) 
The usual causative factors come into play here. The neiiropathic 
constitution is put in the foreground by Oppenheim; Bernhardt lays 
considerable stress upon the importance of bone injm-ies with callus 
formation in the causation of many arm neuralgias. Small punctured 
wounds about the forearm, wrist, and arm are responsible for many 
symptomatic neuralgias, as Weir Mitchell has so well shown. More 





Fiu. 106. — Painful points in brachial neuralKia. 

remote cases are found in vertebral disease, tumor formation, aneu- 
risms, syringomyelia, multiple sclerosis, and tabes. The frank neuritic 
processes in their beginnings must be borne in mind, and cervical rib 
should not be overlooked. 

Symptoms. — ('er\'icobrachial neuralgias are extremely variable in 
distril)ution, extent, and severity. The onset is usually sudden, espe- 
cially in those patients in whom an antecedent history of exposure to 
cold and to wet is obtainable (motormen, policemen, etc.); at times 
the beginning is preceded by twinges and slight distress. On awakening 
in the morning sharp pain is felt in the shoulder and arm. The pains 



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SPgCIAL LOCALIZED FORMS OF NBURALOIAS 

in fcrachial niMinilgia are less apt to be the sharp, shooting variety so 
dreaded in tic douloureux, but sudden accessions of shar}) pains, vor,- 
inp in their ijiteiisity, are frequent. As with most iieuralpic pairut, 
movement increase;! them. Toward eveninR the pains are apt to in- 
crease and the patient, although obtaining relief by lying down, rarely 
sleejM well. Soreness nf tlie skin, slight swelling, and gi-neral reduction 
in tone are the usual awouipaninients. AVith increasing disuse slight 
atn»phy is coninioii. and swrlHng is usual. The trndun rellexes are 
usually more irritable and active. More Htrophy. jiarests with vas(»- 
raolor-trophie symptoms and altered tendon rclie.\es indicate a definite 
neuritic proce,ss. Herpetic eruptions occur with non-inrectiuiis as 
well JL-i with infectious involvements of the sensory ganglia. 

Tender i>oints are ver>' variable. They arc most frequently in the 
middle of the buck; about the level of the secotal or third dutrsjd there 
is usually a S4ire TrtULsseau point, (iowers notes that tin- inferior 
ulnar point in front of the «rlst is the commonest sore iMiint. Bahinski 
has called particular attention to a nulial neuralgia due to a mild or 
severe neuritis uf the nidinl. The piiins otrupy the posterior |)ortion 
of the arm, and are nmisually severe. Neuritic changes are not infre- 
quent. The chief causes seem to be exposure to cold and disturbances 
of the recipHH-al action of the ovaries or testicles and thyroiils and 
other t'luliM-riiiiius glands. The meuiip;iiiseisafn>c|ueiit [H-rioil of onset. 

DiagiKHis. — In the driigmisis partit-uliir i-are is nceiled in exchuling 
alTectioiks of the spuial conl. lueiiiuges, an<l vertelirrt", as well as angina 
pectoris and psi'U<lo-angiiui. l>isea.se of tlie joints and lx)nes should 
ite excluded at the outset, although it may be very dilTicult in some 
cases of periostitis. In tumor? and other organic aii'cctions of the cord 
the painful ]MiinLs are usually absent, but the earliest and only s,Mnptoni 
of spinal-cord tumor, intraniedullarj' or extramedullary, may Ik* u 
bracliial neuralgia. In talics ilic pains are apt to Ir- biluteml. Tlie 
exliHUstion neuralgias are alsnapt to l>e hilateral. Thegi'iicrid indefinite 
features of a myalgia, plus the niusiiilar, rather tluni the nerve soreness, 
are usuall\' sudieient to exclude it. 

The occuiKition nfun)ses involving the ann and shoulder are many. 
The histor>- of protracted exercise of (vrtain groups of muscles is 
usually sufficient to identify the pro|)er cause for the neundgic pains. 
()ecu|Mition neuralgias, like neuritic neuralgias, are neuralgias none the 
less, the sole diagnostic ijueslion arising as tn the causi-, and through 
this the pr«»iK'r niwle <if therai^'utic attack and the prol>able outcome. 
Alcoholic neuritis in its mild grade oilers particular emltarrassments. 
I<ead-poisoning neuralgias are to l>e borne esjM*ci»lly in mind, while 
dial>etes is of prime importance, lirachial i>sv<-halgia is a possibility, 
but the dia>cnosLs nuist l>c made with extreme caution after a rigid 
exclusion |Hirtieularly of organic factors, ll^'sterical and neurusthenie 
i»eiindgia-i occur in this distribution as well. 

Treatment. — Rest is a necessity, and is primarily insured by meaas 
of a sling. The diagnosis uf a cause being assur^nl, treatment sliould 



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AF-FECTIONS Of THE PBttlF/tHitAL NKUMiS 



be begun to rpmovc it, either by medical or surgical means. Nerve 
suturing fnr injur>- hii-s come to occupy an imi>ortjmt place, aiul is 
usually attnuUtI with Kood results, even after lonj{ perio<ls of Iohs of 
function. Tn the early stages active mechanical treatment is to be 
avoi<le<). Hot apjilicatitin^ are U!>eful in uwit ticutc iieurulgia^. In the 
later phases uiH:ssage, particularly the Niigeli movements, arc valuable. 
Galvanism, '-i to milliampcres, is well a<laptt'd to these neuralgias, 
but usually much lietter results are ohtaine<l by the l*duc rapidly 
alternating currents. Salicylates (espeeailly in analgesic oonibinatioiLs), 
iodides, (piiniu, arsenic, ati<l large <li>scs of strychnine are uf value at 
tiroes. The internal secn-tioiLs are curative for some. Psychoanal.vsis 
is to Ixr used in hysterical cases. 

InteKOStal Neuralgia. 'Hie twelve dorsal nerves constitute the 
plexus involved, although tJic upi)er series, esiK-cially of tlie left side, 
are most frequently concerned. Hcrrdianlt says that the site of 
election is mostlv from the (Iflh to the ninth. Since the dur-sal nerves 
divide into internal anil extertial branches the site of the neuralgia 
may be on the surfai-e tjr within (pleiu'tKlynia, etc.). The two upjicr 
ner\'(^ send brniirhes to the internal surfiiee of the arm. anil pain is 
occasionally felt there. Tlie aViduminal involvements are rarer and 
may extend ilown to the genitals. (See Figs. 22 to 30.) 

Women more often show this form of neuralgia than men, and the 
disorder is much more roinnnHi in ctild weather. 

Tlie pains are Msi]rtll> less severe than in other regions, allhough 
their slmrji, -.ticking character im|«iirs chest movements, esijecially 
siiux* all miiveinent tends to aggravate them. Temh-r puinls an* found 
at the site of the ner\e exists near the spine. Skin hyjwresthesia is 
extn^me at times. Herpetic neuritic neuralgias ai"e relatively cumuiun 
in this <ii^tribution. 

Among the cau.ses to be diagnostnl may Iw costal caries, affections 
of the spinal con! and meninges, disorders of the pleura, particularly 
carcinoma uiul tulHTCidosis, aortic aneurism, dilatation of the stomach, 
curciniima of the Ijvcr, angina pectoris, periean litis, local trauma, 
fratlures, etc. 

Mavimnnj uciiralifla or manUufjfnia, which is frequent in the later 
stages of nursing, and in some women at the menstrual epoch, is a 
s|H'cial fcjrni. The j>ain is usually deep within the gland, and may lie 
afciimpaniwl by a slightly increased secretion. The whole skin may be 
sensitive, especially the iii])])le. when the su]«Tficial ner\'cs are mostly 
invoived. Locul glandular induration O(:rca.sioiial!y occurs. This has 
leil to the mistaken diagnosis of carcinoma, but a neuralgia may (x-cur 
due to a eurcinouia of tlie breast. Tabes may give rise to an intercostal 
neuralgia. 

Treatment, — Utcal ajiplicatiuiLs are useful, especially the ethyl 
chloride ^pray. Itlisters are eHicaciou.H. Sup|)«rt by bamlaging aifonls 
marked relief. (leneral measures already described call for no further 
mention. 



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341 



Lumbar Plexus Neuralinaa.— TIicac arc most conveniently arranged 

>ns (I) lumlM-abiloniinal; i'Z) ilioscTotal or testicular, (II) crural (s«at- 

ica). (4) femoral, ami (5) obturator, involving in each case certain 

of the branches of this plexus. Mixed niid indeterminate forms are not 

infre(|iii-iit. 

The Sciaticas (.Stiatic Neuniljiiiis, Sciatic Neuritides). — It has already 
been Indicated that it Is larjicly indifTcrcnl whether one regaols this 
as a neuralgia or a neuritis, since transition hirnis are very frequent. 
It wnsists of pain in the distribution of the ner\'e:4 of the sacral plexus, 
the sciatic and its branches. 



'LIOMVPOAAafNIC' 
IVIO-INOUINAL< 



.1-* 



I- I' 



ttlNirOflMORAI.- 

cirtHNfti 

CVTANCOUa 



TO PSOAS aNO. 

luacu*^ 
eiUL<»NTiiiioni 



OvrwMTON^ 



Fia. 107. — Dlnitnun cf tho liimltu- pltvnu. 

//fWorj.— Totunni, In 17W, gave so clear a description of aeintica 
that the inalndy is often pven hLs name. Valleix, in IS41, described 
the painful point.'* with great minuteitess. I<asenue, in ISlVI,' tU^scribed 
his welbknoHii syiiiptiiitis of iifuritis of the sciatic, situi> wbicli time 
many inonnjimphs havr aptM'unil, the nmst inipijrtant of which are 
tlMtse <tf Hriihl, I^go, Vulpian, and Hernhanlt. 

A'iMj/offi/.— Similar rniLscs are at work here as in the other neuralfttas 
and neuritides. It is unnecessary to amplify these causative factors. .Any 
of the general causes f<mn(l on previous pajjcs may cause a sciatica, but 
BiH'cial empliasis shonlil In* hiiil n|Kiii two or three, 'rraiinm is resimn- 
sible in many cases for the development of .si-iatica. Syphilitic osteo- 
arthritis, and s>7ihilitic meningitis of mild grade are respoasible for the 
develoimient of intnictable sciaticas. <'ertiiin French authors claim 
ik> high OS !>() (jcr cent, of nil sciaticas to l>c due to this syphilitic factor. 

• Afob. CMn. do Mfed. (18M). OppanliMiB. 



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AFFKCrrONS OF TtJS PERrt'lfEHAL NSRVS.^ 

In tills Fes|)et-t then sriatieu stmuki in shnr]) einitrast to the neuralf^ic 
nfuritiiles of ilic upper cxln'tnities. 

Ctoul is Jill infrfqiiE'iit t-iiuHJitive factor, while diabetes is more 
common, csiK'ciolly for tltnil>h'-si*letJ scinticas. Onuhle sciaticas may 
also bf the cxprfssii3ii of a luiiior of tlie iHilvis. of pressure due to a 
Rravici utcms. of venous stasis, spiiml-conl tumor, or new groH-tlis 
of the iMitvis. Occiisionally prostatic cnlarj^'tiiciit of tuberculous 
or (•iiiiorrhcal nriniii ^ives rise tt» sciatJr pain?.. Kxposure to cold, 
with p^t^lolv^'Cl^ standing is frequently met with in the histories, and 



r' 



rOURTH LUhlBAR 



riFTH LJUBAR 



->: 



FtRST SACRAL 



MuIIAl 



MWTCaL ' 



, '^ECOMO SACRAL 



x THIRD SACRAL 



t FOURTH SACRAL 



GREAT I 

SCIATIC* 



/ 



HCSIHt«t.«. TOtrHIHCICa 
ALTVATOKAM 

,', FIFTH SACRAL 
*iKtV.iXJ---i^' COCCYGEAL 



/V- 



Fla. 108. — Pliui of Mil-mi iilmiut with tlit> ijiiiImkIi) tilexin. tOerrUi.) 




nccBsiouiiUy in tliose who sit a urcat dt-al. rn>lnnKfd walkiiiji or 
niarcliinn may ociiisiim an attack, am! liitycHnfi pntlispiises to 
ineclianicHl injury (if the nerve. 

It is a com pa ru lively comiiioii aflVcti(iii, particularly in men, iM-ing 
one of the most frequent neunilKiit;* met rsitli in cHsjH'iLsary practice, 
riironic c<Hi3tIpiitlini a.s ii ran.sc should not \h: overlooked. The 
etiolop^cal factor in i>ome eases h impossible to find. This is a result 
of insufficient methnils of examination. 

Sfdinpfotim.- Tliere is no one sciatica, then* are many, ami it is 
advi.sable at the outset to separate those eases in which the princi]>8t 



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OF SFA'RAtWAi 



syinptoDut un* pain aix) iiiiihility to use the limb from those in which 
there is added nene tenderness, with motor, serLsor>" ami trophic 
phenomena. 

The jiftins rarely commence abruptly, hut hepniiiii}; inure ur less 
gnuhially fnim a sense of son-ness to uneasiness with uecasiona) 
(willies, gmduiilly develop into well-marked severe pains, iisutilly at 
first more intense just beneath the seiatie iioteh, i^radually extending 
from above downward to the entire distribution of the seiatic and 
some of the branches. There is usiiiilly eoiL-%i<lerabIe variation in the 
ehanirter of the pain during an attack. Some patients MitFer for stpuie 
time simply from lioring, dull |>atns, while others liave excruciatingly 
sharp, stahliiiig twinges that make the slightest movements im|M>ssil>le, 
Harely eoiititmous, the paiiu> come in attaek-s, sparing almost no region 
of llie distribution of the plexu;$ either en masse or picking out special 
brandies. 

The pain in the proximal portions of the leg Is usually dee()-seated, 
but beeomes more superficial distally. In some patienL< nn ertensive 
series of involuntary adaptive positiutis take phut- in onter to seek the 
mo»t comfortable iK>^ition, not only of the thigh and leg, but of the 
pelvis, or even the vertebral eoluniu. 

Painful pressure points are fairly constant. The miwt important 
of these are situated at the saero-iliac joint, the sciatic notch, or the 
gluteal jMtint on the gluteal fold over the ner\e, and the |)er(meal 
point at the head of the peroneus. In some cases, often mild, pressure 
points are hiekiug. I.a.s^giie's phenomenon isof ennsidernble diagnostic 
sigiiifieAnee. It is hrtjught out either in the lying or sitting position. 
The patient's foot is graspetl with one hand, the other placi*d tijion the 
knee, an(3 kwping tlie U-g stiffly extended the thigh is flexed uihmi the 
pelvis, when a severe pain develops Ix'neath the knee or higher up in 
the course of the nerve. In the sitting position the pain is more ajit to 
be beneath the knee, since the exteasion on the i)elvis cannot l* ninth' 
so e?ctreme. 

With the general extension of tJie neuntie pnMfws — as in many 
alcoholic i*a.'«'s — the entire nerve may In- sensitive to pressure. 

Minor' has deseril)ed some interesting findings on Imving the 
jwtients arise from a prone posture. Patients with well-marked 
sciatica can rarely get up— without excessive pain— with the arms 
erossfil. They put their two hamls liehind them, push the hips back- 
ward between the arms, Hex the knees slowly beneath the butt^>ck.4, 
then gradually with one hand on the hip, and then on the knee, the 
iiiber balancing in the air, gniilually come to a standing |N>sitinn. l^he 
priHtihire is not invariable, but is useful in gaining some idea as to 
sinmlution, and a.s to the diagnosis of a lumbago. The untruineil simn- 
hitor get^ up in a variety of ways, ibr lumtwgo patient usually rises on 
all fours, the arms in front, somewhat as does the pseudohypertrophic 
dystrophy patient. 

■ DeulM-ti. mml. Wt^hnM^ir., IMIK. 



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AFPECTIOS'S OF THE PERIPURRM NERVES 



III those frmups of patients wHIi nmre iierious neTiritic involvements 
then- lire iiildril the signs of niuscuhir atmpliy, nf cirfHimscrilfetl |»ar- 
alyses, of fibrillary tin ilnitt ions, of coutra<-t iires, of sensory illsonlers, 
and of trophic disturbances. 

The utropbifs Inay be true Btropliics, but arc xisually poi^ition 
or dbiust' atrophieiii. Tliey arc demonstrated by palpation, or by 
mca.siirenicnt». 

Moreover, the atrophies may be sepmentary, or radicular, in either 
of whirh instances the IcK-alizing <iiiicnosis ts aided. The eleetrieal 
exjiiiiiiialion uf the niutseles in seiatif neuritis is usually eoiitnidictory. 
In pcwitlve eases with partial H. D. the nature of the process becomes 
clearer. 

In the hepinninp of the process the patellar reflex is fnxiuently 
increa.sed on the affected sirle. while if marked neuritis be present it 
may lie diminished or absent. The .-Vchilles tendon reflex shows a 
similar reaction. Opijoulicim has eallwl atteutiiui In a mild decree of 
flabbiness or diminution in the size of the Achilles tendon on the 
alTected side. A i)se\ido-Babiii>ki is dcstTilK'd, larjicely a plantar 
flexinu of the smaller toes, with immobility of the great toe. 

SeiLsibility is often uiiuirectcd, but <arcfid tcstliijc. following Head's 
metho<ls, may show a hyjiestiiesia to touch, pain, and temperature. 
OccasionaHy the disturbance of sensibility shows a marked radictilar 
distribution, which speaks for a more or less localizcil process in the 
plexus. frec]uently of a syiiliilitic, iiieningoiiiyetilic, or osteo-arthritic 
nature. 

Trophic and vasomotor phenomena are not infrcfpieut, cimsisting 
either of acroparesthesiie, erythemas. local cynnoses. dimimshe<] or 
increased |)erspiration, clxauftcs in the ;fn>wth ami character of the 
hair or even the nails. True heriws la rare. Glycosuria, polyuria, 
azoturia are rare complications. 

CmtrJte. — In the early attacks in healthy adult.**, the prognosi.s is 
^jood. The patient usually recovers in fmm si\ to ei^ht weeks umler 
proper treatment. A failure to respnnd should excite suspicion as to 
the ilia^iosis, cs|>ecia!Iy with reference (o taVies, to a spinal ^frowth or a 
radiculiti:^. Recurrent cases usually develop a tormentinf; chronicity, 
which exliausta one's therapeutic resoupces. and mrcasionally drives 
the patient into a mental state which suicide or chronic morphinism 
alone tenniimtes. Fortunately such cases are beconiinj; rarer with 
better methods of diagnosis and enlargeil theraix-utic resources. 

Cfinwai form's. — Certain variants — lately ba.sed on etiological 
concepts— may be met with. I'nurnier's gonorrheal sciatica with an 
acute oiLset, slight tcmpeniture, with pn>stutic and articular com- 
plications is one. Itrissaud lias described a spa.snu)dic tyjK- with 
increa.sed tendon reflexes, con1 ra<'tures in the fieriarticular niusc-les 
of the hip. and trepidation or pseuiloclomis. Quenu's varicose .scia- 
tica, which has certain analogies to the intermittent claudication of 
arteriosclerotic tyi»e, is characterizwi by deep-seateil pain, and a very 



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spscrAi Ijocauzbd forms of nbttralgias 

protracted onset and chronic course. Hj'aterical sciaticas may alwa>-a 
be expected, but tlicy arc extTcmely rare, except under war loiKiitions. 

Diagnotit. — The iiu-reasiil kiinwledK*' atT<»r(led by himbar puncture, 
J"-rays. and finer tnrxles of testing for sensory disturbanees is dismem- 
Iktiiiji; the old sciatica group fairly rapidly. ()f tlie more coninmn 
diagnostic errors, tabes dorsalLs and lumbago call for six-eial mention. 

Taljcs ]aek» tlie pressure jxiiut;*. the Lascpie phenomenon, and 
usually shows the lost knwvjerks. lost Achilles-jerk. au<l j)(>ssibly 
the ArKj'll-UobcrtS4>n phenomenon. The pains are usually bilateral. 

Lumbago is usually much relieved by the recumbent posture, and 
is increased by the movements of the trunk: the site of the pidn is, 
as a rule, higher. 

LuniI)osacTut radiculitis calls for si»(ial mention i^nce many of 
the elns^icnl chronic sciaticas fall under this disorder. 

Muscular rhcumatlsni (myositis) lacks the pressure points, Laseguc's 
i^ign. and the pains are more dilTuse. 

Spinal-cord tumors in their initial symptomatology cause sciatic 
pains, usually bilateral, occasionally unilateral, lint careful sensory 
examination soon shows anomalies; s|iecial lncali'.!ing signs, paresesand 
trtipliic symptoms p*iint to a severe lesion of the cord. 

IIi|>-joint di-scase lacks the cta^ssical situation of the pains. Arthritis 
dcfonnum casi>s with sciatic paiits show dimiiushcd power of alMluction 
and adduction and the joints are painful. 

Intermittent claudication occasionally gives rise to diagncMtic 
difficulties. Its arteria<clerotic nature is revealed by italpation of thei 
bloodvessels, and by j-ray examinations which show the tortuousi 
modified vessels. 

Ai-liillodym'a, Morton's tarsalgia, n'laxation of the sacro-iliai.* jtnnt, 
and flat-foot occasionally cause sciatica-like syndromes. 

Thfmptf.—Kvsl and quiet arc the first essentials. Then an etiologi- 
cal therapy becomes imix-rative. Mercury for syphilitic cases, quinin 
for malarial cases, surgical intervention for pressure cases, diet for 
fhabclic cases, rest for sacrtwliac cases, othoperlic measures for flat- 
foot, eto. 

While one is waiting to obtain » clear notion as to etiology, geiK-ral 
treatment may l»e necessary. Such treatment shnuM always lie 
regarded as pruvi>iional, not final. 

For the treatment of tlie pain, analgesics arc imperative. ITiese' 
are numerous, and different patients will respond to different meinlMTS 
of the group. Even iluring an attark it may he found that one aiml- 
ge.sic has lost its value, and anotlicr must Itc substitutctl. It ts of 
value to bear the chemical structure of the various analgesics in mind 
in one's thcrft]>eutic eialeavors. .\ntipyrin, or its related proiluots, 
a<«pirin. salipyrin, pyramidon; the amido-plienol series, with plwnace- 
tin, lacTiiphoniii. e\algiii, apolysin, citrophen, phenosal. phenocol, and' 
salocol, as representatives arc often of signal st'rvitr, but rt'tjuire^ 
coaHtderable testing. .Acetanilid it.self, with its compouruls, is in wide 



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AFFBCTWNS Of TUB I'ERIPIIBRAL XSRVSS 



iisp. 'ITiesc analgesics can he used in combination, wlien smaller Hoses 
of till* twii or tlint* in iLse are more I'fKcierit than large ilnscs wlucJi 
often iiave niarkiHl toxic action, either on the hliKnl ci^lls (acetaiiiliil, 
amido-phcnol series) or on the vaM>niotors (antipyrin derivatives). 

In the presence of aneinia, iron and arseuic should lie added. 

Coiinler-irritation is e;*i»ecially useful. It i.s hest practised by 
means of the actxial caiilery (I'aquelin) but mastanl plasters, canthar- 
idfs plaster, deep hut caR-ftil niiis^aije. ^1^'., are useful adjiivanU. 
Applications should l»e made uloriR the nerve trunks. 

Hyilmtlicnipy is often extrcniely valuaUle but must be employed 
with reason. A too energetic hy<lr(>thprapy with nmssagp often 
Offf^ravates a sciatic pain, especially in the initial sta^-s when rest 
is so imperative. Ijxtcr hot packs, mud baths, spray douches, with 
jnild ina.-ts]ige are indicated. In tnaiiy patients the treatments carrieil 
out in bath resorts is esi)eria]ly indicated. Hot-air treatment is not 
well borne in the initial stages, but later is grateful and of therapeutic 
value. 

Direct ner\'e injections of sulwtances havlni; a degenerative actiun 
on ner\e fibers, osmio acid, carbolic acid, etc., are to be condemned. 
Infiltration uictluKis, using water or coraiue. or allietl substaneis, or 
various mixtures have more to recommend them. Selil«sser has 
reported excellent results but has also had t>ermaneiit palsies follow 
his itijectiotis. 

At times it nmy Im* ticemcd necessary', by reason nf the severe pain, 
to practise injections uf stovaine, ciK-aine or allied sulistaua's into the 
region of the eauda or into Uie spinal cord (Coming). Such injections 
are useful, but their action is temporary as a rule. Nerve stretching 
is to l»e c(mdemneil. 

The opium derivatives should l>e used only as a last resort. 

Ekctrittherapy. — The older methods of galvaniziition and faradiza- 
tion are useful in a few cases, but on the whole are uiLsatisfactory. 
Sinusoidal currents are more vuluable, while the Ia'Huc rapidly alter- 
nating currents arc almost always of some scrvict.- in relieving pain 
but not in curing. High-frequency currents with the use of the nltni- 
vi<(lct rays at times give extremely satisfactory results from the same 
stand-point. 

Lumbo-abdoininal.— The,se occupy the lower half of the trunk, and 
are e\trc-ni«-l\ \jiriiil>le. The chief iicr\'es involvcil arc the iliohypo- 
gastric ami its branches, ihc inguinal, and g«'nitocrural. Strict h)calt- 
zation to one trunk is rare, anil men arc more frequently affected tlian 
women. The chief causes, in addition to those of general moment, 
are local inHunimattiry conditions or new growths involving the plexus 
or some of its bran<-hes. The pains arc usually unilateral, o«-asionally 
bilateral, involve the region of the back below the ribs, the gluteal 
region, the abdomicial and inguinal ureas, the scrotum, or the labia. 
The chief Valleix's points an^ over the hnnliar vertebra*, the hip or 
iliac point, hypogastric point, and the scrotal point. Lumlm-alxlom- 




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SPECIAL IJOCAUZED FORifS OP KRXmALGJAS 



347 



inal puins are usually acramjianietl by Inti'irostal (mins above or 
tlii^rli |miiis Iwlnw, 

Testicular Keiiral^.— Astley Cooper tcnned this neuralgia the 
'"irritable testicle." The pains are u-sually unilateral and pass into the 
testicle which may Iw swollen am! tenrfer to the touch. The pain not 
infrequently passes into the le^ and Imek, and the patient may have 
an attack of vomiting. Henihnrdt notes that the pain may lie so in- 
tense as to cause the ptitient to seek castration. The alT^ftiou is an 
ril)stinate one, and U not hel]>ecl, as a rule, by removal of the t<«itic]e. 
DiagnosLi involves a rigid exchwion of somatic disorder of the testicle 
aliliougb many affections (gonorrhea, tulwrculosis. chronic pro.-<tatttia. 
etc.* are not infrequently a<(ompanie<l by i>ersi?tent neuralgic pains. 

Cniral Nenrtlfia. — The crural or femoral nerve is here implicated. 
Tlie pain exlemls in the upi)er front and inner side of the thigh, to 
the kiK*e, and farther thn)ngh the saphenous distribution to the ankle 
and inner asjiect of foot, extending as far as the big toe. It is almost 
entirely confineil to men, and shows coiLsideraUle variability as to the 
branch involvc<l. It not infrequently aix-onipanies a sciatica. Special 
etiological features are Found in fecal impaction, or even chronic con- 
ittiiMition, di.'*ease (ff the hip or knee Imnes, enlargement of the ingtnnal 
glands, nnoiirism of the iliac artery. Charcot called attention to the 
frequent assiM-iution of erural neuralgia and dialjctes. Spinal arthritis 
is an olwt'nn- cause. 

Movements of the thigh usually arc painful and the p;itient comes to 
bend his VK»dy forwarii in a strained |»osition. The (winful ]>oint.s of 
greatest frcciuency are just IjcIow Poupart's ligament, ju.st within the 
inner condyle, over the nmllctilus, inner side of tlic instep, and one 
over the great toe. Nenro-a trophic changes usually occur in the 
quadriceps, but the patellar reflex is rarely affected, save when a 
ilefinite neuritis Is preseiil. Ileriies, rediiening, hy|)eresthesia arc not 
infrequent. In the diagniisis. <lis*'asc nf the inguinal vi-ssels is to W 
looked for. as well as intrapclvic disonlers, new growths, etc. Cniral 
neuralgias have ii fairly good prupiosis. 

Femoral Neuralfia. — Here the cutaneous fcmori.s lateralis, arising 
higher up in the jieK-is, i.t invoh cd. The pain is felt in the U])|kt and 
outer aspects nf tin- thigh, extending to the knee. \ iwiiiful point uver 
the anterior sjiinous pnjcess of the ilium is usual. I'arcsthcsia \\\ the 
distribution of litis nerve has Ixfn extensively studiwi linerulgiu 
paresthetica). The relation of the pressure of corsets in the causation 
of this type of neuralgia has In'cn |K>inte<l out by Freud, and much 
sitting in adipose individnals is frefjuenlly associated with thi.t 
neuralgia. Tlie protjnosis is fa\'orable. 

Obturator Neuralgia. — lesions of this nene are fairly constant as a 
result of the pn^sun- of the intestinal lonps of » hernia, 'lite |Miu ia 
lo<iiti><l in the inner side of thr thigh, and is aceianpanied by a fe^-ling 
of stilTufss, cni'py. crawly feelings nf the skin, and inability to bring 
the thigh towanl tlu' miildle line of the bmly. 



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AFFKCriONS OF THE PRRIPHKRAL M 



Neorel^ias of the Pudendal Plexus. A large nuinbcr »f ncuralpas 
of the genital pli'xus art' rtxi>r(lcil. Tin- uiediiui IiemorrhoidHl braHclies, 
dtstnbut«l to the rectum, bladder, and vaRina, the inferior branches 
l(> the anus, and the pudendal nerve supplying the tc:*ticular sac, the 
labia, ponis, urethni, and clitoris, are the chief nenes involved. The 
p4'neral terms, spennatic neurnlpiu, anal iieuraljjia, p«'rineal neiinilKiH, 
rectal iieuralKia, vesica! neuralgia nr cvstulpin, urethndgin, pntstalgia. 
penis neuralgia, irritable uterus, ovarinn neuralgia, are utilized to 
dcstTilx* these diirereiit affertiuns. These neunilgias are very rare, 
but often very obstinate.- Spernuitic neuralgias are among the nnwt 
frecpicnt, and are not infrw|uently accf»mpauie<l by painful priapi.*iin, 
perhaps ejaculation 

Since the advent of bicycle riding nouratgia.4 of this general region 
have Iieeu on the increase. The ovarian ncurjilgias arc complex, and 
more often c(;me within the domain of the g.vnccol()gist. as structural 
defects arc often tlw underlying causes. LxK'aliwd herjK'tic cniptions 
accompany neuralgias (*f this plexus. lesions of tiie cauda equina 
an* to In' carefully cxchnlcd in neuralgias of this region. 

Neuraleias of Coccygeal Plextis.^'occygodynia, painful roec\-x, is 
a not infrequent dlsartier in women, esiK'cially in multipara- and m the 
bodly con-stipfttcd. Trauma and carii-s are frequent muses. l*he 
hysterical coccyx is not infrequent, and referred cHHvygcal pains arc 
common. The pain is so intense at times tliat defecation is rendered 
impossible; the patient cannot sit, and a grave neurasthenic c-ondi- 
tiim .sui>ervcnes. The medicoleg.al significance of (»c<:ygodynia is real, 
appearing frequently an a local symptom of a general traumatic 
neurasus. Surgeons frequently lay considerable stress on a freely mov- 
able coccyx in aeciilent litigation. A just e^linuite of the tmc bearing 
of an injury to the coccyx can oidy W arrtvetl at by a can.'ful survey 
of all of the factors of the particular case. 

Local treatment is seldom efficacious save in the truly neuralgic 
types. Resection is rarely a justifiable pniccdure. 



HERPES ZOSTER: SHIKGLES: ZONA. RADICULOGANOUONIC 
SYNDROME lACUTE POSTERIOR P0U0MTELITI3). 

In a broad sense zoster consists of a special type of painful er>'the- 
matous eruption with formation of vesicles occupying the radicutar 
distribution of the segment Involved, due to disease of the pnslerior 
roots and the sens<iry ganglion. In thi.s sense It may Ix* due to an acute 
or chronic meningitis, talx'S, Pott's discAse, aircinoma of the vertebric, 
acute infectious diseases. Lnto^icalioILs or other lesions implicating 
the posterior roots ami the ganglion (symptomatic zoster). 

In a narrower sense it may he conceived of as a s[>ec'ific infectinua 
di.sease alTecting the ganglion cells in the posterior spinal ganglia'' 
and the adjacent fibrillar^' structures (essential z<»ster or jwisterior 
poliomyelitis). 




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HBRPES ZOSTER 

History.— 'Zona was first well dest'rilied by UaytT in 1S35. although 
ntit*'s «ii its occurrcuce (late from Hiiipocrntic times. BncrcnspruiiK, 
in IStil, pave the first important moiioprapli, antl ixjuitcil out the 
implication of the ganj^lia as an essential feature of the disease, while 
Head and Caraphell (1900) called particular attention to the speriHc 
infn'tious type. Itosenon and Oftedal' have isolated streptocoeci from 
tilt- K)iii);lia.* 

Etiology.— Nearly all of the geiwral causes which give rise to a 
neuniltnii or a neuritis may hy an extension or an intensifieatinn of the 
pathological process involve the posterior ganglia and thus develop a 
herpes. In poisoning by arsenic and carbon monoxide these ganglia 
seem to be specially affected, and the acute gastro-intestinal affections, 



Fm. VA'.l .^l\rt\n:ti toiler. Tyiin'^il thunn-ir lorutHiD, "KntuvlciJ 

pneimnmia, and tuherculosl<( are not uifrequently contributory* factors. 
Trousseau first callwl attention to the zoster, which was a specific 
infwtion. which type has been sif extensively studied by Htrad and 
(*HniplK*]l. Kpideuiics of zoster point to the truth of this |M>sitlon. 

Symptoms. — Neumlgie ymios tind a skin eruption ajiustitute the 
niuin syinpttmis. Tlic disorder shows a slightly different onlcr of 
development accorrling to the ctioli^ical factors. In the pure or 
csM'ntial znsters (acute (Kistenor poliomyelitis) there i.s u.tually a 
feeling of malai.se. a slight lem|)erature, and gastro-intcstiiuil dlsturl>- 

> Jinir. Am. MH. Ann.. Jtuiv Vd, IBIA. 

* E. Skbunon : JMi. f. d. ■• N. u. P. nf., •nA. vli, M£., tur rweot wotk uti llib «yDiJroiB«. 



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An-i-:mo\s or tuk i'krii'hhhm. skhvrs 



anccs, ihc'ii iIk; piiticiit luis iifuralKic pains whicli may \k niild ami 
aupvrfirial, burninf; or pricking, or ilcep ami extreraely severe, and 
in from three to four days nn eruption develops. Tliere is inarl^ 
hyiMTesthwia of the skin nlouf; the HfTrcterl seKiiifnt, with redness, and 
siiditi'iily tir gmdually theri' ajipears ii group i»f veslelos varj'ing in size 
from » few niilliineters tct a few irtititnrters. Thest* vesicles an' rarely 
cijntUient, and the Huid, which is at first serous, s«mietiines tinged with 
blood, may later becoine puruk'iit. The vcsick-^ fp'adually dry. leaving 
a scaly, ycllnwi.sh-bn)wn stained sriir which jiersisls for a long [mtIoiI. 
IMceration or ffangrene (KTasinnally occurs, espec-ial]y in dialwtes. 
The cycle occupies alwiut four to eight days. There Is usually some 
anesthesia to lH>tli epicritic and proto|Mithic seiisibil'ty after the acute 
stage has passed. One attack seems to confer immunity. 

In the symptomatic zosters of tlic infectious type there is rarely 
fever or gustm -intestinal ilistuHwince. the development of the eruption 
is itsually irrcgiihir. and it often shows a chronic character. Symp- 
tomatic zona may involve both sides, whereas the infectious type 
is nearly always one-sided. 

