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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    .... 


22 

2:i 

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:i2 

34 

35 

35 

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40 
40 

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00 
73 
75 
70 
7n 
.s:i 
so 
so 
ss 
sy 
so 

04 
04 
07 


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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). 
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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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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. 


Digit 


zedbyGoe^gle 


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 :  0 
Mental:  0 
Nervous:  0 
Epilepsy :  0 

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


Heredity : 

F.,  d.  70;  apoplery. 

M.,  d.  64>  cancer. 

Children:  Only  child. 

TBC:0 

Alcohol;  0 
Birth:  Normal. 
Walk:  A'.     Speak:  ,Y. 
Children's  Diseases:  Measles. 
Enuresis :  0    Thumb :  0     Nail-biting,  etc. :  0 
Sleep-walking:  0  Stammering:  0 

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

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

Shocks:  0  Internal:  Ilg. 

Habits:  Ale:  +       Tob.: -H  + 

Sex:  Moderate  Indulgence. 

Trauma:  0 

Occupation  Toxemias :  0 

Convulsions  (injury,  tongue,  urine):  0 
Constitution:  Healthy.  Weight:  150. 
Marriage:  .1/  32. 

Menses: 

Cliildrcu:  1 ;  d.  in  infancy  (con ignitions). 
Mis.: ;.'; ,{  iiKis.  Dead:  0 


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}' :  0 

CnnulNerres: 

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


Bin.,  N.    Vert.,  A'. 
Deformity :  0 


Subjective:  0 


■lAsafet.:a  A'. 

Positionof  Eyes:  O.K. 


"■  ^'^^'^^  I  L.  20/100. 


Reflexes: 


Hemianopsia:  0      Scotomata:  0 
Fundus:  0  Fields:  Limited;  eon. 

III.,  IV.,  VI.  Eye  movements:  0.  K. 
Nystagmus :  0         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:  0       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:  0  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:  0 
Tremor:  0 
Taste:  a  A'. 
Shoulders:  0.  K. 
Upper  Extremity : 
Atrophy:  0 
Hypertrophy:  0 
Spasm :  0 
H\*potonus:  +  + 
Aluscular  power:  Divi. 
Dynanom. : 
Nerve  trunks:  Not  tender. 


Stammering:  0 
Swallow:  0.  A'. 

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

Malformations:  0 
SjTnmetries:  0.  K. 

Twitching:  0 
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:  0 
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:  0 
Atax.  K.K.T.:.-l/a:r. 

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


Deformity:  0 
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 :  0 


Tnmk  (continued) : 

Equilib.:  Unsteady. 

Vasomotor:  0 

Dermographia:  0 
Lower  Extremity: 

Atrophy :  + ;  legs  fiabby. 

Hypertrophy :  0  Asymmetries :  0 

Spasm :  0  Kernig :  0 

Hypotonus :  +  +  Tremor :  0 

Muscular  power:  Diminished. 

Synergistic  tests:  R  =  L. 

Patellar;  0        Achilles:  0        Clonus:  0 

Babinski :  0       Chad :  0  Opp ;  0 


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 :  0  Trophic :  0 

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:  0 
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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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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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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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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FTm 


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Nrt 


Vllft 
!FI, 


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.VDlv 

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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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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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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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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. 

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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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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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{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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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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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. 

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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 


>»     «' 


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*--, 


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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> 


Orbilat  iOM.  i 


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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\-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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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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.oogic 


100 


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 


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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 


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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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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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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 


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Clltu-i'i'Inut  ^(nlrt. 


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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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i^-"'//  ifr/'ifrs.fafff- 


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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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VEGBTAnVK  ItH   Vl.SCKKAL  XKCROUHiY 


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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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LS 


nXm 


Os, 


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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»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. 


L  J_ 


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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.) 


Digit 


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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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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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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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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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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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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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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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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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142 


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 
wy  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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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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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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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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OPHTHALMIC  AtlGRAlNE 


149 


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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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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 


153 


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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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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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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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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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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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- 
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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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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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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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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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IXriCHNAL  SKCRKTIONS 


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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THE  KSDOCRINOPATUIKS 


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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TUB  TllYREOPATUIES:  TlIYItEOSES 


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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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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THK  THYRROPATtltSS;  THYRBOSBS 


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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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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184 


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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THE  THYREOPATHIES:  TltYREOSBS 


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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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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(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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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 


^^^■a 


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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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|)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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203 


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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THE  BffDOCRI^'OPATIIlES 


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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run  K\D()CRl\OPA  rillKS 


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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207 


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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2(r& 


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. 
14 


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THE  ENDOCRINOPATl 


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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211 


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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212 


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 


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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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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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223 


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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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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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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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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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, 


rwf'j 


\ 


.-?  .v».  V  .V, 
".•'.^  nuF.  i3|W'  jiu»r 


fate-  Itm^-fuat 


// 


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.) 


^' 


.iA 


I 


ytirmar 


ulur 


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. — Begjnniug  «<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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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 


M       *"      «*      «B 


OS 


P< 


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.}. 


...Vi^ 


Ky 


i-Of'ttt 


]({ 


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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CRASIAJ.  SERVER 


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 


^ 


^y 


V 


iO/n. 


0'\ 


--^^^ 


J^th 


air. 


r-^^. 


f) 


"Y  Sirinlerm. 


o-' 


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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268 


CRANIAL  NERVSS 


'/, 


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It 


■  w  ^ 


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I?« 


VI 


p 

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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lOMOTOR  S'KRVES 


269 


■^   \ 


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in, 


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1-Vllk' 


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'VI 


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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CRANIAL  .VBRVRS 


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 


'■^.-^"■^ 


/^V* 


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 


IV.'         I.    ..  I:.--..:        ...i|. 


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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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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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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^ 


rr\ 


I    Nlrf.Bllf. 


Lti.m,<t. 


Tkfort 


Th^l 


S»k. 


Mnf  TV.  r. 
ritati    shV. 


'Jl 


'■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 


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*- 

^    #~    e    -" 

-  l;  tu  I 

V  s  a 

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i==5i : 

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ai<-AS 

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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. 

jnutaM  flUI«a(aHtM 


;\ 


^vV 


'rflvWM 


S  iHttrmtaim 


H  tmtmm^t^ot 


!liirttm§ 


lAVW/MWfWMMt 


'^^ 


AAOM- 

patmtl»» 


t/le  Br.  ,  -; 


■OtUOamailt"! 


■  Tfrnfonlf  fVnu 


Ifm/mwi 


■  OMBaMMtarifHff  f r<a«* 


L/<>t-mlX 


JoHMIar  Mr. 


TatMamtrle' 


A 


■TrmjnnU 
-Bmral 

'Onieal 


Agimmt  'toMM  yitan 


Fn.  lOO. 


PUn  of  the  fuUI  ntul  intcrtnalhu  nrrvM  and  their  roroinunieatiooi  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. 


KWd;  Rev.  NMir.  Paychititty, 


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294 


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. 


"^ 


Ts 


f'/iK 


Ss. 


\ 


\  / 


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 


® 


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,  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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298 


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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300 


CltANtAL  NERVES 


* 


^ 


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 


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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 


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Xmtam 


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kjrMMMiM  <:■     lr?« 

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IbIIv  a|n»-    BkUoB.       If 
doa  aytikcaa* 

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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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308 


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 


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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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DISEASES  OF  ACCHSSORY  AND  llYPOCWSSAt  ffRJtVRS    311 

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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3in 


lANIAL  frtRVBS 


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 
[■dtowaoa  of  tb«  wfaol*  ptvbltcn. 


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KERVBS 


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. 


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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." 


[B, 


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a 


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^ 


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iU 


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It- 


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l-u 


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  mHaem.    (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»> 


rlelol  UW) 


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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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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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 

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SIXTH, 


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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  0  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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SPECIAL  LOTAUZED  FORitS  OF  NEVHAWIAS 


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< 


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cirtHNfti 

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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 


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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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344 


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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34S 


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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350 


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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RADJCULITIS 


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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352 


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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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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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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363 


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. 


I'  ^1 


■'V 


l/^ 


kv 


aJ^, 


/u 


iJiA  Ajl, 


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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305 


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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(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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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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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. 
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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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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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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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/«  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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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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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. 


>  t^Vnmant:  Prmae  luM..  (X'tobor  3i,  1015. 


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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. 


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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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390 


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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ACUTE  POUa-BSCKPUAWMYRUTIS 


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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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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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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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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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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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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404 


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. 


\ 


ri...  ^;l-i  -•■ 


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 
degenerations  in  the  anterior  lateral  columns. 


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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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406 


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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410 


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. 


»IWd. 


*I.oceit. 


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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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AMYOTHOHIW  tATKHAt.  SiClBnOSfS 


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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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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418 


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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PRACTVRB  AND  DtSLOCATtOS  SYM>KO\tKS 


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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COMPRESSION  OP  THS  CORD 


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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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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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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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. 