In the ilorsal types only is the girdle distribution maintained (intor- 
cosiJil herpes zuster), wlu-rcHs invnlveiiient of the (mssfTian, cervical, 
lundmr or sjicral roots gives rise to irreguhir eruption appearances by 
reason of the si-gmcnlal complexities of these regions. 

CJphthalmic zoster is an especially severe type, occurring in in<livid- 
uals alntvc middle life, and often acconipaiiicd by alcoliulic and arterio- 
sclerotic factors. It may t]ev<'lop iipjmrcntly like an erysiijclas of the 
face, with severe neuralgia, and then a widespread vesicular eruption, 
even involving the miienus surface, develops. Ocular complications, 
coiijuiLctivitis, keratitis, iritis, of a severe nature, are not iufrerjiient. 
Facial palsy may lie present in zoster of the Gasserian ganglion or of the 
geniculate. \ symptou^alic ophlhahiiic zoster ilue to lesions in the 
region of the pons occurs. 

Fatholon^. — In essential zona there is an acute, often hemorrhagic 
iiiHiitiitnatiou in the .sensory gunglla. These are swollen, the capsule 
notably thickened, with marked infiltration of leukocytes. The 
ganglion cells are in part destroyed or damaged, and the cnntigiinuR 
fibrillary structures, both initral and [»erii)heral, are also involved 
in the inflammatory reaction. The inltammatiou is usually limited 
to a fe^v ganglia. In the spinal cord secondary degenerations have 
been itbserved, and occa-stonally there is an cxtcnsiem of the general 
process to the cord. In certain cases of what appears to Ik' essential 
zona the ganglia have been free, the only lesions founi] being those of 
a neuritis. There is an imtmstant lymphocjtosis of the ccrebro- 
spiiiJil lluid in the* iuf<■t■ti[ln^ /oIUl^. 

Treatment.- I'nr the symptomatic cases, the cause must be found. 
Otherwise the treatment is purely symptomatic. Loud applications 
of zinc oxide ointment fur protection and the use of a mild antiseptic 
tit prevent suppuration are advisable. For the pains the analgesic 




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351 



rcOMvlies, aln-atly spoken of la the treatment of neuralgia, arc useful. 
(iiistro-iiitostiiml therapy relieves the liisoomfort and itrhiiiR s»rm^ 
wiml, aitd may jHfssihly limit the HceiimiilHtion of a pitssihlt* seLtniclary 
irritiiiit. 

&ADICUUTIS. 

The rfiiliftilar syndrome, nflni mnfuM'd with in-umlKia and neuritis, 
is due tuau iiilluniniatury or trauniutic lesion of (lie sensory nerve rmils, 
usually of the hrHchial. and ot ihe lunihosaend plexuses. 

Altentiun has Uieu given to it diieHy hy French ueurologists, 
notahly Dejcrine ( 19(15) and his pupilA.' 



,^f^. 



V_ 



UU 



fiB*. 200 mnd 201. — TupoKraphy nt iho nfiunry (U«tiirlMUin> in u NviiUilttii- mrfirulitu 
{type Klumpki'] . The Ti nml />,. , iliNlrilmti'xi mt iiivulrmt. iC><>jvfii»p.) 

Symptonw. — These arc neuralgie pains, whieh are u.sual)y severe, 
yet very Miriahle. They usually occur in crises, and are sticking 
and laneiimting in eliaraeUT, at times extremely intense; not infre- 
quently resemhling the pains of tahes. The piiins have a tendency 
to remit un<t then to reeur at sliorter inter\aU, leaving n <frtain 
aorcnr-iis Ix'hind. The nerve trunks are usually not markedly iiainful. 
Then- is usually a nmrked h\ |>erosthesia o\er the radicular segment, 
Its d(M'> not follow the perifiheral ilistrihution as in a nnn-ratlicular 
neuralgia. This h.v|>eresthi'sia is usually followe*l hy uu niM-sthesia 
to both epicritie and pmtopathie sensihility, and occasionally bony 

' I>«J«ritW 9t Ttiontw: Malmltra (h> ta movDu rriini^rv. I9m. 



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AFFECTIONS OF THE PERIPHERAL NBRYBS 



sensibility is involved as well if the inflammatory reaction is intense. 
Deep sensibility may be so involved as to cause astereognosis. Por- 
^thesiie and acroparesthesiee are common.^ 

It is essential that these features, which may be found in other 
affections, be radicular in their distribution. They are not segmeDtaiy^ 
i. e., involving the hand, the forearm, or the arm; nor do they follow 
the peripheral nerve distribution. They are distributed in long bands 
down the arm or the leg, corresponding to the root segments involved. 
(See Figs. 2()C, 211, and also Figs. 23 to 31, and Plates IX and X.) 




Fiuu. 202 and 203.- 



-Schomc of root (nitlicular) scgmcul duitribution. 
(Compare with tigs. 33 to 37.) 



(Flatou.) 



It is a striking fact that sneezing or coughing may bring on a par- 
oxysm of i)aiii in the ccrvicodorsal plexus, and coughing and straining 
at stool may bring on pain in a sciatic radiculitis. 

In the upi)er extrt'mity it is rare to find a pure radiculitis, i. e., one 
without some motor involvement, while for the lower limb the great 
majority of the classical cases of sciatica arc due to a radiculitis. 

In the mixed cases, involvement of the anterior roots causes muscular 
atrophies, likewise radicular and not peripheral in their distribution. 

' Rousollicr, Paria Tli6«e, 1907. 



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RADICVW. 



The atrophy ia rarely arrompanied by fihrillary twitciun^s. or by 
apasnuMlic timtraL-tioiis. 

Atiixiii,s may !«■ met with. Ijks^gue's sigii Is coinmonly found. 

The khiH^jfrk-s are primarily cxagKt'r»t'-'J. 'fttvr diinliiisbed or lost 
in sacral forms. 

Trophic disturbatit-cs. particularly in the joints, and vaanniotor 
signs (cyanosis) arc found in tonfc-standing ca-ses. In rare instances 
the antfrior rctots are involved printarily. 

Diagnosis. — Lumbar puncture may revi-iil a I\iTiph<M'>"ti(sis. As 
niitcd. raiiifulitis of the luudMisjicra! plexus has for the most ]Mirt U-en 
grou]>e<l with the sciatic neuralgias; Imth under the so-called true and 
the symptomatic ncund^ias. 

The prescni-e of s<-usory changca, usmg the procetlures of Head 
and Pcjcrine. the radicular distribution of the hyperesthesiie, the 
ane-sthe-siie and the atrophies are sufficient to determine a diagnostic 
picture. Tlie cTural nerve us more <^ten involved in the radicular 
process than in the poripheral sciatiea.<i.' 

The presence of ataxia in the Ii)w<t lindjs, oecosioDally in the U])[)er, 
UomU'ru's sijtn, and the frctjuent loss of the knee-jerks often leads to 
the mistaken diagnosis of tabes. From one point of view tabes l>egins 
a.s a radiculitis, and the diaf!no.«ttic difTieulty centers about the etio- 
logical element. Since so mucii of radiculitis of the lower extn*mity 
is due to syphilis, the ordinar>* lumliar puncture and VVassermann tests 
are essential to make the diagnosis positive. In tal»es one mu.st also 
take into con.sideration the involvenu>nts of the cranial nerves, Argyll- 
Koliertson pupil, etc. 

Tervicnl radiculitis luiturally travels umler the guise of a <rrvico- 
brachial neuralgia. Here the greater implication of the scn."iory system 
is enough to make a diagnosis. In mild early ca.<«es the diagnosis of a 
radiculitis Is )ni|M)ssit>le. Mu.sctdar atrophy i.s a fmpient complication 
of cer\ical radiculitis. Furthcnnore. pupillary phenomena (Klumpke) 
an- oiminiiu in lht« Xy\iv. 

Bnw'liial radiculitis gives ris<? at times to a typiml Aran-l>uchenne 
atrophy — the bice[)s. anterior brachial, supinator longiis and deltoid — 
the fifth ami sixth tvrvical nK>ts Iwing chiefly involved. Tlie Klun>pke 
oculopupilIar>' phenomena, i. e., diminution in .size of the palpebral 
fissure, slight ntrogressinn of the eyeball and miosis arc pnweut if 
tlie la.st irrvical and first dorsal root^s are involved. 

DisseminaTCii tyi»ett are described by Uejerine* with practically 
all the sign5 of a tabes. 

Occasionally cerebral tuinnrs caune the symptoms of a radiculitis 
witli altcratiiius in the [Kislerior «tlumn.s iitid rudiculnr lesions (< 'oilier, 
IMHJ; .Nage<itle, IHiHl; Haynirmd, l'.H»7). Iloth linib:i nmy U' involved. 

Acroparesthfjfia was des<ril7ed originally by (iiuul>erini in \A\-i, 
later by Nothimgel (1>^^I) by Putnam (1SS2), named by Schultw, 



33 



> l>4>i««iiHi, KuitilnkifclA ilu fyalMne Mfvcnii., 1014. 

> R«v. .N'eun>l., IMM. p. S3*. 




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AFFKCriOSS OF THE I'KRll'HERAL NERVES 



and ilioii tiliuwD by I'ii-k to I)c due. so far as the so-called chronic 
organic cases were concerned, to a radicular or intraspinal in- 
volvement, principally dLstributed in tlie lower half of the cemcal 
region. Other areas may be invol\ed an<i vefjetative level acn^par- 
esthesife (h\']>othyroidisnis) as well as psychogenic acroparesthesis" also 
are frequent. 

Its syniptfkutu arc, in the periotlic eases, pains or burning, or cold 
seiisaticas, usually in the fingers, accompanied by blaneliing and 
ccilduess i>f tlie skin with the sen.^ation of engorgement and extreme 
heavjne?is of the hand or the fingers.' 

Trefttment. — S])(mtaneoiis radinilttis seems to Ih? preeminently 
»yphiJiiii_. Hrmr an antis\^lhi]itic treatment is indicated in every 
case of suspected radiculitis. Other forms of meningitis may produce 
it, however. The jirognosis is gmid in the syjihilitic fonns, but less 
so for tlie others. Many patients with cervical and brachial radicu- 
litis recover simntaneously after from six to ten months. Treatment 
seems to alleviate but not cure. The general treatment for a neuritie 
neuralgia is indicate<l. Violet-ray exposure should be trie*! in the 
intractable cases. 

NEURITIS. 

Neuritis Ls a generalized inflanimntion of the peripheral nenes. 
involving in var>'ing degrees of completeness the motor, .sensory and 
vegetative fibers. In old-standing cases the spinal portions of the 
neurons arc impUc-iited. 

The inllmninfttory changes may proceed cither from the perineurium, 
or from the endoneunum and involve the axis-i-ylinders. These 
may he poisoned anil degeticrate fjmrciiehjinnntons inllamniatioii). 
The pathological nature of the lesion l)ears little rt'lation to the general 
symptomatology, and pathogenicatly considered there is considerable 
interplay of the various processes. 

Etiology.— A vast variety of causes may bring about a neuritis, 
seen either «s tlie rcMilt of acute toxic parenehjnnatous changes, acute 
degeneration tluc to actual jjressure or injurj", or some acute or chronic 
inflammatory changes following a variety of noxa. The most imiwrtnnt 
of these causes are as follows : 

itifectioris- Neuritis may result from the toxins of microorganisms, 
as those of diphtheria, tuberc-ulosis, syphilis, influenza, smallpox, 
dysentery, typhtild fever, pneumonia, streptococcus, occasionally 
measles, .scarlet fever, influenza, whooping-cough, etc. Practically 
there Is no infectious disease tlmt has not pnKhired a toxic, usually 
parenchimatous, neuritis. A seeond group of infections, such as 
leprosy, lieri heri, malaria, rabies, bring about neuritb, but here 
tlie mcclianism is different. 

' PiUiuun: J«nirrui] Nrmnu and Mental DiseiiBe, Beplmnbnr, U1ll> 



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Intoricaiions. — Next in genera! importante are the iiitoxk-atlons, 
either exogenous or endogenous. Alcohol plays the chief role, wliile 
iirseiiic, lew!, carlx»n niorioxklc, snljiliiir, anr! anilin cnmponnds are 
rarer exciting causes. Of the auto-intoxications tlialx-tcs Is per- 
haps the mo^t important. Others are gout, leukemia, and 
uncmiu. 

Trnuma.—.\ third iniix>rtftiit cause for the m'uritic ])rocess is trauma 
to the ner^'e, either us tlie result of ai-t-ident or injury, or tnmi the 
pressure of new growths, dislocations, false positions or other anomalies 
of structure comhined with the prolonged fixed positions rMjuireil in 
certain occupiitions (pnifessiinud lu'iiritis). 

Less important causes, numerically speaking, are exteusioits of 
inflammatory' processes (ascending neuritis), iutlammations about 
joints, inflammations of adjacent organs, etc. 

Symptoms. 'ITie symptomatologj* of neuritis varies enormously, not 
only so far its the etiological factors which determine genemi trends 
of reaction are concerned, but also with reference to location, acuteness 
of onset, etc. 

Only the s>Tnptoms of the generaiized process will Ix^ considered 
!ien% reserving for the sections on I'arescs or Paralyses, Wh of the 
plexuses and of the peripheral nerves, a more detailed description of the 
varioiLs Isolated tj^jes. 

It ha.s already been indicated that tlie conceptions neuralgia, radicu- 
litis and neuritis are ver>- flexible — it is only for the sake of description 
that one draws more or less arbitrary lines between them. Such do not 
exist in nature. 

Tlicre is a generalized type of neuritis which of ntnl by itself <'on- 
stitutes a fairly definite syndrome. This is so-i-allal multiple neuritis, 
or poljTieuritis. It is largely due to toxemias, either of organic or 
inorganic nature. 

I'nder the general raptlon of peripheral neuritis, one eorwiders a 
hirge number of peripheral palsies, wliile as localized neuritis one has 
to consider » nimibrr nf the pmfessional neuritidcs. 

Polyneuritis, Multiple Neuritis.— This is a genend, widely distrib* 
uti'd, diifusc, parench>nnntous neuritis in wlneh the entire peripheral 
neuron Is involved. Vriinary or secondary degi'ueratioius of the 
cerebral neuroas take place. 

Etiology.— Multiple neuritis Is almost invariably due to sMne 
toxemia. Such toxemias may lie Hue to (I) alcohol, lead, arsenic, 
zinc, carbon monoxide, bisulphide i(f ejirltou, sulphuric acid, aiwl 
some of the rarer metals: mercury, e<i|>i>er, phmphorus. etc., (2) or 
to the toxins of acute or chronic infect i<ius diseases, such a.s sniall|N>x, 
li."phoid fever, grippe, measles, sciu"Iet fever, diphtheria, pneumonia, 
dysenterii's, streptoco<'eemia.H, leprosy, malaria, tulxTculosis, parasitic 
worms and syphilis, or the inlliimniiition nuty result from (3) auto- 
inloxinitirm-i such as ihalHtes. Icukemias, severe anemias, etc. Acute 
chilling of the Ijody is held to hv res|X)nsible for certain cases, particu- 



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larly in tlip presence nf sotur infoctimis diseasi«<, or acute tcixeniioA, 
notably in alcoliolic cast's, t-asfs of nilm-s, influenza, etr. 

Occurrence. — Kg gimeral laws ciin I>e made with refprence to occur- 
rtMUT ht'iaiistt of the wUr niiip* of etiologintl faftors. 

Symptoms. -Clinically roiusi(|prc<l. ont' mtt'ts with 3uharute and 
acute cnses. In the sulwcute cases, which are in pcnerul miMcr, the 
patient usually I)rjcin.s to have a rapid projcressivc enfwhleinent of the 
muscles, as a mlr, ftf the l^wer extremities. There is rarely any fever 
at the onset, and thi- Inss nf |niuer firndunlly exlend*; from the prriph- 
eral secmenls toward the Inink. Thus, the extensors of the leg 
and nf the foot first show weakness, and later those of the thigh ami 
hip. At the same time, ur closely following, the upiHT extrvniities 
niay be invo]ve<i, iti iK<''ir(hince with the same f^Mieral law. the niiLscles 
of the liantJ. wri.st and forearm usually \mng primarily involved. 
There are oeeiLsicmal exceptions to this general law of pro^jression, but 
they are comparatively rare. 

It is further i-haraeteristie that the weakness and parat>'sis are more 
or less syniinetrieiilly distributed. AlthnuRh one le^ or one anu may 
show a f^ater aimmnt of weakness tlian the nxher there is almost 
invariably quadrilateral involveuicnt. In the uiiUlcr cases quantity- 
ti\'e variations in the severity occur, and in the mild sulmcute cases 
the cranial nerves are less often di.seaseil. Still the muscles of the 
abdfmien, the diaphra^i. the face, eyeballs nr tonpie may all suffer. 

In the more severe <'ases, (he inipli<'ation of the pneumogastric is 
.shown by tachycardia, dysjiuea and feebleness of the pulse. 

The supern<-ial reflexes may first be exajigerate*!, hut later become 
lost, as a rule, and the tendon n-Rexcs usiially exhibit the samephcnnni- 
enoii. Histurbam-es of sensibility are usually more marked. Initial 
pain is more or less universal, but the sciisntioiis of actual pain arc 
often prcce(lc<l by tingling or creeping seasations, and the skin, nnis<-les, 
nerve trunks and joints may all show hyjM^resthesiie. The Las^ff^»e 
phenomenon is universally ]>resent. 

Careful ti-stiiig of ejiieritic seasibility may show no loss, althnugh, 
as a rule, the sense of localization to light touch and the ability to 
distinguish between two pttints of a compass soon becomes some- 
what diminished. A certain amount of loss of epicritic tcmiwrature 
sense may also be met with. In the milder cases the atn>phy gnidually 
disappears, and there is no tendency to the development of contra<'t- 
ures, but in other eases contractures may follow, and the limbs become 
fixed and immobile. 

In acute generalized pnlyneuritis the attack begins very abruptly, 
iLsually with high tcinpeniture-iMul chill, hciidiichc, malaise, suppression 
of urine, allmmiuuria. tini\ the general signs of iiu acute illness. Par- 
alyses develop very rapidly, usually involving the lower extcrmities first, 
and gradually ascending the trunk and the arms, closely resembling 
the afw-emting ty]>e of acute anterior poliomyelitis (I^rolry). There 
is great tenderness on pressure over the nerve trunks, sharp, shooting 



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pains, markei] hx'pert-sthesiu of the mustlfs iinri tlic Lasegue phriiam- 
eimii. Till- n'Hi'xcs an* raiii<il_v hIkiUsIk^I, the pntiiMit Iitscs fpieritic 
wii^iljility, Ls unable to ltK.-ulizt' touch, t-aiinot dibtiiigui.sh points of 
the L'ompass. but rarely loses sense of pain or of deep pressure. The 
:4phim-lers are not u.HUalIy Involvwl, except in ejiremh. Atrophie-R, 
contractures, trophic disturbances of the skin, such as glossy skin, 
p<'nij)hipns-hke enijitions, pprfomtinp ulcers, frngilr nails, thick ami 
fniK'l*' hairs, etc., th-vclnp. 'I'licn iicular palsies an* met with, mva- 
sionally facial palsy, tinnitus frcfpicntly n-sults from ci>chlear ilistiiH*- 
ance, aiuJ ncuritic vertigo from \ cstibuhir ilisonler is fonm). Pupillary 
inequalitiua arc frctjuent in tlic severe cases. Sluftgish hpht and 
acconinHxlation rcfk-xcs arc fairly constant and rKTasion»lly a true 
ArKjll-Holx-rtson pupil is found. Ixtsa of aci-ommmlation with 
retained light reflexes is met with occasionally. Amaurasut, (>rrmpletje 
or [Mftial, is not infrequent. 

The cranial nerve nuclei are nut infrequently invoK'eil. In the fatal 
casea the implii-ation of the pncuinogastnc causes death. The svmi>- 
toms arc those of asphyxiation^ *>r with canliuc irregularity and 
paralysis of that organ. 

Coone.- DUfnosls. Treatment. —Inasmuch as multiple neuritis 
varies not only with rcfeniice to its symptomatology' and course, but 
offers special diaRiio-itic problems accordiiijj to the etiological factors, 
and sini-e the treatment must depend ujMin a due consideration of the 
etiological factors, it is l)est to di-scuss the?* problems under siwcial 
heads. 

Aicoholic Multiple Neuritis. —This is the most couimon of all the 
types of multiple neuritis. Any form of alcohol -containing drink can 
cause it, including beer, Cologne, ether and other sul>stanct's (if the 
marsh-gas series are among the etiological curinsitieit as causing 
neuritis. 

It is usually subanitc In dcveh»pment, although (Kiasionally, 
especiiilly if the patient has Int-n subjected t" si-vere citid, the dLseasc 
may begin in a very acute nmtiner. an<) present the picture of a I.andr>' 
syndrome. In a few instances an apoplectiform onset has been noted. 
Intercurrent infectioiLs rli.si-nse in an alcoholic may constitute the [Hiint 
of de|»iriure for a p*»lyncuritis: this Is especially true of influciiy.a. 

These patients usually complain of tingling sensalitms: of fnnnica- 
tioii over the hanils or down the legs, with occiLsional twinges of 
pain, iHirticiilnrly in the legs. The skin is ustially hyiirrcsthctic 
through<)Ut the entire l»o<ly. anil the muscles liccnme very sore. Such 
symi'lonis may Ik* pri'.senl for week.-* or even montlts. The |>atient 
commences to notice difhcuhy in walking, inability to go up and down 
stairs anil ooi-asional fulling when callcil ujMin fur ivrtain mtLscular 
exertions. 

I'^Anniinutiiin of the nniM'uIar pi>wer at this stage shows marked 
wiiikni'ss, |>arliculiirty in ihe extciLsi>r> uf the feet, niul "f the hands. 
Ill walking there b a lemieucy to "foot-ilrop," and the |Mitients lift 



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AFFBCTtOSS OF TIIK FBltlPnSRAL S'SRVSS 



tlie \eiiA a little hifther, and may show a chanicteristic flopping step 
suiwrlirially ri-sMubliiig lluit of the tabetic. 

In lliis ^tiim*, before jBitients are confined to bed by reason of the 
musculnr weakness, an exajjKeratioii uf the leiuKin reflexes is otvttsion- 
ally found, altlw>Uj(li diniinutiou and loss Ih-cohm-s the rule. Atrophy, 
flabbiness of tlie nmsirles, and tlie trophic signs may then appear. 

A nundx:r of these patient:^ are able to be about, and are often 
misUken for eases of l>ef^nmng tabes, espe<'ialiy as there is very 
frecpieiitly n eertain amount of ataxia, definitely marked in the lower 
extremities, less so in the up|)er. The sphineters are, as a rule, intaet. 

In some severe iiLses, in luldition tu the physical signs, a very definite 
psyeJitisis develops. This is treated under the he4id of i>olyneuritic 
psychosis- clinMiie aleoholic delirium, Korsakow's psyehnsis. (See 
obtpter on Toxic Psychoses.) 




*• 



Flu. 1:1.11 .U 



'In in I'dniiiH' .tt.'HEi' «iUi ri.inir.i' !.arL-.i. 




Course. — Aleoholic polyneuritis shows an iu3umierab]e number of 
variants, hut in the main it runs a subacute eoiirse. The patients 
go through the usual symptoms of chronic alcoholism, with tremor, 
sleeplessness, gastric disturlwiticc and malnutrition. In the severe 
cases which develop markcil mental signs Korsakow's syndrome — 
they usually go through one or more periods of acute delirium (detiritua 
tremeiLs). 

Then the neuritic symptoms commence to appear, usually with 
forniicatiim or other pareslhesiie in the arms and legs. Sudden lwiiige.s 
of pain, particularly iu the lower 3inil>s, are frequent, anil an unusual 
sense of muscular fatigue develops. I'ynamometer readings show this 
loss of iK>wer and excessive fatigability early in the disorder. The 
average case, if drinking continues, and the malnutrition and insomnia 
are not overcome, takes three or four to eight weeks for the develop- 



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ment of definite palsies. The patients note great diffieulty in going 
np and down stairs, with much palpitation and shurtiicss of l)reath. 
llit-n on some sudden exertion tliey full, or their legs shut up like u 
jaek-knife under them. 'Hicy totter iit their walk, or show a steppage 
or ataxic }fsit. The liLsease may be arrested at this stage, an<l rei-^jvery 
takes place with proper care. Inadvancinf; cases, loeomotion becomes 
inii«)ssihle. Foot-drop, wrist-iirop, and ptosis may dovelop, and the 
atrophies, mniractiires, mid trophio disturhaiitrs (vme on rapidly. 
The paiiLs are of increased severity and frequency, and are apt to 
Ik- excrvidatinii:. The hypen-stliesia. which lias l>een exwssive. may 
now be j;radually and irregularly suppbnted by h\-pe3thesia or aiie.^- 
thesia, hypalf^'sia, or analgesia, and extension to the cranial nen-e 
nuclei may he looked for. Sensitive nerve trunks and l.asegue's 
phenomenon are invariably present. 

The patient who has lulvantxtl to the stage of paralysis, atrophies, 
and trophic changes is usually confined to Ix-d for several niontliit, 
and then commences to make a slow and irregular recovery. It may 
lie complete, but there is apt to be some local, persistent impairment 
which may require treatment for years, especially if fibrotendinous 
contractures have developed. In the Korsakow cases certain grades 
of residual mental impairment are extremely common. 

No two cases of alcoholic polyneuritis are alike. There is a general 
tendency,' for the tJisonler to involve all ftiur extremities in the pro- 
nounced cases, but the lower extremities are more severely implicated. 
II.\'])erc3thesiR' and paresthesia ore frequent. Special predilection is 
shown for the extensors of the foot and wrist, trains are extremely 
severe and are universal. HHndncss (amaunwls) is frequent; with 
methyl (wood) alcohol it usually comes on in advance of any other 
neurit ic sjinptoms. 

Treatment.— Treatment of alcoholic neuritis involves the absfilute 
withdrawal of alcohol in un.v form, complete rest, fnrtrd fi-cdiiig. 
particularly with foods rich in fat — milk, egg*., butter. Pain is lK*st 
relieved by hot applications: continuous warm balhs are very grateful 
if there is marked hyperesthesia of skin, muscles, and nen'e trunks: 
the temperature should not exceed 96* to U7* R, if the bath Is to be 
continued for any great length of time. Active catharsis and iliapht>- 
resis are essential in the early stages. After the stage of acute hyiH-r- 
estliesia is passed the forced feeiUng should be continued and the use 
of strychnine and electricity conimcnciil. Gn-at care shmild be taken 
in the selection of the hypnotics used to give sleep. sinc(^ so many of 
them conttiin alcohol, and a few are directly immmiuoiis lo the nerve 
tnmks. Bromids, hyoscinc, or cxrcaaionally the opium (Icrivatives may 
be cinployeil. If an alcohol h>-pnotic seems neeessarv |Hiraldehydc 
and chloral are indicate<i. 

(ily<'ero|ihii>pliites with calcinin nn; valuablr, preferably not given 
in an ahiilHiIic mc<lium. Massjigc and muscular nniveinerils of 
various tyiK-s are indicated in the chrunie stages, and muBt eases will 



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THB PERIPHERAL NBi 

repay constant working upon them. In the presence of contractures, 
surgical intenention may be necesaar>% but fihoiild be deferred until 
persistant rnfiw>iige and miisrular thenipy have Wvu exhausted. 

Le&d Neuritis. — I.A'ad Valay. — In neuritis from lead poisoning which 
occurs fRini the gradual intake nf lead in sonic form— drujis, hair 
dyes, cosmetics, contaminated water, certain ot'cupations (ptiimbers, 
workers in type foundries, printers, glaze workers, potlers. etc.) tlic 
pirtun; is very different from that seen in alcoholi-un, although the 
ttT!iiinal stages may be similar. The histological alterations jire 
prartically identical. Many ca.ses are complicated with alcoholism. 

Symptoms. — Then* are the initial gastrcMutesliiial symptoms of 
lead jjoisonini;, furrefl tongue, c<mstipation, attacks of colic, heailaches, 
nneiniu, painful joints, and pi'rliaps the signs uf a neptiritis. The gum 
lead line is frequently j>rcsciit. After a few months, or even a year or 
so of exposure, the neuritis develops, often after an attack of colic. 
It usually attacks the upper extremities, by preference, nlthough there 
is always some slight involvement of the lower Hmbs. Definite lower 
limb palsies are rare, and usually occur only in children. The pareses 
predominate particularly in tlie extensors of the index finger ami tltumb 
—the sensory s>in|>toms, hyiK'rpstlicsiic, pains, nerve tenderness, 
Lascgue's phenomenon, i>arcsthi%ue, are usually much ies» than la 
alcoholic neuritis. The supinator longirs is very frequently spared. 
The paralyses are usually symmetrical, but may be quite irregular; 
the proximal trunk muscles may t>e involve*! — the ilistal ones free. 
Thi-s occasionally happens in alcoholic neuritis as well. Ueaction 
of degeneration apjiears in the paretic muscles. Anesthesia, atrophies, 
tntphie disturbann's, and contractures are met with, but may l>e 
considered exceptiotml. ()c\il[inu>tor palsies also occur, and optie 
lUTVc atri)]ihy is not iiifn-qiieiU. Other cranial ner\ert. those of the 
larynx, pharynx, and face are also implicated, though rarely. Lead 
enceplialopathies resembling those of alcohol are known. 

Course and Trca.ment. — The course of lead jM)lyneuritis is essentially 
chronic, lasting from several months to a yciir. 'Hic prognosis is 
usually favorable. The treatment is the same as for neuritis in 
gi'iieral, with the adtlitiori of excessive diuresis, and the use of such 
rempilies as ma>' hasten lead elimination, such as potjwwium iodid. 

Arsenical Neuritis. -Dejerine,' in I8.S3, first insisteil on the es,sfnlial 
similariiy «tf neuritis of ak-obolie and arsenical origin, winch view- 
point lias lx*en amply verified in the cxtciuiive studies following a 
severe epidemic of arsentctU p4>lyneuritis in England, in ]S!)!(-iy(H).* 
The most fr(*qucnt source of arsenica] poisoning ha.s ht«n shown to 
come from impure glucose pmdncts; the sulphuric acid used to con- 
vert the starch <'ontjiining arsenic. Other sourets arc^ wall-papers, 
certain nnunifactures (dye-stidfs), artificial finwers, easmctics, Iwauty 
pastes and powders, hair dyi-s, and arsenic used in medicines. The 

■ Oiu|itn RimkIiw. Or>|.ilM>r, |H.<Ct. vol. xnviii. .Vo. 17. 
> Lnoect, IQOO, L, l(ilO. 




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pathological altrrations {a parenchyma lous neuritis) do not difftT 
fntm those seen in alcoholic neuritis. 

Symptoms,— Acute pnlyneurius from arsenical poisoning is rare. It 
sets in shortly after the KHKtr«)-intestinal svinptoms of acute toxemia 
have passed. 

In llie chronic cases the general syniptcMns of chronic arsenic 
intoxication are firet observed. These arc ihc anorexias, congestions 
of the upper respiratory tnict (nasal catarrh, cough) or more frank 
diarrheas of pastro-intestinal irritation. The neuritis develops simul- 
taneously with the symptoms of chronic intoxication. 

As with alcoholic neuritis, sensoi>' symptoms, parestliesite, hyperes- 
ihesiip, nunihne^s, shooting pains, sweating, develop first. A pig- 
mented condition of the skin, most marked about uonnnlly pigmented 
an'tts, is found in the majority of the cases, ^^le pigmentation may 
jcoroc very general and vcrj* dark, and is associated with herpetic, 
fizematous, or scaly, papular eruption.^. Certain of the newer prcp- 
'nrutiun.>* of arsenic which have I>een exteiLsively advocatc<l for the 
treatment of syphilis, notably atoxyl and arsacetin, are rep<irted to 
have cHiistil optic nerve atrophy with blimlncss. 

The signs of sore nerve trunks, Lasrguc's pliononienon, hiss of motor 
power in both extremities, are present in arsenical cases. Ataxias 
fflTiir, and i-ases of arsenical neuritis have Ixm confounded with tabes. 

The prognosis is usually guwi. but the blindness has been |}erumnent. 

Other Intoxications.— <'ar bo n monoxide, diabetes, and illuminating 
gas jHiistiiiiiig. if s^-vere and not lethal, frequently develop a severe grade 
of multiple neuritis not differing in any marked degree from alcoholic 
jiolyiieuritis. The gases found in nntiinil giLs, and in many artificial 
gu.^s contain the same cbemical radicals ^s alcohol, and the toxic 
action is itientical. hi the very severe cases, polii>cnccplialiti3 develops 
with multiple softenings, not entirely confined to the tluilamus nr 
corj>»ra striata. 

Carbon bisul[>hide. which is extensively used in nibbcr iiidnstries, 
may give rise to a multiple neuritis. The toxic ion is not iMinilely 
known. Similar poisoning results from sulphonal and trional, two 
sulphuric ncid-alcohol hypnotics. A num^MT of the nitrobenzol series 
CUD pnuhur Idcitli'/ed tir general neuritis. 

I'hitsphorus, mcrt-ury, copixT, and silver can [jrodiice poisoning with 
the dcYclnpment of multiple neuritis. 

Infectioas Disease Types. — Mild or severe general neuritis has JK-en 
nbsirvfd to have occasionally fonowe<l practii"nlly cver>' known 
infectious disease. 

Dijtfithrrta. — More the neuritis is rarely generaliyxtl, and the cranial 
nerves Itear the chief brunt i>f the poison. In mild fonixs ihe soft 
palate and phar>'ngi'al musrles ore first or alone implieateil. Oculo- 
motor paUics arc al.-«i frcipicnt. Some di-gn'r of facial pfd^v is also 
met with. In the seven* tyiK-s the larynx, tongue and the pncunnv- 
giu-^cric innervatioiLi become invaded.' 

'Arf^iaiiilMnll.; C'iltur Osnilloti lti%-n|n>rn«AU. Joar. Nrrr., md Ment- [U<., I0I7. 



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AFFBCTIONS OF THE PEftlPllEHAL !^RRVK8 



Generalized forms occur, diHerinR in no essential i>articiilar from the 
types already described. 

l>il)htheriiic palsies may come on soon in the disea.se or they may 
follow a month or six weeks after the siihsidcnre of the disease proper. 
For linjse patients who develop polyneuriti.s the dtugnosis is usually 
grave. The cranial nerve types are usually less severe, akhutigh 
oceasi(]nally une finds pneunui^u^^tric palsies wliieh are fatal. 

luJiuenzn.^-'Vhii toxins of the infliiciiza oriifanisin seem to have a 
special attraction for sensory nerve structures. Neuralgias, lo«aH'/e<l 
neuritides, are extremely common, and po!\iieuritis not a rarity. The 
polyneuritis is of a parenchymatous type, is usually mild, quite irregu- 
lar, and differs in no essential manner from other types descrilted. 
Its course h rnrvly over a few months in duration and the prognosis 
is usua.ll>' RotKl. 

Polyneuritis of a mild parenchymatous type wcurs as a sequel of 
tj-phoid fever, smallpox, er.vsij>ela.s, ])neuinonia, i)leurisy. acute articu> 
lar rheumatism, parotitis, gonorrhea, dysentery, measles, Pasteur 
rabLe,< treatment, whoopiiig-eoiiEh, and puerperal septicemia. 

Ill ehroiiie tulHTcnlosis mild grades of neuritis are frequent, and 
severe polyneuritis Is occasionally met with in the marantic tyjie. 
Syphilis rarely causes a polyneuritis, but it is known. Malaria is 
also a rare cause. Leprosy causes a aiKreialized form. 

PLEXUS PALSIES. 

Plexus or root palsies are comparatively rare. They occur mnre 
often in the upper extremity. Brachial plexus palsy, as Erb's birth 
palsy, is the type. Lumbar plexus palsies rarely occur alone imcom- 
plicated hy cord lesions, since they are usually produced by compres- 
sion, resulting from tumor, fracture, Poll's disease, etc. Sacral 
plexus palsies, however, are not infretiuent. They make up the 
classical cauda equina lesions, ari-siiig from the pressure of a tumor, 
from hemorrhage, fracture of the sacrum, bony disease of the lumbar 
vertcbne, pelvic luujor, abscess, etc. 

Brachial Plexus Palsies. —These most frequently arise from piiUinff 
or wrenching of the urnis fro^m acci<Ients. Dislocutum of the shonldcr- 
joitit can cause a plexus injury. ( "ervical rib is a rare cause, aneurism 
of th« subclavian also. (lUnslmt wounds ocaision them. (See Kig. 
205.) 

The plexus is made up of the lower four cervical (fifth, sixth, seventh 
and eighth) and the upper dorsal roots. Extrasjnnal as well as intra- 
spinal le.siims go to make u]) tiie symptom picture. This picture is 
rarely complete, but as the fibers making up the plexus have a fairly 
definite arrangement so far as muscular distribution is eoncemed, a 
study of the muscles involvett gives a key to the roots injured. 

The fifth and sixth cervical roots contain the fibers going to the 
deltoid, biceps, bracJiialis anticus, supinator longus, supni- and infrn- 




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sciipuluris, the elavicuUr fascis of tlie pectoralis mujor, and the 
scrratus mflgiiiis. Tlw a.'vi'nth (rrvical root coiitjiiiis the PiIkts dia- 
tributed to the triceps, tlie sternal portion of the pcetoralis major, 
to the dorsah^ mapius, to the extensors of the wrist, and also some 
filaiuenLs to the meitian and ulnar nerves. 

'I'lic eiglilh cervical and the tintt dorsal form the brachial, internal 
cutaneous, ulnar, niffrlinn and parts of the radial ner\'es with their 
muscular innervations, as strii in the ilIuslrntions. (St*c Figs. 2*2 to 
30, also Fig. 195.) 

The clinical picturt^ seen ari*. those of a tot«l hrucliial plexus palsy; 
11 suixTior and inferior type. 



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Flu. 205. 



'i'vatory (luturtMncvs in wvnn nuw 'if kuiihIkiI wouikIh of the lintrliia] 
|)l«nu ID Ihe "Worid Wv." (Edinoor.) 



Total Brachial Palsy. Here nil of the mnscles of the hand tire |mr- 
ulyzed, those of tlic foreann, the arm and the shoulder. The arm 
hangs limp like a Hail. In the early stages the skin is cyanose<], 
there are severe pains tin tlie accident cases), and a suppression of the 
secretion of sweat, .\trophy cttmes on qnickly and is extreme, with 
loss of electrical respoiLses. Trophic disturbances are usually present. 

Sensory disturbances are present. There is loss of all fonns of 
sensibility, including the sense of position in the hands ami the fore- 
arm. .\nteriorly the upper border of anesthesia ceases just aUive the 
internal condyle; externally it extends to the uisertiim of the deltoid. 

Furlherinore, since ifrvical syinpatlietie filers are i\'presente<I 
in the communicating branch of the first dorstd, one finds oeulopupil- 
lary signs, tirsi demonstrateil by Ma<lame Dejerine-Kliimpke (iS85). 
They eciasist of n contrartion of the pupil on the paralyzed side, a 
dinuhution in the size of the palpebral Kssure (pseudoptosis) and a 
n-traetion of (lie i;IuIh^ of the eye within the orbit lenophtlinbiuts). 



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levt-1 of the third rib iu front atwl the spine of the scapula bchimi, 
im-hiiiiiiR thf upjior f xtremity. all confined to tlio side injured. 

Inferior Boot Type. — This hits a!s»> l)«>n dcsidnntiHl the Klumpke 
palsy. It follows H less cnmpletc lesion of tlif pU-xus, iuvolvhiK the 
eighth cervical and the first dorsal. It may result from direct iiijurj- of 
strain, ^iishut womid, l)irth palsy (Krb's palsy), from rt'r\'ical rih, or 
from .Hyijliilitie deposits. The small inuaeivs of the hand are involved. 
The atrophy is nipld. There is {-deum of the skin, cyanosis, jHTliaps 
trophic eliannes in the nails. The anesthesia is less extensive, l»ein(( 
limiteil to the rlLstribution of tlie rudiid and internal cutaneous ncrve-s. 
The (K-nlopnpiUary siyns are evident. 



Cv.vi. 



WCr; 



-Cv 



CVD. 



C VI VI 



V 



210 and 311. — Topuxnphy of tactile, p«iii, wad UiDniutl wnaury diatiirlionraa in 
bnchial paUy type duu to injury to Hm Hliould«r. 'Ilw MUt, Hxxh, itnd 
an-MiUi iwrviral mala atv involved. (Uojurino.) 

Superior Brachial Plexus Fals7. Here the upjier hranclies, fifth and 
MXth itr^'ieal, are involved. Dnchenne rlcscril>ed the earlier ca^ps 
ininut4*ly. The [wLsitxl muscles have liren mentiimi^l. The sen.sory 
distnrhanees an- more extensive than those observed in tlur inferior 
type. The pupillary symptftms ure ahscnt. 

Mixed Types. — Thi-str are more frequent. In the recent great 
World War a vast medley of plexus jMilsies liave l)een ot>seni*d.' 
Tlw more common fonn of so-called Erb's palsy belongs here. Many 
of these, art^ hUatcral, the two anns, however, lieinj; dissimilarly in- 
volved. The study of the muscles involved in the atrophy, the 
electrical chnnj^'s, tlie Mcn.sor>' changes, Xa light touch, heat, cold, jmin, 
Iwny sensibility, nnd to imsition, the presence of tntphie disturlwnces 

' Tinol: t*y niiavum dm Nnrfii. Mn«ou <'t do, MMO, in uuc u( \hia IfMl oi tlw tuauj' 
puMicatintu iipoii war Injuriua u( aorvuB. 



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AFFKCTimSOFfWB PKRIPHKRAh NERVRS 

(prnto|>Alhic system fhiingcs), «iid the oculopupillary phrtioineim 
dfU'rinine the roots involve*!. (Sec Figs. 2:^ to M.) 

TInTP are n numlier of liony foiwlitions wliich ran Hcterniine brachial 
plexus i«ilsie?^. TutHTt-ulous. syphilitic. c-arfinoniatoiLs, siirctmiatous, 
arthritic iiifi It rations about the vertebral canal impinKiiig up<in the 
cords of the plexus ciiii give rise to palsies of this type. Similar 
chances not infrequently also cause pictures which are often confused 
with brai'Iiial neuritis. Some of the severe arm pains with milil atni- 
pliies HFC fiiniis of brafliial radiculitis (ly. r.). either inflaininatory or 
trouniatic iu origin. In the course of a rheumatoid arthritis one 
not infrequently encounters these radicular disturbances which »re 
undoubtedly rt^ferable to a vertebral urlliritis. 



Fw. 212.— DriiiM. .. 



ril>. i.-aUBiiiS mwoi h ;■■■ 



ruliwl [>iLUy. (On.Klliftrt.) 



Course. — General statements regarding the course are mislending. 
The majority of Krb's palsies due to olwtetrica! accidents recover, 
especially when only a few roots of the plexus are involved. Total 
separation from the cord, as in severe dislocations, falls, etc.; with 
complete plexus palsy, usually means an incurable affection, not 
remediable by surgery. 

The underlying etiological factor dctrrniiiics thi- course in a number 
of others. Palsies cnuiH'd by cervieal rib. or subclavian aneurism ili) 
not get well spontaneously, nor does UKlid help them. Proper sm-gery, 
as indicated by the a'-ray findings, may be of service. 



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PLEXCS PALtitBS 

Diaffiiosis.— TJif rartT nuclear anil iieurilic iitrnphu's ami Hystmpliies 
have Ixrtn niistakciL for these radinilnr piibu's, but tlie study of the 
seasory clianpc^ sliouM at once estahlisli llii* tliiTiTeuccs. Spiiial 
pliosia of the ui)per arm tjiK* will show dUsociation syrnptnuis. indicat- 
ing the intraspinal nature of the lesion. Such a dissociation is a 
retention of tactile sensibility with lo,ss of pain and theimnl seiusj- 
bility. ^*8riDUs uenritides, lead, diabetic, have a peripheral rather 
than a ri>ot distribution. Certain exceptional cases of tidies, witli 
atniphy. can he rM'iMirnlc<l. but may require a tvrebrospiiud fluid 
cxaiuiimtiuu. .Syphilitic crrvical spoudyUtis cases at times show these 
symptoms. 

Treatment.— There Is little treatment for the severe, tearing lesiotis 
of the jili-xus. Whether they ran be looped up with other roots to 
ndvunta^e has to Ix* answered in the future. 

The cause of the jmlsies, other than tearing, ran often be remo^'ed. 
Thus surgical treatment of neck glands, subclavian anevirisms, cervical 
rib, spondylitis, and oste<»-arthrilis is efficacious. The treatment of a 
een'icotiorsal Putt's by proiM-r fixation, and the aiitisyphiUtic treat- 
ment of a luetic spondylitis are satisfactory. Hare cases. <»ften bilat- 
eral, due to pn^fiaind secondar>' anemia, are often very refractory. 
True radicular neuritis is also stubborn. 

The pains are l>est relieved by analgesii-s; antipyrin, aspirin, pyram- 
idnn. or other combinntiMns ore vahiiible. Heat is usually not well 
iMime, and massage is ccmtra-indicated in the early stages. ()stetipatliic 
manipulation is a dangerous procedure in the early stages. In certain 
ORte<>-arthritic cases it proves valuable later. 

Simple counter-irritation over the site of the plexus, above the 
clavicle, is invaluable in many mild ncuritie attacks; while for the 
severer attacks high-frequency currents, violet light therapy, Ix'due 
current at times cause great relief. 

I>ietetic and general inanagement in the neuritic cases is not to Im* 
overlooked. They need fats iu ample proportion. Tlus is best supplie<l 
through taking large quantities of milk. 

Lumbosacral Plexus. — The attention of the neurrjlogist is often 
focusseil about the process of deliver^'. Whereas it is the child that 
oecnsiiuially has a birth )ialsy which is brachial, it is the mother who 
has a lunibitsacrul palsy due to loug-oiuititnicil pn-ssure of the bead 
upon the plexus. Here the palsy may bi' partial, or it may In* fully 
deveIopc<l, resembling a palsy due to a lesion of the i-auda etiuina. 

Intra-alMlominal pressure may also ari,se from Iwjny tumors, from 
pelvic inflammation.^, ami pus collections in the pelvis due to old 
appendicitis, salpingitis, etc. (iunshot wounds occasion .sacTal plexiu 
palsies. 

Intrntnedullary t-auses for liimbuftcarHl plexus |talsies are more fre- 
quent than for brachial palsies, becaiLso of the arrangement of the 
nencs. 

The Cauda (xiuina comprises the entire group uf cocc>'gi>al, sacral 



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AFFBCTlUN^i OF THE I'EHU'UEHAL MCKVE^ 



and liisl thrtT limidftr runts. Thesci-oiul ttiiiilmr Is iiractically iudude*! 
witliiii \\\r mtial. (Stt Klfts. 1*) and 10.) 

Symptoms. — In the fully developed pk-tiire one finds complete 
fliittid puUy of the lower extremities, nicrt" is marked fixit-drop, 
and limitations of all the motions of the legs. .Atrophy of the 
museles takes pla<e rapidly, esjieciolly of the lower extremities. The 
niiiseles of tlie anterior portion of the tliiph intierva(c4l in part hy the 
seeond lumlmr, reniala normal anti aetive. Fibrillary twitrhinjp* arc 
ri'e«iuent in the atrophied nmsoU-s, and reacliou of degeneration us 
present. 

The cutaneous reflexes are usually absent, the Aeliillea reflex is 
absent and that (tf the patellar as well unles.s the lesion strikes below 
the third lumbar r«»ot. 

Pains are nsiially very marked and persistent. They oeeur in 
paroxysms, ami iire usually extreme. 'Hie chief piitb is that of the 
sciatic, but they may Ik- liK'ated almost anywhere about the thigh. 
They inav Iw bilatiTal or unilateral and slilft ^►nsiilerublv. 



JvA Jv 



/\ 



/■n 






Fi(i. 213.— StMiwiry diHlurtinnro* iii five rsuiofi of Kimtl plcxiiit injury due Li> K*ir>^l>ot 
wi>uuils. Ill ilio fint ciuic there wns u t<>t»l tiibiv in tliv ptwiincuA luid ijliinlia iwrve 
(lutt.rihu(.inn: Jii thi> m-roinL iJn- jvn^neiLS ■trtne wm inv«!\-(xi: in thu third llm (ifrnnpiiB. 
ti>iiiilix. iliiwiucuinatiH and nlrtunitui; iu \ha fourtii Lho pcn^ucus niw] tibialis; to tlio 
(ifUi Lhi' crumt norvo Jwtrihution bI^bo ouflnrml. (I-^liugcr.) 

Sensory examination shows typical diminution of nil forms of 
sensibility following the neiiritic ty[H*. Lesions luRlier up involvuig 
the eonus or the cord show dissociated sensory phenomena to be 
discussed later. 

Tltc touch anesthesia extends to the limit of the second dorsal. 
i. f.. at the upper level of tile sacrum, ineludinn the anus, perineum, 
and genito-urinary organs. (i!^ec Plates I X and X.) 

Vasomotor phenomena, cold, somewhat cj'anotic akin, and hard 
edema may be present. Thft bladder, rectum, and genital controls 
are involved. This is the usual i)icture in a total lesion. In pnutice 
this is k-ss often seen than the many irrepular types. 

Course.— Profnosis.— Limiting the discussion t« the cases of pressure 
of parturition one finds that these patients often suffer froni irregular 
sciatic |)ains in the later stages of their pregnancy. A few dayy after 
a protrai-ted delivery the pains often increase vcr>' markedly and then 
a paralysis of the lower extremities develops. This is usually more 



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PRRiPUEttAl. PAfJttES 

nifii-kod on one sMe. Blaililrr ami rrctnl Hiflirulties uriw «ml the 
patient slimvs the picture usually of an inaimplete plexus polsy of the 
InmiiosarrnI region. After a mnnth ur so soineliiues several munths 
in the st'verv eases a complete ret.t)very asualty takes plaw. 

The results of saerni plexus injury by gunshot wounds are less 
promt!ting. 

Trfifttment. — Is that for a neuritis in general (r/. f.). 

PERIPHERAL PALSIES. 

Numerous forms of p.>ripheml nerve palsy are found. vaO'iog 
acrording to the particular fibers invulveil. The branehes that arise 
fnun the braehial [ilexiis }iave alniady liei-ri deseril>wl. Any of these 
may be injnrei) or influined with a resiilliiig iKirtial nr euniplete iMilsy. 
The various iieuritidL-s will not be reexamined and the fulluwing seetions 
will deal with those peripheral palsies largely due tn defect or injur}'. 

Defects, Dmgenit&l and Acquired. Muscular defects in the upper 
and lii«cr rxtreniities are by nn meaas imconiinon. They have 
lieeii di-serilK'd for some ivntunes. Their precise formulation began 
with Zicmmsen's work in IS.'jT. The later literature is suuimeil up by 
Biog.* Ijorenz,' and by Hirschfeld.' Tlie causes for these muscular 
defects are extremely eonipli<'ated. 

The oceurrenw ts very maiiifoltl. Biuft was the first to collect the 
entire group, and Abromeit, in UMK*, complet<'d the study which shows 
tluit an ahsen(« of any muscle of the l>ody may be expected. One in 
lO.tKXl shows such defects. 

In the majority of the cases the defect is unilateral, and they are 
more frequent in men. 

Abnimcit collected reports of ISfi cases of defect of the pectoral 
muscles, the sternocostal portion being most affected.' Tliis seems 
the most frequent of such anomalies. The tra|)ezius was aK>«^nt 
in 'X^ cases, the serratus magnus in 22, quadmtus 2<i, omohyoid Iti. 
seniiniembranosis 7, rectus muscles 11, pyraniitlalis, nften found 
absent iKwtmortcni, fliaphnigm '.\ times, ilelloid .'», stenuK-leldnnuistoid 
^, etc. The smaller muscles of (he hand are not infrequently absent. 

Certaiu combinations of muscles may 1k' absent, constituting a 
grou|) complex. Atniphy or loss of other jtarts may be condtiried and 
gross anomalies nf structure may be combined witli market) muscular 
defects ; various monsters, syndacty lia , phocomelus.etr. The hepeditar>* 
nature of syndactylous anomalies had given occasion for some im- 
[Ntrlaiit studies. 

The symplnms involve the physiological h>ss nf the siiei-ial mii^ele 
function or the resultant of function from the muscles present m a 
nnnbitiation. 

' Vlii'h An'li , 170. 1003. > Dip Miukcl FlrlcrmnkuiicMi. KnUiita«Rl, l«H. 

■ K'>n«Ariii(tlc M ii*kol(M«kt«. Lcwiodowvky's Iluwlbuch, IVll. 
•9m> L«>wuiulnw»ky. II, [*■ 363. 
34 



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AFFECTIONS OF THE PERII*11ERAL NEItVBS 



These patients rarely show as inarke<l loss of efficiency, cs()ecijilly 
with one-siflet! tiefmit, as Ho those who acquire a defect. Aetiuinil 
defects are usually bilateral. They usually involve a (froup of muscles; 
the (liscase rarely causes a total loss of muscle substance, and onomalies 
of aceoinpanyinff structures arc tnissinf;. 

fibrillary twitching^ are often diagnostic of the acquired muscular 
defects. 

The prognosis and tjeatment require little (li»ciis.sion. Gjinna-stic 
exercise of the residua! muscular combinations directed ti> the a<-quLsi- 
tion of greater eflicienry by skilful uppli<'atiiin of niei-hauical priiicijiles 
is always an individual goal that cannot be more thau mentioned 
here. 

Peripheral Palsies Due to War Injuries. —This section discusses 
peripheral palsies due to nerve injuries rather than to those due to^ 
general neuritic proccis*-s. An injury may alYect a nerve cither in Jta! 
contiiunt>', or in one of its temiinaE bmnchp,s, thus giving rise to 
different symptoms, and refpiiririg a <liverse thera])y. 

Injury in amtinuity may result from i>ciietrHtitig M'Qunds. traction, 
jircssure, blows or by ()i)eration. They may give rise to complete or 
incnmpletc division. 

Symptoms. ^The recent World War 1ms ainpiifie^l the existing 
ma-^s of information relative to ijcripheral nerve injuries. In view of 
the more rcreent investigations initiated by Head and Sherren and 
carried into the field of war neurology by Dejeriiie and his pupils, it 
seems jjossible to separate the peripheral ner\*e injury syndromes into 
four. (1) The interruption syndrome; £2} ( 'ompre.ssion symiromc; 
(3) Irritation syndrome; and (4) Uestomtiou syndrome. 

(!) The hderruptwn syidwrnc, when complete, causes abolition of all 
of the funeti<»ns. Paralysis of the involvet! muscles Ls complete, tonus 
is lost, the limbs a.ssumc attitudes caused by the antagonist prMlomi- 
nance. There is no pain on prc-feurc of the muscular masses and there 
is muscle anesthoiia. To thtwe may Iw added ; Abolition of the tendon, 
osseus uud cutaneous reflexes, exaggeration of. the myotatic reactions, 
aniyolrophies, dcfurniitics. as dorsal tunmr of the tarsus or carpus, 
niixlificd electrical reactions. The sensory changes need some elabora- 
tion auil the principles involvwl applied to the other s>Tidronies to be 
described later. In complete division Sherren and Head have shown 
that the sensory ]H*ripheral fibers may Ijc divided into three systems: 

I. 'J'hose which subsene deep sensibility and conduct the impulses 
produced by pressure. Tlie filx;rs of this system nin mainly with 
the motor nerves and are not destr<iye<l by division of all the sensory 
nerves of the skiu. 

In a part innervated only by tfiis s^'stem gra<lual increase in press- 
ure can be recognized and pain experienced when such pressure 
becomes excessive. The patient can also appreciate the extent and 
direction of movements produced passively in all the joints within 
the affected area. 



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IBRAL PA LSI i 



371 



2. Those which subserve iirotopathic sensibility. Tliis system of 
fibers and end-organs respond to painful cutaneous stimuli and to 
the extremes of heat and cold; it also endows the hairs with power to 
react to painful stimuli. The dLstribution of the prntnpnthic fillers 
usually overlaps greatly the area ^upplied !>y similar fibers from 
adjacent nerves. Vegetative fibers may Im" the proropathir- fibers. 

3. Those wluch subsen'C cpicritic sensibility. T!ie ner\'c filwrs and 
end-organs of this system endow the part with the pitwer of resp<mding 
to light touch with a vvell-localize<l sensation. The existence of this 
system enables one to diH<Timinate two points and to appreciate the 
difference between cold luid heat. 'I'he distribution of tliese fil)ers in 
large periplwral nerves, such as the median and uhiar, has ver>' little 
overlap com|»ared with tin" greateroverlapping nf the protnpathicsupply. 

These investigations were curried furtlicr, [larticularly with regard 
to deep sensibility and the distribution of heat and cold spots, by 
Head and Uivers after voluntary section of the radial and extertul 
cutaneous nenes in the former's arm. 

To iilustnitc these changes in sensibility after divUion of a mixed 
ner\-c the ulnar is an extvllent cximiple (Fig. 21o). After troniplclc 
division of this nerve at the wrist, if no tendons have been divided 
at the same time, the patient is aftle to appredate thnsw stimuli txtm- 
monly called tnelilc. A touch with anything which <lefonns the skin 
may Ik; readily appreciated and correctly localized. When prickwl 
with a pin the patient knows that he ha^ been touched but fails to 
(Mireeive the sharpness of the stimulus (deep sensibility). Dut if ten- 
dons are divided at the same time or the section involves the nerve 
above the jioint at which its miLscuIar branches are given off, deep 
touch nmy be uii|)er(icived. These characleristies are of the utmost 
importance, many cases of iicrvu injury have been overlooked from 
failure to rciognizc these facts. 

The point of a pin and all tcmiH'ratures are unajjpreciited within 
an area which varies somewhat in each case (h>ss of protopathic 
seiLsibility). Surrounding this area and corresponding closely to the 
distribution of the ner\'e as Hgnreil in Plates IX and X is a territory 
within which tlie |>atient is unable to appreciate light touches with 
nilton-wool and l**m]H'r«tures l>etween aJMUt 22* and 40* (?. (minor 
degrees of temperature), and fails to discriminate the points of a 
jMiir of eompas:ses when separate<l to many times tlte flistance necessar}' 
over the correspomliiig portion of the sound limb or the unatleeted 
portion of the injured one (loss of epicritic sea*iibility). Within this 
area of loss of .sensibility to light touch, to which ihe.y gave the name 
of "intermt^diatr zone" the ]mtirnt U able in appreciate tiie sharpness 
of a pin-prick anc) to <ittrcrcntiate temiK'ratures U*low 20" C and 
above 45" C, naming them correctly. 

IHvision of a |>eriphenil nerve )iroduces a well-defined lass of epicritic 
sensibility, u smaller loss of protopathic sensibility with, u a ride, Ul- 
defined limits. In many cases there is no loss of df«p sensibility. 



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372 



AFFECTIONS OF THE PERIPHERAL NERVB8 



Complete division of certain nerve branches produces no objective 
change in sensibility, these are the rausculospiral below the point at 





Fio. 214. — Ti» illiislrate the Hmtiites in aenmbilUy itu't wiLli nfter complete division 
of B periiiheral nerve. The orea inrloseti by a line is that, in whiph epicritic sensibility 
is lost. The sliatled areii is that of loiw of epieritic and protopiithir aeasstion. The 
unshaded [wrtion is Ihc " intt-rmediat-c Bone," (Shcrrcn.) 





Fk;. 215. — Loss iif Honsihility after eompletp division of olnitr nerve, (Hherren.) 

which its external cutaneous branches are given off, the radial, and 
certain cervical anterior primary divisions. 



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PKHtPHERM. PALUfRS 



n73 



/« iaromplete diriition the sensoPr' symptoms may be «i7. Tlic 
I>atH*nt U conscious of an arvii alttTwI in sensihility, ami it is often 
[>os.sihle to ilemonstrate this hy the changed sensibility producfd at 
its Imnlfrs when a piw* of t-olton-wool or the pi>int of a necille is 
dragged lightly across the skin fniin sountl to alTected portions (line 
of change). If tin- area of chanyi^d ^iMisil^ility is Wfll marked, rf!S]X)nse 
to the conipass test will be defective 

In CHs*'s of ^'aler severity the loss of sensibility to cotton-wool may 
be absolute, with borders as well defined as after complete <livisiou. 

When ihe injury is more severe, impairment or loss of protopathic 
.sensibility results and the sensory loss may resemble exactly that seen 
after cmiipletc di\ ision, 

Shem-n has shown that, contrary to the usual teaching, the motor 
\o8s ill incomplete division is not more than llie st^nsory loss. Paralysis 
nf muscles of the injured nerve distribution may result after eight to 
fourtfcn liays. llie usual reaction on or about the tenth day is tluil 
liip muscles do not respond to the intcrrnpti-il current but ihi react 
to the a>nstjiat current. The .strength of tlie current needed to cause 
a contraction is less on the sound side; the contraction is brisk in 
comparis4>n to the H. I>. and polar reversal ts absent. 

Pain is a fn-quent aftcr-n-siilt in incomplete di\'ision; there may also 
be tender and glossy skin anti cbang«-s in the nails. 

Stages of Kecopfry. -VvWowUin cumplete division, in from six to 
sixteen weeks, the restc»ration ()f protopathic sensibility coumicuces 
and is completed in from four to twelve months after suture of divided 
ner\-e-s. Hlisters niiiy occur early, but later all uders heal; blisters 
no longer appear. Kpicritic touch is unchangcil thniughont, but in 
from twelve to (iftcen oionths the whole area is sciLsitive to light touch 
and intenne<liHte degrees of temperature. Improvement in the [Miwer 
of accurate liH-alization Is the thini stage, ami is tested nut by the coni- 
psas. The motor recovery is gradual, the electrical reactions of 
incomplete division HrsT appearing. 

It seems (x*rtain that no regeneration takes place in the peripheral 
end of n tliviileil ner\e without niiiou with the cent nil nervous system. 

After incomplete division of a mixed ncn'c the loss of sciisjitfon and 
motion may at first resemble thai which follows complete division, 
but the method of recover>" is entirely different. 

After eoinplete division of a nerve and suture, sensibility to prirk w 
restoreii before the commencement of recovery of sensibility to light 
touch. <'(iiuplete .sensory rei-overy often cKTupies severid years. 

But after in<-ontplete divisicm sensibility to light touch and tti prick 
are restored together and, unless nerve filn'rs have been anatomically 
divided in consiilerable nund>er, the power of appreciating two points 
(the compass test) is soon regained. Tliis In an txtreniely bn|Mirtant 
point, fnr upon the n*cf»very f»f this power of IfK-alizing (leju'iids the 
utility of the part for fine work. It is imiMtrtant to recognixe that in 
injuries of nerves without interruption of their anatnntteal continuity 



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AFFECTIONS OF THE PERIPHERAL ffSRVBS 



the power of localization returns quickly, unless the injury has been 
sufficient to cause complete division; in this case the usual three stages 
are present, but the time of the third stage is much shortened. 





Fio. 21S. — End of tint stage of reoovery. (ShBmo.) 





Fio. 217. — Commencemont of second stage of recovery. The dotted line marks the 
area reguiiiiiiK sensibility to cotton-wool. (Sherren.) 

Knowledge of this method of sensor>' recover^', first described by 
Head and Sherren, is a valuable addition to our powers of diagnosis. 



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PERIPHERAL PALSIES 



375 



If both forms of sensibility are recovering together, it is certain that 
the injury has not been severe enough to produce complete interrup- 





PiQ. 21H. — IxtsH of sensibility after complete diviuioQ of ulnar nerve. 





Fni. lillt. — Sliowiim niethcxl of rtsv)Vor>' afUT iiirximpletc ilividion. (Shcrron.', 

tion of comhu'tion in tlie injured nerve, with degeneration of tlie whole 
peripheral end. 

Alotor recovery after incomplete division follows the same march 



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376 



AFPECTIOJ 



THE PBRIFHERAL K 



as after pomplele division; the muwles nearest the seat of tlie injury 
first regain volimtarj' power anrl excitability to tlte interrupted 
current. 

In the eases in which the n-aetions typiea! of iucmnplete division 
an- present, voluntary power usually returns before the rw-stablish- 
ment of excitability to the interrupted current. 

Seiusory recovery usually l)e^ins in almut three week-s, and is com- 
plete in about six months. Motor recovery in from a few daj-s to ten 
weeks. 

These times of motor and sensory recovery are approximate only, 
an<l vary with the severity of the injur>' and its distanee from the 
periphery. When epicritin wiusibility nlutie is lost recovery is mueh 
more rapid than when both forms of seri-sibility are alfecled. When 
the injury alVccts the brachial plexus, considerably lunger time is 
nece.ssary for the commem-ement and progress of recovery. 

To simi up: After incomplete division of a mixed nerve, both forms 
of sensibility (epicritie and protnpnthic), If lost, return at the same 
time, cftiniiii-ncint; at a date whicti varies with tlie distance of the 
injury from the iKTiphery from about three weeks ut the wrist to si.t 
months in tlie plexus, and nlso with the de|jrce of the Injury. Complete 
recovery, as a rule, rapidly en.sues. Mu-seular recovery commences 
at a lirne which varies in the same way. In cases in which the muscles, 
thniijili paralyzed, retain their irritability to the interrupted current, 
recovery commence^ In three or four weeks, sometimes earlier, and 
soon becomes perfect. This degree of injury is seen mitst often as the 
result of conipression of the museulospiral nerve, producing sleep, 
anesthetic or cnitch paralysis. If the reactions typical of incomplete 
divisitui are present a much lun^'r time is necessary. 

.\fter neurolysis, or when the nerve has been relieved foira any 
form <if pressure, recovery follows exactly the same lines. 

Treatment. — The indications in cases of complete division in alt 
firearm injuries in which symptoms of repair do not occur is to operate 
wlmle\er may Ih- llic lesion. The surp-nri should frt*ely rescret all the 
indurated tissues about the nerve or In its course (fibroma, neuro- 
fibroma, keloids), and suture the upper and lower segments end to end. 
In large gaps a graft may Ix' taken from a functionally less useful 
sensory nerve. If collateral motor branches an* cut (iuring the opera- 
tion they should be sutured at once. One should Insist on the great 
tenderness of nerve structures and insist on great gentlertess in manipu- 
lation on the part of the surgeon. 

Siftt/frtnire tif Cmtii>rcj*ifum. — There is tenderness of the muscles and 
of the nerve truidis. and in general many of the signs of complete Inter- 
ruption. Then' is usually, however, retention of tlic umsele tonus, the 
reaction of degeneration is less pronounced, slight resistance movements 
may l»e elicited, deep sensibility is less involved. The causative lesions 
an' about llie nerve, .splinters, callus, fibn^ds, bits of cloth, aneurisms, 
tabscesses, hematomata, etc. 




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Surgifal intervention is calked for to free tlie nt'r\'e and remove the 
o!)j*'ft pn'ssitiR upon it. After this the uervi- is isolated and phired 
amid heftlthy tissue, preferably mu^lc plane:> which prevent further 
pressure. When tlwre is interstitial sclerosis it is useless to plouj;h it 
up blindfold (Pejerine.l. Indeed, it is better to leave it alone entirely. 
In tr<^atin(t srIpro>is the greatest nicety of oiierative techiiic is requirt^l. 

Sftniimmr of Irritation. — Dejcriue describes this a,s clmrarterized 
by the ubsenee of complete i»aralysLs, abcience of the tlyseslhetie dis- 
turbances seen in complete section, already described, persistent 
hyperesthesia, continuous painful phenomena and trciphtc disturlmnf-es. 
These latter may Ix; muscular, osseus. articular or cutaneous (h.\^x■r- 
triclMwis, etc.). In grave irritation the pains are extremely severe 
(Cansalgia of Weir Sliteht^llj. The slightest motion us painful and 
wearing. Local applieation<i of water, motst clothes are very grateful. 
Sometimes the irritant is very trifling, bits of bone, fragments or 
splinters of forrign btKlies liardly touching the ]ier\'es. These cases 
tend to spontaneous recoverj". 

SyndrotHe <*j R^fti trafi on. —^vnsory symptoms so4>n appear. These 
are spimtuneous stubbing, darting pains along the injured nerve. 
These continue from eight To fifteen days like electric sho<'ks and teml 
to subside later. There is pain on pressure of the nerve trunks. 
Shrinking of the dys^-sthelie arca-^ (see I-'igs. 214 219). Slow n'tum 
of muscular tissue, of muscle tonus, painful nuLselcs ilisap|H>ar and a 
return of voluntary contraction takes place. 'Hie eleetrieid reactions 
remain a-s Itefore. 

Signs of restoration contra-indieate operation, but if it be seen that 
the motor loss continues after the seiLsory restoration, ojieration is 
advisable. 

The general trend in recent war surgery of the nerves is to greatiT 
and i;n*!(.I»T con-HTViitisiii in oiwrution'^. 

Iniuiies to Facial Nerve. - Facial paralj'sis may result from injury' to 
tlie nerve (a) abiA'e the geniculate ganglion, (6) between the ganglion 
and the point at which tlw ehonhi tympani is given off, and (r) IteUm 
this point. When injured at (b) taste is atTccted over the anterior 
two-thinis of the (i>rre> ponding side of the tongue. 

.\part fnim the so-called 'rheumatic" alFecTion^ of the ner\'e (Hell's 
jialsy}, intcrfereiiw with the function of the ner\'e in the middle ear 
as a result of disease or operation is the usual caust-. The ner\e may 
suiter ui fractures of the skull prinnirily, or mor<* often from involve- 
ment in calhis. Outside the skull it nuiy Iw injured dviring operations 
in the parotid regiim or in the removal of tul>erc\ilous glands, nr 
from forceps pressure (luring childbirth; in most of these cases the 
"division" is int-omplete and spontaneous rw.'overy ensues. 

In rases of inctiniplete division the usual tri'atmcnt din'cte<l toward 
mnintiiining the rottritiott of the [^mraly-M-d unis<^-l<'s must Ih- adopted. 
When due to niiddle-*-nr iliseav it U an indicalion for tlir complete 
mastoid operation. 



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AFFECTIONS OF TUB PSRJPnSItAL NEHVSS 



When the n-nction nf de^neration Is present, showing that com- 
plete HivLsirin, eithor aiiutuinii-al or pliysioIuRiral, lias ocoiirred, thir 
tnatmeut to be mlopted depends on the cniise. If it follows h rudic-al 
mastoid operation, the sooner o|XTation h carried out after the wound 
has lieale<t the better; In rases nf Hell's palsy it is jiistifiahle to wait 
for six months. If the nerve Is divided during the course of a nia.stoid 
n[)erati(in, the ends should he adjusted in the aquedtirt, when restora- 
lian of fnneliiin may lie expeettil unless neuritis is set up as the result 
of sejjsis. If disc-nvercd after the operation the eleetriea! reactions 
should be tc-rted at tlie end of a fortuiglit; if the reaction of dem-uera- 
tion is present, the wound should be oj)cned up and an attempt made 
to adjust tiie ends. If this fails, nerve anastomosis must be under- 
taken. It must be rememlwred that the injury during mastoid opera- 
tion is in mo-it cases ineoinplt-te, and that spontaneous recovery follows 
the usual urtii-npenitive trcatnirtit. 