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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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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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441 


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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LEStOyS  OF  TBB  SPlXAl  CORD 


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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443 


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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Fin.  2fi5. — Panly  scheuiattn  rrprwmntation  of  ■  widosprend 
»yriiiKonvypIini.  ahowinK  thi*  lR»ii>n  throutihoiir  tlio  card  ami  at  \'arioua 
cmwt  li-vi'U  uf  Uie  smiiiu,      (J.  Hufrmuiiii.} 


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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  usually  posterior,  may  traverse  tlie  entire  cord, 
midbrain .  and  even  be  found  in  tfie  cerebral  hemispheres,*  constituting 
a  true  svringomyeloencephalaria. 

Patbogenjr.^ — No  unanimity  of  opinion  has  yet  been  reached.  The 
present  general  tn-nd  is  to  reganl  the  pnH-ess  as  (iegeneralive 
rather  tlinn  one  n'bulting  from  a  productive  inflammation.'  The 
geiKTal  hypotlu-ses  are:  (IJ  it  is  due  to  a  defect  of  de\'elopiiient; 
(2)  it  i-s  due  to  an  intramedullary"  tumor  formation  which  later  breaks 
down:  (H)  it  is  the  left-over  remains  of  an  inflammator>-  (chronic 
myelitis)  nr  hemorrhagic  priK-ess  (hematnmyelia);  (4)  it  is  due  to  a 
modification  of  pressure  in  the  ependymal  canal,  brought  about  by  a 
trauma,  a  cwnprcssion.  In  general  It  seems  that  iin  one  hyjmthesis 
ran  explain  all  of  the  cases. 

'  SpvlnoyM-:    Zsii.  N*.  u.  P..  ur.  M3. 
tdfilla-:    Jonr.  Nepr.  and  M«al.  Di*.,  lOlfl. 


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LBS/ONS 

Thuj*,  acconling  to  Schlesingtr,  one  divides  the  cavity  formations 
that  may  ottur  in  the  spinal  cord  as  follows: 

1.  Cystic  formation,  after 
(a)  Traumatic  destructit)n  of  tissue, 
(6)  Tniiimnlic  hcinatumyelia, 
(c)  Kon-tniiimiitic  iiematomyelia. 

2.  Softening  of  an  inflammatory  or  non-inflaramfttory  nature  with 
short  course. 

3.  Syruij^myelia.s: 
(a)  True  hydrnmyelia  {as  malfonnation), 
(&)  True  tumor  with  cavity  formation, 

(c)  Sj-Tingomyelic  gliosis, 

(d)  Syriiigoniyi'IiH  fmni  vesst'l  drseasr  without  K^iusii*, 
(f)  PachxineningitisHud  [eptonienin>ritis  witlu-avity  fonniiliou. 

Ill  a  similar  maimer  the  cavity  formations  vf  the  medutla  may  be 
cla.sslGc4l  as  follows; 

1 .  C.VHts  following  aoftenin;?  or  hemorrhap*. 

2.  Softening  of  inftammator.'  nature  with  acute  course. 

3.  Cavity  formation  ffillowiriK  degcncrHtinti  of  Ininors. 

4.  True  syringobulhias  and  syriiiRoencepliulias  ;in  typical  localities). 
(a)  Embr>'oiial,  lying  in  the  center,  and  in  combination  with 

liydromyelia  or  syringomyelia. 
iff)  Witiioiit  combination  with  3iy<lrtmiyelia  or  syringomyelia. 
(c)  Arising  in  later  life  ami  lying  laterally  nn  continuation  of  a 
syringomyelia  due  to  circumscribed  bulbar  or  cerebral 
changes. 
Treatment. — Since  hemorrliage  into  the  glial  cavitie'.'i  iw  a  fret|uent 
w<*urrcnct'  ill  syringomyelia,  it  is  advLsahJe  to  avoid  hard,  muscular 
work,  since  such  seems  to  favor  blei-diug.  Severe  muscular  elTurt 
also  aids  in  spontaneous  fractures.  Occupations  involving  heat  are 
to  be  avoided  because  of  the  danger  from  burning. 

For  the  pains,  the  treatment  is  symptomatic.  Here  the  vbHous 
analgesic  antipyretics  may  be  employed.  .Aspirin,  acetanilid,  anti- 
pyririe  in  -j-Rrain  doses  are  sufficient. 

Specific  therapy  is  as  yet  unknou]i.  One  is  justified  in  recom- 
mending a  spiiuii  cord  o[>cration  in  tiie  case  of  large  liemnrrhagcjs  with 
sudden  increase  in  pressure  symptoms.  Here  the  principle  of  open 
expression  of  the  clot  can  be  practise*!  to  advuntage  ( KlsbcrgJ. 

("ertaiii  adv«nt!ige<nis  results  liave  bwu  reporti-^l  from  tlic  u.se  of 
high-frequency  currents.  These,  however,  have  not  been  employed 
long  enough  In  determine  iheir  absolute  efficiency.  Beaiigfinl  and 
I'llerniittc'  nnmiumeiui  weekly  applications  of  penetration  rays,  79 
(radio  chronometer  of  Benoist),  dose  of  '-i  II,  ut  a  ilislance  of  15 
cent,  between  anticathode  and  the  skin.  Twenty-six  s^nces  are 
recommenrie<3. 

•  8«iu,  M^.,  ]9C<. 


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447 


MULTIPLE  SCLEROSIS. 

Historical. — Because  of  the  .striking  variability  in  the  symptom- 
atology of  this  cMMinler,  it  is  not  altopetlier  surprising,  historic-ally 
i-otisidert^ .  that  the  Hrst  rhies  to  its  final  delimitation  should  have 
l>epn  gained  from  the  |uLth<>Iogif*al  rather  than  frnm  the  cliniral  side. 

I'lMJer  the  nldrr  notiological  si-henies  one  finds  ihese  |witients;;roupfd 
an  epilepsy,  paraplegiii.  treuHir,  chorea,  danee  of  St.  Guy  chninica. 
and  a  host  of  other  comlitions.  Although  Sylvius  de  la  Hik'  roeognized 
an  intention  tremor  as  dilTerent  from  other  tyi)es.  it  cannot  Ik-  said 
that  the  clinical  conception  assumed  it*)  modem  form  until  t)ie 
work  of  Vulpian  (lS(i2),  Ordenstmn  (ISBS)  and  Charcrtt.  The  initial 
|)atho!ogi(-Hl  notiuti  was  given,  howevtT,  l»y  (Vuvfilhier  (lS;i2-l!S-l5) 
in  his  famous  cas*'  of  Darges  (in  1840),  a  vtmk  in  the  Salp^trit'Tf,  a 
sketch  of  whose  cord  is  here  reproduced.  Carswell's  picture,  appearing 
in  )8:{S,  is  prolMibly  the  very  first  illustration  of  this  condition  on 
rw-ord.  From  this  time  on.  brain  and  .spinal  cord  sclerosis  becanif  an 
active  subject  of  iN-NCussion.  in  which  the  works  of  Frerichs'  and  X'alen- 
tiiier-  Ktanc]  out  ])rominently.  The  former  made  a  rliagiiosis  of  bratti 
scleroHi;«  iluring  life  ami  found  multiple  sclerotic  {uiti-lies  at  an  nulojKty, 
and  tried  to  cret-t  n  clinical  entity  with  differential  [mtholugical  diagno- 
.sis.  which  later  was  amplified  by  hiji  student  Valentincr,  who  ciillectcd 
a  .•wric*  i»f  ca.*fti  re.-*cnibling  those  of  Frerichs,  and  who  al.-^o  gave  a 
remarkable  summary  of  the  sjmptoms.  When  these  reports  are  read 
it  may  Ik-  seen  that  they  xvould  not  l»e  included  within  the  moilern 
concept,  yet  Valentincr  picked  out  the  facts  of  involvement  in  early 
years,  the  niarki-d  motfir  disturbances,  hemi|Kireses.  tremors,  sjh-ccIi 
ilisturluinccs.  the  remissions,  the  unilateral  onset,  the  greater  involve- 
ment of  motor  than  sensory  functions,  the  involvement  of  the  cranial 
nen*es.  the  long  course  and  had  prognosis.  The  mental  s\'mptoms 
jLs  outlined  by  Valentincr  are  not  as  characteristic.  A  diplcgic  idiot, 
for  instance,  is  incliHled  in  hi.-*  series  of  fifteen  cases. 