Spinal Accessory Nerve, -The external or spinal {lortion of this 
ner\e is not inrri-qiii-iitl\ ilivided duriuj; the eourae of operations upon 
the neck, partittdarly during the removal of tuberculous glands. In 
ninuy of these eases the branches of the cenical nerves to the trapezius 
arc atfwted at the same time, producing its complete paralysis. The 
extent of supply of the ^pinai accessory and the cerNicoI nerves to 
the trape/.ius varies; hh a rule the upper portion of the trapc/Jus is 
paraly/ed by diviwiou of the spinal accessory alone, 

Cerrical Rib.— Sjtnptoms usually appear in early adult life and 
Bpe due in most cases to pressure upon the lowest trunk or nerve 
entering into the plexus. In many cases they consist of wasting of the 
intrinsic muscles (^f the hand, most marked and starting in th<)se of 
the thenar eminence; if of long standing tlie reaction of degeneration 
may supervene. In other cases the principle complaint is pain along 
the ulnar border lA tlic foreurni and hanil, or a general weakness or 
heaviness nf the whole limb noticed at the end of the riay. SciLs<iry 
changes are unusual and when present rarely exceed cpicritic loss. 

This condition should be thought of in all casp,s of " brachial neu- 
ralgia," or of wasting of the thenar muscles. The ribs can usually 
l>e felt but occasionally can only be danonstrated by a'-ray exami- 
nation. 

Although a cervical rib be pres<Mit it does not necessarily mean that 
it is the cause of tlie symirtoms. Several cases have Iwcn oWrvctl 
in which a cer^'ieal rib was removed from ii patient suffering from 
syringomyelia to which the symptoms were due. ThomiLs Mur|ihy 
has reconled a case in which the symptoms were due to the prc-ssurc 
of the first rib. A similar case is re|>orted by Sherren. 

Treatmeot. — Treatment consists in removal of the rib together with 
the periostemn covering it, followed by careful after-treatment. 

The Long Thoracic Nerve (Nrrir nf ^rVf).^This nerve is most 
often injured in males between ihc ages of twenty-five and forty, 
usually on the right side. The iiijurv" is generally caused by prolonged 



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pressure in the supraolaviculflr region, it occasionally follows \'iolent 
miisscular cfTorts aii<l ilint-t violeiii-e ajiplicd t<i the shoulder. 

Paralysis of the serratus magnus rarely occurs alone; it is usually 
combined with ptiTiilysis of tiie lower trapezius. 

The Circumflex Nerve.— Injury to the circumflex nerve is by no 
means so coniinon as is usually supposerj. It has \ieen said tn follow 
direct blows on the point of the shoulder, but in most eases the injury 
is to the anterior primary division of the fifth cervical nene, and careful 
examination will show tliat the spiiiati also are affected. In other cn.seR 
the wasting of the deltoid in nminion with the muscles around the joiiit 
on which the clrcunifiex injury was diagnosed Ims been found tv be the 
result of a traumatic arthritis. 

Careful examination is necessary before coming to a decision with 
regard to treatment; testing miLst he carried out for all forma of sen- 
sibility. If thert! is no loss of seiusibility, autl there is paralysis of 
the deltoid with the reaction of d<'gcncrati<»n, it is extremely improbable 
that the circumflex ru-rve is injiu-ed. If the signs are those of complete 
section of the nerve, the age of the patient an<! his occupation must be 
taken mlo consideration; in some c-ases oiK'ration can Ik.* avoided by 
training the neighboring muscles to take the place of the deltoid. 

Ulnar Nerre.— This nerxe is fre<|uently woundwl in warfare and by 
dislt)cation or fractures nf the humerus, and at the elbow-joint. It is 
fn^iuently wotindt^d at the wrist. 

If the injur>' l>e alwve the ell>ow flexion of the hand becomes diflieult. 
llie little finger cannot lie moved and the middle and ring fingt^rs 
cannot In* Hcxeil in the last joint. The basal phalanges of all the 
BngtTs cannot be flexed. The fingers cannot lie alHliicted or addueted. 

Injuries lf>wer down in the forearm <-ausc only a lotus of power of the 
intert»ssoi and muscles of the thumb. Main en grxffr develops. 

There is usually a definite deficiency in the prehensile functiim nf the 
tluunb and first finger. This may be used as an indication and gauge 
of nhiar jMiralysis, including its influenctr in causing disability in the 
(KTCupalional !>ense. In the detection of a weak prehensile (unction 
mgnifying parc:*is or paralysis of the ulnar ner\e, the patient may be 
made to grasp some thin object, such as a folder! newspaper, first 
Itetween the thumb and forefinger of the normal hand, then l>etwefn 
tlte tliumb and forefinger of the atTecte<l huml, while the cxiuniner exerts 
stnmg trai'tion on the other end of the thin objwt. Where the ulnar 
ncr\'e and the prt'hensile muscles it sup|)lies are nonnal, the object will 
Im- strongly gra^jH-il with the thumb lying flat iigainat it. op|x>site the 
likewise cxleniic<! f(trcfingcr. (hi the i>aralyze<l side, on the other hand. 
the thumb will he fouml flexed, ami, no matter how much force the 
patient intends to apply, will be in eontan with the uhjwt only at its 
extremity, i. e., with its pulp, and there will lie a tendency for tlic object 
to slip from his grasp if Mime degree of force is ajiplii-ti. The reason for 
this lies in that forcible ]»rchensinn is Bccompli.shed with the adduc-tor 
of the thumb an<l tlie Internal jxirtion of the short flexor, which are »up- 



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AFFECTIONS OF Tilt? PEH/PIIERAL NERVES 



plied [except sometimes the deep hea<i of the flexor) by i)ie ulnar 
nerve. In feeiile, delicately udjusleii pn-heiusinn, oq the other hand, 
the adductor muscle is not used, but aliiuist cxdusively the ilexora 
of the thumb an<] index Hnper. supplied instead by the mefUaii iier\'ii. 
Thus, when tlie uhiar is pan'tie or paralyzed, only tite feeble, delicate 
tyjic of prehension is possible.' 

The sensnry loss is coiiiplete in iIh- little finfcer, the ulnar bonier of 
the hand liiia diuiiulsbed sensibility : Epicritic touch and heat loss 
extenil to the ring finRcr. In wrist wounds tbc sciisorj' changes arc 
apt to be minimal. 

Ulnar palsies most closely resemble plexu.s and spinal palsies of the 
eighth eerviral and first dorsal and must be carefully <^|>arated from 
tlieni. 'V\\r K'liinipke eye (inilin>:»i are Hbsi'iit in the ulnar palsies. 

Musculocutaneous.— This nerve supplies the aujscles which flex 
tlic fon-arm un the ann. .*^evere lesions cause pan-sis of tlu? biceps, 
corHcobrachialis. brachialis imticus. There is 
also a sensory dcfcit, cutaneous itnesthesiu in 
the areti indicated on the figures (Ki^. 2i'(l.) 

Median Nerve. -This nerve lies deep in the 
ujiiscUvMif (III- nrrii and arises by two branches: 
an external fnmi the sixth and seventh cervical 
roots iind an internal from the cijihtli t-ervival 
tind first dursal. It suppliesmolorfib+TscbicHy 
to the forearm musck's, and sensory libers to 
the hand. The chief fnnctioas are prtuiation 
of The wrist, flexion of the hand on the forearm, 
(lexlou of the fingi-rs. by the ileep and super- 
ficial flexors, hi the liand (tic thi-nar muscles 
except the adductor poUicis. Tn median inju- 
ries these movenu-uts the» are lost. To the 
patient the loss seems Rreatest in the tine 
movements of the fiiif^Ts and tluimb, button- 
ing, holding the peji, constitute the greatest 
loss. The two first lumbricales are also par- 
aryzefl but the loss is overcome by the intact 
interossei. 

Bullet nuunds, fractures and dislocations of 
the humerus, pressun; of ciillus and from 
crutches, all may cause median nerve disorder. 
A type of nccupiition neuriti.s in worlters who 
use the small nnlscl(?^ cxtensivt-ly is not infre- 
quent in carpenteis, seamstresses, cigar and 
cigarette makers, nnlkers, iroiiersctc. 
In addition to the motor signs there are usually distinct sensorj- dis- 
turbances involving anesthesia of the palmar surface of tbc Imml as 
far as the middle of the ring tiiigcr extending np to the wrist. This 



/ 



Flo. 220. — CulaMi-mi* 

Mrtinn (if the mum^iIrK 
vutaneous. 



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382 



AFFRCTIONS OF THE I'ERIFHKHAL NERVES 



disturl>anct*s of tlie fingers from the first joint outwanl. There is 
usimlly a marked atrophy of the tiienar mtt^Krlcs and some llutteninK of 
the Hcxor mu-scles of the foreami. Skin disturbances, ulcers, elongation 
of the nails orciir in severe bnllet and tearing wounds. Severe causalgias 
m^-ur in median nene injuries. 

Comblnetl lesions of the mediati and \ihiar which are frtfijuent in 
warfare produce very charatterbtJc syndromes. 



Fm, ai'i.^AliitinIi? ill iianilyai-i of ilit? mdi^l. (Tind.) 

Radial or Musculospiral Nerve. — ^"I'liis is pnHMninently the nerve of 
extension of the ami luid is more freciuently involved than any other 
nerve of the jinn. It exU-iicJs: (1) The forearm on the arm, hy the 
triceps; (2) the burn] upon the forearm by the radial an*! posterior 
cubital; (3) the fiuKers on the hand by the common extensor and the 
exten.sor of the thumb, index and little finger. 

The chief causjitive le.sii>ns are war wounds, fracture of the humerus, 
"crutch" pressure, prc^^sure from slcepiiit; with anns over the hack nf 
a chair, "Satunhiy night" paralysis, niri'ly in anesthesia from nver- 
cxtcn>ion of the arm. It Is partly involved in lead palsy. 

Symptoms. — Tlicse will depend upon the site of the lesion. Wounds 
or pressure in the axilla cause a complete palay. 

The arm hangs with the forearm drawn up semiflexed, the wrist 
dropi»eih the fingers in semiflexion. Only the first phalanges are par- 
al>*zed, howe\'er, for if the arm be supported the terminal phalanges are 
capable of extension by means of the interossci which are uninvolved. 



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AFFECT/ONS OF THE PERfPlfEIiAL KEIiVEA 



\YoiinHs in the lower fon'arm almve the wrist cause perhaps only 
extensor weakiicsw of the wrist. 

There are few sensory changes, some numbness an«i the sense of being 
C<it(|. almie, or at times with slight anesthesia over the nulial branch. 
Slight pnmiincru* ()n the dorsum of the wTist is frc (juent from elTiision 
or from relaxation in the extensor sheatlis. 

The electrical reactions are those of the syndrome of intemiptioii in 
the severe lesions. They may be less pronounced in the simple 
compn-ssion eases. 

Treatment.— Kxtension, even hyperextension, of the wrist in a pro|>er 
brace is a xinr <{iut nnti of trcAtinent of muscnlospiral and rarMal palsies. 
The rest of the treatment follows the usual lines already outlined, 
de]Mnidiii^ upon the syndrome present. 

Sciatic Nerve. Tlie wlatic by reason of its great volume, its long 
course inid It:* many Urandies is particularly prone to injury, particularly 
in war. It arises from the fourth and fifth lumbar roots and the first, 
second and third sacral, uniting in one large trunk in the lower third of 
the thigh where it tlivieles with the external and internal jjopliteal 
nerves. Its neun>pa(hii|i>gy may bi^st Im* studied as (1 ) Lesions of the 
external popliteal, [2] lesions of the intenud popliteal; (3) lesions of the 
trunk. 

External Po pi iteuL— The chief collateral branches are the long 
saphenous and the iM^roncus; the chief terminal branches the anterior 
tibial and the musculocutaneous. The external [lopliteal innervntes 
the antern-extenud muscles of the leg, the extensor longus digitonmi, 
the extensor propnus pollicis, the tibialis antictis, iwroueus longiis, 
peroneus longus, peronetis brevLs. 

Paralysis therefore causes loss of ability to extend the foot and of tlic 
t*>cs, rotation of the ftmt on the ankle and raising of the internal bor*Ier 
oi the foot on the ankle. The foot therefore drops, the toes (jointed 
downward. The gait is of the steppage type. The seated patient with 
the foot flat on the ground cannot elevate, the toes nor raise the sole from 
the gmund. Syudmnies of interruption and of compression may be 
distinguisheil. 

The sensory disturbances are as illustrated. Trophic di.st«rbanee3 
are dorsum etlemas, paleness or cyanosis of the skin, desquamation, 
ulcers, h>"pertrichosis. 

The upjjer antero-external area of anesthesia results from lesion of 
the cutaneous l)nitieli of the peroneus: the posterior from the peroneus; 
the musculocutaneous on the inferior aspect of tiie leg and dorsum of 
the foot. T\\f. anesthesia is rarely eomplcte nor eon.stant. It is 
chiefly found ou the antero-external surfai-e of the leg and the dorsum 
of the foot. 

hitenml Pa jilil ea( .— lesions here cause loss of function of all of the 
posterior muscles of the leg and of the plautars. There results a lo3« of 
flexion of the foot, of llexion <if the tr>ps. enfeebled movements of rota- 
lion and adduction, loss of adduction and abduction of the toes. 



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PERIPHERAL PALSIES 385 

The gjut is not markedly altered to casual observation. The foot is 
put down flat, the patient does not rise on his toes. On rising from a 
sitting position, no support is given by the toes. The plantar arch is 
highly curved, pes valgus develops. The toes in repose are hyper- 
exteiuled. There is a loss of the plantar and achiltes reflexes. 

Sensory disturbances are marked as illustrated. 

TropMc disturbances are apt to be mild or absent. Hyperidrosis is 
frequent, ulceration at times occurs. In neuritic types the trophic dis- 
turbances are very marked and widespread. In lesions of the popliteal 
nerves the trophic disturbances are apt to be less than when the sciatic 
trunk is involved. 

In trunk lenons there is a combination of both syndromes just 
described. There is marked general atrophy of the entire leg which 
moves more as a stump held rigid by the quadriceps. Hie glutei may 
be involved also. The chief types seen are the paralytic, neuritic, 
causalgic, and neuralgic. Partial and dissociated pictures are the rule, 
especially in the wounds of warfare. Severe pains and tender nerve 
trunks are the rule. 



28 



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CHAPTER VII. 
LESIONS OF THE SPINAL CORD. 

The anatomy, histology, and physiology of the spinal cord will be 
discussed only insofar as problems of localization and pathology are 
concerned. 

A large group of disorders, chiefly limited to the cord, come under 
review. One may present them as a series of syndromes which affect: 

1. Chiefly the peripheral motor neuron (anterior horn cells). 

2. Combinations of anterior horn cells and pyramidal tracts. 

3. Chiefly pyramidal tracts. 

4. Chiefly posterior columns. 

5. Sympathetic cell groups. 
0. Central gray. 

7. Combined and diffuse lesions. 



Eadlea ilurialit IrH' 



Radisti ilirrtalei !> J/I 

R'iiitcrt lii'wtiirra 



Traetia 
ctrtbtilu «iiJni]i 



aiiinitUa frui^iat\ 



tplnalla aattriar 



■OvatnaU 
^trff ditto rf'wwsl ri^ tOftrt' 










tin uH-aapt*ati* 

eraetatUM 



Fibrae luioBiallvaf frrrrr^ 



riKta) if'irtl-euBjilnrilfB 
yaa,-lrnhi> >nf(.-'->"nin/|fHil(i 
Fatclculva longtiadlnatft doraalU 



Fiu. 227.- 



CrosH-scctiou of spinal cord showiag loc-tilizatioD of chief Btnictures with 
lesions. (Vcraguth.) 



These subdivisions are largely arbitrary; at times they correspond 
to clinical entities, so-calle<I, again they are fortuitous combinations. 
Thus a poliomyelitis may clearly delimit, /. e., in its end-results, a 
group of motor neurons, anterior horn cells, while, on the other hand, 
spinal syphilis may show any of the localizations just tabulated. In 
the beginning of a syringomyelia the earliest signs may be those of 
irritation of the pjTamidal tracts, i. e., lateral sclerosis type of lesion. 



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388 LESIONS OF THE SPINAL CORD 

Soon added thereto atrophy of muscles begins, i. e., anterior horn 
syndromes. Then a loss of pain sensibility with intact touch is seen, 
t. e., central gray lesion. The arm begins to be edematous and trophic 
changes develop ; sympathetic cell group involvement. If the student 
keep in mind the cross-section of the cord it may be seen how these 
various pictures may be developed. (See Fig. 227.) 

The chief clinical pictures are summarized in the table on page 387. 

A study of the cross-section of the cord will bring these localizing 
factors more closely into view. The localizing features are brought 
out in Figs. 27-32 and 34-38 (see pp. 02 and 03). 

Location of Lehio.v. Chief Symptous. 

1. In the p<Klerior root Bone. Irritation rau^es hyperesthesia. Destruc- 

tion causes li>Ba of superBcial aensibility 
in the root diiitributioii apreadiiiK over 
at least three roots. Ataxia and event- 
tially atttcreognosia in the extremity 
involvofl. 

2. In |>i>!4tcrii>r oihinin of one siilc Anesthesia tu deep sensibility and to 

touch. Ataxia of niotameros l>elow the 
lesion. 

3. In Ooll'a columns of Ijoth side*. Anesthesia to deep sensibility and hypes- 

thesia of the lower extremities only, 
cvpn in hiKh lesiiins. 

4. In central Eray, e»i)ecially of ant«riiir Dissociated acrisihility (thermanesthosia 

commissure. and anali!(»iu in the affected metameros 

as indicated in the skin distribution). 

5. Posterior imrtion of the laloral columns ('rcissed hcmihyppsthcsia plus the ^mp- 

with inteirrity of Uniiting layer. tonis <>( (i, 

6. Pyramidiil tracts. Spastic pnr.ilysis of the caudal metameres 

l>plow the lesion without reaction of 
done ne ration, otten crossed movements, 
no atrophy and with increased reflexes. 

7. Anterior horn**. Klarrid paralysis of the muscles of a num- 

IxT of root zone*, atonia and atrophy 
iif muscles of involved metameres; 
K. D., loss of reflexes, 

8. Spinocerebellar paths. Kilateral involvement causes cerebellar 

ataxia. 
0. Lateral rcce.'w. Sympiithclic disturbances metamerically 

diatribuK'd. 

The majority of these cord syndromes are considered here, some are 
discussed under their etiological groupings: syphilis of the ner\'ous 
system, for instance, taking over taljes, spinal-cord gummata, sj'philitic 
meningomyelitis. 

ACTHE POLIO-ENCEPHALOMTELinS. 

Historical Note. — This disease has affected mankind for centuries. 
Mitchell reports shortening of the femur, presumably due to this 
disease, in an E<;yptian mummy. Jonathan's son (II Samuel, iv, 4.) 
possibly had this disease. Numerous drawings and paintings of the 
fourteenth and fifteenth centuries (Hieronymus Itosch) attest to 
its prevalence in those times. Throughout the period of the later 



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ACUTE POUO-EXCBPItALOMYEUTIS 



3sg 



Latin writers it was usuully included under paralyses, hemiplegias, 
etc. I'lidcrwoixl in 17.S4. descrllK-d adiseaM", to liirii new, "Debility of 
Uie Lower Extremity." that gave a tlirect impetus to its definile 
tpnration as a type by Jacob v. Ileiiie in I.S4*). In l-SHI Jorp gave an 
'Vxwilent <;ase. histon-, and in \Hi'.i, independent of Heine, Killiet and 
Harthiez contributed an important article to French literature. They 
railed the disease an essential paralysis, and thoupht it had little spinal 
patboiojjy. 

Although much was written prcvinus to Duelienne's tiiiie. his work 
in I8or» nnirked tlie Ix^giuiiinK of a new eni in llie study of tins dise^is*; 
and in Heine's second «lition. IS(>(), llie tftutus of the disease ot that 
time is well n'flectcd. In 1W>5 attention was fir>it calleil to the p(»s.sible 
relation of infantile to adult poliomyelitis by M. Meyer, wliicli study 
was followed by a larg^ numl>er of further contributions from Charcot's 
sluileiits. 

The anatomical era may Ix' sai<l to have o|xmed with Toniil in lSf»3, 
and there then grew up the Clmreot the>iis of a primary affection of tlie 
guunlinn cells of the anterior horns, which has had to ^'tve way to u 
more extensive pathology through the recent studies of Wickmann, 
llarbitz and Scheel, I-lexner, Strauss, and others (liMl7-19IH). 

.Seelijimiiller's masterly monograph in IVS(1 pnutically contained 
the standard teachinps up to the apiH-urunce uf Medin's' work in 
18%, when the epiilcmiiilo),'ical features of the disi-nse were bmuglit 
out. In later years Lovegren (1904), Wickmann (I0(to-I0()7), Harbitz 
and Scheel (UMlT)) have still further refined the clinical and pathological 
aspects while Flexner, Landsteiner, Fopi>er, and others have been 
able to convoy the disease from the human to monkeys, and thence 
to other monkeys (l!H)i)- 191 1 ). 

The most recent monographic treatment of the subject is found in 
WickniannV' very able contribution in the Handhurh itrr Xninitogfe 
(1911) and Miilier'sctpially valuable ninni)j:riiph ' HH I ). uneby Homer' 
U'Jl n. and by Pcalxnly and Draper (Mtbi).* 

Etiolos7.— The disca.sc is an acute infectious disease. The organism 
is probably a living one; it can be conveyc<l to human beings, to 
monkeys and to rabbits. A small amount of the emulsion of the spinal 
cord iif biiniiins injcctwl Into the brain of a mnnkey Iuls mnseii the 
disease, which Flexner has transmitted from monkey to monkey for 
twenty-fi\c generations. The organism Is thought to \)v a small 
anaerobic organism, capable of passing through a Kerkefeld filter, and 
one whose virus is destroyed by heat nn<l weak disinfi-t-tiints, but not by 
cold nor dryness. In many resiM-cts the vims n-scmbles that of rabies. 
It liius been Minvcyetl by direct injection into the brain, thrnu^h the 
uninjured and scarifii<d nasal mucous membrane, ami through injection 
of the intestinal lynijili glaials uf atfectiHl aniiiuls < Flexner). 

* JpUiRo hjiiI [>c(|ftor- Aluviist aikI NvupjlriciM, 11119. 

■ Tr»ni4iit«Hl In Mrrvaim uwl Moiiul Dbcnw Moo/>Kniph HttHcM. Sew Vurh. 

* Wni. Wo<»l A (?<i.. ftn Yorlc. * RockefnUot InitiUit*. 



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lesioKS or tub spisal cord 



An imiDunity of yet unknown length seems to be cstahlislied by 
one attack. Setunij attacks, thuiigli nirt', do (KX-ur.' The diseajte 
seciub to be coiivcyei) by direct coiituct, ihrouKh imlirect contact, and 
thmugh nasul and (;astro-intcstinal secretions. It doeji not seem to l>e 
lii^hly cx)ntagtuu.s. 

Epidemic cxtetLsions have now been studied for nearly sixty jTars, 
and Cortlier first rxpres.sed a i)elief in its contaj;iruisni^s. Sleilin 
definitely i)n>ved it {is9(i). Some eighty or more epidemics liavc Iwen 
rejHirtcd to 1012. The must recent fmn-i'pidemie apparently started 
in Norway and Sweden in \*Mi i'i)i.\4, spread to the Inited States in 
1W7-1912. to Germany and IVantv in I'.KKS-lGll, with isolated far- 
lyinx outbreaks in Tuba, xVustralia. etc. The epidemic of 1910 iu the 
vicinity of New York is the most exten.sive on rewml. 

Uural district-s have suffered greatly, and density of population lias 
not seeinwl t<i play a large rule; rnid rliiuales seem more favorable to 
thfoutbreakof t hi- iliseasc, and the season of greatest Intensity is usually 
in the warm months of July. August, and Scptemlx.T. ^HImc epideniics 
have (K-curred in winter. 

The majority of the eases occur in children from one to live >Tars of 
age. latra-uterinc cases are known anrl jndividnals as old as sixty 
have contracted the disea.se. Certain epidemics liave shown markeil 
variability in the matter of age incitlente, the Swcflish cpidcntic of 
UM>5 having u.'s high us U) per cent, adults. In large cpideinics adults 
seem more often affected. The male sex has secmetl to be more often 
involved, but the dilTtTcnces are tiot very murked. Nationality seems 
to play little role, although it has been assumctl thiit SciindiuaviAus 
are (WTuliarly susft'ptible. This may only hv an indication of the 
more tarefnl stmly given by these authciis. I'rtnJispiising bcjfedit«r>' 
inferiority factors are as yet unknown. 

The irieuliatinii jjeritHl vnrirs from one to ten days, tlie majority 
allowing a pe-riod nf fnini oru- to Hvi- days. In exiierinientid polio- 
myelitis of monkeys the incubation time is about six to nine days. 

Patholonr. The older concepts <if a primary int4)xicAtion or of an 
inflammation of the motor horn cells exclusively must l>e abandonetl. 
Acute poliomyelitis is due to an acute interstitial inflflmnmtion (a 
meniiig<miyclitis), invohiiig all [xirts of the nt-rvous system. There isa 
congestion, infiltration, and edema of the Icptomcningcs, cord, nntdulla, 
pon.*t, cert'lH'lhun, ami cricbrunu The dura is usually k'ss unirke<tly 
invuKed; the pia is congested and infiltrated with round mononuclear 
cells (lymphocjics). particularly in the sacral and lumbar region. The 
vessels are cong»'stcd antl their sheaths infiltrated, the progr<'Ssion of 
the inftammatory reaction apparently following the vessels fmm the 
periphery to the interior of the cord. The eerchmspinal Huid is 
increiisett in quantity, almost opalescent early in the dlsea.si', with 
markedly increa.sed lymphoeytcs, in some of which Ijiforn and Hough 

' Tnylftr, E. W.: Josir, K^rv. ant) Mrnl. [)M<.wft, Soptomtwr, IWlfl. fur ixmipK-le 
dUeiiHHinu. 



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391 



have found pictures rewmliling the I^'ishnian-Doiiovau iKidu-s. The 
fluid later bec-omes dearer, hut stlU sliuws a pathoIoKicnl iiK'reai;c in 
K-uk<Hytes. 

Within th«; i-^ird tlie iiiflnmniHtory process follows the pial processes 
into the depths of the anterior fissure aud aUmji, the sheatlw of ilic 
central vessels. Tlie posterior root fillers ami the spinal panRlift .ire 
also infiltrate*!. 

The vasiuLir lesions are particularly noticeahle. ami the interstitial 
and canglionic chan^-s de]K*nd larpdy upon them. Tlie vessels 
thrciuxhuut art* dilated and rnnorfted, the capillaries often beinjt 
cuonnously distended. This marked hyperemia Is found throughout, 








Fin. 23K.^A<^il« polIuniywlEib, Alifjwiiiii lu^ 
0(iiHiiU<>l moninxiiiB rI ilia ixJicr of n»nl. 



Piu. 220. — AmiP prriixiii.vi'Jiii.i. nlitm* 
ins iho VM*irul.if (iiiigntiiifi *(mI Uto 
Hiirroiindliut uifllUattDn ana ol iba 
aiiU'rior njiuitti nrUT>'. 



and vascular hemorrliaKic lytic changes arc frequent hut small. As 
in rahifs. an*! to some extent In s\i»hills there is a marked iM'rivascular 
or intru-adventidul infiltrulion, apparently of lyinphoe^-tes, not plasma 
relb. Interstitial changes in the gray and white matter, chiefly *tf an 
infill ration (>f cells, and prf>lifpration of jiha cells, occur. By rea.'son of 
the rich hlood supply the gray matter of the anterior horns Inars the 
hnmt of the inHammatory eilema ami hj-peremia, with de-^tnu-tion of 
many of its motor cells. 'ITiis is a sei'ondary proivsa. Ilarhitz and 
Sclieel lielieve timt small abscisses are fonneil, hut tins is an exceptimi 
if it din> occur. 

'n«' pinnlion cells undergo vurj'init deijrees of degeneration, some^ 
what prn[M>rtioned tn the infiltration, the axis-cylinder finally breaking 



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392 



LESIONS OP THE Sl'tNAL CORD 



HowTi. Amid the degenerated cells many normjil ones may I>e Found, 
ami the distribution of degenerated area-s is ver>' variable, the sacro- 
tuinbar cord hi-ing more seriously affccte*!, although any part of the 
wrebrospinnl axis may be involved. All classes of >iaiiglion wlU (to 
under, but the lateral dorsal cord regions are much less involved; 
however, many vegetative system cells are injured. 

As a rule the functional involvement by reaJson of the c<lema, 
hy[>eremiii., and intiltration, is far in exee.s.s of the pennanent anatuinieal 
Ititw. hence the widespread churarter of the paralysis in tlie early 
stages and the inarkeil degn-f of rtfovery possible. Only ii small 
p:c^)ortion of the primarily involved ganglion cells degenerate entirely. 



Flo. 230. — ActjU; iiiiljjmi.vclilJrt. The v.^rimis dtit^^A at destruction of thL> 
ailU'rior horn ('i>Ih. 

TIte fiber pathways iimy sh(»w pennHneiit infiltration changes with the 
priHbit'tiittL cil' iiniinialiius spastir ]>1inLnii)ena. 

The spinal nervea are involved usually at their junction with the 
cord, imd some polyneuritis may l>e present early in the disease. 

The medulla, pons. (vrehelUiin. and crrebruni idl an- invt)lved to 
a greater or les.ser degree. Certain ea.ses show tliat the main lesion 
is in one or more of the.se regions, rather than in tiic spinal cord. 
True eneephalitis, with varying degrees of feeble-mintleduess, is & 
frc([uent enil-resnlt of these involvements oF the upper-lying nervous 
struetures. 

'I'lie other orgiints of the bo<Iy do not escape. There arc evidences 
of an acute general infection everywhere.' 

' Walter: DeuWcb. Ztsrhr., vol. kIv, No. 2. 




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ACVTK POUr>-E\XBPUAWMYBUr!R 

Bymptoma.— The study of the recent cpiHemits has shown a great 
varialiility in the affetlion, hut pnutK-ally alt of the cases show the 
effects of an acute infection as pnxlrurnal iiiid early sijtns. The later 
course of the (liscase, dcpfudeiit upon ihc liK-atimis cliieity iiivolvi-<l, 
fKTroita a separation into several tyjies of which \Yickinann recognizes 
eitjht clB.tfiical pictures. 

PrmirnmiUn are muftl. Tliey \ary in the dilU-n-nt rpidcniics. 
They ciwisist of fiitipthiliTy. loss of ap|K*titc, sH^'ht dijicstivc ihstiirlj- 
ances, with nausea. Imiseness of the bowels, coryza or hronchial irrita- 
tion (bronchitis, bronchopneumonia) u-ith slight elevation of tem- 
perature. Conjunetivitia may occur; lymphatic swellings are usual. 
The pHlirnt may thus sulTrr for twenty-four to s<'venly-two lionrs 
l>eforc till' acute prostrating efTects of the disease become manifest. 
Siiiue few cascii slutw almost complete recovery after such pro»lroninta, 
and then again taken ill suddenly or may go on to rwovery (almrtive 
cases). Careful observation will probably reduce the numl>er of rasi-s 
ri'iKtrted as i-imiinji mi without prndrornata. 

The ivrt-brospiiitil fluid in llie pntdminal stages may show o|>id- 
escenit* with very marked lympliiM-ytosls. The blood changes are 
ajjpjireiitlx not constant. Iji I'etra has reportei! a leukwj-tosis 
of from llf.tNX) lo 2(^()0(): wlierea^ Mijller tins found a leukopenia of 
from 'MXH) to .lOIXt. ami also finds leuko])cniii In exfH'rinienta] monkey 
piiiiumyeiitis. The lymphocx'tes are increuscil. No |>arasit*'s have 
been found in the MiMirl up to the present time. liacteria have been 
isolated but it is not yet pnjven that they arc the true causative agents 
(inili). 

After twenty-four lo seventy-two or uion* hours the tc«i])erj(ture 
suddenly rises. It varies from \t\f V. to |0L»..->* V. or even ItlV F. to 
106* F., and Iwars little relation lo the severity of the disease. Abor- 
tive cases have shown high temiKratun's.anri severe caso. tittle. ChilKs 
iiikI cimvulsioiis (K'ea.sioruilly atteiwi the rise in tempeniture. The 
tenipeniture enr\'e is imt chjiract eristic, being either remittent or 
continuous. Subnormal temperatures occur, and imlieate marketl 
cervical involvement. 

Headarhe is a frequent symptom. It is often severe and usually 
frontal; it may be occipitut. restinbliiig a meningcid hctidtiehc. I'nw- 
tration is marked, diarrhea is extremely et>nunon, vomiting is frttiuent. 
and ciiiLsti[miion is tutt umisual. i{cspirator>' .sxmptoms are not 
murkiil. save when respiratory palsies occur. The kidneys show little, 
and the heart's action is that of an acute inrci-tion, in genend with 
a tendency to s1h»w nervous tacbvcardia. esp<'cially in the cases with 
nie<lullary involvement. Weakness is liie rule. 

Karly )>roruse .sweating is a fr«|uent symptom aud skin eruptions 
ore (Kcasiitnally seen, although herpes is rare in contrast with cerebro- 
Hpinal meningitis. Other e\antheiiuita iMva.siitnally ap[K'ar. 

SrrnniJi SymittoiiiJi.—Aa^ a rule there is consi«lerable rerttlessnrss, 
ewpt-cially in ctlder |>atieiits. The children are peevish, petulant, or 



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LBStONS OF THE RPISAL CORD 



very fretty. Sleep is often disturbed, with frequent crying out. 
Some cliildrcii lie dn)wsy or n|>atlii'tic. ancj may. tl)uiif;li rarely, sliow 
coma, delirium, or convulsions. Pain is a frequent early sjinptoin. 
and may be very severe. Marked lijTHTfsthe-sia is n.sual (\H> per cent.), 
and is hnMi^ht on I)y tlie K'ust attrtupt at motion of iliu limbs, pressure 
on tJic nerve tmnlcs, touching of the skin. Heine ca!l«l attention 
to ibis ill l.S4rt. Movfinents of the head and spine are imrtiiidarly 
painful, and some patients air extremely anxious and fearful, whinijH'r- 
ing continuously, closely resendjlinR. in the early stages, meningeal 
eases. Tlieni is frequent photophobia and hj-peraeiLsis. 

The infiltration in the eord i-ausea other sensory s^inpttHns, such as 
paresthesia' and anesthesia'. Stiffness is not infri-ijucnt, wth slight 
though not niarkeij rt-traction of the hejul (Kernig's sign) in S(Hne and 
varying degrees nf rigidity of the limbs, with eontraeted |>osition of 
the lower limbs partieularly. are freciuent. 

Twitching and jerkinR of the liinhs are also fretjuenl. 

The stage of paralysis soon sets in and. aeet^rding to the predominant 
knulization, following Wiekniaim. eight types may he distiuKuisIu'd. 
These t>7Jes represent general tendencies rather than hnnl-und-f«st 
diHerenees. Thf further sjiiijitoinatohigy will be gi\eu iti a*'e4ird- 
anee with these divisions. These tyi)es are: (I) spinal jwliomyelitis 
forms (the commonest type): (1!) acute aseendirig types [Lan«lry's 
paralysis); (.'J) bulbar or pontine forms; 1.4) entephalitic forms; (5) 
ccreljcllar forms; (li) meningitic forms; (7) neuritic forma; (8) abor- 
tive form>. 

1 . Spinal Pormfl.— 'I here is usually an early proilrMnal weakness, 
or even a pare.sih whieh is very widi'spn-ad. This develops to a rela- 
tively marketl paralvsls. sometimes witliin twelve to tweiity-fnur hours, 
but mon- often in from two to five (lays, oceasionnlly after a WTck. 
Careful obser^*ulio^ 1ms slifiwn that the paralysis is u pnidnal, nitlier 
than an nbnijrt one. It begins with Mwikness, aih'ances tt> paresis, 
and finally be'-<)mes a definite paralysis, when'as the weakness, how- 
ever, is ver\' wides]»read, the jialsies are less st.', and the paralyses 
even more restricteil. When the ultimate stages are reaelied, the 
weaknesses elear up, the palsies gradually disappear, and the restdiud 
paralyses often represent init a snudl part of what appeared to be a 
wholesale de\'astal ion. This is in strict aceordanee with the patliologieal 
feulEires. 

'Vhe <li.stribution of paralyses is due to factors concerning which 
there is little definite information. Any muscle of the Iwdy may he 
involvi-d. Iriv()hintary nuisiles are freipiently impliifttcd (sym]»atbe(ie 
nuclei) with ehmnie ptoses, vascular disorders, intestinal symptum.s, ete. 
From a purely statistical study of the ca.ses it has l>een found that the 
lower limbs are involvwl twice as often as the upper; in some epidemics 
four times as often. The entire limb is ran'ly involve<l pei-manently, 
but special niu.scle groups are picke<i out. Thus in the lower extremities 
the qua«lnceps, the pwonei, and the tibialis ontieus arc the oftenest 




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385 



affected; in the upper extremities the iicapulBr and deltoid mu»(*le3. 
A.s,\*miiRar>' in the final picture is the rule. The miiseles of the trunk 
are involved next most frequently, while the arms are least frequently 
involvnl. The tnink muscle palsies are often ovcrlortkcd, however. 

In young children it is almast inipossihle to liK-alize the paral,vses 
in the early stages, espufiallj- as many such patients jfi) througli the 
Initial sia(;t*^ of the disease without then* Ix'iuji a suspicion uf the real 
difficulty. Jlere tlic loss of the reflexes, the hyp<it(inus. the careful 
scrutiny of the ])osition of the limbs, the behavior to passive motion 
and resistance movements and the tickling responses lead to a correct 



Pin. 231. — Alxirfmiiiiil jumm U. |.,U; j-.li-.mj.liiLt. ( PthiukiUmI.) 

appre«-iation of the difficulties. Tliey also permit a diagnosis of rudi- 
mentary an<l nf mikj cases. Itahies in anns iH'hnve us tlmugli they 
were lnm|>s of dough, an<l the mother notice's the hyixttonus. 

Weakness of the musi-lrs nf the ahdcmien U an im{M>rtunt early 
diagnostic feature, es(wcially In the differentiation fn>m meningitis. 
The involvmietit is usually bilateral and diffuse. The nuisdcs are 
hyp4itonic, antl swell tnit as though the int<rstine« were inflattil with 
gns. Thi-re is nften a ]i»ss nf tin" epigiotrir- aiifl alxloniinHl rcHcxes — 
synunetricid orasynunclricid. The|>aticnls, further, are unable tocntne 
l<fnmi a horizontal toa sitting iKKtition. In .some |>atients the alxlominal 



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396 LESIONS OF THE SPINAL CORD 

muscles are alone involved. Obstinate constipation usually accc»n- 
panies the abdominal palsies. 

Of the back muscles the latissimus dorsi are the oftenest involved. 
The glutei are also somewhat implicated. Children with these palsies 
waddle when they walk. They behave like children with muscular 
dystrophy on rising from the floor. 

Only rarely is the diaphragm implicated. They are usually among 
the fatal cases. Unilateral diaphragmatic palsies have been observed. 
The muscles of the hips are involved in at least two-thitds of the cases. 

The following table from Wickmann will ser\'e to indicate the 
general run of the cases. The figures represent the study of 868 
cases in the Swedish epidemic of 1905: 

1. Paralysis of one or both lci(s 353 

2. Paralysis of one or both arms 75 

3. Combined paralyBca of anne and legs , 152 

4. Combined leg and thigh paralyses 85 

5. Combined arm and thish piiralyses 10 

fi. Isolated tliiRh piiriilysis 9 

7. Paralysis of tlie entire rauhculature 23 

a. Ast-ending paralysis 32 

9, Desreiiding paralysis 13 

10. Combination of spinal and cranial nerve paraly^s .... 34 

11. Isolated <-rnnial nerve palsies 22 

12. Localization uncertain 60 

868 

The figures of the Committee of the New York Neurological and 
New York Pediatric Societies give similar results.' 

Sen^wry Diiturban/'es.— The older teachings that sensory disturb- 
ances are unifonnly absent is not true. Almost invariably there is 
in the beginning of the disease a marked hyperesthesia. The slightest 
touch causes marked reaction. Loss or diminution of sensation is also 
not uncommon. Complete anesthesia is rare, but has been observed. 
Hypesthesiiv are common, and may include both thermal and pain 
sensibilities. In young children the difficulties of observation cause 
one to overlook these sensory anomalies. 

Vegetative Jnmhemenis. — The bladder is frequently involved in the 
early stages. Urinary retention is frequent, incontinence is rare. As 
a rule the disturbance is transitory, hence overlooke<l. It is frequently 
thought to^beja symptom of the general Infection, but Wickmann 
regards^it as due to central nervous lesions. 

Constipation is not unusual, and marked disturbances of the intestinal 
functions do occur. These are often of the nature of colitis, mucous 
colitis, etc. A chronic intestinal weakness may be a residual of a 
poliomyelitis. 

Vascular disorders are very frequent. Skin lesions from reduced 
skin tone are often met with in later life. >'isccral ptoses, relaxed 
ligamentous attachments, and other vegetative nerve-level disorders 
have been observed. Bony lesions are very frequent. 

' Nervous and Mental Diiscasc Monograph Horios No. 7, New York, 1910. 



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ACOTB POLfO-ENCEPHALOWrSUTiS 

Alropitic SUigi'Jt.-- \'nr a vnrial)lL* leiiglh of time, a year at leusl, the 
palsied or paral.vaccl muM-Ies Krntlunlly rejiaiii their form and their 
funetion, hut stujner or later, deiK-iuliiiK on tlie Kriidc vt ceiitrnl involve- 
ment, a more or less jHrniaiient state of inactivity is rearhed^a 
rcsitliinl jwriod iii which an account of stock may he taken. In 
this stage one meet.s with the definite atnif>hie8, the licginninf^ of 
the various defonnities, ihan^jes in the hones aiul joints, and the 
residual seeretory ami tnipliie anumahes. 

The various fjefoniiities helotij,' more in tlic domain of ortlmpedies 
and caunot be taken up here. I'es equiiiu:). pes calcaneus, pes 
valgtis, pes varus. hj-pcR-xtension of the knee-joint, genu valgum, 
genu vanini, scolioses, kyphoses, lordoses, torticollis, (lail arm. etc., 
arc aniotij; the more common residual ileformitie^. SeeliKuiiiller's 
nionograjili. nln*iul\ citinl, treats of than at Rreat length. 

The permanent vus rtiiotor disturl»ances are ehiell\ cold extreudtics 
and cyanosis. Dryness of the skin is fntiuent. 

2. Acute Ascending Form— Landry's Paralysis.— Landry, in ISo9, 
desirilR-d iin acute a.s(-i*:iditii.' iKiraly-ii.-, uliich later sturiv' has shown to 
be, for the most i>art at least, a true p«»lioenceplialomyelitis. In certain 
CAA^A it is a neuritis. Kalues al.si> ha,-* a I^ndr>' pantlysis type. Here 
the jwlsy shctws itself usually first in the lower e\treniities, then the 
mus«;les of the hip. the nlnlonich. the thorax, and the cranial nenes, 
are invnived and death ycnerally occurs thntujili implication of llie 
cardiac and respiratory centers. Heath takes place in from four 
to live <lays, usually with clear consciousness, or slight ct>ma. The 
seiiHihility i.s usually intact, or only slightly finllcd. 

Occasiimatly tlie patients recover, and then show the residuals of 
a sevrre spinal polioniyelitie ly|>e, with ndxture of liulliar or pontine 
features. 

A desecmling form is alwi to he distinguished. This is much rarer. 
Here the hulhar synipto?ns develop early, and the spinal extension 
shows later. 

The majority of the fatal eases of epidemic polioeneephalomyelitis 
.ihow the tyix- of a l4tndr>' paralysis. 

3. Bulbar and Pontine Forms. — Here the features that stand in 
the fori'ground, ciilur us initial or as n-sidnnl miiditiitns. arc the 
cmniid nerve palsies. A large mindier of the patients with iKtlioniycIitis 
show some cranial ucr\e complications, but when llicse are the cliicf 
features, and the spinal paUies are the minor complicating factors, 
then one speaks of the hulhar and jKintine ty])es. 

.Many of these palient.s >liow isolateii i>alsies— others have two or 
more cranial ner\'e involvements. The facial is oftenest implicateil 
(III |ier cent.), next the hy|»onlosMd, TlieM* are usually unilateral, 
although Medin has de9crihc<l a bilittenil facttil palsy. Kye-muscle 
palsies an- infrequent; the third and fourth less often tttan tlie sixth 
(Wickniann. Miillcrl. ■ . |m 

IHwis. <iphUialnio|)legia interna, externa, nystaj^us are among 



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LESIONS OF TUB SPINAL CORD 



tlie rarities. Ptipillary (listiirbancps arc not infrrqiient, at-crtrditiR 
til Lui»llH>rg. Here Ixith light and accomnuxlatioii retiexes arc inter- 
fcr«i with. \Vry rarely one ohscrvi's amAtirosis with optit*-iier\'e 
invylvenieiit. TIip prer*cncc of i-hnktil iHsk in int'nliij;itis is an ini[iiir- 
tiint cIlfTcrfiitiul. The I\th. Xth, Xlth art- itivnlvttl, mtuilly in the 
fatal cases, tKcaMoimily unilutei-al plmryiigeal ami laryngeal palsies are 
residual conditions. Speech disturbanc-es may be present, hut are 
infrw^nent. <"oniplete wntral ileafnesa has been ohsen'ed. Midbrain 
involvements with jieculiiir tremors. vertigiK-s, forced niovrnients. 
atlu'toid inoveuientfi, |>ftralysis agilans-lJIie rmivcnu-nts, n>tat()ry move- 
ments, ataxias, cerebellar ataxias, cerebellar gait, etc., are among the 
curiiuities. 



Fiu. 232. — Kyc ijulniiv, p>jIi»iii>-cliU». 
(Fra.uenihal.) 



Fiu. '£i3. — Fui'Liil iiiTve jtMlw)'. p>ilii>- 
Diypliiin. (Frauotithnl.) 



4. Encephalitic or Cerebral Form.- Striiin]H'll (jiliefl partieiiiar iitteii- 
tioii t« the i«>ssil)ility of n pure encephalitic form of the disease, thus 
widening the conception from a poliuni^elltis to a polioencephnlo- 
myelitis. Medin's valuable stuily cnnfiruied his teaching, iiitd the 
investigations of rtH'ent ycai-s have still further amplified the find- 
ings. Here the iiifiammntory reaction spreads throughout the entire 
cortex, as in the conl. The eeiilnil and frontal g>n, the lm,sal ganglia, 
the iiiternul cipsule, acid centrum ovale arc most frefpiently involved. 

Here, in addition to headache, stupor, and convulsion.s one encounters 
apa.stic palsies, hemiplegic or diplegic in type, usually associated with 
bulbar |>atsies. 

Tiiese cerebral forms are probublv rare, and often fatal. They 
are also rare iu expt-rinicntal monkey poliomyelitis. Miiller is inclined 
to regard the spastic palsies tliat occasionally ocnir as due to pontine 



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ACUTB P0UO~ENCEPHAtA)MYRUTl8 

rather than to motor rortcx involvt-mcnt, whorwis Wiekiiiaiiii lays 
paitiftilar strt-ss upnn the prolmhilities of their fortiral origin. 

5- Cerebellar Ponna. — Media dcsfrilx'd forms iii which the patients 
sliowwi ataxiu in waikiTifr, with stagscring or ataxic gaits, and others 
beliaving like Fri«ireich'a disease of amtc onset. These forms are 
closely allied to the bulbar and pontine t.vpea, and als<» may be oc- 
casioned by extension of the disease to the cerel>ellum. The latter 
stnicfure is almost always involved to some extent in this disejw. 

(i, Meningitic Forms. Here meningeal s\-mptotns iK-rupy the fore- 
grounti. Headache, vumituig, pain in the ucek with stiffness, Keniig's 
sign, stifTness of the back, opisihotonos, convulsions, strabismus, 
somnolence, and uncons<iiui.sness are present. These cases either then 
develop marker! spinal and bulbar sj-niptoms of the ordinarj' ty[ie, or 
the symptoms recede with either minor redisuuls, eye pulsies, etc., or 
go on to c-omplcte recovery. 

7. FobrQeuritic Forms. The study of recent epiilcnucs lias shonTi 
the great frcfiucney with which jwiin is found in the initial Iilstory. 
In ninny eases there are painful iier\e tnniks. with I<asi'gue's phenom- 
enon, and great hyi)eralgesire over the entire bo<ly. resembling polyneu- 
ritis. Anatomically, however, markeil nenritlc ihaages are wanting. 
These cases Wiekmann prefers to call neuritis-like. 

S. Incomplete or Zktinor Forma.— The study of the recent epidemics 
has shown that in a nimiber of [>aticMts the illness began with the 
characteristic s\Tnptoms of poliomyelitis, and tlicn went on to recovery 
without any pabiea. In others again, widespread, though mild palsies 
with h>-potonia devekiped and complete recoveries occurred wit}nn a 
sliort time. Wiekmnmi brought these facts into pronunenee, and showed 
that tln-si' wen- t<i Ih- n_'ganlal as jilKirtivc I'ft.'+i's. The most fn'cpient 
forms under which these cases develop are (1) that of a mild meningitic 
type with the usual priNlnimal signs, a-ssociateil witli llie ne<'k sjTiip- 
toms, irtiflfness, pains, sometimes opisthotonos and the like; (2) 
with the s,\Tnptoms of a general infection only: (-il eases running 
f'A course like an iiithien?^; (.4) cases with markeil gastro-uitestinul 
signs. 

Wickinann has estimated that at least l/i per c«it. of all the cases 
can l>e gnuipcd utider this rubric, while Miiller believra them lo CKvur 
much uftener. imleeii. mure often than the usual iy\yi. Their signi- 
ficance in the epidcmti>lugy of the disease is great, l)ccause it is highly 
probable that its ^read may be conditi<med by these ambulatory 
^abortive CAses.. They are more frequent in children, but may also 
'be present in atlults. If Miillcr's slJiiul la* ciirn^t. vix., that they occur 
ofteiier than the well-*IeveloiK>il forms, their importance from this 
stand-]Kiint Is enormous. The question of rarity of tlic disea.se after 
puberty may be solely eomlitioned by the fact ol previous minor 
tucks in many indivuluals. Miillcr states that in the study of small 
li^iidemics he has found that in the abortive cases there is a marked 
(tendency to show the same symptoms in their epidemic extension. 



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TUB SPINA 



Thus frastnwiiitestiiml ('ast-s Rive ri.s« to pi.stn>-ititestinal cases, respira- 
tory to rcsi)iratorj-. meninpeal tn meningeal, etc. 

IKainosis. — SnomHir mul i-puk'niif politienceplialctmyelitis are prob- 
ably ciiiHliticjiieiJ by the sjiiiie erlnloj^inil fiictors. If iiii epiilemie Is in 
prt>((n's,s, pHrticular attfiiticm slu>ul<l be givi-ii to all acute infcctitms, 
wIictbtT tlicy show marked palsies or not, and careful examination 
be made of m-rve ternieriicss, hyfM)tfHiias. tendon reflexes, and limb 
motility. Most cases develop eith(rr in the guise of general infwcion.s 
with ternperiiture, or with distinct W'al s,\Tnptoms, either in the respi- 
ratory or Kiistro-iiitestinal tritcts, or in the nienitiKeM. Inlluenxa. poly- 
neuritis, angina, bronchitis, gastro-enteritis, tjiihoid and ejH'denuc 
eerelinwipiiml meningitis come into n-view. A marke<l general liyper- 
esthesia, and a distinct pathological tendency to perspiration is sig- 
nificant. Leukopenia, according to Miiller, with fever is also of| 
imitortanee. Sleiepiness, to drowsiness of the children, during the day, 
wakefulness, and fretfuhiess at night, easy fatigability, weakness of 
the extremities, los^ of nmscidar tonus, espei-ially in the abdominal 
nuiH'Ics, with meteorisni and loss of the ahdr»inina] reflexes, point to 
poliiimyelitis. An early hiTiibnr puncture will rr?M.iK'e many of the 
diHicultics. Inlluenza i.s separated with considerable difficulty in the 
early stages, so mucli sn that certain observers (Borslroml have held 
that poliomyelitis is mtthing but a .severe neural type of intlneiixa. 
.Monkey oxperimenlalion by l'"lexner and many others has disposed 
of this liy[M»tbcsis. 

Polyneuritis also offers [jarticulardiirii'ulties. This is rare in elilMren 
apart from diphtheritic neuritis, and is usually quite sjinmctrical in 
its development. The time ncede*! for dcvelopnuMit of the palsies Is 
longer, the pains arc more persistent, there are usually more objective 
sensory disturbances, particularly deep sensibility, and early edemas 
are more fnipient. 

In (liplitheritic neuritis, car<liac irregularities are the rule, in polio- 
myelitis the exception; the jwlsies of the palate arc fiu-tlier charac- 
teristic in the former. 

I*ure ncuritic-like forms of poliuniyetitis are sometimes ])resent, 
but there is here m[)re tendency for a mild dissociation syndrome, 
diminution of pain and teni|H-ntture sensibility. Neuritis is more apt 
to iiK'lude all ihe forms of .seiiT^ihility, or gives a diminution in touch 
(epicritic) with an increase in pialn sensibility. In very snialU'liildren 
these difTercnces are difficult to bring out. Williamson lays stress 
upon the loss of bony aetnsibility in neuritis, whereas m |)oliomyelilis it 
is rare. 

Further diiVerentials fnim Wernicke's poliwncephalltis superior, 
myelitis, heinatomyclia, myotonia congenita, hysteria, Tarrot's palsy 
hi hcretlitary syphilitics. etc., must be sought for in monographs. 

In the ineningitic forms, and ui many of the onlinary spinal eases 
the se|Kiration from spinal or tuberculous meningitis is very difficult. 
The lumbar puncture here usually clears up the diagnosis. CUnieally, 




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ACUTB POUOgXCBPHALOHtYBUTIS 

lite more marked iiien(»l symptoms, the marlted degree trf stiffness of 
the spinn) column. Kcrnig's sign, and nt times papillary edcran, enr 
eoinplicatioiis, and lKT|>es, all spe«k fur tnetiiiigilis- In tubertulous 
meningitis the spinal fluid findings and the longer course usually 
estaljlishej* the diagnosis. 

Procnosis. — I'he older teachings tliat the disease is nirely fatJil and 
always shows persistent palsies, must l»e mcxlified in both directions. 
Many fatal cases do occur, and complete recoveries are frequent. 
In certain epitlemics the m<irtality is very hi^h (42 jht cent.), in others 
ouI>" 10 per cent., wmutinji only those patients with evident palsies. 
In the New York epidemic of 19()7 the mortality was approximated 
[as 5 per cent, in that of 1916 the mortality was much higher (20 
tTcent.) 

If the very mild cases are iiiclurlcd the pcrcenta^jc falls markedly. 
The mortality Is higher in the older patients, us high as .50 per cent, 
in one epidemic (Lindner aud Malley). The period of danger lies 
usually in the f<iurth ami fifth day of the disease. In the second aud 
thin! week bnmcJuipneuuionia is a dangeroas cum plication. 

As for complete recoveries, they have varie<l from 10 to .50 per cent, in 
the various epidemics, and are more common in younger children than 
in those over fourteen years of age. (See Wickmann.) 

I'rom the stnnd-p'Mnt of electrical prognosis, the okler views are 
certainly false. Tlic wliole sirhjcct is in need of entire revision. A total 
loss of faradic excitability after a week is no certaui criterion of perma- 
nent palsy, as has been taught by Opijcnlieim and others. 

Itcparation takes i)lace most rapidly in the first six months, hut con- 
tinues throughout a year or more, and with continuous, rational treat- 
ment weak and [rarahzcil niu.scl(^ will i-ontinue to impn>ve for many 
years. 

Treatment.— Prophylaxis, treatment of the acute stage, and of the 
chn>nic stages are to Ik- dislinguished. 

Fntphfihiji^. — Isolatioti and disinfection are as yet unprecist^ in 
their application. The mode of transmission of the virus is as yet 
unknown, and whereas there is little difficulty in isolating the severely 
attacked, the abtjrtive cases are not. and rarely can be. properly regn- 
lalerj. That alwirtlve casi*s ilo carrj' the di.sca.se seems definitely pn>vf«l. 
Tlie projMT length of time for isolation has not been determined. 
VVicknuinn regards three weeks as sufKcient, Miiller eight weeks. As 
yet tJie data do not [jcnnit definite counsels. 

The virus in monkey {mliomyclitis seems to have been found in the 
nasjd munms membranes and in the fe<-es. Hydrogen peroxide, 1 
per rent, solution, and mi*nrhol solutions can be usei^l for tJie f<»mier, 
formaldt'hyiie or carliolic acid for the latter. Special attention stiouU 
lie dircct^'d towani the {Hickrt handknchit^T. 

ttiMHns may be disinfw-ted whh fomialdchyde. Preventive imx'uLi- 
tion, aiutlogous to Pasteur ndnes treatment, may bucumc pructicublc 
in time. 

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I.BSI0N8 OF THE SPfNAL CORD 

Actde Slage. — Alisnhiti' rest lit Ixtl is to Ix; enforced, and if an 
epidemic hv in progress, children with mysterious diarrheas, pseudo- 
influenzas, mild iictiritic pains, etc., with fever, should be kepi in I>«l, 
even after tliey appear to have reeovereii. The patients who have 
been ^ick for a couple of days, and who gjct up and around, and arc 
then suddenly stricken down, are in reality very numeroua. Foresight 
here cannot be nven-alucd. 

Counter-irritation t<» the spine, by muslard plaster or other mean^; 
prompt catharsis, first by enema ami tlu-n by sidinc iiittiHrtics. shmdd 
be employed. The motor restlessness and pttin are In-st controlled by 
analfci'si<rs, and the various salicylate preparations. Codeine may he 
employetl. hni its inhibitory action upon the bladiler should not be 
overhKjki-d. I.undiar pnntture is often of siijiml service. 

Diiiplioresis by hot fjacks is helpful for the pains, mnscular M)rcnes». 
and, possibly, in aidinji climiniition. FrtHjueni treiitmcnt by free use of 
deep, warm baths, 102*10 104* R, is liijihiy dcsirablf. Thewiimi water 
relieves the sense nf pain anil the irritability greatly, and is gr«itl>* 
appreciated by tiic imticiit. The baths can be repeated every three 
or four hours; the lime in the bath is fn>m ten to twenty minutes. 
On taking the child from the bath, he .should he roiled in a blanket and 
dried in hti\. Continuous warm haths.iK" tolM>® F., are worth trying. 

Ill the biter stilus the bath trealmenl is inv«tiuiblc for straiKhtcnin^ 
out the contractfti limbs and iii<ling in active motion. 

Urolropin may l«^ lulministered. It is thought to rt-ilucc t() f(»rnial- 
dchyde in the cerebri tspiii id flind in sufficient amounts to act as an 
antiseptic. Tlie hypothesis lacks (lefiiiitc experimental coidinnatioii. 

The use of the serum of thost- who have had an attack of poliomyelitis 
ha.s seemed to be of service in some |>atient.s. 

Orlain very severe antl appnrcnth' fatal ca.ses may be saved by 
continuous artilicial rcspiratictti with oxygfii adiniuistered by pressure 
appjimtiis, and In low bh>od-pressni-e cases, adrenalin by mouth, injc<"- 
tion, nr by rectum has definite value. '^ c,c. I tu HWX) solution, every 
four hours, diluteil with '2 c.c. salt solution by iniraspinous injection 
is Meltzer's recouimeudation. 

Chronir Siagm.— Afwr the acute sta^c has pas.sed there is the long. 
hard stage, lasting for weeks or months or years, of jnirtial or total 
paralysis, great weakness, extreme tenderness. nprvi>us irritability, and 
niusculur puins. with gradually ilevek)i»itig defonnilies. 

The <lict sliould be full and regularly administered. A careful 
inventory should be made of every afle*'tei! muscle, both in terms of 
its functional capacity', and its electrical excitability, the milliamp^res 
Deces-sary for bringing about eonlraction In-ing carefully noleil. Full 
measurements of the limbs -should be taken. Careful note must be 
tftken of the position of tJie limb in Iteil. and appropriate siip|)ort 
given t" relieve pain, nvtiid stretclnng. and diminisli contraction. 
lic<i-S(.>res. sore heels, elbows, etc., need very careful treatment. 

Chief reliance is now laid upou massage, passive motions ami 



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403 



resistance motions. Here the deep, warm hatli i.s iiivuliiable, sprvJng 
to help the motions of the limbs, and lo strnijilili-n out thecimtmctions. 
Mnvt-nu-nts in water are more easily i)erformed, and small children tan 
pla.v in the rleqi tub for hours. Special exercises should he planned, 
both for the water and in be*!. Special cali^tlienics roust now be devcl- 
o\K*\. dejK-ndiiip u[npii the mux-le ^roup ilIVt^lvt•d. K.spt'<-ial emphasis 
must he laiil upon the [witient's <-nnsciittis and vohiiitary participation 
in these exercis<-s. The Ihwi methtMl to carry these out Is by tlie 
Mensendieck system which Is h scientific t\-pe of muscle kinelics. 

■'articular attention must be directed to the mental life of the child. 
He is apt to be mon>se. reticent, shy, and resentful, becomes very 
sensitive if his dcfnnnity be inarke<l. and selfishness and exactinpicss 
de%'elop easily if puinpercd because of his weakness. 

In tlie later stages, and for those old cnoufrh, smmming is the best 
exercise. 

The cftrreetion of the deformities is a matter for the orthopedic 
siirpetm. Mechanical aid should l>c aWeit as wioii as possible, if it 
carries out a pnigrc-ssive tliemiM'utic principle. Operative procedun's 
should he coiisenatively considered, and not used too early. These 
]>aticiils make vvuiiderfnl r*'covcries unaided, or by tlie persistent use 
of the Mensemlicvk exercises. Many opcrHtive procedures are, how- 
ever, imjwrative. Ner\*e splicing, and tendon splicing have their 
sjweial indications. 

Klectrical therapy is of use only as a bridge to gap the periixl after 
the fir^t onset until such time as definite willed movements can be 
start«l. 

Prug therapy is of purely symptnmatic value. \nm, strychnine, 
calcium are the most useful n>inedies, and meet special iii(li<-utions. 

PRIMARY PROGRESSIVE MUSCULAR ATROPHIES. 

'llic spinal motor neuron in dilfercntiMted uito three parts, 
termed the anterior horn cell, the motor nerve HIkt, and the muscle 
plate. It would he a great advance toward the simplification of the 
vexed questions regarding this group if a cliniad division ctHtld lie 
made in strict accitnlnmr with the |Mitho|iigicid alterations of these 
parts. To a certain extent only is this justified. For categorical 
puqtosi's then one can distinguish:' 

1. The progressive nuclear atropines, or inyehtgeiums or myelo- 
pathic type.-*: h'tifiogy: Heredity, trauma. c<*lri. t«)xins, infections. 
Aniiltiniif: Primary degeneration of the anteririr horn cells, with 
secoiuhiry fiber or musi^le changeA. h'orfun: Infantile, HotTmann- 
Wenlnig; ttdnlt, .\ran-l)uchenne; mixed forms. 

2. The iH'und nruritir, <»r s|>inal neuritic atn>phtc:>: KtiiAngy: 
Herr<lity. AwiUtmy: IVimar\' dcgmeratirm of tlic mot(»r nene fil>ers 

* Kftaricmi. Itritrac- mu rwunJmi itnicn^^lvmi )itiiAk*llii>t<hi*'it, A.n.li. f. I'syrlin IWlP, 
Xlv.H4. 



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IB810N8 OF TBE SPIffAIj CORD 



with secondary ganglion, wini, and niusrlu flmngvs. Forms: i'ero- 
ncjil-jimi t>*pe (Charcnt-Marie-Tooth) ; tabetic type (Dejerine-Sottas) ; 
pcRHR-al ty|>e and arm type (Sainton and Ilacnt*]). 

.'J. The muscular ciystroplues or myogenic types. Etiology: Heredity. 
Possible vegetative nerve disorder (cniioerinopathic). Analumy: 
Primarj' clianges in muscles. Forms: He-reditary (I#yden-Mol>iu8); 
juvenile pseudolijpertrophy (Landouzy-Dejeiine) : and mixed forms 
(KHi-ZiiiHiierliii). 

The separation i»f these fonns has <KTn]>ie<l the attention of neunil- 
ujjista since al>i>ut IS49 when Duchenne first attiieked the problem of 
disraeraberment of this lai^e group with muscular wasting. 

(^linicians for many centuries iiad (lesmbed progressive muscular 
wasting. I'ictiirea and images in stone and wood of the ninscuhir 
atn>phies and muscular dystmphies dating from the fifteenth, sixteenth 
and seventeenth centuries are in existence. Van Sweiten, Ahercromhie, 
and others gave general descriptions. Tliis group was first lin>ken 
into by Duchenne. in 1S49. by tiic loose description of a special type, 
wliich a year later Aran (1S50) supplcmetited. Ouveilhier. in iN-oIi, 
and Luys, in 1 Slifl. sharpcne<l the picture somewhat by their demonstra- 
tion of the exchisive implication of the anterior horns. In ISlio 
Charcot elimlnaterl the amyotrophic lateral scleroses from the group. 
1 duchenne himself had, iti 1S.').'{. alsi»set aside the pseudnhypertn>pliies. 
the mu.-iculHr features and viirleties of which were later dcnuvnslrateil 
by Euleiilicrg (ISliO). Charcot, I-eydeu, and Pejerine. Waehsmutli. 
in ISW, rctopnized tiie bulbar forms. Finally, Duchenne also called 
attention ti> the presence of sensory anomalies in certain of his 1853 
studies on the atrophies; these were for the most part s.mngorayelias, 
which Kahler and Schultze sepan»te<l definitely in 1SK2. .Another 
small group were the ncuritic atniphies, first clearly recognized by 
Dumesnil (I8(M). Thus it t<M)k thirty years for the sorting out of 
this medley of mU8<"ular atrophie^s; the groups as they are at present 
Tccognized. at least two of which, syringomyelia juid amyotrophic 
lateral sclerosis, being entirely set outside of the muscular atrophies 
■per w. One result was that the original disorder of Aran-Duchenne 
was so much reiluceil that finally Marie, in l.St)4. (rieil to sweep it 
away entirt^ly, but his iconoclusni had not yet becui justitiwl. 

In this volume the muscular dystrophics nre removc^l entirely and 
treated as vegetative nerve disorders of the niuscle (see Part I). 

Group 1. The Pro^essiTe Nuclear Atrophies: ;1) Spinal, (2) Bulbar, 
and (3) Mesencephalic Forms. 

1. Spinal.^Tliree main forms are here to be reeoguized. (a) ClinJiiic 
poliomyelitis per -vc, with lesions limited primarily to the anterior horii 
cells; (b) Aran-Duchenne's disease, progressive spinal muscular aln^by 
Und {c) infantile hereflitary — Werdnig-IIoffmann. 

The two fonner tj'pes are much alike, and many authors maiatftln 




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PRTirAfiY PttOCRESSIVe HWfiCULAR ATROPHIES 



405 



their Mentity. Tliey are \wk ronsiilfpwl st*piiratply, sim-e sm'h a 
course s^'l■nl^ jiistifin] cliiiiciilly If nitl |mtlmlu^'irHlly.' 

(«) Chronic Poliorajrelitis.- Here are j;r»ni|N'<l those rare subacute 
gr c!m>nic muscular iitropliie^ u:^uully ixTurriiin in the late years 
of life, in which certain toxic ajceiits seem to account for the Hisonler. 
Such toxic factors are lead, diabetes, s^'philis, and other unknown 
toxemias, llereciity is sometimes present. 

The anatninical Ie.?iions art.* a pmjn^essive tlestruction of the anterior 
liorn cells, with ehroule vascular alterations. 



\ 



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I- ■!]■ -[|] S .'III !.• 



iirri! ,ilr'ii'ti> "I ii.iliilx. 



SymittuMx. — There is a progressively developing flaccid paralysis, 
witli ant4'eedent v^fakness and diininutiun or los» of tendon reflexes, 
hut witliout ?tens<iry ur trophic signs. The nerve tnniks are not ten- 
der or swollen. Kibrtllary twitching appears, the myotatic irritability 
is increased, rejulion nf degeneration is present. There are no disturb- 
ances of tlw rectal, vesical, or genital functions, and the bulbar nuclei 
are rarely involved. 

Tlic localization rtisy vary; the legs i>r arms first showing weaknt^-i 
or atrophy, somclimesi one arm or Iwlh. one ami nrul one leg. orlntth 
Uga. The atrophy and palsies usiuiUy lake plate slowly, with at times 
periods of more rapid development, and also stationar>' periods during 
which no wivanec Is made for years, or the patient slowly reci>vers. 

Tlie distributitm i>f tlie atmphie muscles Is charactenstic. Certain 

■ Mftrtiiu]|: lUiMlhurli. d N'Min>ta|{le. 101 1, vol. li, p. 2MI. for onraplelA litonture; 
LAroKraat, Zur Keantnifl dct l*ul. nouta uniJ rhrooic-a. Kargitr, I6(M. 



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LBSIOnS OF THE SP/SAL CORD 

musrlp jiniiips arr spftrerl. Thi' arraiij^'irifnt is seKmriital, not radicu- 
lar. Thf irk'cps may t-stapt' with all the other nuiwles of the unn 
uttaekct!. or the flexors of the Hrijjers may Iw intnt-l. la the lefjs the 
lihifllbj aiiticu^ may stmid uut imimpaired. The eoursi- \s usually 
very chronic, lastinj; years. Subacute onset.s an* more favorable.- 
Sime iMitirtits recover, e.spm-ial]y those with suspicion of a radiculitis 
or a neuritis. In the progressive cases the patients at times Hevelf^ 
biilbnr s\inptonis, ami die of aspiratii>n piieuniornu, nr weakness. ^ ^ 



frimary mirlcnr alrijtliy. 
. M- Hbiiuiuhi'I.) 



Flu. 230. — Prlniiir>- niiHcar nlmphy. 
(Ci. M. llauiatuiidO 



Trcatnienf. ^IKesl, hydrotherapy, gentle massage, electricity, over- 
feeding lire the diief indications. .Syphilitic nises need specific 
therapy. 

(6) Aran-Ductaenne Type.— Progressive Muscul&r ktnphy.—Ktiotoytf. 
— Here heredity may play a part in the development of a familial form, 
seen in infancy, and also in mhilts (Benihanlt). It may follow acute 
poliomyelitis, Oilier factors, as toNcijiias. traunni, cold and wet, 
overexertion, are not deiinitcly cstabltsbed. Occupation utniphies 
are at times incorrectly included here. PatholoRically tliere h degen- 
eration of the anterior horn cells and fibers, with some secondary 
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PRrMAUY PttOGftESSlVB Ml^SCVlAR ATftONitES 

It is a rare dL^nnliT. The RyiidnHue b<^iiis very slowly, tlu- upiwr 
extremities are attackttl. ami rarely the lower. The ^nailer iinisoles 
of the lumil are iiiittiiUy alTeeted. Weakness, atruplu , um) (lairici 
paralysis ih the sequence. Kilirillary twiti-hings aceoTii|miiy iIk- 
utroph\' and there is reaetioii of defeneration in the imiseles invulved. 
Sensory uti<l trophic disturiianees are lacking and (he tendon reflexes 
are diniiiiiKhtsI or lost. Karly overexeitahility of the tendon rt^flexes 
ma.\' be iioteil in lM»th of thex* fitrm?*. 