The  first  real  foundation  of  the  symptomatology  may  be  said  to^ 
have  been  laii)  down  by  these  two  authors,  and  little  practical  prof 
was  made  until  the  work  of  Vulpian,  Onlenstein  anti  Charcot  (IS62- 
rstilM  and  his  pupils,  as  summarizo'j  in  the  monograph  of  Itourneville 
el  (iueranl  llH()9),  when  the  multiple  .s<-!enwis  of  the  pres^'nt  ilay 
BSMUnied  definite  form.  As  eariy  a.s  ISti2  \'ulpian  and  ( 'han-iil 
brought  the  cla.s.*tical  triad,  scanning  tpeech,  npxUtgmua,  and  inO-ntiim 
Irewvr,  into  pntmincmv  as  diagimslic  of  the  condition,  and  in  the 
later  studies  of  the  (  han'ot  scIkhiI  the  clinical  ami  |Kilhi»l(>gicul  foun- 
dations wcK  laid  much  as  they  were  held  up  to  within  recent  times. 

It  ia  becoming  more  aiul  more  evident,  however,  that  the  picture 
insiiUed  uiNin  by  ("harccit  is  not  a  satisfactory  one.    Sennory  jiictures, 

•  Cwtwr  HinMHnrnvv.  Arrb.  (.  d.  a-  UmI.  Hwwr.  I»4D,  p.  3:^. 

*  IVbvr  die  :M«r>M  dw  G«4iinu  und  RQrkvimurk.  D«ui.  IClUilk.  Itt&A.  p.  ii7. 


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LESIONS  OF  THE  SPINAL  CORD 


neglected  by  him,  had  to  be  reckoned  with  in  the  later  studies;  also 
interference  with  the  bladder.  Decubitus  as  a  symptom  occurs. 
Then  cerebellar  syndromes  were  recognized;  then  Erb's  spastic  par- 


fti 


N 


Fia.  256  Fit).  257 

FiOB.  256  and  267.— Early  aketches  by  Carswell  and  CruveUhier  (1838  and  1840)  of  the 
sclerotic  patches  in  multiple  sclerosis. 


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440 


alysi?  fell  largely  into  the  multiple  sclerosis  group,  then  this  author's 
rhriiiiii'  (li>nMil  myelitis  with  ojiti*-  rh»ii(»es.  HcmipAresi?  not  ijiie 
to  emlxilism  nr  thrtimiii  lieeame  reeupnized.  Alternating  Millard- 
Gubler  types  were  described.  Then  many  bulbar  |>alsies  pa.s^  into 
its  confines,  jjontine  encephalic  picttires.  pure  nphthulmoplcgiHs.  and 
occasional  forms  with  painful  attacks,  re^^'inblinf;  syphilitic  menln^o- 
inyelitis.  Amyotrophic  lateral  sclerosis  (Dcjerine)  and  pseud<»pare.'*is 
were  later  diagnostic  possibilities,  showing  the  extreme  multi- 
plicity of  fonns  under  which  this  dtsiinler  may  show  its<^f.  The  I»est 
recent  monogniph  of  real  value  is  that  of  Miiller.  lOO-l.  The  more 
retTut  literatur*'  is  gathered  by  Wohlwill'  and  Marburg'  wliilc  the 
histology  has  been  exhaustively  treated  by  Dawson.' 

At  the  out.set  It  is  desirable  to  call  attention  to  the  fact  that  there 
exists  a  multiple  sclerosis  due  to  a  fairly  definite  pathological  process,! 
and  fithcr  clinical  types  resembling  the  former  s<i  clearly  as  to  l>e  clinifv 
ally  iiiilisttngiiishalili*,  bvit  in  which  one  finds  nndtipletiimors,  innltiple 
enflarteritic  lesions  (syphilitic,  orteriosclerotic),  multiple  cm-ephnlo- 
niyolitic  uiflajnmBtory  proceases,  etc.  These  will  be  discussed  with  the 
pattii»log>'. 

|-'rimar>'  multiple  sclerosi.s  then  i.s  a  disease  essentially  itf  a<!ole}icent 
or  young  adults,  iK^ginning  very  gradually  for  the  most  part,  ad\'ancing 
slowly,  initially  verj-  %'aried.  but  ultimately  assuming  a  very  chamc- 
teristic,  alnifisl  monotonous  rharacter.  It  is  characterized  by  begin- 
ning muscular  weakness,  with  spasticity,  by  disturljainces  in  sjieech, 
nystagmus,  intention  tremor,  by  forced  laughing  or  crying,  and  by 
changes  in  the  fundus — temporal  pallor.  Sensor>-  si-mptoms  may  be 
present  but  are  not  usually  prominent,  bladder  sj-mptoms  are  not 
unctimmiin,  while  vasomotor  and  trophic  disturluuiees  are  eompam- 
tivcb-  iiifrcfiuent.  The  pnw-'css  persists  for  many  years,  shows  striking 
^eulis^i^tls — ni)(ed  by  \*Hlentiner  in  ISiVi — and  the  |>atients  usually  die 
t>f  exluitistion  or  intercurrent  disorder.  Occasionally  tlie  process  comes 
to  a  stand-still.  In  rare  instances  the  disorder  is  charactcriznl  by  run- 
ning  a  very  rapid  course— acute  ilisseminateil  sclerosis  of  Marl>urg. 

Multiple  sclerosis  is  a  relatively  infrequent  disease.  Of  l^.(KX)  cases-! 
(if  nervous  disease  nt  \'antlerbilt  C^linie  it  was  diagnosed  as  occurring 
27  times,  i.  c.  a  i>erccntage  of  0.(X)1  +  jjer  cent.  In  European  clinics  it 
would  appear  to  Iw  more  frequent.  Uraniwell-Wilfiamson  show  '1  |H*r 
cent.  Possibly  better  diagnoses  account  for  these  differences,  -lince  the 
American  statistics  are  obtJiine^l  fnmi  injlyclinic  material.  Thi-sf  are 
not  cheekeil  by  autopsy  findings,  and  are  suggestive  nither  than 
conclusive  «>f  it-s  fretiuency.  Personal  figures  show  I  patient  in  200 
of  ncr\'nn»  dLsonler,  ()..*>  iht  cent. 

EtioIoc7-     .\  definite  i»««ition  n-garding  tins  cannot  yet  be  taken.| 
Prnclically  all  of  the  infections  ha%'e  l>eeu  hcUl  responsible.    Ccrtaii 


'  aurjir.  f.  N.  11.  v..  lA.,  11*13,  viL 
1  Le«raiw|nw»ky'*  nnmOiuHi.  101 1.  U. 
20 


•  Proc.  Ilo>-al  »iy-..  F^inburcli.  1010, 


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tnetalHc  poisous,  ziiic,  copper,  maugaiiese,  give  rise  to  t'Iink'fl.1  pictures 
At  times  closely  re&eniblinR  nvultiple  sclerosis.  Traimin  has  been  held 
responsible;  so  also  have  sexual  excesses, cold  iiiitl  wet  a tul  child-bearing. 

Hereiliiy  may  bean  itiipoi-taiit  factor,  according  to  ninny  (I*elizens 
and  utlicrs),  and  StrUmjwll  contends  that  the  csaential  feature  is  an 
abnormal  congenital  factor,  which  is  made  to  develop  by  any  one  of  the 
ntlier  causes  here  enumerated.  Miiller's  critical  sinnmary  would  seem 
to  exclude  practically  all  the  exogenous  causes  since  they  occur  in  but 
a  very  small  propnrtinri  of  his  cases.  He  allows  that  a  secnnHarj' 
multiple  sclerosis,  in  the  sense  already  outlined,  may  possibly  follow 
infections,  but  tJiat  multiple  sclerosis,  in  the  narrow  sense,  develops 
only  on  the  basis  of  a  congenital  pre({is[>osition. 

Sex  plays  practically  no  part.  Uoth  the  results  of  Charcot's  and 
Whitoff's  studies,  which  spoke  for  greater  fretjuency  in  female  and  n»ale 
material  respectively  are  due  to  their  particular  clientele.  Polyclinic 
statistics  nearly  always  show  a  greater  frequency  of  wtTinen.  because 
they  are  freer  to  visit  dispensaries,  and  usually  go  to  all  of  them  In  a 
big  city.  The  imly  reliable  statistics  are  those  of  MiiUcr.  which  were 
controlled  by  autopsy.    They  show  practically  no  difference. 

Age. — Three-fourths  of  the  carefully  observed  cases  occur  between 
the  years  of  twenty  and  forty.  In  our  own  statistics^  iwiMliirds  of 
the  patients  were  under  forty.  Ca.ses  have  been  reported  in  children 
as  young  as  five  raoiiths,  and  in  adults  as  old  as  seventy-five  to  eighty 
years,  but  for  both  extremes  diagnostic  mistakes  are  not  ruled  out. 
Marie's  view  that  multiple  sclerosis  is  common  in  children  has  not 
withstood  the  severe  critique  of  autopsy  material,  and  Miiller  takes 
the  stand  tliat  the  disease  is  found  extremely  seldom  in  very  early 
youth.  The  initial  stages,  however,  may  Iw  traced  very  often  tn 
the  years  of  adolescence  or  early  adult  life.  Occupation  plays  no 
n)le  that  is  yet  known. 

The  possibility  of  iti  being  a  definite  infection,  possibly  of  a  proto- 
zoan nature,  is  coming  to  the  fore  on  the  basis  of  the  histologj'  of  the 
lesion  and  sennn  reactions. 

Symptoms. — The  accidental  features  of  the  distribution  of  the 
s**lerotic  patches  in  this  disorder  makes  it  possiltlc  for  almost  any 
(•orabination  of  iicur<»]ogicnl  sign.s,  and  the  greater  the  ruimber  of  cases 
stu<licd  the  ri<-lier  lias  become  the  .\vniptomatology.  Certain  patients 
show  comparatively  few  symptoms  for  years;  others  .show  additions 
almost  from  montli  to  month,  mitil  they  become  veritable  neurological 
nuiseums,  wii}i  signs  of  involvement  from  the  frontal  poles  to  the 
tip  of  the  Cauda  eijuitm.  No  two  patients  are  alike,  yet  most  svrni  Ut 
attain  the  same  level  in  the  end  and  almost  come  to  present  a  stereo- 
typed picture. 

In  this  picture  the  most  striking  feature  la  the  involvement  of  the 
motor  system,  giving  rise  to  muscular  weakness.  hyi>ertonus  and 

■  JrllifTcr    Jmir.  tif  Nvrv.  nnd  Ment.  !)»..  IMM.  p.  440. 


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general  spastic  phenomena,  both  in  the  crauial  and  spinal  paths. 
TTie  extrftme  range  is  xhv  feature  that  charnctertzes  multiple  M-lernsis 
in  its  fully  ilevflojR'd  fnnu.  One  fiiuJs  iwilated  nr  Kr'-)Up  pheiiDnieiia  all 
over  the  bo*]y  jiist  in  the  same  proportion  as  the  accidental  distribution 
of  Ihe  sclerotic  patches  is  isolated  or  difTuse.  For  this  reason  it  has 
bci!u  thouf^ht  advisable  ti>  bejcin  the  (leMTiptiou  of  the  s,\-n)ptoms  witli 
those  of  the  rrantal  nerves,  and  proceed  systematically  tlmuiphout  the 
ner\ous  system.  The  older  and  clasHieal  triad  of  rhnrcot  is  (tnly 
partially  true,  and  today  a  multiple  seleroMS  may  be  diagnosed  from  a 
tem|Htra]  pallor  of  the  optie  disks  eoiubiurd  with  bladder  incou- 
tirience  in  the  absent*  of  ny:jta^us.  intention  tremor,  or  si-anuiJig 
speech. 

The  elaasieal  picture  of  Charcot  may  be  fouml  in  nut  more  than 
15  per  cent,  of  all  the  cases,  at  a  periinl  when  the  presence  of  other 
symptoms  )>erniit  one  to  make  a  dtaKnosi>i  of  tnnltiplf  sclemsia.  If 
one  waiLs  for  the  "classical"  picture,  one  raa>  have  to  wait  for  years. 
.Some  patients  with  true  multiple  wlepuais  never  develop  the  rhnr^itt 
"triad." 

Oifacivrfi.  Ilalhiciimttoiut  of  smell  are  wvasioually  found  but  In-lonp 
to  the  ranT  am!  irifrefiuently  recorded  psj'chical  s\fp\n.  Bilateral 
an(»sn)ia  has  \tevn  ns-onl<il. 

f>p/f^.— The  re^^'anhcs  of  I'lithiifr  have  cni|ibasi7.<^|  the  frequent 
oeeurrence  of  ehanj^i-s  in  the  optic  <lisks.  Atiout  oO  t»fr  cent,  nf  the 
|)alients  show  chaniin's  in  the  papilla',  and  it  is  .ntriking  tJuit  these 
changes  (K-cur  early.  They  are  in  the  nature  of  [mrlial  atri>phifs, 
and  5h«w  themselves  for  the  most  part  as  a  simple  atrophic  pallor 
of  the  disk— usually  most  marked  temporally.  'I'nie  (ipric  atrojihy 
is  found  in  some  of  the  ea.ses,  anri  again  in  still  fewer  a  true  papillu- 
edema  nr  chtikeil  ilisk.  This  usu»II>  ni-i-dcs  iiinl  cither  lcavi*s  no 
siirn  or  an  atrophy.     A  gn-nt  numlMT  <if  variations  are  known. 

The  sight  is  frequently  affected,  wmietiuics  blindn(*ss,  imrtial  or 
complete,  unilateral  or  bilateral,  is  an  initial  s,Mnptom.  litis  nut 
infrequently  clears  up.  Complete  blindness  with  double-sided  atrophy 
is  extreniely  rare  ((^iuanck-rhthotT).  Pariiutnd  has  nuidr  thr<*e 
classical  lyi>es.  but  later  stuilies  bavesliown  that  there  Is  no  uniformity, 
and  the  variations  in  sector  blindness  and  flimne>s  are  very  uiuny. 
The  loas  nr  diminution  in  sight  m  multiple  se]en>si»  i.s  cbaraclenTi'd 
by  its  advancing  anrl  ret-eding  character,  and  by  the  fati  that  as  n  rule 
the  oplit]ialmo.s<i]pic  pictiu'c  is  u.siully  more  promauicetl  in  severity 
t)mn  the  symptoms,  and  nlTers  no  sittisraclor>'  register  of  the  vnriidulily 
in  visual  acuity. 

Tl»e  fields  of  viiiou  more  nften  sJiow  ceutrui  scotomatu  with  pf-*r- 
iphcml  clcarui'ss  than  iN'ripheral  vxitomata.  T'nilateral  :^cotomata. 
ipiadninl  scotuniiita.  and  a  great  variety  of  oilier  fonns  are  known  as 
well  IIS  u  icrtain  amount  of  variidulity  fn>m  tiuu*  ii>  time  in  the  individ- 
ual tiisi-.  The  color  Hrkis  ^lou*  similar  viiriatiutLs  and  ^  arialiilities. 
Optie  Imlhieinatinns  also  occur.     (Sec  Fig^.  '2SA  to  2fil.) 


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Oriilar  Symitttmm, — 'I'lit-  cl in ract eristic  phriionicium  here  is  iiystaf;- 
mils.  Its  i)«-iirn'iiri'  as  u  8yni])tom  nf  "hrnin  si|pri»-sis"  whs  lipst 
poind-)!  nut  I>y  ViiU-ntiiKT  (l.s.'i(i)  nriil  ("Imn-ot  fivcrvnluifl  its  rlijignustic: 
imjHtrtaiK-c.  Tniv  crTilnil  snytuKiiiiis  is  ran?,  hut  nystaj^iiioid  imive- 
mciits  on  latrnil  iriotluii  uf  the  eye  occurs  in  from  70  to  SO  {jcr  cent,  of 
the  casc3,  es|>e<jjilly  in  the  later  stages  of  tlic  dis<'»sc.  Verticnl, 
obticgue,  rotatory  nystaRmuH  is  imhiHed  with  the  otlier  forms.  In 
eases  with  pronounced  cerebellar  involvement  the  iij-stagmus  is  «»f 
this  type,  and  rotJition  of  objet-ts  with  subjec'tive  rotutlon  and  forwd 
{msitions  are  to  be  exiMX'twI.  These  eye  movements  nniy  lie  sum- 
marizeil  ns:  (I)  continued  rhytlwnical  oscillations  (tnietrntnd  nystag- 
mus) anali>)Zous  tu  the  ct)ntinu<ni.>*  tnovemcnts  uf  the  lieud  und  Ixnly; 

(2)  rhythmic  o.seillations  set  up  on  movement  of  the  biilh  in  any 
direction,  analogous  to  the  intention  tremor  of  the  hands;  (:i)  n>-stajz- 
moid  movements  on  extreme  lateral  or  vertical  niovenierits,  unaliiRous 
to  fatigue   (paresis)  movements;  (4)  ataxic  movements.     Of  thc« 

(3)  is  (he  most  frequent;  practically  all  arc  couditioncd  by  central 
disease,  although  pcriplieral  involvements  arc  dcscHlKtl. 

Eyr  Muscle  Palsies-  lliese  are  important  in  diagnosis,  ami  present 
theniscives  infrequently  as  isolate<l  or  complete  i»abic.'(,  transitory  or 
|H*rsisting.  Paralysis  of  eiinvergence  is  more  often  found.  In  general, 
from  17  to  46  jjer  cent,  of  the  patients  show  palsies,  the  statistics 
varying  according  to  the  more  or  less  strict  interpretation  of  paralysis, 
rhthoff  demands  "double  vision"  as  a  criterion,  which  symptom  is 
not  an  infrequent  early  symptom  of  multiple  .'wlerosLs.  MuHer,  on 
the  other  hand,  admits  milder  palsies  tn  his  statistics  I4ti  per  crnt.). 