Op]H-nlietni Iia> i-alltil uttentima t( the tendetiey for thes*' atniphies 
to jump fnmi itiie muscle gnuip to another. The atmphy is very 
gradual; the disease n<lvaiiciiig slowly for years. Uemlssions rxi-ur, 
hut n"coverie.s are very unusual. 

Tiie distribution of the alfe4te<| nuistles varies considerably. Death 
usually results from paralysis of the muMrle? of respiration. 

Diagntuiut. — The .sepamtioii of these two forms is at times impossible. 
There is a tenrlency for the former to advamt* more rapidly, to involve 
the lower limbs, to advani-e to the medullH. to show longer reinissi<ins, 
aiul to recover. Further, there is a greater lendeney t" segmental 
distrihutiiin in the muscle groups affected in the fonner type, with 
marked los.s of |><>wer followe<l by atrophy. In the latter tj^H* the 
atrophy seems to precwle the [>alsif*s. and the |>atients are often very 
adept with their residual niiisrles. 

The sensory disiurb«n<e> of iH-iu|*ation atntphies, of neuritis, of 
aynngomyelia should exclude these, while the increa-swl tendon rellexes 
of amyotn)phi<- lateral sclerosis eliminate.^ that flisorder. Rndictditis 
needs seimrHtioii. Here the atniphies lire apt to be unilHtenil, and are 
radicular in distribution. There is a Icm-gnide neuritis, and the 
l>cjcrint^Kiumpke syndrome appears in the cervical type. 

7'rfo/mf?i/.— This may be treated as the preceding atfection, but 
surh therapy seems of little avail. Strychnine, arsenic, anfl fats arc 
indieateil. Ncwrr iileas must h*- gainetl if any cffi*etive cnntrol of 
this dis<inirr is to be hoiwd for: the older methiMlsare useli*ss. 

{.V) Infantile Hereditair Forma (\Vcrdnig'-Iloffmann'.).— These are 
rare here^htary type*, beginning in infancy, first descriljed in IS91. 
The disease l>egins gradually, usually in the |)elvic ginlle atnl thighs 
(ileopsoas, quadriceps fentoris*. L^ter the baek, neck, and shoulder 
gintle is involve«l. Kinally the distal extn'mities are involved. The 
intercostals and diaphragm are often afTected. Occasionally the 
bulliar museies atn>phy. The atrophies are usually 8\'nHnetrieal, 
often as.s<»ciated with apparent h>perln)phy (adiposis). 

There is graduall\ incn-iising paresis and loss of skin luid tendon 
pctie.xes. Fibrillary twitching seems to be absent and a peculiar lrend> 
ling of the fingers is descrilKil. Scolioses. taUpes. and other contracture 
states develop. These little patients often acquire unique niiMles of 



> XrMv. t. ^vhiMtiti. 23. M. 

'. Deiitwlw ZviUrfarift t. Nen^snbeitkumlc. t, 10. U. 



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mo 



lanitiiotioii. KiiradH- furrcnls arc home hetter than Kftlvank- currents, 
but rt-aptiun It* 1m>i1i Is (liitiiiiiished ur lost. 

'I'he coiirst- is usually pmijrvssive, rarely stntiotiary.' Mental 
r«ilUtinii i>. not ilsiijtl. 

2. Bulbopontine Types. Chronic Frogressive Bulbu- PalsiM. — In 
thfflc fonns the progressive atrophy is limited to tlie muselett of the 

fHrc. tonpie, palate, and larynx. 

Etiology.- N«»tliinj; is known of the causative factors. Certain 
toxie factors— It-ad, syphilis— liavo seemed to play (i rnlt- »t times; 
cimslaittly recurring cleetrical shocks were a factor in one jiuticut 
personally observed; the majority give no ejue as to ctiologj'. A few 
cases are observed in ehildlnKxI. still fewer iti adult manhood; the 
majority occur after thirty-five years. 

Symptonu. — Tln-re is a >*low prnj^rssivc weakne.-w of tlie toiiKue. atiii 
muscles of the cheeks and lips, f(»IIowe<l by fibrillary twitehings and 

>wly progressive atrophy. Speaking beeomes fatiguing, at»l slight 
cliai]g(!H in the voice become apparent. In eating tlie patients find 
they must use their fingers in liislodginp foul from beliind the teelli in 
the ebix'k. Gradually increasing difficulty in :*\val]ottuig is observed, 
uml difficulties in l)reathing appear. Finally ti»e speech becomes 
lalling, dy.sarthric, the lingual letters rf, t, /, r, n, 9, are first sliirre<l 
over, then the labial letters /j, ;>./, w. ii', (», r. The laryiigt;al weakness 
causes hnarseness, monotimy, and finally aphonia. The pharyngeal 
muscles and those of the tongue do not act in eoneert, and li(|uid food 
n,'gurgitiitcs tlirough the nose. 

The face la-comes atrophieci below, the lips thin and folded. Tlie 
timpne is atrophoid, wrinkled and tremulous and finally lies inert on 
the HtHir of the mouth. The patients cannot pmtnide the lips, nor 
whistle. The letnporals aiul inasseters also become alTeitPtl. and the 
movements of the jaw bectnne impossible. The massi-tvr, [jliaryngead, 
and voiii iting rcHexcs are absent. The sensibility is Intact. 'I'be upper 
face region, including the levator pal|«jbne. is rarely aU'ected. 

Vasomotor disturbances are oL-easionally obser\*ed. Vagus involve- 
ment Ciinses cardiac irregularity. 

The usual pn^ression Is from the tongue to the lips, then to the other 
facial niusritvs, and finally to the fifth, and by|K(glossaI and vagus 
muscles, An apparent increase in saliva, an annoying symptom, is 
largely dependent upon the inability to swallow-. 

The usual course extends over foiu- or five years, deatli taking j)lftce 
most frequently from pneumonia or from inanition. 

Pathology.— Mere one finds changes in the bulbar nuclei, precisely 
analogous to those found in progressive spinal nuc-lear atroi»hy. Tlie 
eorticobnlbar tracts may be involved somewliat, but rarely to the degree 
found in amyotropliie lateral sclerosis, yet intermexHary forms are to 
be expected. 

' Ijite litpRiture. Biittcji: Laitnet. Jmio 3. 19II. 8<'aator; Chnril* AuniJen, 1902. 
Lcn^c: DeiitAch, ZlM-hr. t. Norvcnlicilkuiidn, tOlO, 40, 




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pniMARY rnooREssivi mvscvur athophies 4od 

Dia^osis. — I'nusiinl ty\tvrn of ^lidsis, of iiiitltiplf sclerosis, tumors, 
giimniata, arteriost'it'njsis. |L;eMPra) pairsis may rmisc sitiiiewlmt 
similar pirtiires at lirst, but tlii-s*' also soon show oilier symptoms, 
iiulicatiiiK tliat the lesioa is not confined to the nuclear structures, 
r^eudobulbar palsy shows palsied rau.s<:les. still ele*trieally reflexly 
excitable, without atropines. Myarthenia Rravis shows the typical 
electrical myasthenic reaction. 

Prognosis. .Misoliitely had, save in syphilitic cases. 

Treatment. — Thus far none is known. One should always he on the 
lookout for specific causes of the syiidromc, csijccially, in the initial 
stages. HcR* a nihilistic therapy will be recopiizcU too late for recovery. 

Galvanization has seemed to help the swallowinii of some patients. 
Atropine, hyoscyamus, etc., or other related drug.s can be used to 
control the .salivation, and the pains and <liscoroforts of couf;hinf;. 
dj^pneft. etc., relieved by narcotics. Spi-cific therapy is valuable in 
the Wasscnnann [xisitive cases. 

•I PontomesencephaUc Fonns.— Chronic Progressive Ophthalmo- 
plegia. — Clirunlc progressive ophtlialmuplegias as a part of an anl^■lK 
trupiiic lateral .sclerosis, of tabes, of general ])aresis, multiple sclerosis, 
tumor of corpora quadrigemina, or otlier organic disease are not rare. 
As pure, chrcmic nuclear affettions they arc infrcipient. I'thotf 
crerlits them as high as j-l [ler cent, of the clirouic uphthalnioplegias. 

Then* Is beginning weakness of the eye iim.scles, usually the external 
rectus, with slight internal strabbonus, frequently worse »t night. 
Diplopia is not usually present, because of the gradual development of 
tl»e disorder, and its sjinmetry. In hereditary types, in iufanls, 
biiKK-nlar vision may not have deveh>ped. 

The internal eye muscles are usually intact, although occasionally 
irregular pupils oociu'; light-immohile pupils are not present although 
loss of ac<:-omm(x]ation movements liave iHTurred. Ptosis is not 
infrtignent; nsually worse on one side. 

In II completely developed case the Hutchinsitn face develops 
bilateral ptosis with inability to move the eyetuills. 

The disorder is usually prr^gres.slve. Starr has described a stationary 
condiliuii, and .'*ome patients recover entirely. 

Treatment.^AVhe?! a WasKermann test ha.s revealed a positive 
reaction, men-ury and iodiiles are imhcated; otherwise geneml tunics, 
strychnine, inm, arsenic, and gi-nend dietetic treatment tlircLted to 
the rtsluetion of arteriosclerotic changes. 

Group 2. Tho Meoral, Neuritic, or Spinal Neoritie Atrophies. 

Hnnlsmd-fust lines cannot as yet be drawn Ix-twecn the neuritic 
atrophies and certain nuclear atrophies on the one luind, nor certain 
dystrophies on the ipther. Jendrassik, in a recent monogniph fUMl), 
qieaks of them ils "dystrophy forms nith degeneration of the peripheral 
ner\M." 



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TMK SNyAL CO} 



Many forms of neural atrophy have been descrihwl. The most 
(■haracttristic are: (1) the peroneal, fureami tyjH'^Charrot-Marie- 
Tooth; {'2) the tabetic, or hyjKTtrophie interstitial ueiiritie type — 
DcjiTiiif-Stillas, Marie's familial fiinu; {'A'i the pen«H-al Ivpe — Siiintoii; 
f \) till- firni t>|iif Iliienel. 

1. PeroneaJ-forearm Type. -Chart-oi. Marie ami Tooth tloscril>c(l 
this form whith is eliaraclcrizf^l by tmisciilar waslinff in ihe flistal 
parts of the cstreniitie-s, froni kn^- and eibiiw outward.' 



Fia. 237. — Clia»N]t-Mafic-TonLh di«easv. Alropliy nf ilic \ff» below the kaoea himI al 
the ntsn* Iwluw tlte ulbvw*. (Sun-.) 

Etioloffy.- Heredity is the only factor lis yet reroinii7'e<I. Kiehorst 
found thirteen cases in sax ji^'nerationa and llaenel thirty-twu in four, 
while others have fcnniil only one. 

Symptoms.— The feet are usnally first involved. There is early 
cfjiiiiiiis |njsitiini froin loss of power of extension of the great toe. 

* 1S81. Rev. <)(• M^rl., IHSQ; DniiEi, X, '24:i. Siiiltrr. Jnurrtnl of Ncrvniia nnrt Mmit«l| 
Diwwff. 1W)7. 



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PRIWARY PROf!KEf:SIVB MVSCVLAR ATROPHIES 



411 



Then thr leg. frtmi the knee down, thins and atrophies. The gait 
thereby heeomes either widespread ur steppage. A similar pnjtess 
In^ins in the forearms, usiwlly advaming from the muscles of the hand. 
.Monkey hand, or main en grifTe ilevelops. Hftrely the upper e^xtreniily 
Htrophy precedes. The shoulder, ami, nwk, buck, hips, iind thixh 
nni-jeles remain iniiu-t. 



I''lli JJi.S - 'r>IC rii'liMlli' Iririll 111 tllll^'J'illlir TU--£rli> 



.lit, 'I I 



.•^ensorv rlmti^s are tisnally present, and sH^ht pains, intermittent 
ami JaiiciimtiuK in rhunieter, coming and going, liyiK're^thesiu. par- 
eBtheiiia, hj-pesthesia. espwially to e4jld. arc present. Painful nerve 
trunks an:" ini-asionally found, \'asirtnotor disturl>anees are fre<]uent. 
fold, marbk-like skin with inercttse*! .'«.'<*R'tion is obserAeti. 

The knet^jerk> are (tften initially increased ; later they are diminished 
or absent. Tlie Achilles reflex i? ui^ualb' absent, as is the radial- 
perinsleal reflejc. 

Ueaetion of degeneration in the reginiis affected is the rule. Fibril- 
lary cuntractures and mns<'le unrest iirc constant, often persisting 
during steep. Tremor- and ehoreic-Iike mitveuientsarc not une(»mmon. 



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LB8WNS OF THE SPFKAl CORD 

CouTM. — The disease usually heginit in childhood, advances dowly, 
usually ]irrtgrossively. sometimes halting for long periods. 

Patboloffy. — Simv HrtfTinunn's ih'scription (ISSlt) of a ri*'iiritis in 
the distal periplicnd iiervt-s. this disorder lias passwl as a miNcd iumi- 
ritic atnipliy. but later Siemcrling. Gierlieh.' Kugelgeti," Spiller,* and 
others linve shown changes, not only in tlic periplicml nerves ami 
niusclfs, hut that there werc^ extensive changes in the other parts i»f 
the nervous system, in the eighteen to twnity <-i\m"^ thus far autopsieii 



Fiii, 2311. — ^The neuriitc fonn of ninaciilur ntro|>hy. (Bptller.) 

(1910). Tliese were parenchymatous and fatty degeneration of the 
muscles, usceuding degeneration of the peripheral motor nerves, 
especially iiiternuiscular bnuiclu-s. witii clm>nic interstitial neuritis, 
dt^encration i>i' spituil ganglia, atn>phy and loss of anterior horn cells, 
sclerosis of columns of Goli and Burdach, with changes in lateral 
columns and posterior roots. 



Arch. f. Vayc\t\Mtriif, 1909. 



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PTUAtARY PRO<!REii.'ttVE MUSCVLATt ATROPHIES 



413 



2. Tabetic Type (l)ejerine-Soltas'). — This is apparently an hereditary 
forni, tbesympiuiiis bc(^iniiin(i In rliildliood. TlH'niiisfulHrrliaiijiesurc 
similar to Uiose seen in the Charent-Marie-Tootli fctrniH. but the sensory 
nervous sysicm is much more niRrkedly involved. There arc present 
piipillar*- ehanges— niyosts, or even Argj ll-UoberLson pupils, beginninfr 
or complete Itoinl>erg. nystaj^mus. and ataxia. I'ain is present. The 
|ieripherftl nerves are enlar(fe*i and palpable. Reaction of degeneration 
was stale*! to }»e absent by Pejerine and Sottas. 

It may easily be confounded with a juvenile tabes. Dcjerine 
maintains that it has no relation to the Charcot -Marie-T( with atwphies. 

Other forms arc described in which the atrophies are limited to the 
lower extremity (Sainton), to the upper extremity (Haenel), and to the 
femorotibial region (Kichorst). The transition types are many. 

Diagnosis. — ^A eomplete separation of all the forms is not |)Ossihle 
in the present state of our knowledge. The Wa.ssennann reaction anil 
cerebrospinal fluid examination wil! probably llirow considerable 
light on the hy|>ertropbic ueuritic types of Dcjerine, ami may remove 
them from this group entirely; also cases described by Marie under a 
aimilar name. 

For t}ie classical cAsesof neuritic muscular atrophythere is little ground 
for confusion, but the numerous al>errant forms introduce difficulties. 

Tlie sepiiration from the dystrnpliies is usually made on the gn>nnd 
of pseudohypertrtiphy and the absence of reaction of degeneration ui 
th^ cases. Certain transition forms are undifferentiable. 

(^hronic [Milyneuritts is rarely hereditary (unless one follows Oppen- 
heim in classing the neuritis atrophies here under consideration as 
hereditary rbronic multiple neuritis). In ]jolyneurilis there is rarely 
a clulnfuot, the progress U more rapid, and recoverj' is apt to take 
place. With tal*es. only Dejenne's type can cause confusion. The 
age and hcreility are the eliief features. Newer studies on comple- 
ment •fixation and spinal Huid are wanting. 

In ainyotn>pliic lateral sclerosis tlie increased reflexes, the extension 
to the hulluir nuclei, the spasticity, and rapid course arc chamcteri-Htie. 
Multiple sclerosis, syringomyelia, chronic poliomyelitis, myotonia, 
and lii-n-ditflry ataxia occasionally call for differentiation. 

Prognosis. — I'suully |NH)r, but the disca.M- is very chrt)nic, and 
patients die after twenty t*t thirty years of intercurrent disorders. 
Sometimes stationary ix'riods are met with. 

Therapy.— Electricity, Itnths, massage, intenial seiTelions, genenil 
tonics, and orthope<iics arc useful. A few cures are known. 

AMYOTROPHIC LATERAL SCLEROSIS. 

History.- The position of the progressive umscular atn>phies. with 
their many clinical variations, and the anomalous pathological find- 

■ ' Afrh. ft. Nwim. >i Set., v.il. »vU. No. 01; Itev. d« HU.. (K07; B*v. Neur.. igoj, 
1900. 



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414 



LE.VOyS OF TltR SPSSM CORD 



ings li still ill rieeil uF more ik-tuilt^i Hiial.x'siK. CliarL-ot. in lUtiH, sepa- 
rated frtrtn this ma-ss a speiia) Rnnip which i-nmliiiinl thr fenturcs 
of H poliomyelitis and a lateral st^erosis. Atrophy with spasticity 
was the determining feature, and in 1X72-IK74 after previous studies 
witli Joffroy and GouilMiult he gave it definite form. Oejerinc later 
(1883) showed that the nlosao-lahio-larxn^cal palsies of Duehemic 
were a constituent part of the dise;isi\ and tlie wttrk of KojewnikotT, 
Miiric, Uoth, Fioraiiil, Ilidnies, Spiiler, Hayniond, (Vstan mid t»thers 
has st-rved to establish thk disorder upon a sound pathological and 
clinical iMtsis. 

It is H disease of the entire motor neuron, although Hohnes has 
shown that this is not universal. S<-hnltzc has therefore suBgestol 
the term motor tahes in contrast witJi sens<)r>' tHl>es of the classical 

Etiology. — Thus is a ci>mparatively rare disease. Little, is kmiwn 
Cf>riiiTtiinK its causes. It has been thought of as « primary atrophy 
of the motor system— an ahifitrophy, but this is only pushing the 
explanatiun Imck a step fiinluT. It is most prevalent in «iHy H4hilt 
life, thirty to forty, hut It is also known t<t occur in cliildrt-n (Erb-SeeHg- 
miilhTi. and .Soques. Itoussy. Ituymond. Probst and others have 
descTih-d cases occurring in the fifth decjule. Women seem to have 
the disease somewhat oftenor than men. hut the differences are not 
striking. The statistics of th« Vmiderbilt ( 'liiiie for ten years shiiw the 
reverse eonditions — II men and U women. 

Arteriosclerosis, infection, intoxication, syphilis have eaeli Ix'cn 
shown to jilay some role in the causation in some patients. The 
ri'latitmship of trauma is still unprove<l.' 

Pathology.— While thL- disease is one in which the entire mot*>r 
system is preditminantly affected, this is not exclusively so. as 1 lolmes 
has ricfiiiilrly shown. The spinal motor neurons are chiefly affectetl. 
both ccutnilly hihI fu'riplicrally. 'i"hc anterior hum n-lis are dcKcn- 
erateil, and the motor nerve fibers as well. 

The corticospinal tracts are also degenenileii. This degeneration 
can he followed to the Betz cells of the Holandic cortex In practicully 
all of the cases of any duration, but in some patieiit^s the degeneration 
iti the pyra[nifhd tracts has noT been tmcetl beyond the |)ons. 

Degeneration in the bulbar motor nuclei Is the rule, and inthcc«trtiei.»- 
bulbar tracts, as was demonstrate<l Ijy J. Dejerine in \hKi. The ihirtl. 
fourth, and sixth nerve nuclei usually escape, thtnigh a few reconled 
degenerations here are known (IltK-he, Pal. etc.). 

Degenerations can also Im* traced in the corj)ns callu.sum. Kollowing 
the degcnerutinii there is some replacement sclerosis. 'I'his widespread 
ilegeneration in the motor system may l>e accompanied by otlier 
degencralii'us, however, although such <Ugcne rat ions seem to stand out 
less prominently in the clinical picture. Thus, degenerations in tlie 

> Erti; DouUrli. Ztm-hr. t. NcrvudMilk.. xliv. mil. 



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415 



Isters] Liiluuiiis, ('larkf'i> culiuniis, puHtrriur Iniigidiiliiml Iminlli^, 
spiiifx'fiflu'llar tnn'ts, nnd vi-iitrolateral jn^U'xI IhiimIIcs nri.* itfonhHl. 

Symptoms. Tlie tiisonltT may Iwgiri in alirinst any motor ntnc 
it'gion: bultmr. cenifal. dorsal or lumhnr; more than one area may 
Ih* initially aiTtrtecl .siniulUinfously, but thp ilsuuI hejifinninf; le<«ton.s nrf 
prwictminuntly in the muscle (jroups of thr cenioal corI. 'I'lie onier 
of involvement is pniloniinantly raillenlar. 

The u-siinl !syniptfi[i,s are niiisevilar weakness, with wasting of the 
muscles, usually distally. with inereased reflex cxeitahility. The 
piitieuts first note that the Imntls gi-t tire<l, they are elunisy in dress- 
ing nnd undressing. Buttuiititg and unbuttoning, sewing, writing, 
und the earrying nut of the more delieate finger nmnipulatiuns beeome 
inereii singly difficult, first fnmi fatigue, then from stiffness and nuttor 



l-K.. -'^>) - Aiiiy"rr<i]iliir Inirrnl piIwiiA ihimtin au«>|ihy <■( ihr arma. 

palsy. Atrctph)- of the thenar uihI hypotlienur eminences oeciirs. then 
pnignsuk-s tu the miiAcles of the forearm, arm. and slionlder-^inllr. 
\Vi'akne>s and slitfneA-^ thru make themselves evident iti the lower 
extremities. an<l a similar p^lg^e^^illh taken [tlaee. Then after nionlhs 
or a year or stt the inaseles of the lips, of the timgue, and swallowing 
and plionalion gnulnall.vlK'citnu'implicHteil. The tips Iwn-ome thinned, 
(tapir itioutlil the tongue Htri»i»hie;*. -iiM-eeh fatigue is followed by in- 
ability to ^jk-ak; swallowing oeeurs with reKtirgiiatiou. eanliac irreg!i- 
larities ilevelop. atid the patientt die of aiipirnijim pneumouia, weukneu 
or other intercurrent alFeetioiM. 

With the niropliies (here develi>ps n gradually inerenshtg sjwislieity. 
The tiTwioii reflexes are Increascil. there is inerejitied jaw-jerk, or 
mmndthutur cluniu; titc bieepi:^ ami tnee|i», and s-apulnr rellexe^ an* 



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LKSIOXS OF THE SPINj 

increased, i>ate)lar rlimtis, inrtt-nsf*! kntHskcrks, incwftseti Aohilles, 
ankle-clonus, Biiliiiiski wnd Oppctilii-iin rt^fk'xes nre manifest. 

The muscU's thcmsi'Ives show increasoil myotatic irritability, fihril- 
lury cuntnirtions are coiiiuioii. or the atrophies may lje so marked, 
that Hacciil conditions develop. The reaction of degeneration occurs. 

Sensory anomalies are extremely rare. Pain is probably present 
at aime ijeririd in many cases; it is that of fati^ie or spasm, however. 
Till- bladiitr and rectal fum^tions are not usmilly invotvt-d, and the 
majority uf the patients show only the involvement uf tlte motor 
ueui'oiis. 

Alental symptoms are prtmitnent late in the disease; increa^tHl 
emotionaliKii] is usually present, and as the jmtients are often nitu-h 
depresscil, the involuntary crying, which is vcr>- frtxjucnt, I.-* augmented 
thereby. 

As has been noted, the onset may be in any part of the motor sys- 
tem — thus tlie disordfr may pn>Rrc.ss for some lime, even tu death, 
as a btdhnr typt- of palsy, witli increased reflexes in the motor cranial 
ntTves; death wcurrinp in some instances Ix'fore there arc aiij' s]jiiial 
symptoms. Again the distribution may Ix* hemiplegic, and then 
triplegic. and finally quadriplegic and bulbar. 

Again the disorder may bear the stamp of a Km-er exti-emity [uira- 
plegia, or an up(XT liiid) diplegia; again, whereas the distal riuiscles 
are ii?iual!y initially involveri, some patierils show proximal atn)plues In 
either upper or lower extremities; ami tlic more cases reported the 
greater are the possibilities encountered in the way of anomalous 
Imalizatioti. 

But through(fut, after a certain lapse of time, the combination of 
weakness, atrophy, increasofl reflex activity, without sensctry changes, 
stamps the process as essentially a motor degeneration, and whereas 
one may even find the sjiastic phenomena antedate the at n>pliic dianges, 
yet ill the end tlie two level up, unless the course luis Ijccii unusually 
active, and death rcsnlts early fittm the disease or frtim interenrrent 
disonler. Mere the ]>athological |>icture may seem to contradid 
the clinical findings, and the interpretation remains that the patient 
did not live long enough to show the classical syndrome. 

On account of this ])()ti.-morphism, certain authors have erectedl 
ty|H's which may be nsefnl clinically, but which are rarcEy borne 
out, save for certain ]K*ri<Hls, during the develojiment of the tlis- 
ease. Thus Kaymond and Cestau (U. N., 1905) make (I) an ordinary 
xpinaf type with the classical imtin en griffe of Charcot, increased 
reflexes, |>articularly in tiie upper extremities, less marked in ihc 
l()wer, with occasional failure i>f the Babinski rellex; {'I\ tahin^hx,i(>- 
laryngt'ol *i//w— apparently iui«t frequent in women- which begins 
in the muscles of the lips, ttuigue, pharynx, or larynx, oecajuonally 
with facial ijalsies, inability to chise the eyes, etc.. with fibrillary 
twitchings, lively masseter-jerk. .Some of these, but not all, run a 
rapidly fatal course froni four to nine months, and die bcfure the lower 



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yttArrr'RE Asn nrsmcAT/ns HYsnnnsrRti 



JlT 



neurons show their charactcriatie diaiiges; (3) an amjfiATophir ly/x 
with pronounced atn>phies wbifh overshadow or mask tlie spiustirities 
and the increase*) reflexes. These patienti resemble ehn>nir polio- 
myelitis, often for years, and eonstitute a m*»st diffienlt group to differ- 
entiate. (4) .1 w/^wfiV iyiie, in wliicli the reverse <-onditli>n exisLn, 
snd in<Teased reflexes and spasms, eontraetures, etc., antedate the 
atrophies. Thi-se reM*nihle multiple sclerosis, lateral selenwis, ete. 

Kin a 11 J, it should he reet)pnize<l tlmt eertuin jiatients represent 
transition f<)nns; they arc not pure types, ami the apjMirint elinical 
picture of amyotroplue lateral sclerosis is due to other thjin the recog- 
nized patholojncal foundations of this disortler. 

Coone and Durati<»i. — The averape time of duration of some hundred 
nr mnn- cases analyzrri is hIhiuI two years; hut this liy mi means tells 
anything about any indivi4lunl ease. Death in four months after 
the onwt has been the result in a score or more of eases, some hn%'e 
persisted ten yeara. and a few questionably diagnosed cases even much 
longer. The rule is toward steady progression; there are few leaps 
and regression.s, as is seen in multiple selenwis. and so far as is kmwn 
the disease is a fatal one. A few .stationar>" cases are reported. Bulbar 
palsies, when not among the initial symjitiuns, usually develop )>efore^ 
the seeoml year, anrl are often the cuus*' of death by choking, or 
dyspnea, ("ardinc irregularities, pneumonia, exhaustiim, se<Tndary 
inftTli(»ns. these are the usual mt»des of death. .Suicide is unusual. 

Diagnosis. — Tlic chief disionlers needing separation an' multiple 
sclerosis and pn>greasive spinal mu.scular atrophy or chronic polio- 
myelitis. The ffirmer rarely show*; atrophies, and the eye-grounds, 
o<ular nnisile signs, and eharacteristie trt-niors shoulil separate this; 
the latter disonler when it sliows iiMTeasefj n'lle\t*s, as is iM-ea.sionally 
the case, h separated with great difficulty. Lumbar puncture dm-s 
not thntw any light on tlie diagri(»sis. 

Treatment. — No specific is known. Overfee*ling, liglit ma:<siige, 
much rest, avoidance of fatigue of affe<'ted mu-sdes. eatfeine. strych- 
nine, are the only metluKls at present of service. Certain anomalous 
th>T»>iH insuffieieneies have been associated with progressive mu.scular 
wasting, and in<1irii(e n field fi>r experimt^tal theru[>eutics. Parathy- 
rtiid myatonias, niyastheiiiaH, family iwrindie paralyser, etc.. offer a 
suggestion in this line <.'f a pf.Tvcrt«vl p«ratliyn»id activity that may be 
seized upon f(»r the study of the mineral metalKilisin. es(teeially o( 
calcium. Personal ea.ses treated along lines suggestwl by the mimrral 
metabolism of the body offer a glimmer of hoiK' in a hitherto hopeless 
di,sejis*'. S\-i»liilitif ea.-4es need s[>eciHc therapy. 

FRACTURE AND DISLOCATION STNDB0ME8. 

Spinal cord injuries result from bullets, penetrating instruments^ 
ar fnim blows or fall.*<. 
Bullets and cutting instriimenls cause henuirrhage, with, rh a nile, 
27 



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LBSIONS OF TUB SHNAL COHD 



partial or complete severance uf the cord, with JM-plic infection of the 
copti and nicninges. Ulows and hard falls occasion fractures or disloca- 
tions, with f-niahhip nf the cord to a greater or les.ser detfref. Mild 
injuries ma\- result merely in the hrtilsiii^ of the ami, or minute 
heniiirrhaKfs within the vim\ or of the piJil or durnl spaces only may 
he ])nMkieeil, sometimes even from excessive exertion, long marching, 
severe athletic exercises, sudden spinal torsions, etc. Dislot-atioii 
of a vertebra practically always causes a crushing of the cord ; the 
9(M;alled dislocations without spinal conj injury are more apt to he 



t 



'•I 

1 1 



•-— * 



Kiii. 241— Total irotu-iecttun nf .ipinnl ami ul tho Icvfl nf r« ahutrinc the nmiKs 
Upou llio long tibvr tnicta. Middle aKtiuD indic-Btcc level of iajur)'- CixNwliatfluiia 
abovo and hHuw in(Nrat« thr dniptiu'ratinn!! or liim of funntiuti. (VeroKUth.} 

wrenches of the vertebra' or very limited dlsltK-atious. Fractures 
may n-^sult with hut few spinal syni])tonis; cnishing of the ccinl causes 
more or less disintcgrntion. usually nccompnuicd by severe hcmorrhiiges 
within or without the cord substance (hemiitomyelia, dund hemor- 
rhage). Hcmatiiniiyclia usually extends up and down the <-or(l from 
the point of injury, sometimes involving several segments uf the cord. 
Symptoms. — Fractures or dislocations of the spinal vertebne u.siially 
cause liH-al deformity, much puln anri muscular rigidity, particularly 
on moltoii. X-ray exHuiination reveals the nature anil extent of the 
bony lesion. The niotctr and sensory phenomena at the level and below 



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FRAiTUne AND DlSiaATlOS SYNDHOMES 



419 



the site of the legion indicate the iwation. extent and elianieler of 
the injury to the spinal cord. The s\-mptoms usually <If\cl(ip iinme- 
diately following the injury, become shphtly proprP->sive. if hemorrhage 
only, and then slowly recede until, after a variable length of time, 
usually fnmi two to three riioiith.s, the residual s.\-niptoms indicate 
the pcrmauL'iil iDipainncnt of function. 



^ 



L3 



Ki«". 'Ji\i itail a43.— .StmwinK «u|>L>rii<-ULl wiuiliility difttiiilKini** in tvmi[tl«l<^ rmii.fvcnic 
Imiun.^ r>( iKp tyirti at tfi*- level* of Tt, (\. !)%. nml I,,, n-opo'livrty. (Vormtulh.) 

The chief syndnnnes, which develop fnmt injury to the spinal conl 
at different levels, sre here destrilHi) I>y menus nf charts. A careful 
sensory exaniinutiiii) is indispeiisid>lr inul should fnll«iw Th<' dirwlions 
already laiil (li>wu. 

It is iuipnrlant U> rit-all that thi- spiniil cord scKnicnts and the verte- 
bral segineuts. while nearly currespondinn diU'Litg iiifaucv, do not ia 
the adult. It is rare that absolutely syrometrical involvements result 
from spinal uijury. 

A total destruction (if the spinal cnrd wilt result iti initial and ill 
residua] symptoms. ThLs may result froin accident, bullet wound. 



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42U 



LESIONS OF THE SPINAL CORD ' 



diving, caisson disease, myelitis, tumw — Pott's disease chiefly. The 
course, prop-ession and mode of treatment will depend entirely upon 
the causative lesion. The chief sjmptoms of acute transverse lesion 



General Func- 
Bnm ow I^bbion. tiok. 

lAtAiiity. f 



Lamlrar: 






ImriAL Stkdbohb. 

Symmetrical flaccid palay of 
the lower extremities. 



Symnietrical flarrid palsy of 
the abdominal mueclea and 
lower eztreniitifw. 



Symmetrical pals^ of preced- 
ing plus nacrid paley of 
iDtercostalB. 



PrecedinB fligns plun flaccid 
palay of upper limbs and 
disturbances of breathing. 

Symmetrical loea of superfi- 
cial and deep aensibility of 
the lower extremities. Re- 
tention of spinal sensory 
functions below lesion. 

Preceding plus loas of super- 
ficial and deep sensibilities 
between D. 6 and L, 3. 



Preceding plus lose of super- 
firial ana de«p eensibititice 
between D. 1 and D. 6. 



Residual Stnimome. 

Symmetrical spaatic paralysis 
of lower extremities to level 
of L. 4. 



Symmetrical spastic palsy of 
the abdominal muscles and 
lower extremities. 



Symmetrical spastic palsy of 
preceding pfua intercoetals. 



When not resulting in death 
total bilateral spaatic par- 
.alysie. 



Jn Ml 



Ocrrtco Di>rfei\ 
tC8. Dii 



Preceding plus loss of super- 
ficial and deep sensibility 
between C. 1 and D. 1. 

ToUl loss of patellar.Ai^hillrs, 
plantar reflexes. Cremas- 
teric preserved. 



Preceding plus lom of abdom- 
inal relfeies. 



PatellarreRex retained, AchiUea 
increased. Clonus and Bab- 
inski and contralateral Bab- 
inski obtained. 



Preceding plus apontaneoua 
abdominal movements. 



Preceding with oculopupil- 
lory disturbs ncen. 



Preredlng with oculopupillary 
disturbances. 



Cerrlial 



DtililC^ 



Preceding without oeulo- Prccedinn without oculomotor 

pupillary signs but with disturbance and increased 

loss of reflexee of upper reflexes of upper extremities, 
extremitiefl. 



Total bladder and intestinal 
palsy. 



^iymmetricat dilatation of 
vessels of lower extremity. 



Preceding with vascular dila- 
tation in upper extremities. 



I'utal bladder and inteatioal 
palsy with later hyperirri- 
tability: also of ^nital 
reflexes without priapism. 

Objective symmetrical chilli- 
ness and cyanosis of the lege. 
Later sncrnl decubitus. Skin 

and nail disturbances. 

Preceding with objective sym- 
metrical cold and cyanosis 
uf (lie arms. Shoulder-girdle 
decubitus poHsible 



Fig. 244. — Locidiaiil ion of symptoms at different levels of the rord. (Vernguth.) 



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FRACTVRK ASD VJRWCATIOS SYNDHOMES 



421 



«re exprcssctl in tlir table Fig. 24-J and (tiafrraiiis act-unlitijc to the site 
of t)ie Ic^idti. 