I'Xit&K  is  less  frequently  found  (8  to  15  per  cent.),  usually  onc-side«l, 
occasionally  double,  usually  incomplete  and  ephemeral,  (hie  alsii 
meets  with  external  nphthahnoplegia,  al>iJueciis,  and  tntchlearia 
palsies.  r>ivcrgcnt  palsy  hiis  Wn  iiotc<!  by  Bielschowsky.  Internal 
ophthalmoplegia  bus  not  yet  Ik'cu  reconled. 

i'upillary  inequalities  are  not  infrequent  {24  per  cent.— Miiller),  and 
tiiese  are  changeable  and  frequently  early.  They  may  represent 
spasms  or  paresis  of  muscles.  Miosi.n  is  fre<|uent  in  the  later  stage 
(Purinaud),  but  the  reflexes  un'  usually  norinnt.  I'lipillary  unrest 
(hippus)  is  found  (Kriinkl-IUK-bwurt),  Argyll-ltuberiMin  pupil  uius 
found  only  four  times  in  SW  cases.  One  ca.se  of  I'hthoff  was  controlled 
by  autopsy;  2  cases  by  Had,'  Wasscrimiim  control. 

r.  Trigeminus. —  Facial  netirutgia  ha.s  la-en  obser\'«i  as  the  first 
s>'mptom  of  a  multiple  s<lerusis  lOpgienhelni),  but  invulvemeot  of  both 
the  sensory  and  the  motor  branches  Is  rare. 

VII.  Facial. — Facial  palsies,  usually  associated  with  other  central 
(hcmiple^c)  {xititiiie  (alternating  palsy),  or  pressure  syinpiiinis,  ocea- 
sionally  comhig  on  very  acutely,  are  not  infrequent  ( !.">  per  cent.};  a.s 
lui  i.solated  ]m\sy  il  h  rare,    like  other  |Hil.-«ies  their  lliictuating  char- 

■  Ncnir.  C-BBtnlbL,  1911,  m.  £M. 


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acter  is  strikiiifr,  llu-  scveir  |M-rnmnr>rit  ty]itys.  Uv'tna  '■"'^'  (Biiiii-ImiKl), 
US  an^  iils"  WilatiTiil  pulsies. 

IV//. — llraritiK  is  nirely  «ifift«|.  ('ompU'k*  «r  purtliil  iK'Hfnc.% 
lias  Weil  rwiJixiwi,  as  well  as  tlit*  ()C<-urrcticc  of  iidist's.  Auclitory 
haIliK-inatioi):i  are  possible,  but  nut  simtoniiealiy  proval.  llyiH-T- 
e8tlie5ia>  are  freciuent. 

The  vestihular  hraiich  of  the  eighth  nerve  is  not  infrequently  in- 
volved ill  il-s  oerelH'llar  fiuiiu'ctious.  An  explanation  of  somr  of  the 
more  severe  nystagmus  muvements  may  be  fnimd  here.  Giddiness 
and  dizziness  are  very  prominent  symptoms,  and  oeeur  either- frum 
involvement  of  this  ner\'e  or  other  sensory  cerebral  ar  spinal  tracts. 
Uotatory  giddiness  with  temlency  to  fall,  revolving  of  objects,  etc.,  is 
present  in  a  few  rases  of  multiple  sc-terosis,  and  certain  Meniere  rases 
belong  here. 

A'.  Pncuwogantrir  involvement  is  rare.  M  iiller  re)iort^  a  <*»se  of  par- 
oxysmal taehyeaniitt  in  multiple  selerosis.  Dyspnea  is  ahv  known, 
but  is  infrequent. 

The  tuvtr  has  been  nitKtihed  in  a  few  cases. 

.\II.  i^pcech  /J(.?/(yrfe(inef,'.— Charcot's  typical  speech  disturbance 
was  of  slow,  monotonous,  ami  scanning  character.  Thi.s  s|)e<'inl  ty|M'  is 
present,  hcjwrver,  in  only  a  small  proportion  of  tlie  cases,  and  then 
usually  only  in  the  later  stages.  Miiller's  autopsy-controlle^l  material 
(81  cases)  gave  only  25  per  cent,  of  this  character,  whereas  patients  with 
other  tyjx^s  of  s|)eech  disturbance  run  higher — 35  to  liO  per  cent. — 
making  about  half  of  all  multijile  sclerosis  cases  with  simie  di.sorder  of 
speech.  Vl&sy  fatigability,  with  increasing  misteadiness;  stuttering, 
with  acreittuated  nnmth  movement*?,  are  other  types. 

Singers  soon  riotii't-  tlies*'  alterations,  especially  ihe  fatigability. 
and  an  increasing  inability  to  modulate  the  tones.  Dysnrthrin  and 
explosive  speech  aa*  obtained  in  later  stagc.s.  Articulator}-  disturbances 
with  repetition  of  syllables,  or  words,  is  frequent  in  later  .stages — r,  I,  p, 
and  g  arc  particularly  difficult.  Aphonias  or  other  laryngeal  complica- 
tions are  (jcca.sionally  met  %vith  (Kethij.  The  tongue  occasionally  shows 
mild  transitory  palsies,  with  mild  atrophies,  usually  unilateral  and 
fibrilhiry  twitchings.  Ataxic  movements  of  the  tongue  arc  frequent  in 
the  later  stages.  Occasionally  subjective  sensations  of  fulness,  thick- 
ness, and  difficulty'  in  movement  arc  observed. 

Chewing  ami  swallowing  are  involval,  the  forrae-r  rarely,  the  latter 
not  infrequently,  less  often  transitorily  as  an  early  symptom,  more 
often  as  a  permanent  terminal  sign.  Exces-sive  .<yilivation  seems  verj* 
iiifre<|uent. 

Motor  01.ttnrhmu-eA.~T\ie  most  characteristic  are  the  intention 
tremor,  ataxias,  and  palsies  with  later  developing  atrophies  and 
contractures. 

Ataxia.—By  the  finger-nose  test  or  the  finger-finger  test,  and  by  the 
static  position  one  can  dcmtmstrate  an  ataxia  in  ihc  upper  extremities, 
separate  from  an  intention  tremor,  in  a  large  number  of  tJie  cases 


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(MuUer,  7U  per  cent.).  A  siniilnr  ataxia  may  l>e  sliuwii  in  the  tower 
extremities  in  even  a  more  strikiii^  maoiier  in  testing  by  the  knt-e-hivl 
(«st.  The  atiixic  uiovcmih-iiIn  iksuhIIv  prei-wlp  the  ilevehipnieiit  nf  the 
iitleutiun  tremor,  and  are  later  often  ttivered  up  by  the  saini".  Oei-a- 
sionally  the  ataxias  are  increa^  uu  closure  of  the  eyes,  occosiiunaUy 
not,  showing  that  at  least  two  t>'pes  are  to  be  observed.  Keccnt  find- 
inffs  in  tJie  sphere  of  deep  sensibility,  position  sense,  etc..  iilTord  an 
interpretation  of  these  ataxias.  They  var>'  clinically  from  the  tabi*tic 
aUuia,  pRrticuJArly  in  the  increa.se4l  tempo  of  the  individual  movements 
and  the  irrepilar  contraction  of  tlie  agonist  muscles.  The  usual 
hypertouus  of  (he  multiple  sclerosis  patient  is  in  marketl  contrast  to 
the  hypotonus  of  the  tabetic.     Crossed  hemiataxia.s  are  recorded. 

Inh-ntivn  rwrnw.^  Present  ia  from  oO  to  7j  per  cent,  of  the  coses, 
this  symptom  is  one  of  the  most  striking  in  %vell-advam'ed  multiple 
sclerosis.  It  may  he  absent  for  a  number  of  years,  and  yet  a  diagnf>sis 
may  l>e  made  on  other  grounds.  Considerable  care  must  be  eJtercised 
in  not  Confusing  fin  Intention  tremor  with  an  ataxia,  an<l  vicewrsn.  Cer- 
tain .shell  ,4liiK-k  tremors  obscrviil  in  warfare  have  closely  resenihled 
this  intention  tremor.  Miiller  has  laid  considerable  stress  upmi  this 
point,  and  because  of  his  more  rigid  criteria  regarding  the  diiTcrcnces, 
.states  tliat  real  intention  tremor  was  present  in  only  2.1  per  cent,  of  his 
cases.  Thi.^  intention  tremor  is  increasevi  by  prolonged  effort  and  by 
cm<itii>nal  ilisturbances.  It  is  not  niJirkpiliy  incrcasiil  by  shutting  the 
eyes. 