Ix'sioris of the upper ccrvifal st-gments iLHually rause iii<itant death 
from respiratory paralv sis. I njiiry lower down is very fn-quent, 
oceurriiiK in workmen fniin objwts falling ujMm the bent ncek or in 
rerkles.s diving. The svtnptom.s are ehartetl. Many nf lln-s*.' patients 
live f<)r some time, even yeai-y, dying usually fnim Idadder and kidney 
complications. I.lorsa! legions are et)niparativel,\ ran*, and often show 
tlie Brown-8equard syndrome, which latter may, however, develop 
from lesioiw at all levels al>4>ve the conns. 

Lower dorsal and upper himhar tesion.'t are the most fre(|ueitl of all. 
'I'heir syinptnnis an* iii(ii<Hted in the chart. 

Injury to the hnver lumliar vertchne c-auses cauda equina lesions, as 
the corrl profxT tenuinates at about the Brat lumbar. 

Intramedullary lesions — hematomyeHa—haxn a s.\-mptoinatolog}' oil 
their own. 

("an'fnl sen.s<try testing show.s thai in an intramedullary lesioti there 
\& a tendency toward a complete strpunition of the impulses underlying 
the appreciation of posture, the dl-wrimination of two imints. and their 
(*orrelut*Hl facultii-s frtmi those of other sensory groups. 

All piiinful Hiicl tliemial iinpnls4-s coming from the pi*riplicry undergo 
regroupitig after entering the spinal cord, and, whether they arise 
in tlic skin or in deeper structures, become arranged according to 
functifmat similarity. Then, after a longer or shorter course, they 
pass away to the opposite side of the spinal cord. (See I'late X.) 

This pHM-ess of filtration leiives nil the impuLxes a.ssiK*iated with 
(KMtund and sparial recognition to r-ontinuc their course unaltered 
in the posterior citlunnis; they are the survivors of pcriphund groups 
broken up by the passing away of certain components into secondary 
afferent s.vsteins. At any |K>int in the spinal c<trd. these columns inuis- 
mit not only impulses from the periplicr\' whi<h are on their way. after 
a shorter nr Ir.nger passage, to regrouping and Transfonnation, but at 
tlie same tune they form the j»ath for impulses, arising Ixjth in the 
cutaueiius and dt^p afterent systems, which undergi* no n.*gn>uping 
until they reach the nuclei of the medulla oblongata. 

Thus, a lesion confined to one-half of the spinal cord, even at ita 
highest segment, may interfere with the passage of seiLsor\ impulses, 
some of whic)) are travelling in .secondary paths, while others are still 
within the primary level of the nervous system. All impulses nmcerned 
with i>ainfnl ami thcnual sensations from i]i.stanL parts, distur)>c«l by 
such a lesion, will In- travelling in secondary paths and will have come 
fn>m the opposite half of the iKxIy; for, after regrouping, they have 
pas»e<l across the spinal cord. But thi>se impulses underlying the 
appreciation of (msture. the HjuipiLis test, size, sliu|>e. fonu. weight, 
fUQsistence. vilinition, will be atTectcd on the same half of the Inniy 
as the lesion. They still remain in paths of the primary- level mid 
luive undergone no regrouping. (See I'tates IX and K.) 



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LKStOffS OF THE HPIffAL CORf> 

III :*iK'li ft rBM* the iJBrts on tlit* side oppdatHl to the )e»iiiii may be 
insfiisitivr ici imiii, heat umf (vtld; hut nil tin- postural uiiil sjiaclal 
aspects of spusatitm will ln' [wrfoclly maintainol. ^*et, all power of 
rw<>^iztiif; [wisitinn. of estimating size. sliaiM*, fonii, und wclfiht, or of 
iliwrimiiiatin^ the twn <-cin)i>as.>4 |Miints. will he Inst in the linihs whieli 
lie on the side of the lesion, although taetile sensihilitx uut\ ItK-aliKation 
of the spot stiinulfitcil may he iH'rfwtly preserviil. 

This reuiarkahle arrangement enables one t(i analyze, as Head lias 
jmintwl ont. the nature of the peripheral impulses uixni which depend 
the |K)wer of po.stural nnd sparial rpcojiiiitiitii. Obviously, even at 
the |>eriphery. they must be independent of tourh and pressure. The 
power to ilistinguish two pi>ints applietl siniultaneoiisly and to reer^- 
nize Hs sueh size anil shape, requires as a preliminary the exislenee of 
sensfltiinis of touch ; hut the patient may he deprivetl of all such powers 
of s]>jicial riTugnition without any disanerable loss of laelilu sensibility. 
In the siunc wny our power to appreciate tlie pttsitioji of u limb, or to 
estimate the weight of an objtTt, is basetl u|mhi impulses which, even 
at the periphery', exist ap«rt from th<tse of ttnu-h :ind pressure, called 
into sinuillaneitus being hy the same external stimulus. 

This long ilelay of the postural and spacial elements in reaching 
secondary p»ths enables thein to give off nfferiTil impulses into the 
spinal atiil cerebellar coordinating nieelianisms, which lie in the same 
hdlf of the spinal cord. The impulses which pass iiway in this dirirtion 
are never (ie.sliried tr> enter nmsi-lou.sness directly. Tliey influence 
coordination, unconscious posture and luuscular tone. and. although 
arising fn>ni the same afferent end-organs, they never hi-rome the ba.sis 
of a seiisjLiion. 

l*'injdly. the last survivors of these impulses from the iHrijiliery 
become regrouped in the nuclei of the jHisterior eohunns and cross to 
the opposite hiilf of the mi-dulla oblongata in paths of the seeoudar>' 
level. So thev- pass to the optic tliulamus and thence to the cortex, to 
urnlerlie (lu)se sen.satjons U[M)n which are based the recognition of 
proture anrl spacial discrimination. 

Diagnosis. — Accurate testing of the motor and sensor>' functions 
leaves no climht as to the presence of a spinal con! injury of a major 
grade. The results nf niiruite lesions nuiy csca|M' re<*ogiiition. Total 
se\"eriincc of the coid is unusuid, most, even severe injuries. teHve some 
pathways utuHvidcd. which, after the immediate effects of tlic injurj' 
have subsided, give i*ome sensor>* resiKmse. Total, citraplete severance 
cans<'s uhsoluie anesthesia to all forms of stimuli, tlamd paraplegia, 
with Ittss i>f all reflexes and all visceral reactions below the site of the 
lesion. 

Half-sided lesions produce the typical Brown-v>6cjuard .syndromes, 
which vary nccoKling to the segments, as seen in the aeeompanynig 
scheme (Fig. 247.) 

Prognosia. — Thi.s is ImuI in praetically nil spinal eoni injuries save 
small hemorrhages or limite<i cauda equina lesions. High lesions are 



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423 



»lmusl iniiiirduitrly falul. IxjwfHyuij; ones— fourth wrvioul and 
ilown— vnn in ilu-ir iiiiiiKHiinto and remote rr^iults. accurding to the 
site of tlie Ifsiun hikI it:' rxteiit. 

The questuin of regencratkm of spinal neurons ha-s iKit as yet b«;n 
entirely settle*! i'V{ieritiu-iitall> , hut the prt-iHiiulemnfe of prai-tieal 
evidence is aKHiiist it. Pathways iKice «lestn»yttl remain so. -Just 
Ht what period it may he snii] thut the re-slrlual symptoms will be 



T 



u 



J 



Flo. 345. — Leslnn of tltc cmrd |»rmluoinc • 
Rroirn-SJ^)iiiuTl ii>-ndrwi»e>. (Veramllt.} 



Km. 24a. - - Bniwn-fyW|iiitM wyu- 

Adal koenhaii Mid jotDi &n«MJu<«ji; 

pMnna h>iM»r«p|fc»w« luitl p«f- 

tiy^B. t Vt-ragutb.) 



permanent is larjtely a matter of the extent of the legion. As a rule 
the findings at three nionttvs arr apt to be those of i)emianenrf. still 
(Kfasiiiiially iiiarkn] inipnivenient, partieulariy in bladder and nH-tal 
fiinetionii. may take plaee after u year or nu»re of tntal lins-s. Ntany 
spinal lesiitiis. esjH'rially tlmse depeiulent chiefly mi heinorrhagf, will 
show nidt-Npreiul symptoms early, and later these will be reduee<l lo a 
minimiun. The chief t>u^)enr as to life tn the hln<lder. Great care 



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424 



IKSrONH OF THE SPIffAL CORD 



sliuulii lie taken of it in the early stages, and every availiiUlf nieasurc 
taken ta kefp it sterile. 



8t» ur 
LmoH. 



Ill InmboJ 

MLunll 

avgineuti 



KCiCTHMi. 



iMoiiiitr 



Su:ifl]blllty 



UOTSRi 

■egitioals/ 



BtltiXCS 



Cervlrail 
•ugnionu/ 






•igiw 



IsmiAL Stwiwoh*. 

On the aide ol llii- Iwktn. FUr- 
rid |uU«y <(f iTimifli'!* vrh'wc 
nvuroiiN li« oHudad lo lemon. 

Numial '>■■ opfK^il*- Mdo 

f Onilu>M(loof iholwiirtn. Dinlurh- 
atirc ot deep wnsiliility, (<epe- 
rinlly Joint hypoithcMn, ciiUfJMl 
t'j affertod oieuuitera. Small 
t(>n<> n( »u|>er(irlRl ■nwthMil 
atxtk-e cliL' iKtl.iif^ riKiior vme. 
Hyiimtliwrn f'lr U>w)i cmh\ji\ 

tv afft^vl-cHl iiietunivrut. 
On l.lio rrtwsnJ nide. nnd parlly 
cm l.lie idde of Irviuii, herMUMe 
uf liniitatiurm in cm§BiD|C Bpnco 
nf fiheni Itelow ImIoii. miper- 
fifial hy[ieeth(«ia, ofqK'cinlly 
th£>rnn)tiyiK'«tlic»i™ anH hyijsl- 

^ As nlmve. 
Ol) tiK* itidr nf the liMun. Lmw 
of lendoD and tkin reflexea n( 
iliu lijwrr rxlTfriiil y. Diiluii- 
nki phennmciioii, 

Ol) rip]>imilo xirlr, Lom nf akio 

TwIivxHi oE till* Itjwifr HxLrriuity. 

T'ifmlinic and \ota cif abdoininal 

'Ptei>ediiu[ and Ion of tendou 
r<>fl*«xr* of the upper pxtmnity 
fjl lUe stdv of ttit! k'iOiML. 

'On tlitf aide ol iJie 1«miiii Itie 
(•kill (vf tlif mudid metumertu 
rod find hoi. 



Oil wlm nf luinu, spa*- 
lie imUy uf miwrkiit 
whiive neurons li« 
(-■audod b> Imion. 

Normal on cul« <^]>4>- 
8it« t4> iHiiou. 



HyiK'nni.litMJH 
pviim itb'irtly. 



iliwp- 



On tlie (rrowed vide normal. 
Prorcclinit ])lu» noiilopupillary 
niKiiN fu arFtfc'ti-d t>id«. 



On the aide of Um 
Icrtion. InrrcMic of Mi* 
doii Hiid &kiii refldXM. 

H!ihiri*ki ('•mtriiliil- 

eriU BiabuiakJ. 



Pnrn-tliuR nnd indrc-Oaod 
ubUumiuaJ reOi'xm on 
dido nf Lc^uii. 

PT«cedLna plus liaitd- 
rlontiit, riiuvtinii tia- 
nu0. eU., oil uffected 

KtllC. 

On nide of liMion Uio 
skiu nf thp fwidd 
inetAni«re9 cither 
numinl ur rynnoljn 
nr objeotively cool. 

On cwoaMod ada our- 
md. PrtK'nliitic wuh 
ocul"pupilliiry eiiiiis 
on iJir' M<lc nf hiHtiil). 



Fill. 247.- 



Ai-tmiLp ftbuwiiLg luo&Iiaation and syiuptoina in Brown- ^qiiurd nyndnjinwi. 

(V^MTlJtllth-) 



r 

■ Treatment,— Surgical treatment is indicatf^J in most spinal injuries 

^M even thougli tlie prognasis i,s ncit at all reassuring. The persistence of 
some Turui uf sensibility (all types shuulil lie tested) is an iiidii^tion 
that the a^rd is not completely severed. Operation during sh<H*k is not 
advisable, yet t(Mi loiij; a liclay is unwarrantetl. even if all sciisihUily 
seems abnlishwl Ih.'1ow tJtc lesion. The functional loss practically 




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425 



always exnttls thr aniiti)niM-jt1 ili>fc4-r. X-ray rxaniiiiatiuii slimili] (>c 
niHi|piniinwlinlcIy for diagticttsis, and "if there isevulencfof (H)niprt*:vsi(>ii, 
operation is advisable a:* early as is a>inpatibte willi tlic palierit's 
cunditiuii. In the abwiKT of evidence of c-oinpre.s»iuii, earlier surgeons 
advi.'ted af^inst operation as darif^eroii-s and futile. Since in the hands 
of comiH'tent surgeons most of the dangers of spinal eord injury have 
disjtI)|K-ari*«J, then- Is » urtiwiiip icudeney to o)HTate more freely and, 
at times, fortunately. More often there is little gain. 

0])erHtiuns, after spinal injury, are often futile, yet with care rarely 
do any harm, and not uifrequenlly. if the iTtrd itself is oidy being 
pressed upon by hemorrhage, may Ik- distinctly advantageous. Evi- 
dent surgical inflicatiuns (frai-tiire, dishtration) should be met. The 
patient Lh rarely l>euefited but is entitletl to tlie doubt. 

The general treatment of tlie patient is of great importance. It 
should l>e direi"te»l toward giving u niaximuni of relief from duitress; 
iivoiilaiK-e of bladder inhi-tiou. |irevenling bed-sores, and careful 
bowel attention. Anlispasmmlics ami unulgesics may have to In.- used 
for a long lime, but murphin and its derivatives are to be avoide^l if 
possible, save in chose agoniyjng ca.'*ts where it gives the only reJief 
from Torture. Kl«*tricity is largely a placelxt. 

Ilalf-sided legions priKluce the t \ ptcid nn>wn-.S«|uanl syndroniea. 

COMPRESSION or THE CORD. 

Compressi»jn of the conl. as a slow chronic proces.* results from (I) 
laiuy IiyiKTtnijibies, (2t tnt*ercu]i»Nis, (■i) tumors, (4) syphilis, (5) 
uneurlsnis. ilii meniogral distiLse. 

Bony Bypeztn^hies (Osteitis, C^teitis Deformans, Osteu-arthritls, 
S|)on(lyl(xsis |{hi7.omeliquc).^rnder these various nanu-s one Hnds 
patients who present signs of more or less spinal cord c(Hnprestiton, 
eitlier with or without stiff backs or deformitif^. 

They show gradually increasing wejikness. going on to pjiresis, 
or complete jKiraplegia witli spasticity and increased reHexes. Kro- 
tiuendy tln-re \s severe i>au» and, when the iKiny di.sease impinges ii[>fiii 
the intervertebral foramina, neuritir pains and symptoms i>f iH-riiihcnd 
ner\e jiulsy llc^clop. u'^ee I'lcxus Talsies.! X-ray examiiuilions revnil 
the nature of the bony changes ami the location of the pressure, 

TabercolosLS (Caries).— Thi:( is a must widesprcail fausc of spinal 
ettnl I (impression. The tuberculous focus usually begins within the 
iMxIy of tiie MTli'bne; breaking down and destnution i)f the verlebne^ 
take place, with displacement and prnji-iiion of the vertebne i-itht 
forwan], backward or lat<>ndly, rauhing (Ih* various <lefi»rmitit*s of 
I*ott's flisease. The tuben'tdous prm-ess ijsually spreads to the spituilj 
meninges (tuberculous iMichymeningitbii. Thus if tJic comprcssic 
arwi's it may 1r* from tM»th pHK-es^-s. Kven ninn' rarely, tuben-nliais 
myelitis occurs from direct extension, ui^ually through the lymphatic, 
channels. 



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IE.VONS OP rriB SPtXAL CORD 

Symptonuj.— Tlu* i-liii-f >\ niptuins art- pain in iJir luirk, i»flfn n-lKiltil 
uiul rtiinplaiiifil nf jii kiu-i- liinpiirtaiit tn \n-iiT ill mhv\ in childn'ti), 
.stiiTiii'Ks <if iriUM-li-s, rigiilit\ arul li-iMimifss (in iniitinii in llif early 
stages. With thi- <le\elnp[nent of :i kyphosis, lonicisis or -kvIiosls. 
deforujities iLpiX'ur ami symptoms of con) i-onipressitHi and plexus 
prftusure l>e|;in. The plexus symptoms vjiry with tJie segments involved, 
as already diseusswi. (See IVriphcral Plexus Neiirili<les.) The eord 
compression gives rise to inereasiuK bilateral sjtasticity helow the site 
of the lesion, slnwly de\'i-lopinK sensory inipairinent. which may develop 
into signs of u I'lmiplete t-uttlng off of the entire i-onl pnthwnys hclow 
the site of the ctimpression. {Soe ttihli-. p. 420.) 

I-ympIifwyt^tsLs in the <-erehrospiiial fluid is n fretpient sign. X-ray 
examijmtion will earh' reveal the sigjis of tnlKTrulous hony disease. 

The s.XTnptoms u.siially show very gradually, as the tiihertTulous 
dlsea-te is usually a slow one. ()e<>a.sionally they show a fulminating 
i-nurw. es]>efially in rlilldhoixl, or even in young adults. 

The ituteomt' depends upun the sneees,-; ohtHineij In fonihatiiig the 
ttihereutosis by orthopt>ilte. snrgieid unil K«'iit-riil lieiilth nieHsun>s. 
Early diagiiasis is eswutial. and the spinal flnid exanunations and 
x-ray finduigs will aid in stieli itn early sizing up i>f the situation, 
whieh will lead to the proper procedures. Surgical iln-nipy i-arly, 
Alhee's bone splint or relate<l proeediirf mny help tn flo away with 
the cundiersoine linices formerly so extensively- u.-^ed in tniiting 
Pott's disease. 

Spinal Cord Tumors. -The consideration of spinal cord tumors 
makes a large ehupfer in i-ontenipnr!ir\ sciis^n-imotor neurr>logy, which 
can only l>c sketehe<] here. They are compitrulively rare, yet frequent 
enough to put one on one's guanl in an.v spiiuil cunl contlition showing 
compres.sion phenomena, i, e., weakness, siwisticity. and inrr«i»ed 
refiexes. i. e.. pressure symptoms of the spinal motor pathways. 

Spinal e()n! Tunnirs are as variable as those found within the cranial 
cavity. Tlie\ jirc fnund extrailnrally. dunUly, intratluraliy and 
intrflnntiullary. They are small and large, ajid locutwl at aii.v. 
sometimes at all, levels {mitlliple sareomala) of the cord. The tumors 
of the s]>iua[ ci>r(l are identical in histologicnl features with those of 
tlie brain 17. r.i. I'seudotumors — cysts, angiomata. serous collections, 
pnlarg<'<I veins. :ind many anomalies occur within the spinal canal and 
protiuee tumor syminoms. For the most part they He laterally and 
|ji(slertorly, aTid are thus more accessible ti> surgical removal. They 
occur lit all ages, and in bfjth sexes, and show a Frequency com]mrable 
to those- located in the cranial cavity. 

Symptoms. The chief symptoms of spinal cord (iimor are [whis, 
sensory signs in the skin, ami evidences of motor paresis. 

Sharply localized pains »t the site <*f the timior are frequent, but may 
he altsent; all pains may be absent, but this b infrequent.' The 

■Railoy: Jnur. Am. MH. A^hu., 1014 



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r'0^rPREssJn^• of tub coro 



127 



iniHT iisiiiil iMiiiK Jiif tli4>sr of tlir r<H»t urcA or Jirfus iiivnlvnl liy Uii* 
iHinnr. Tlif pains nrt' nstiully iitiilatiT.d. l>iit widtvspn-ailiii); tiiinors 
(■nusc hiUtcrHl pain later. Any sim-h11<-iI neiiralf^iit, N«'iatHvt, <-tc., 
ntay \w. the initial pressure pain of a spinal rorri tumor (»ee fliM-ussion 
on neuralgias). I'nder tlie popular 
ntinniimer, " rheumatism," many 
spinal «>nl tumor* and ncimilnii- 
pains are hidden until it is t(H> lat<- 
to nhtuin relief. 

The jr-ray picture Ls usually nopa- 
tive. The cell count of the cerebn)- 
spinal Ihiid often ^i^'(-?^ definite in* 
forniatinn relative to the subjei-t of 
irritative meningeal si^is (hi>;h cell 
count tneaning acute inflamnnitorv 
disease), and most tumors hIiuw a 
liipli ^lohulin content in tlu* (vrehro- 
Mpiiuil Huid. The Wassemiami teeli- 
nir will nile nut i^niimata a.s a nile. 
Ill some tmnnrs there Ls un abscnii- 
of fluid, or fluid under a \ery low 
pr»'ssure,l>eIou tlu'siteofthe tunidr 

The motor etniipression signs arc 
variable, paresis wivaricing tu par- 
alysis (iwraplegir), h>*pprtonicit>-. 
sjwstieily. inereasefl retjexe-s. Bab- 
inski, clonus, etc. At the level of 
tlu' tum<ir there may be <lestnirli\r 
lesiofLs with signs uf peripheral 
motor neuron disease, i.r., atropliy. 
loss of reflexes in tiie di^'iisetl area. 
reAdiou of degeneration, tropbii 
ehauRes (.bed-sores, etc.). 

The sensory phenomena will var> 
also, (Mie sifle often Hhi>wing inon 
markedly than the other. Then.' i ■ 
hyperesthesia at about the level of 
the lesion which i.-* changed U' 
VHfitrtis grades of anesthesia hn\u\\ 
the lesion. Slight l(ks.v of epicritii 
touch is apt to i>e an early sign 
Greater sensory loss lidvauces with 
inereasuig eompressiim. lUaddi'r 

and rectal ilisturlmnces are freipient. Sniuli tumurt (c>-sts. cUr.), intra- 
mednllary, -winn'iimes cxtranieilulhiry, cause typical diss<K-iation symp- 
tom?' with retention of epicrilir ta4-tile sensibility iiihI loss of prolo- 
pathic pain anil thermal sensibility. 



jiH 



1 tcU''i|ili> n-» 
r|.ikrkiij.t 



li •|iMi(i. ...ril. 



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LESIONS OF TfTE SPINAL CORD 

The s>'Tnptoins for locali'/^tioii uf the tumor have already been 

HiscussLHi. 

Diagnosis. — X-ray examination, spinal fluid examination, and 
a fomplctp neun>!ngical status should i>n!il)li' nun to arrive at a j^atis- 
fiK'tory liianiuisis. 'VUv chief «iiagn()slif proldem is syptiilitie nit;iiingo- 
myelitis. Bony disease is usually excluded by the j-rays. Multiple 
st'lemsis is not iiifre(|Ufiitly uslu'ri-d in v.'it!i st-nsory signs, also syrinnu- 
myelia. They present real dUfieullies in (liafrn<tsi,s. The applieation 
of proper ]icuri>h>Kieal and psycho-analytic procedures will determine 
the cimversion mechanisms of hysteria. 

Intniinedulhiry or extrainedullary diagnosis is practically unim- 
portant since spinal ct>Tt\ snr^ry has heronu* so satisfaHctry. Theoret- 
ically i'nipIoye<l, the prnbh-ni is of interest; pnu-ticidly, less so. For 
locali/.3Ltion s^mptiims consult Figs. 243, 244. 245, am) Plates IX 
and X. 

Treatment.— Apart from syphilis the treatment Ls surfcicHl and it 
should he employed early and for practically any or all tumors; not 
necessarily with the promise of rure Init as a rontine exploratory pn>- 
eedure. In skilled hands the dan^r is sli;<iit, and ajMirt fn»ni spe<'ia] 
cotitra-irulii'Htions, tin* risk is \ery frotpieutly worth while, as very 
uiiexpertcfl things turn up within the spinal ctivity.' 

The localization is the most (ILflieult problem. Most tumors are 
found a couple of Inches above the site usually sought for as deterroine<l 
by the level of the anesthesia. .Surgical progres.-^ relative to spinal cord 
tumors is rapidly advancing and cannot be dlseuswed here. The 
general jtrogiiosis has improved both with reference to the finding, as 
well as tlie surccssful renn>vid of the tumors. There may he recuriTiiees, 
and nuiiiy (wticnts are not IwnefitiNl. l.itlle is to be exiiectcd in (hi*se 
loug-standing tumor cases with marked signs of s|)inal cord compression 
degeneration. Yet e\'ery patient is etititlcd to the beiieJit of the duubt. 
Surgical failure is better than a let-alone policy covered up by morphin- 
ism. This latter even is not necessjirx'. since i-arofnl (division of the 
ali'eetwl st^nsory rm>ta in inoperable cases may give relief from pain, 
even if life cannot be saved. 

Most patients the of the myelitis bed-sore and bladder etrtn plications 
after one or two years it) itici]KT»ble cases. 

LATERAL SCLEROSIS GROUP, 

Historical. — These disorders, which elinically may resemble a number 
of spuial cord conditions, have been isolated from the mass of rnchial- 
gias of the eighteenth century, aial from tlie paraplegias and myelitides 
of the nineteenth, more particularly by Seguin, Tiirck and Erb. Tlie 
latter, in 1875,' posited a hypothetical degeneration of the pyramirlal 
traets in their spinal course, terming the discAJ^e primary spastic 

■ FJuboTK: Ruriteiy of the Hpiiml Coitl. 

■ Virchowa Arch., vaL Ixx. 



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LATKHAL SCLEROStS 



420 



paralysis. ('har«)t accepted Krb's teachings and spoke of the dis- 
turbance as a spnsmoilic taltcs ilorsalis. The disorder, as iinderstrnKj 
by Krb, has been fnund tu be much less frwuient thiiti was at first 
supposed, as the lateral seh'nwis picture was found to be but one stage 
of a number of other cerebral an<l spinal affections, notably, as in 
multiple sclerosLs. syringomyelia. Iiy<lr(«ci)lialu)*. tumor of tlie conl. 
iiiicmia of the rord, rlitfusc myelitis, senile changes and amycitriipldc 
lateral sclerosis, etc. Of recent summaries, those of P>b' and ^pillei* 
are available. 

Patboloey. Ideally this iinisists of a simple degeneration of the 
pyniniidal tract which rarely ascends to the i-ortex. A repliiceuicut 
glia infiltratiiHi is present. But few autopsies are rccordeil witli the 
ideal lesion. 

Symptoms.— These are exclusively motor, and usually of the lower 
extremities alrme, although the disonier may show itself in the amis. 
The ordinar>' picture is that of a spastic paraplegia, i. c. motor weak- 
ness, increased rellexcs, clonus, Dabinski. spasticity, uith no sensory 
or visceral sigiLs. 

Gradually increasing weakness of one or both legs is first obser\ed 
aft(T a l()ng walk, or dancing, or any prolongwl muscular exertion. 
A rcrtain stitTnejis develops, but very slowly, often tmly after several 
years. The tendon reflexes are exaggerated at a very early dale. 

Slight motor weakness supervenes, and simie stiffness to passive 
motion, and then the patients note that their gait is more constrained: 
ihey do not !>end tlicir knees, but shuffle S4>mewhat and stumble 
easily. The limbs become stiffer and stitTer. the exteiis<ir nniscles 
being more invohnl. this brings ulmut extreme rigidity at the jonits.i 

In this stage, which may be arrived at in a few years, or more irften 
after many, the patient walks with a stiff, stubbing tread, pcrha|)S 
the knees overlap (scissors walk) or knock earh other; the toes are not 
lifteil, but rather shoved along, thus wearing the shoes markedly at 
the toe. 

The cutaneous ami temlon reflexes are exaggerated. There b 
markedly increased knee-jerk, patellar clonus, ankle-clonus. Babinski. 
and paradoxical and Heehterew-Men<lel signs; StrilmpeU's tibialis 
phenomenon is apt to be marked, .'^[•asms frequently i>ccur in the 
affectnl limbs. In the latest stages flexor contractures usually result. 

Sens*ir\' symptoms, save the muscular [jwins of sjiasm, an* absent. 
The bhuldcr and rei'tum are not implieate«l. In rare instances the 
upjM'r I'xtri'rnitics an' iiuol\i-«l. and even the bull>ar motor tracts. 

Tonns and Varieties -I. Hrrtrliittry FitniilinI Tj/jirji (.Strfmipell,* 
Newmark*).— Here the disorder shows itself either in childhood, or 
late in life, and many generations nuty be affected. 

• IViiImIi Zlu-hr t. S'<m-viihe41k.. lOOIf. Kn. 23. 

•CMor'i MiiWm MvdiviM, 3 rd., vol. v; Bono: Kn-. il. Mfd.. Mwdi. IfKM. 

•Areh. r. Pttych.. s, rrii. IWU. > UMiUch. Zuehr. f. NKTenhsOk-. 'IT, 1004. 



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430 



iKsroxs OF me spisal cord 



The synipUdiis are thot* of muscular hypiTtoma, spasticity, exag- 
gerati^l tendou n'flexes. oiitl Inter palsicM ami fiuitrartun's. The 
skin ami iiiial n-flext-;* arc- k-Jis apt to be invulveci in the familial types. 
In some ruses {Neuimirk. Lorrainl there are more widespread disorders. 
optie aln>phy, feeble-iiiindednes.s. luusc-ular atrophies, etc. Deep .sensi- 
bility is oceasionally involved with .sh^ht UonilHTR. 

'ITie changes in these patients temi to bwome more or less stationar>- 
after a eertaiu leiiKlh nf time,' but rlu* disease may extend to the ui)|M*r 
part of the eerelmispinal axis. 

2. Inftmfilr Tt/ju-ji. Infantile types be(:iiininji from tlirtr to six 
years, iire ilue to ((evelopinentnl <lefcet.s in tlie pyramidal .system. Here 
the lower extremities are most involved. The advent of the Wasser- 
mann teehiiic* is relejpttin^ the p-ejiter inimbt^r of these to some 
httra-uterine or earl> syphilitic process. 

.t. VuihtU-rul .\:trniii'tnij nud I)e.nrnuUfUj Ti/jtrx.'* — 'I'he valirlity of 
this type is not yet established. It shows itself as a gnidually pro- 
gressive bemipleKia. suppixswily due to primary de^ueratioii of the 
pyniniidal tracts. 

4. MLreil Tf/ffm. — These previously deseribed as due to syphilis, 
to lead, to lathyrus potsoniiip, anemia, etc., are more properly more 
or less IrreKuljir Tonus of myelitis, and are trcnted utnler that title. 

.'». Ciittfit'iiiltil Titfu- I Little's DiseaseN — This will In* i-nnsidrrerl under 
r)ist'ase-s of the Urain. 'J'lie pyrumidul trael disease is seeotidary to 
other lesious. 

Diaenosto.— Pure types of lateral sclcrosLs arc rare. The underlyuiR 
condition often develops after careful observation, sometimes cxtemlcd 
over .several years. The chief disor<iers to bear in miiifl are multiple 
sclerosis, nmipressicm fnim tumor, aniyi)tropluc lateral sclerosis, 
myelitis, old encephalitis, brain tumor, with or without hydrocephalus. 

Mysteria can Im* readily excluded by the careful scrutiny uf the 
reflexes (Habinski, (Iras^-t, Ilmiver signs, etc.) 

Treatment. — Focrstcr's o]>eralt(Hi, or posterior rutit soctiou, may 
help the spasticities in some patients. At llie present time, nothing 
is known that will .'«top the advance of the disorder. A W'assermann 
examination should be made in all cases, as in s(»me an unknown 
syplijlitic eletiient lias been revealetl. M*ptor training: (Meuseiidieck 
method) will help the patient to control the spasticities. 

COMBINED SCLEROSES. COMBINED DEGENERATIONS. 

One speaks didactically of a combined .sclerosis as a system disease, 
in which the lateral and posterior columns are involved; clinically 
a condjinatiiHi of lalx's and lateral sclerosis. It is a doubtful question 
whether any one disease exists which may Ik* desifrnateil as a combined 
sclerosis, but u Rreat nmnl>er of rotuHtions ure found in which both 

' Boiio: Rev. d. Mfd.. Marc-h. ItKIS. for suniuiury uf lUi iiiaca. 
i Mills iiml ,S|.illOT-: Bull Univ. Ppiiti.. lOOB. 



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VOMHISKD SCLKROSES 



\ 



lateral aii*l posterior rolumiui are fle^eiierateil to a greatek 
extent, ami as a result varyiriK sympiom-pietures arc present 
die i>r the iither Is more or h-^s iniplica1<tl. v 

Thus in true tal>es, (U-geruTHtWiii of ihe lateral (tilninns iidt 
qiiently wcurs; in general paresi? there are typical enmbined seler 
ill many eJiscs of syphilitit* nieniiigoroyelitis, (kitenemlkins nf posterior 
unci lateral i-olnnins iHHiir. likewise in se^T^e anetniu.'t. in |K>isuning 
from IrHfl. (TK^it. jH'ltagm, latliynu. various ha<'terial tind protoMHin 
infections; In thesfiiilreonl similar <-hiiiipe> arc founrl. In fact, a great 
variety of degeiieratioiL'* are fount! in tlte t-onl involving Iwtli sets of 
eolnnins to n greater or less cxtrnt. Sano pn>(MiM.*:i lo tliviile this group 
into the psmidiksystfrn <li.s»'nst's niul the pnlysystcni diseases.' 

Whether, as Westphal first maintained (IstlT). there also exists in 
this niotle>' medley a true system disease of these eolumns is not yei 
a settled que?ttian. Among this large group, however, certain clinieal 
t>*pes stand out, whieh |>ermit of mi»n* or less cIpar-iMit deseriptitm. lu 
prac-tie*' they an- s^'paratt-d one fn»m ani>ther only with great ilifTienlly. 
By Ix-yden and lii>s*-hool, most of these i!isordi"rs Ufn-classtil with the 
I'lmmie myelitides. IleiuieltiTg' uses tin- lenn funii-idar myelitis for 
one group of non-sysU"ni eomhintHl <|(-gri)(Tations. These latter are 
usually due to IdtMHi changes, and should Ih- elussed wiih the myelitides 
rather than with the eondiineii srlrnwes. 

The more fixtnl of thf <-MndMiie«l scleniscs t>i>es which are here 
eonsider«l are: (1 1 eoniluntil selcrosis (atAxie |Niraptrgia (VVestphal) ), 
and spastie paraplegia (Slriimpell) forms; {'!) genemi pan-sis fomis 
(see under (h-ihthI I'ari'sis); {'•\) toxie, nneniie forms; (4) senile fumis. 
ThiTearc Illarl^ iiUtrinediary form>. 

I. Combined Sclerosis (.Vtaxie i'ftrapk'gia (Wesiphal) Types). — 
Here the eharaeieristie features ore those (rf a spinal tabes, with some 
signs of 8pa.sticity. i. »•., Hahhtski's reflex, and a crawling rather than a 
typical tabelic gait. Ataxia, pains, bladder ilisttirlianccs, sometimes 
pupilliiry stiffness, etc.. indicate that the nieningnncnritii- element U 
predominant, the p\ramidal tract involvement of less marked extent. 
Pertain patients start witli lypic-al ataxic signs, then gradually develop 
H[Misti(-lties and tin- spastic element fiiuill> l>ecomes pred(»tnlnant. 

Spastic Ataxic Type. Here the spastic element enters predominantly 
into the picture. Weakness precfnles, the gait then beiiimes stiff, and 
the toes tirag; there are Increased skin ami temlon reflexes, just as 
in at>7jical lateral .sclerosis; then |>«ins ilevelop; radicnhir sensory 
distiirbunci-seimuneiiif; the knee-jerks l>eeonie diminished; hyjmtonia 
griiduully takes the place of byjK-rtoitia; one h-g nniy Ik* hypotonic, 
the other hy[>ertuni<'; vi.-^eeral disorders are added, and ataxia and 
Uomberg are present. I'ns^ibly there is ailrled optie atniphy, or 
pupillar>' stiffness. N.V'stagmus i^i not mfretpient. The Uabinski reflex 
is apt to |M>r!ii.st. 