It  develops  gra<lually,  occasionally  suddenly  after  an  apoplectic 
attack,  is  uiorc  often  bilateral,  ci)rres|xi tiding  closely  with  the  pareses. 
The  anns  are  more  frequently  involvi'<l.  then  the  trunk,  and  tJien  the 
head;  rarely  the  chbi  and  muscles  of  tlie  face. 

Only  exceptionally  are  the  legs  markedly  affected  by  an  intention 
trem<»r.  In  the  tnmk  tJiis  disturbance  gives  rise  to  a  tjiie  of  con- 
tinual Udancing  or  rocking  motion;  it  also  involves  tlie  n^uscle^  su|»- 
porting  the  head,  causing  a  nodiling  and  swaying  serieis  of  movements. 
Paissive  tremors  of  the  hands  when  at  rest  are  also  observable. 

The  precise  anatomical  reasons  for  the  intcntiim  tremor  are  not 
completely  analyzed.  .Spinal  cases  do  not  show  it,  and  the  greatest 
probability  is  tliat  the  lesions  causing  the  inteution  tremor  are  those 
that  cut  off  p<irrions  of  tlie  (■prebcllo-rubro-thalamic  tracts.  .\  complete 
analysis  of  the  filter  tract  involvements  in  multiple  sclerosis  ha-s  yet  to 
he  made  before  alt  (juestions  relating  to  kn-alization  can  he  aiLswered. 
(Sec  discussions  of  athetold  (retnors.  thalamic  loixlrome  tremors,  cere- 
bellar tremori,  paralysis  agitaus  tremors  In  thctr  respective  chapters.) 

H'ritinf/  shows  characteristic  chauges  due  to  both  the  intention 
tremor  aiul  the  ataxia.  'l*he  strokes  are  irregular — too  thick  or  too 
tliin^ — and  the  excursions  in  forming  the  letters  irregular. 

Motor  I'liirrr. — Mittor  weakness  Ls  usually  tJie  earliest  symptom 
noted  in  multiple  .tolerosis.  It  may  be  the  arms,  oftener  the  l^s, 
or  occasionally  in  some  ftfiecial  group  of  muscles;  larynx  in  singers, 


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LESIOSS  OF   THE  SflXAL  CORD 


linnil  ami  jiriii  in  |Miiriters  i»r  playcTs,  iii-t*«sinii)ill\"  Madiler  ur  rfciiiiii. 
Market.!  fatipiliility  is  ait  ini|xirtant  .syniiHoiii,  anil  may  jirtrrilr  llie 
«rtliLT  syinptoins  for  years. 

Sjiajttir  parr:n,<t,  witii  hyiHTfomis,  tlit'ii  devcloi>s,  and  tiiou^li  varying 
considerably  in  intensity,  often  ilnniinates  the  picture,  leading  later 
to  the  initst  sfvere  fornts  iif  (-(Hilraeturv-s.  The  ty]H.'  uiay  be  heini- 
plegie  or  parafileRJc,  anrl  usually  iiiilieates  involvement  of  tlie  j>\rain- 
idal  tracts.  The  lower  extremities  are  involved  much  oftener  than 
the  upper.     Irregular  Br<iwn-SC'quard  paralysis  is  ocenjiinnally  pre^-nt. 

Gait  disturlmnees  are  cdninmn  and  variable.    They  nmy  be  purely 

pSpastic,  or  in  the  cerebellar  cases,  >t)a.stic  ataxic.     I'ure  ataxic  paits 

ftre  very  rare.     A  simstie  paretie  gait  marks  tJif  pre-Iiefl  stage.     Oeea- 

sionally  »ne  timis  the  tumbling  or  reeling  gait  of  eereliellar  tract 

implication. 

Certain  nuitor  anomalies  are  encountered  as  the  patients  rise  or 
sit  down.  A  Romberg,  which  is  nut  much  modifie<l  on  closing  the 
eyes,  w  not  uncommon. 

Mti/icular  Atrophies. — ^These  oeeur,  but  are  rare. 

Seiutory  Ph^iwmtma. — Marie's  earlier  contention  that  sensory  ilis- 
turbauces  do  not  belong  lu  multiple  selen.»sis  has  been  delinitely 
disproved.'  On  the  contrary,  they  are  very  freipiently  found,  but 
largely  by  reasun  of  tlieir  tluctuating  character,  both  as  lo  intensity 
and  extent  arc  overlooked  or  falsely  interpreted.  The  frequently  made 
false  diagnosis,  "hysteria,"  is  usually  founded  on  these  Huctuating, 
sensory  signs.  HofTinan  and  Freund  found  sensory  cli.-^tnrbanci-s  in 
from  70  to  90  jier  cent,  of  their  eases.  Muller  found  them  in  7)>  per 
cent.  Pains  are  not  frt-ciuent;  paresthesia',  on  tlie  other  hand,  are  very 
common.  Anesthetic  or  liyperesthetie  spots  are  frequent :  the  patient.s 
frequently  complain  of  dead  or  numb  fingers.  Tactile  anesthesia  is 
not  infrequent,  oceasional  tactile  agnosia  is  present.  'I"he  sense  of 
[localization  is  frequently  faulty,  and  btmy  sensibility  is  also  often 
involved,  with  diminution  o(  po.sition  .>icnse  and  disturbance  of  tliemial 
sensibilities. 

Skin  liffrjrm.—Thc  Hbdonuiml  and  epigastric  reflexes  nn*  ntntost 
invariably  mo<Jified  (SO  per  cent.).  Tliere  may  be  unilatenil  diminu- 
tion or  loss,  or  more  often  bilateral  diminution  or  loss  vt>2  per  cent.). 
Thus  bilateral  loss  of  these  reflexes  constitute  a  very  important  differ- 
ential for  the  diagnosis  of  not  only  an  organic  ner\-ous  diF^ease,  but 
especially  for  multiple  scli-nisls.  ("areful  studies  by  Miiller  have  shown 
that  when  eorrectly  tested  tliey  are  nttxlified  in  only  almut  .'>  jier  cent, 
of  noruml  individuals,  and  these  occurred  most  often  in  nomcn  who 
had  had  children,  or  in  very  obese  subjects.  The  cause  is  to  be  sought 
ill  an  interruption  of  the  sensory  tracts,  either  in  the  cord,  in  the  median 
{emniscus,  in  the  thalamic  end-stations,  or  in  the  post-Holandic  sensory 

>  Jeremiw  Km  collAi^tMl  ihi>  rii:'li  liti<rauirt>  benriiig  an  aevaary  disturbanoe*  in  miiltJplft 
scUuxiiuiv.     Dixnert.,  1898;  mx  also  MOllcr. 


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WtriPLB  SCIEROSIS 

(listrihutiuiiH.  ITie  iiiultiplicity  «f  tin*  scferotic  iiatchc^  mukes  it 
liable  thnt  tlii^  rt-flcx  [mili  wilt  1h*  iniptinitnl  ^jriirwlHrn-  jti  iu  uiarch 
l»i  tlir  cortex. 

'I'lu'  (TtTUiistfric  rrtlcx  is  ulsii  iiftni  iiivnivitl  iiiiilatiTiilly,  <ir  fiilatiT- 
ally,  lint  |i-ss<irt<'n.    Alwi  tlic  voniiliiix  ffHcx,  tlumgh  imi  sn  iiftrii. 

HHbiisHki's  ptiL'tmnu'iioii  is  very  fivc|uent;  Miiller  says,  almost  pon- 
slanl.  Cnissttl  Uithinski  mny  I'vvu  Ik-  uIimtvwI.  Oppt'iilH'iiii  rcftfx  is 
very  often.  llinu(:h  less  frequently,  found. 

Uke  all  of  the  symptoiiiK  of  multiple  sclemais.  tlie  skin  rcfiexcs 
are  iitibje<-t  to  eoii.^iiierablp  variations.  They  infrequently  return  after 
showintt  a  los:^. 

Tfudtm  Hejlrxes. — In  erineiirilancc  with  the  spasticity  and  liyper- 
tonu»,  increased  temion  leflexes  are  to  be  expected.  The  upper  ex- 
tremities show  increased  triceps-jerk  and  increased  radiopurlosteal 
reflexes.  The  Achilles-jerk  is  exaggerated,  unilaterally  or  bilaterally, 
as  alao  the  knee-jerk,  ami  usually  then-  is  unilateral  or  bilateral  ankle- 
clonus,     I'atellnr  clonus  is  less  often  observetl. 

\'a»umi)toT  ami  Trophic  Siffnn;  i)ther  Signs. — One  finds  a  number 
of  anomalies  of  this  ||^)up  in  a  large  i-ftllectiou  of  multiple  8clen>sis 
cases,  but.  as  a  rule,  they  are  sparse  and  isolated,  .-\mong  these  may 
be  mentioned  hyi>eridrosis,  angiospa^^ms  (cyanosis),  vessel  palsies  with 
etlema,  erythronielalgia-Iike  affections,  syrinK<»mypIia-like  trophic 
disturbances,  abni>rmal  blushing.  Hy|ieri>yrexia.s  are  encountered 
with  apoplectiform  attacks.  In  the  ordinary  cases  the  patient.^  show 
markcfl  lability  of  the  body  temperature. 