Dull. 4e YAfiX. ^v. tie MM. '|r HHic. \^U, 



* Arch. r. P.. 40. lflU>. 



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4:V2 

Tlir itHifM-iii Imtli funiis, nf which tht'tcan? all iMwsihlr firadiitioiis. 
13 rhruiiif. ('(implctp disuse of the iowcr limbs follows. The patients 
arc bo<l-ri<lden with contrarted. Hran n-up limbs. TwitfhiiiKs. spasms. 
BIhI lird-s.rf- -ii[>rrvfii(\ 

2. Combined Sclerosis in Paresis.— (See Paresis.) 

3. Toxic Anemic Fonns. - Here one may group a motley army of 
rtHnbiiKnl >*lenis4's. These arc due to pois4>iiiii}( from thelcpm barUlus. 
to diabetes, to Inthyrus, to peliagni, to cr^t, to alcohol, carcinosis, 
malariit, chronic septic states, pathopenie protozoa, tultepculosis, 
Addison's di.^asc. anemia, lenkemia, etc' 

The anemic types offer s|>ei'ial feutures, especially tiiosc of i>enitoioiis 
anemia.' The anemias may he of nianif<4d pathogeny. They arc 
infrc(|uenl. The patients complain of parcsthcslie of the extremities, 
there Is slight paresis and frequently some ataxia which latter is prone 
to increase with lofvs or increa.se of tendon reilexe.s. deep .sensibility los.s. 
In the spastic types the knee-jerks are increaseil with clonns, Habiiiski. 
and increased knee-jerks. In the ataxic types there is a trend toward 
loss of n-flcxcs, cti'. The spinal disorder in the pernieions anemic ty|M's 
Ls profjressivp, and the patient dies in a year or two with great emacia- 
tiun, cachexia, and prustnilion. The precise relationsliip between the 
spinal changes iintl the pernicious anemia is not definitely understood. 
Other types hiivc similar s;Mnptoms hut \'ar>' in their cf)nrsc. 

4. Senile Forms. — Slowly projre.'^sinp weakness of the limbs, with 
numbness, palsies, and stiffness is frefpient it) many <ild people. There 
devehips a shufiling gmt, and gradually a mon' or less cfimplete para- 
plegia with incrcaseil rcflexi-s, Rabinski and clonus. The tipper 
extremities sluan* soniewhat in the feebleness, tremor nnd spasticity. 
These senile myelopathies are very obverse in their nature. l.'Her- 
niitte' finds (I) perivascular sclentsis, (2) marginal scleroses, and (3) 
combined scleroses of the pyramidal and iM>stcrior tracts. I'ronzon 
has found in this last group, iHiretospasmtKlic. ataxospasmodi'C, and 
ataxo-cerebello-spasmodic t.\i)es. 'I'hus it may be seen that the s<'iiile 
con! iiffci-s a great variety of patliologieal changes with ii large M-ries 
of elr»sely related clinical pictures. 

STRINOOENCEPHALOMTEUA. 

Historical.^As long ago as 1jG4, Eticnnc described cavity formation 
in the spinal cord; it was further recorded a hundred years later by 
IJonet (KiSS) in his celebrated Sfpufrhretniit. Morgiigni nr-lO} ami 
Portal (]S(X1) saw and dcscriljcd cases, jind Ollivier.of Anglers (18:i4), 
first gave the name .syringomyelia to what had been taught by Eticnnc 

' For lilpratuw to 10U3. w«f Sano. I. v. 

»Lul>e: Dcutwh. Ziwlu. f. Ncrvmhwlk., IHH. xlvi. afltl; Lirhlheuu. l*S7; 
Fiilnam and Dniin: Jour. Nerv. and Ment. DU.. 18ft] : Minnich. l&t>2: See Nonne 
for (jilTpmnt typn. Uoutsrh. Ztschr. f. NvrtTtihHIk., IKUS. 

> Th^«f t\f Pnru. 191)7. 



L 



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XYRISGOBSCBPHAWMYEUA 



433 



to be a persisting central cnna). but which Ollivicrclaiuictl vas a jmtJio- 
loKicuI funuatiun. 

The stiidicr:^ of Gull, of Landau, and Noiut, with those of Stilliiif; 
ftiiH Wjildeyer. first ga\'e the impetus to the (H>nTlation of the ana- 
ttunicul lesion, and the cliniral s^nnptoms. Dut-lienne lh\ IH5:t) tliun 
ealltil attention to eertuin musiular atropines with sensory anomalies, 
whieli dilTentl iiiarkedly fnmi llie diroiilc mii^-ular atroplui"^ he was 
descrihinK; hut it was not until as late as 1-SS2 that hoth Kahk'r and 
Schnltzc hroufiht out the factors that pennittcd a diajrnosis during life. 

This marks the periixl of active neurological interest in the disease 
with a sudden growth in its sjinploinatolog>'. Wiehmann (IS.S7) and 
Anna Haumler (l>i>i8) published monographs, the latter collecting 
1 12 cases, 

In the six years following, up to the appearance of the first edition 
of Schlesinger's masterly monograph, contributions appeared fn>m 
cverj'where, and the rclatc<i subjects of leprosy and Morvan's disease 
took on an active interest. Scldesinger*3 (IMM) monograph fixed the 
lines of re,««arch. which are shown in his thon^URh ami mnnumenlal 
aecoiwi edition of M)02, a monograph of simie liflO pages, since which 
time few striking additiiHis have been made. Kaend's eiaitnbutiou to 
Lewandowsky's llnndbitck gives the later literature to Idll. 

Etiology. Men arc more fre(|ucnlly afTeetcd than women, in alnrnt 
the projK.rtinji .»f 2 to 1. Alxmt 70 jjer cent, of the cases occur before 
the age of fort>-. the greatest age of incident being between the ages 
cif twenty and thirty. Tt is not knonn that occupation has any In-ar- 
ing on the etiolog,^. Toxic factors are not proved; infections may 
play a role in eaiising ciird hemorrhages, enibnli nr thrombi, with 
secondary cavity formatiou St-hlesinger l>elievcri that in such develop- 
ments the cord was not previously normal. Syphilis may Ik* sucli an 
infecting agent, also the t>'])hoid bacillus. Syringomyelia In mother 
ami son, and in different members of the .^ame family luis t>een ohserveil, 
but Sblrsinger did not note any hereditary' history in any of his 
lUUiieroUM cases. 

Traumatism imrhMibtt^lly plays a role. Ilematomyelia dcvelo[)s 
after spinal tnuimata, and then may give rise to secondary cavity 
formation. Kienb(»cb. lutwevtT. has followed many of these cases of 
tnunna and rarely found any i-oik^equent syringomyelia. IxK-al trau- 
maUi witli a.swnding neuritis have p<i«sibly given rw' to later deveJoping 
syringomyelia. Leprosy may also condition a syringomyelia. 

The i-s-seiitial feature l.c an organ inferiority. The various factors 
]ust enimiiTati*<l arc pun*l,\ i-niitributory, either singly ftr one or more 

tOgl'lluT. 

Sjrmptoiiu. — Ijkc multiple sclerosis, .syringomyelia Ls chamctenzcf) 
by it*t extremely rich anrl variable .symptomatolog)-; like thi* disonler 
alao, almost anything is to be e\|MVted, since with the gradual incniaw; 
in extension of the cavity formation in the cord, new arM<i become 
involved, am) older boundaries enlarged. It is therefore a disorder 
28 



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skill and joiatsi (3) motor disturbances either irritativi' or paretic iu 
chamctcp. Not all of the nases slmw tht*se s\'mptonis. hut iiiasnitich 
as die cavity formation ]> apt to ocfup> certain portions of tlic con! 
more often than others, this grouping of symptoms occurs more often 
tlian other gnnipings. 

1. Sriigory Di^wcialion (Kahler. Schultze).— ']"hi.s consists in a loss 
of ahility T<i recognize :^nsations tif heat juhI <-o1H and sensatioiiH of 
pain hut witliniil any liis> i>f touch, espttialty of epicritir ttiiirh. 

■ lliis dissrM>iHtion varies irm.sii|erably, U may I«* absent. In one 
patient or in one area the (hernio-aiie>>the<<ia is very pn>found, the Iosa 
of |Niin sense less s<j-again. in others, the reverse is true. In the 
majority of patient-s the loss i> only a partial nne. not an absolute onr. 
Most c-ase.s if seen early eni»ugh will show only slight re<luclioiis — 
epicritic heat and cold arc lost before protopathic heat and cold — 
sometimes the reverse is true, ur therum-«iie«thesia anri analgesia 
may W- prewut un one side only. Again heat or i-old alime nia\' he 
affectccl. Kpicritic touch nnty be involved, but it is not usual. 

Thi*st' wnsory anonnilies may l>e distributed over very small areas, 
rarely bulbar (mucous surfaces included), most often cenical; op 
lhc,> may extend almost throughout the entire spinal axis from the 
trigcminiLs to the ^-iiuda (loss of testicle pains, and analgesia of the 
bladder, etc.). 

'I'lic areas of diminished or lost sensibility to heat and ftain are 
usually bilaterally asymmetrical, not infreiiucntly they are unilalernl 
for a time, then !>pn'ad to the opposite side. They show the nio>t 
uiiifpic distribntioiL'*. The distribution may be exquisitely mdicular; 
again, it is prt'rlominantly si-gmcntal or nietanieric. Si.'hlcsingcr's 
most recent rescanhes speak for the segmental type of disiributiou 
for the majority of the ca.«es (Fig. 251). 

In thr beginning, one frequently encounters the glove atu) fttorking 
ty|)e of sensor\ I'lianges. \jttvT u whole limb will br invubriil; ilu-re 
may U' ginllc •sensation. A hemianalgcsiu, or hemitlicniio-fthesthe:iia 
UIH.V be present. Allwhiria is usually abwnt. 

The sensory changes usually take years to develop. This scnwory 
diss4K'iatii>n is frequently pre<.-eded by puri'sthesiK- burning pairh-t, 
c<i|d siM'ts. neuralgia-like pains, etc. Position sense is rarely involved, 
even in the advaiicwl cases. Tactile agnosia (astereiiguitsis) i.s rre<|Uent. 
The l>oti\ .s*Tisihility is very freqiiwitly involvetl (Kgger). It may also 
be, although rarely, an initial .tign. Deep preHsure sense in often 
ilivolviil. Koinberg ami ataxia an' naturally nut infnfpieiit. 

2. Mti/icular jUrophkn and Oth-r Trojihir rAo/f^*"'.— '1 licse changes 
(.M-<-ur most often In the small musch's of the hand (ulnar distribution), 
and of the arms. 'Vhxia are produced typical claw-luind.i. which develop 
ftlowly and Insidiously. Here, again, no absolute rule is followetl. Thi* 
inti'niHset niii\' atro[>hy first, or tlic miisclf-^ of the thcnur ur hy|M^ 
thenar enunmci's. A (meillan) typical monkey atrophic haml ii)n> U- 
present, or tlic "preachrr-haml." C>r the almphy in the hands mnv be 



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LESIONS OF THE SPINAL CORD 



skipped or combined with that of the shoulder-girdle (Aran-I)ucheniie 
types), the wings of the scapula stand out, etc. Atrophy of the 
trunk muscles results in various distortions of the spinal column. 
Pes equinus, pes valgus, etc., occur in the lower extremity, though less 
frequently. The bulbar nuclei may be involved, causing speech dis- 
turbances; and these may be initial symptoms, though infrequent. 
Cerebral extension is even recorded (Spiller). 




Fio. 251. — SjTingomyelia, ehuwiiig the dtasociated loss of sensibility. Areas of loss of 

seosibility to pain. 

These atrophies are usually progressive; like the sensory changes, 
they are usually bilaterally asymmetrical, and show much variability. 
Thus one may find a daw-hand on one side, and a monkey-hand on 
tlie other, etc. 

Reaction of degeneration varies, being present In some and not in 
others. Increase of electrical excitability is present in others. 

Fibrillary twitchings are common in the degenerating muscles, and 
even more active movements are observed, consisting in static tremors, 



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SYRIXaOESC/iHH A LO U YRUA 

L-liumc-likr iiuivriiu'iit:^. iutciitiuii tn*uiors, or |>iirnly!<is-aKitiiiis-liko 
trmu>r.H. <'rain|i» arc iml irifn-tiiiriit, am) ]M-(-iiliar iiiyntniiic coiitnic- 
tiuiitt. 'llii'se irritatlvi* uiutor ]ilieriimit:iiii Ik'Ioii;; ntore to the curly 
stageH. 

Tlic riHitori)f»w(Tis iiriirornilyiliiiiiiiislieil with ihf it)iis4.ii[ar ntrophy, 
oiii) spasiii iir c'initra<ti»ris am! rigidity iimy be pw^^'nt. Spa.stk-ity 
h not iiifn-quonl iii the lower i-vtretiiities. This only argues for 
pressure UjKin or involvement of the pynuniilal tmets by the lesion. 

The gait is not infrequently involve*!. The patients tire easily; 
they commence to walk more slowly; hcmiplefric tyiH'S. paniplenic* 
tj^pes, patients beni to one side, or bent strongly forwanl are seen 
in the later sta;^. Ataxie and tumbling gaitH belong to the enriosities 
with rare Imlbar hx-ali^jitions. Seblesiiiger re]Mirt.s a large variety of 
rare anomalies. 



l-'lu. 2A3. — SyriuipMuripUft t"prmliiti-r liiLndi<"). 

Trt/pkic Dw/ur/wm:**.— Theae may l>e many. They may vary in 
numl>er and extent in strict ac<iinlanee with the invoh'ement of the 
trophic cell^ in tlw cord. 

In thi- skin one finds byijen'Oiias, either activi- — iiHopathrc cunges- 
live erj tbemas-or iiassive. witJi the foruiation (»f dark nil jiatihes or 
various patches of a dark blue color— cyanotic. These ehnnf^ are 
usually assfjciated with others of the muscles or of the bones. 
Cutaneous anemias himI cutannMui edemaH (sueiiitent hand), with 
or without dbitinct Itaynaud sx-mptoms, may ix-cur. The glandular 
ortivities of the .-skin also Nuircr. The iwrspiratioii niay be absent, or 
execHsive. or one eiK'OUnters curious anonialtes, such as increased 
pi^rspirnrioii to cold stimuli, or islets of iiicrenMxJ fienpiration in nonnal 
akin, or ixTspinition-absent areas. These arciujof altenxj perspiration 



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lj?.^/o.v.'7 Op thS snxal conn 



slum- aiioniiiloiis ilistrihiitiiiiis c|iiiti^ <-nnipar»l)le to those seen in the 
sensory spliiTc. <.'lijinjri>s in tin- fiitlj st-cretioiis mny he ItMiki-)! Fur. 

Chniiiirilrrniiitost'&nrc also t*iK-ouiitvr*-<! with cxiirhitivt- phriifininiH; 
urtii'urins, an^nuiii'urutic manifcstutiou^, phlyctt'iiula', ilermatitis bul- 
losa. Ilcmorrhapic inHltrations, or even ulcer and ^anfjrtTir of the 
skill arc known. True hypfrtroiihifs, sch-roiliTnins ;uwl chuiiju'.s in 
the iiuils are reronliil. 

'I'he bony structiirts uLs(» siifler. Arthmpathies are commnii (10 
piiT eent. — SnkoUtfT; 20 per t-eiit. — Schlesinger), but mnre iiften in the 
!i]>IH'r rxtrfinitics. In i^harp contrast to tlit- lower linih distrihutiMn of 



Kim. y5S. — SjTiiiKMiiij'i'liti. ^liiiwiiJir lln- ^'llr^a^vln' ol (In* liiict, ninl itw.' alr'Ji)hy of 
the ainiiU nniarleft of tlip linnrls, 

talKs. They nsually iitrcur late in tlie disease und pcrsLst for many 
years. The onset is nsiially acute, with pain, swelling, and destruction. 
Miltl cases v»n>*: little or no clef«>rinity. Roth atrt>|j]iii- and hyper- 
tropliic rhonpfs rxi-nr, wltli fixation of x\w jiiirits. disloeatluiLs or fraet- 
iirt's. Tlic sensory, secretory and tniphie disturbances aix; tisually 
ill closely related areas, imd bony sensory anomalies are to he expected. 
Occasionally suppurations occur. 

Bony changes in the x'crtebra', with thorax deformities, occur either 
as a ctmsetjiicnce of arthn>|>athies, iir as muscular atrophies. These 
scolioses occur usually in the upper dorsal, and give rise to comjien- 
sator>- cunntures. 



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Vhi. 'JM. — Pouiiuo Nynilmme. n-illi vy« imImim u( esDlml tmgia nixl o-riucuiMyHie iti»- 
Kuoiallxn, Tlti-rv b hmtr * cronml trnnmnratlMMfi with aJtcnuttiiiK iMintlyiiM ■>! ihe 
VI Mid Vtl rrntiinl iwr\-f«. anmtlKwi'i of the V u«rr« duv t'> heiii'itrliHiR- in the iMtvntl 
■od tow«r portion of tKc poDlloe Umncntuni of the loft tidis. Th(> riffAZ-^Dnrf AruM 
ahnwa till! li«iui>iint(ht'3Ui, UtMiwiAtrd M in nt/ri'tifumu'li't (hMtiuLiuditvHui tutd ltL*ini- 
tbrrntnnrAttvaiB dni^ in It^nti iif ihr rrownl aftwiry \vnhjvnya of lltv l«t(>ral portHiti nl 
iho n^tt'iilni UmtMtion. Ttwrr i* i>T«>M>r\ ud'xt of tlx' tAriili' uiid [io«tiiral sMMUiilitiea 
nnd of the >it«retigniMttic MtUM*. Ijccaune uf tiut iunmntleut rxlf([»tiin f>l thr lonin bo ibn 
modiui IcmoUK-UM fftm). The kft-hand fiaurt «buws 11) »ln>pltii- (fitnJyMa of the VU 
nsn'Q with raartiuii uf dntBtuwatiuii, to<pphUttlini». ilruopias of t)ir> ll|w, Iom o( tmcM 
RilmirT>-, pnnUyma of tb» •ndrv Ml facial (Vtt) indicated (Fi«. <i): t3) atMMrtl»«M« of 
iha facv, following invulvmnvot uf tbo dcwepndttis root irf thr (riacnuntu (am V va aOi 
13| pandyvifl of the i>>t«nul nxtaa with conveti^Dt auahiatmu by nmmoa of the ovir> 
mttioa of tbo aiitacoiu*t>- b\inb«nnurv. tbrra u a pftraljMa of th« Utaral aMvaoMliI* 
flf lh» ayvbalb toward tho left notwithnandiiiK the integrity of Ih* poatarior longlMdllMl 
laarfeulua iFlp,). of th# ouctout of ibe VI and <>( the adlaMut rttimUr lownalJhn. The 
Uwinn of Delkini' tiaHou*. aim] d4 iho latiyrtitthiiM? umlurMAry Sbara which luiita DeHcra' 
DU«l«u» <V/>1 to tlx* i)iii-lri <if xlit 111 Mild VI rausoi thin. Hy roasiiit of tbo ovMuction 
nl the lUilAC >!■•«('• thr jintient lr>nk« li> (he rtBhi. tAtt»f Dejrrinr.) For ntiltn^intUitM 
of ihn atnltuiiical akMrh trr Mi'linn nii Midlintin. 



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LE.VOXS OF THE SPtXAL CORD 



ThM biiny jttriK'tiires ofaii eiitirt' limb ina>' be involveij — li luu»l nr 
a foot — with utnuililfs uf llif iniist-li's. MiTiMicnHin-jiHly is to Ih' riiltil 
out usually f>y tin- tlfforiinvl. ciMitructt'd rmturt' of iIr* t*\ rinjioiiiyelic 
hand or fiKit, tlic itiHrkfd iiiusciilar atrophy, and tlir isolatttldianu'ter 
of tlie limb iiivolvi'<l. Syriiij^ohulhiu may caiisr a facial hemiatrophy 
or ht-mihypcrtrophy. 

Ufflexre. — (ireat variabiHty aiul fhniipoHhility is prcsont. Tlie skin 
reflexes vary from i-imipletc hiss to rxHfjKeratioii. 'riic Ilahiiiski reflex 
may or may not he present, as well as tlte abdominal, epigastric and 
crejiiastcrit.' reflexes. 

The tendon reflexes are often striking in that one reflex in tiie arm 
for instance will be lust, the others present^ or even exa>rneratod. The 
same holds true in the lower extremity, but is less striking. Increased 
reflexes are here more apt to be foimd. hureased knee-jerk, Achilles- 
jerk, and even ankle-elonns are not iiifn-tpiciit, particularly in hish- 
lyin^ syrinfiomyeliHs — bidbar, eerviciil and upper dorsal. Lost knee- 
jerks, unilateral or bilateral, may alwj occur in syringomyelia, either 
lus ail early or a lute symptom, and. may be associated «itb increased 
skin reflexes (Uabinski). 

Rare cases are enconnteretl with increased jaw reflexes. 

I'ljurntl Sj/ni]ittiinn. — Hladderdistnrlwnres urenoT the rule, although 
at times appearinp. usually Inte in the disease. When appearing early 
they are apt to be transitory. 'J'hey may be sensory or motor, irrita- 
tive or paralytic. Cystitis is not infrequent ui the later stages of the 
disease. In syringobulbias one finrls anomalies of secretion, polyuria, 
'glycosuria, diabetes insipidus, pollakiuria. 

Obstipation is not uncommon; incontinentia ulvi less so. Los:i of 
sexual power and of desire also occur. Persistent priapism is one of 
the curiosities of this disorder; also analgesia of the testicles. 

iitilhar Spinptijiiis. — Tliese are frequent, when istdaled, being 
then termed syringipbulbia. They arc usually more benign than when 
found in other afTections (ehronie bulbar pidsy), have a ver>' chronic 
ctjurse, are usually unilateral, and often ioiplicate tlie vagus. They 
occur in about one-third of all cases. Certain affections of cranial 
nerves have been reconle<l for many year.s. Smell and hearing ure 
involved rarely. Vestibular vertigo is alsr> rare. A dulling of the sense 
of taste is not infre<|uent, and shows irregularities of disturbanw — 
half-tongue (DejerineJ; dissociation (Ilitzig, Simon) — ajiteroposterior 
changes. 

Optic nerve atrophy or swelling of the disk occurs in advanced 
bulbar cases; a few cases show rcstricliou <if the color fields. The eye 
muscles may show nystagmus or nystagmoid movements, i>anilyses 
and sympathetic complications. II. Simon reports an interesting case 
of nystagmoid movements with both eye^s, absent when only one was 
in use. Schlesinger reports transitory diplopias in 1 1 |x'r cent, of 
the cases; they art* not infrequently early signs, and do not necessarily 
recur. The abdueens is fretiuently iiffectcd. 



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I'tmis is nut iiirrvfiueiit. »iitl is oflvri an iinptirtiitit nirly sijjti, It.> 
rflfitinns to tin- sniipnttu'ti'- nrc iiitinmtc. Myi>srs Is FdiiinI in a siniill 
IKTcmtaja' of nist-^. uiwl (lillcrfiicfs in ihtr pupil art- frwiucnt, ai least 
25 per cent. iSchleslnBer). 'Ilicy arc mostly due to syiupatlietic 
palsies. A r>:;.vl I- Robertson pupil has been observeil, but chiefly in pre- 
Wasiwrmann ijays. iHMice theabsft-nre of syphilis has not been proved; 
its presence in syriiiiKuniyflia is anatomically conciMvable. 

The Klumpke syndrome is frequently met with and points tn the 
upper dorsal localization of tlie lesion. Myosis, diminished lid aper- 
ture, retraction of tlie bulbi. and anonialous pupillary reactions (loss 
of eoraiii dilatation, etc.) are sipis of .symiwthetic involvement. 

The trif.'eniinus distribution shows sensory anomalies, either a.s 
paresthesia.' and [lains (tie dnulimreiix) nr as analf^ia-, with loss of 
the trigeminal reflexes and corneal trophic cbaiiKes. I )issoeiati«jn in the 
tri^niinal distribution is also observed. I*aiM and lemiHTaturr are 
mostly atrc<'tcd. Deep sensibility is less often involved. 

The facial is involved in but few cases (11 |>er cent.) but impuinneiit 
of abUity to swallow is not infrequent. The tongue is involved, pro- 
jects to the paretie side, shows fibrillar>' twiti-hinjj, and hemiatrophy. 
The srift palate ami laryngeal musculature is often involved at the 
same time, which witli llie loss nf stai-sation often cnus<'s deglutition 
pneumonia. 

I^ir>ngeal palsies are iiJrequent. They are eharacterized by the 
palsy of one recurrent nerve, and the usually acx-ompanyinK homo- 
lateral palsies of ihe pharynx and soft jialate. Posticus |>alsy and 
homolateral bulbar palsies ^o hand in hand. From \h to JO percent, 
of all syrinKomyelias have laryngeal sj-mptoms which not infre- 
quently antedate the other bulbar or cranial ner^'e symptoms. 

Speech disturlmnn-s an- cuiiirnoii. as one or other of the relatiKl 
mechanisms are apt to be invoh-ed. Itecurrent palsies give the hiKb, 
ni>piug voitr, tongue involvement, the iJiick, hul-potulo si)eech of 
the bulbar paretic; palatal {>alsies cause s "nasal" voice; occasion- 
ally & scan ning-l ike sj)eeeh is observed. 

Tachyeanlias, braiiycanlia-s. and dyspnea are anions the rarer 
symptoms. 

Apoplectiform or epileptiform attacks have I)een described, and are 
sufficiently frequent to attract attention. They, however, arc usually 
awompanied by signs of vestibular involvement — rotatory* vertigo, 
uystagmus. vomiting, etc. 

Mental .S'j/r«;>tomj.^.SjTingomyeIia is often associated \nx\\ chronic 
h^'drocephalus which two ootiditions arise simultaneously, Heredefect 
symptoms in the form either of debility or imbecility are present. 
Other patients are reticent, surly and vindictive. Sfany patients 
come to develop a totally perverted feeling alxiut their anestlicsiw, 
unalgesiie, etc. and eamiot be eonviiicetl regarding its true character. 

CooTM uid Profress. — The great multiplicity of symptoms, and t)>e 
almost fortuitoiLs sittmtion of the tumor and cavitv formation make it 



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im|)ii»sil>l<.' Ut f^TiicTftlixc tou .simrply aliout (he syitiploin );nitipiiif;s, 

l>\it ill K*'>ier(il fine c-an outline four intirt' or Ics-* rlassii-jij ly|R-s. These 
«rc thi.' bulbar, tin' tt-rvk-ttl, tlir dorsnltiiiibar, am] tin* sdi-nibinilmr. 

1. liuHuir TiijH-ti. — S}/n'titft>hulhia. If rcstric-ttti snlely tii tbe nietl- 
ullary legions, tbis is the Itrast common uf tin* typt-s (Schlf singer). 
Bulbar syinplonis, however, are very often foiim! in the otlier types. 
[ii this T\ pe the lesion is limited to the cranial nerves. T\k' lurynseal 
jialsies are prominent; difticnities in swalJowinp are present, either 
transitorily or persist tint ly, ami cause death. .-VtropJiy of iln- tuMj;iie, 
ant] paresis of the m-ular museles an- fre(|i]ent. Sensory fiisturhaneea 
in (In- region of the triKeuiinus are frequently ftiund. 

Initial .tyringobulbiaa, in eontrast to thtise developiiifc with or fol- 
lowing spinal si^ns are not as dangerous to life imt **r. 

2, Cervical 7'j/Ar.^This h the commonest and Ix'st know-n. The 
patients first eomplain uf wt-akness in the small muscles of the 
hand with c-lumsiness for finer movemeni.s. Paresthe-siie an<l paiiw 
are frecjuent in the hands Hml arms. The patients frc(|ueiitly Iium- 
se\ere sort's on the hanrls from IwiiiR wonmled nr hurnitl, and then 
note the advancing analgesia, muscular wasting, and loss of ability to 
teEI hot from cold, analgesia*, total or partial, with intact touch sense. 
The difficulties are Hrst unilateral, and later spread asymmetrically. 
The knee-jerks are apt to Ije exaggerated. .Xdvanring disease shows 
itself in the greater atrophy, with claw-hand, preacher-hand, monkey- 
hand, and the whole slioul tier-girdle may show involvement. The 
knee-jerks are increased, clonus and Bablnskl may be present. There 
may be begiiuiing scoliosis or kyphosis. Trophic disturliances in tlie 
upper extremities appear. 

;j. Jhnulumhar Type. — Strictly localized dorsolumbar types are 
rare. Here the t>7>ical syringomyelic sensory anomalies are met: with, 
Paresthesitp, paiiis followed by analgesia, therrao-anesthesia, preserva- 
tion of touch, kyph<»sooliosis are fretptetil. The muscles of the [K'lvic 
girdle become involved and tlie lower extremities show atrophies and 
deformities. The Klunipke type of s.i.'mpatlietic involvement is seen 
here as well as in the preceding t\pe. i. c. unequal pupils, iiieipiality 
in the pal|>el>ral fissure, recession of tlie eyeball. The gait l>ecomes 
spastic p!irc-tic, the tendon reHcxes usually increased- at times lost. 
(lirrlle sensations and involvement of the bladder and rectum are not 
infrequent. Secretory and trophic anomalies, already noted, point to 
the localizHtion of the process. Many of these eases Hosely resemble 
tumors of the cord. 

4. Sacrolumbar Tv^jf*.— ^These arc rare Ij'pes, and are characterized 
by muscle atrophies, especially of the Iowlt extremities, and the smaller 
muscles of the feet. The glutei may also be involved. Segmental 
sensory di.-iturbances of the perineum and genital regions of tliedit*- 
sociateil type referred to are present. Tn)phie disturbances are usually 
proFtiunii anil extensive, such as fractures, ulcerations, running sores, 
etc. Vasomotor disturbances are present. The tendon reflexes are 




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ii.simlty tncTeji.s<Hl. Habinski niii.v In- prcsenl. UIh(Ii](T uihI n-ctiiin 
aiT itstirtlly iiivotvud. ('ontrHcttirfs nre pommoii. nml kyphoses and 
scolims^s <H'C(ir. 

Chontcierintir Grvnjnnga. — Not uuly do iTrlain t,viK*s ^sUiiuJ out, 
ciiinlitiinitNl Wy tlir tnimgrwphy <if the intranie<UiItnry lesion, hut 
certain i-usis sliuw prt'iltHuinimt rtirni^ uf Ic-sjoii. sui-h as motor, M'U^iry. 
trophic, nr secrctorj-. Thus certain casc-t rcaemblp aniyoln)phic- lutcral 
sclerosis very clii«ely; others ngain ha^'e ihe ftencnil fcaturi'i uf a 
spastic s|)iniil |>aniple^ia, others H^'in shiiw a churn rteristic Aran- 
Diicheinic si-apulnhumcral atrophy. A few cases nf gcni'nil »m.'wthe-'si,'i 
are on riH'4)r(J, and ccrtnin seii-sory t yjies may Ik* confnscd with liysteria. 
Trophic cases witli an isolate*] picture uf Morvim's disease arc striking, 
and tabetic-like forms are likewise puzzlinfc- .SchtcsiuKer also calb 
attention to a piich\-nieningitic t>-pe. 

'I'he illustrative case of Sohniitt and Haral»an. which is not unique, 
sh(»ws the striking varluhilit,\ that may Im* i»resent in the synipi*>in- 
atnlnK>' of thin disorder. At varitius times this |>atient was diag- 
nosed by competent authorities as tal)es. chnitiic diffuse myelitis, 
am>otn>phtc lateral sclerosis, and spa-stic [uirapU-Kia nf unknown 
cau>jitiou. 

Diflerentiai Diagnosis.— The chief disorders that come in review 
are atypical multiple !tclerosi», amyotrophic lateral sclerosis, tuinor of 
cord with spastic paraplegia, tliffuse sclercsis, pn>Rressive muscular 
atrophy, central myelitis, .syphilitii' menlngomycliti-s, jMily neurit is, 
lcpn)sy, prilagra and ergotism. 

The nn/nif of the disease is ver\" chronic. Lari^ cavity formations 
involving areas controlling the functions of the intestines and bladder 
soon lead to death in from four Ut aix years; whereas If the lesion 
does u<»t compress the entire c«jrd and lies «)ut.side of the more vital 
nuclei the {Kitients may live thirty to forty years. Mejerine has 
reported a case of Kfty year*' development. 

The patients die more often uf intercurrent disea^'; tuberculosis 
in partictdar. Bladder itepsis, with kidney eomj^ications, is also 
fretpient. 

The patients frequently sliow an up-and-<lown course, quite analo- 
giins to the course seen in multiple sclerosis. 

pAtholocjr. — Syringomyelia, pathologically speaking. Is Hue to, a 
ca^'it>' in the cerebrospinal axis not in genetic relatimi tn the i-entral 
canal — (Hlatations of this latter structure are lietter temietl hydn>- 
niyelia.s. (.'avities due to hemorrhage an* recognizwl as lu-itig dilferent 
from those in syringomyelia proper and are classed with the hcmato- 
myelias. On opening the spina) canal, which is rendered diflieuli by 
reason of the vertebral deformities, the dura is usually found to be 
normal; occasionally a pach\ meningitis complicates the picture. 
7*lie pia is iLsualty thickened, onti evidences of swelling or of some 
internal irregularity are seen either as [taths of grayish degeneration, or 
cj'sti^'-like irn-gularitie^, with flattening in pliuvs. Tlie posterior 



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fissure frequently appears deeply sunken in the cord, causing, as 
Thomas says, a iioul>lc-hiirrclU'<i. shotgun appearance. The (x)rd 
collapses on euttinj; and clear fluid escapes. Ilepeated section, beat 
made afier hardening of tlie cord, shows the txistence of one or several 
cavities, of variable lengtii and diameter, and occupying various 
situations in the cord. Its most frequent site is behind the neighbor- 
lifHxt of tlic i-entrul canal, usually involving the posterior conitni.ssure, 
u]id with a tendcuc.\ to reach backward more tliaii forward. The cn> ity 
seems to hove a spet'ial fibrous wall, which is well limited, smooth 
or papiUated; often a ghoinatous ma.s.s fills Uie lower end of tiie i-atuil. 
In the hydromyelic type the cavity is round and usually occupies the 
center of the conl. The cavity is lined first by a layer of epithelium, 
and is surrounded by a fitinniatous wall. 

In the syringomyelic type there arc idso sonic ependymni tvlls, 
but tliey are leas regularly arrangt^l. Tlit^' are interspersiii with 
neuroglia celb and rest upon u solid wull of gtia cells, many of which 
arc in pnK-ess of disintegration. .Small vessels are frequent, among 
which may be found many undergi>ing hyaline degeneration. Tbe 
picture is different at every level, and in many sections the cavity 
hiLs no lining at all in place.s, iMmiering directly upon the nervous 
tissues, rieetions thningli the glionm show perhaps no cavity at all. 
Fresh hemorrluigic remaint^ of old hemorrhagic foci are frequent 
findings. 

llie glioma may Ik* sharply delimited -central gliositi or (he 
ncurogliar tissue may infiltrate the cord in all directions — dilfusc 
gliosis. 

.Secondary degeneration in the parts impinged upon or invaded 
takes place by process of atrophy and then of tissue replacement with 
characteristic neuroiiophngia. Regenerated fibers arealsf»encouritere«l. 

In cases complicated with pachymeningitis one fintls tlie lesions of 
tJiis pn>ci.>ss, anil in ilie trauuintir fonns one usually finds tJie remains 
of an ancient fracture, with inflammatory thickening of the meninges 
and ])iii. Tbe cavity is usuall