Pilunuilor  reflexes  are  frequently  disturl>et!;  tiius  dermographia  is 
eonunon.  and  may  show  unique  isolated  loealiKutions. 

bladder.— Thv  bladder  is  frequently  involved  (8*)  per  cent.— Oppen- 
heim;  75  per  cent.— Muller),  often  transitorily,  and  also  it  may  be  an 
early  sjTnptom.  The  patients  feel  a  sense  of  insufficiencj"  and  have  to 
strain  to  |>ass  their  water.  ( 'umptcle  paresis  witli  incontinence  is  ran*. 
There  is  a  great  variability,  with  numy  ups  iinil  downs  in  the  bhulder 
8>'mptoms.    Polyuria  and  glycosuria  have  been  observed. 

Obstipation  is  frequent;  loss  of  control  less  so,  but  is  present. 

Menstruation,  childbirth,  parturitinti,  etc.,  are  not  markedly 
affected,  (icnltal  hyperestlicsia  is  at  times  pathoNtgically  increa.sed 
and  (jccfusionally  there  is  anesthesia  with  impotence. 

LumJtar  l^uncturt. — The  experience  thus  far  gained  shows  no  appre- 
ciable changes  in  pr»'ssure.  (j-tologieally,  ticcA.sionall,\  slight  lymphn- 
cytosis  has  been  observed,  but  the  majority  of  the  eases  have  licen 
negative.  Serologically,  some  |)ositivc  \Va.-^LserniBnn  reactions  have 
been  recorded.' 

Menial  Symptom*. — These  arc  noi  constant  nor  prominent,  anil 
are  for  the  most  part  absent,  yet  careful  anal>'sis  shows  them  In  be 
much  more  frequent  tlian  in  usually  taught.     Mild  intellectual  n'<luf> 

•  N'nnnr:     Ihtitoeh.  Zt«nlir.  (.  NM^ciih^k..  1910,  1013. 


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458 


LBStOm  OF  THE  SPIXAL  CORD 


tiriii  ill  the  furiii  of  II  Oi'iiit'iiliit.  liHlluriaatiuris  of  hniriii;;,  uf  sifflit,* 
lialiiirinatory  stntts  with  mild  confusion,  passing  idi'us  of  rffiTent-eaiuI 
of  perswnitiori.  difficulty  in  thinking,  spasmodit;  intermittent  alterna- 
tions in  the  rapacity  for  attention  and  concfintration,  ljip:<t's  of  ini-niory, 
etc.;  these  have  all  J>een  recordeti  The  latter  iiiionialies  are  not  infre- 
quent, and  often  are  colmYrd  hy  depression  (melaneholic)  or  excited 
(manK-)  states,  or  more  frequently  the  emotional  tune  Ls  one  of  indif- 
ference.    Pseudoparctic  states  may  he  exjtected  at  times. 

JfiV'lnutnri/  hinghing  ami  Cryiiiff.—TUvsv  wvrv  deytTiheil  by  C'ruvnl- 
hier  in  his  clas-sical  <-tt.*se.  and  correctly  appreciated  hy  Bonrncvillc. 
They  arc  purely  neurolr^ical  sipns.  for  neither  tlie  laughing  iu*T  the 
cryinfi  arc  necessarily  aceompaiiiecl  by  their  usual  emotional  state-s, 
m>r  do  tliey  necessarily  betoken  any  intellectual  reduction  (evidence 
against  tlu-  Jfunes-UiriHC  emotional  liypwitliesis).  They  are  very  often 
found,  forceil  laughing  being  the  more  frequent  (40  per  cent. — Miiller). 
Tlicy  are  both  to  Ik*  referral  to  iniplicution  (in  part)  of  the  cortico- 
bulhocerebellar  reflex  (mths.  An  analysts  of  all  of  the  variations  is 
not  |)o.ssil>le  here. 

.■tjMjplfftiJorm  (inii  I'.fiifriitiform  --If/fifA-^,— Tlieseoccur  but  iMitasfre- 
quetitly  as  wjls  held  before  one  was  in  a  position  to  rule  out  anomalous 
paretic  attack.s.  liut  the  frequent  occurrcnei*  (20  to  25  per  cent.) 
of  mild  attacks  with  transitory  disturbances  of  coiiseitnisness.  or 
attacks  of  giddiness  or  faiutness.  with  unilateral  ur  bilateral  pareses. 
or  9eiisor\'  unouuiHes  in  the  distal  extremities,  should  he  enipluisizi'd. 
Such  mild  attacks  rescmblinj;  arteriosclerotic  attacks,  often  mark  the 
initial  stages,  nr  accompany  the  sudden  pr<»gres.siona  n-hich  are  ehar- 
a<'teristtc  of  this  dist>rder.  KpileiJtifonu  attacks  are  much  leaa  often 
obser\'ed  and  u.sually  s|jeak  against  a  multiple  sclerosis,  but  tliey  do 
iH'ciir,  and  very  frequently  show  as  Jai-ksmiiaii  attarks  (Gus-senlmuer). 

Characteristic  Fonns. — .As  alr-eady  noted,  the  elassical  signs  of 
Charcot,  witli  nystagmus,  inteutiuii  tremor  and  scaiming  speech,  in 

ility  are  found  in  only  a  comparatively  small  proportion  of  the 
'cases  ill  tlie  earlier  stages  of  the  disease.  In  the  interest  of  early 
diagnosis,  this  must  he  borne  in  mind,  especially  as  true  nystagmus 
is  always  rare,  nystagnioi<l  movements  are  (o  Ije  judgt*'!  with  care, 
and  the  tremor  and  scanning  speeeli  are  usually  later  symptoms. 
The  "uou-lypical"  cases  in  Charcot's  sen.se  (forinc«  fruste),  are  really 
more  frequently  met  with.  Any  attempt  to  state  which  s|)ecial 
group  of  symptoms  occurs  with  more  or  less  frequency  is  apt  to  be 
misleading,  especially  in  view  of  the  great  variability  met  with  and 
the  inconstant  changes,  the  advance  of  certain  symptoms  and  the 
retrogression  of  others. 

I'or  purely  didactic  purposes  one  can  divide  the  more  common 
symptom  pictures  as  follows: 

1.  Cases  that  begin  with  isolated  or  prominent  cerebral  symptoms. 
These  occur  less  frequently  than  the  spinal  cases,  perhaps  than  the 

1  Xonne:     Mitt.  Hunb.  StaftUkranlcMihiiUA.  miO. 


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MVt.TIPLE  SCLRROSIS 


4ri9 


Ktillwr,  Imt  iiviu-K  are  alsn  mujtc  likely  lo  be  iivurliniknl.  Merc  iiptic 
ntrophk's,  with  dcfwrts  nf  visinn.  ocular  pulsifs.  traii'^itory  diplMpias, 
crossed  eyes,  etc.,  muscular  wcakiifsses  arc  prouiinent,  and  occasion- 
ally ossocifited  with  giddiness,  DaUi^eti,  ami  lieuduche. 

2.  Cajwa  with  Isolated  or  prominent  bulbar  iiymptoms.  These 
begin  a:*  mild  «r  severe  bulbar  |>alsies,  and  are  nire. 

'.i.  Cases  with  im'Kular  and  prominent  rtpinal  s>nnptoms,  ninMlly 
involving  tlie  lower  extremities.  Jlere  the  patients  complain  uf  Uie 
legs  becoming  tired  easily,  and  after  a  time  they  stumble  iir  trip 
easily.  They  then  l)eeome  somewhat  stiff  and  walking  up  stairs 
becomes  increasingly  dilHcult.  Mild  blad<ler  disturbances  may  have 
preceiled  or  accompany  llic  weakness  ami  stiffnes.s  in  the  legs.  Par- 
esthesia are  also  frequent.  These  patients  soon  show  spasticity. 
increa.sed  knee-jerks,  clonus  at  times,  Hahinski's  sign.  The  abdominal 
anil  epigastric  reflexes  are  diminished  or  absent  unilaterally  or 
bilaterally. 

This  is  apparently  the  most  frequent  mode  of  onst-t,  since  very  often 
the  patients  have  paid  no  attention  to  the  rapid  passing  of  transitory 
diplopias,  slight  si>eec-h  difficulties  or  weakjiess  of  the  blmlder,  or  mild 
attacks  of  giddiness,  yet  sliarp  questioning  usually  elicits  .some  of 
these  other  signs  as  liaving  preceded  or  accompanied  these  spastic 
paraplegic  tj-pcs.  WhereAs  these  signs  nsuafly  come  <m  very  grndiially , 
they  may  appear  to  have  had  a  sudden  onset,  as  after  a  lung  walk,  or 
slight  Mifident.  or  following  childbirth,  or  other  striking  Jnten-urrent 
event. 

-1.  In  the  vast  majority  of  the  cases  there  is  a  gradual  onset  of  both 
spinal  an<]  cerebral  symptoms.  Headache:),  diplopia,  difitcnlty  in 
walking,  slight  changes  in  speech,  giddiness,  abnormal  mii.scular  tirt% 
paresthesia*,  transitory  bladder  weakness,  etc.  These  symptoms 
progress  and  then  n-cede — usually  attributed  to  the  skill  of  the  phy- 
sician or  tliought  of  as  hysterical — and  then  re«pi»ear  in  the  same  or 
•in  an  entirelj  different  order. 

o.  A  small  number  of  cases  begin  with  a  mild  iuitial  ajwplcctiforra 
attack,  and  Uien  either  progress,  or  remain  stationary  for  some  years. 

0.  Marburjt'  has  describeil  an  acute  disseminaterl  sclerosis  which 
runs  a  rapidly  fatal  course  terminating  in  from  three  to  six  months. 

A'*rtwA«nif(rr(>/(>  Farvta. — These  unusual  forms  may  be  simimar- 
i*ed  as  («j  forms  which  run  a  more  distinctly  psychic  course,  with 
the  picture  of  skiwly  ailvaneing  dementia,  and  pseudoparcti<'  foriu5; 
{h)  forms  that  n-semble  brain  tinnor— hydnK-ephalus;  (c)  Jack.soninn 
attacks  due  tu  patches  in  the  motor  area;  ((/)  hemiplegic  forms  due 
to  patches  in  the  cerebral  course  of  the  pyramidal  tracts;  {t)  bulbar 
paralj'sis  and  pseudobulbar  paralysis  l>'pes;  (0  sacral  forms  as  dcscrifx^l 
by  (>ppenheim,  n^sembling  tumor  of  the  cauda  e*)uina;  {g)  forms  that 
give  an  acute  onset  resembling  iM>iitinc  encephalitis;  (A)  cerel>ellar 
types,  n-si-inbling  pamlysis  agilans  mot  iiifntjueiitly  misnanifd  early 

*1a«.  tit. 


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|Minil.vsi.s  ftjiitniis);  (i)  forms  that  Rivn  h  pictim-  like  eeivhri»spiiial 
s.vpliilis;  tj)  proKn-ssivf  inii.st-uliir  Jitr<>pli\'  iiiiij  aiti,vutn>pltiL'  laltrul 
st'lprnsis-like  forms;  (k)  tnlM'tic-likr  feirms;  J)  (ninsversi'  myelitis  anri 
pCOinbiiKfl  .srlrrosis  t\[»t's,  iitiil  finally  (itr)  ItiliMil  and  irrrssivc  forms 
which  are  dilTen-iitiatwl  from  hysteriii  Ilell^ulaKicall.^  only  ufter  many 
years  of  tlic  most  exact  scrutiny. 

DiafDosis.—  Knonph  has  been  said  to  indicate  how  a  multiple  sclerosis 
may  a[)peiir  undtr  theKuiseof  a  iiuml>er  of  orRanie  diseases  (»f  the  brain 
and  w])inal  ccinl.  'riieiimsl  inipnrtant  features  in  tlie  dia^Tiosis  eoiicern 
tiie  age  of  the  patients,  voting  iiidividuab,  the  usual  lark  of  herojity, 
the  failure  of  usual  external  causes  to  account  for  the  symptoms, 
absence  of  Wassermann  reactions  ami  of  spinal  fluid  findings.  Of  tlie 
more  important  objective  findinfjs  for  the  early  diagnosiji  one  coimtd 
on  the  early  feeling  of  motor  wejikne.ss,  feelings  of  giddiness,  the  onset 
of  spasticity  with  increased  rcHexes,  clonus  and  Bahinski.  the  presence 
of  the  fundus  changes,  the  loss  of  the  abdtmiinal  reflexes,  f5ne  ataxic 
uiovenierits  uf  the  legs  in  tlie  knee-heel  test,  and  of  the  nnns  in  the 
finger-finger  and  finger-nose  tests. 

In  the  later  stiLg''-"*  the  full  pictures  as  already  outliiiwl  appear 
and  make  a  diagiiosi,<*  certain.  One  feature  of  perhaps  the  most 
striking  importance  is  the  |)eculiar  advancing  and  receding  course, 
the  remissions  during  which  the  entire  picture  seems  to  fa<le  away 
and  which  permit  a  patient  condemned  to  a  chronic  organic  nervous 
lesion  to  turn  up  in  the  physician's  consulting-rouni  apjmrtmtly  well. 

It  is  for  this  latter  reason  perhaps  mon-  than  any  other  that  tlie 
false  diagnosis,  hysteria,  Is  so  frequently  made  in  titcse  cases.  Then 
there  are  m  addition  the  almost  daily  fluctuations  in  tiie  sensory 
sphere  which  ahvai,s  suggest  hysteria,  and  which  only  a  rigid  analysis 
will  pxclufle.  Furtliermorc,  it  must  not  be  forgotten  tluit  not  only  doe~s 
one  experience  the  cliangeability  in  symptomatology  sugge-slive  of 
hysteria,  but  a  helpful  optimistie  psychotherapy  can  most  markwlly 
alter  the  symptoms  as  well,  causing  sfjmeof  tlieui  to  entirely  disappear. 
The  rise  in  the  level  of  nerv()us  energ^v  by  such  psychic  means  sa-ms  to 
enable  the  patient  to  force  a  better  control  of  the  disturbances.  In  the 
failure  of  a.  typical  hysterical  character — the  hysterical  constitution — 
this  disorder  sJjould  not  be  diagno.sed.  Kinally,  one  has  always  to 
reckon  with  a  symptomatic  hysterical  reduction  in  the  patient's 
resistance  due  to  tlie  presenci:'  of  um  organic  lesion. 

Kurther,  diffuse  sclerosis,  general  paresis,  brain  tumor,  chronic 
hydrocephalus,  arteriosclerosis,  cerebral  syphilis,  iufautile  palsies, 
encephahtis  of  a  diffuse  disseminated  type,  bulbar  palsies,  dironic 
leptomeningitis,  infantile  ataxias,  Friedreich's  ataxia  in  particular, 
disseminated  myelitis,  meningomyelitis,  F.rb's  .spastic  palsy,  heredi- 
tary' spastic  palsies,  syringomyelia,  tabes,  spinal  cord  timior,  (laralysis 
agitans,  chronic  zinc  poisoning,  chronic  manganese  poisoning,  chronic 
mercurial  poisoning  and  spinal  cord  edemas  all  come  in  review  in  the 
differential  diagnosis  of  multiple  sclerosis. 


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MULTIPI.E  SCIJIROSIS 


461 


Pathology  uid  PathoteiMris. — On  autopsy  in  tJie  rasrs  of  true  multiple 
wlenisLs  one  finds,  an  a  rule,  a  niirmal  duni.  tlit-  brain  itst'If  usually 
shows  irrof^lar  atropliie^  with  tliinnin>{  uf  the  cortex  and  some  internal 
hydrocephalus.  At  times  one  can  observe  on  the  surface  the  irregular 
patch-like  aroa-s  of  atrophy.  These  usually  show  much  more  frequently 
on  the  surface  nf  the  pons,  metlulla  and  coni,  a.s  f 'arswell  and  rnneil- 
liier  sliitwcil  i-ttrlv.  ()n  seilion  ipf  the  brain  one  finds  few  (five  or  six) 
or  miiiiy  (severul  hundred)  irregular  sclerotic  patches,  which  are  usually 
isolated  one  from  another. 

Microscopic  cxuminatlou  invariably  reveals  many  not  seen  by  tlie 
iiakc<i  eye.  Tliey  var>-  in  size  from  that  of  a  pia-head  to  ">  or  (i  cm., 
which  larji^T  patches  are  usually  made  up  of  wjveral  smaller  ones.  The 
general  ttjlor  tone  is  pray.  The  reddish  patches  usually  Iwlong  to 
the  secondary  enccphalomyelitides.  The  plaques  either  rise  slightly 
from  the  surface  or  arc  level  or  show  a  sll||iht  depn'ssion:  tlie  tissues 
almnr  an*  slightly  cilcnmtous.  At  times,  j)articulnrly  in  the  optic 
niTves.  there  is  distinct  shrinkugc  in  the  tissues.  The  consistency 
is  usiiully  tough,  or  almost  leatheiy.  The  soft  plaques  arc  apt  to 
resemble  disseminated  myelitis,  encephalomyelitis,  etc.  The  patches 
arc  verj-  sharply  differentiated  from  the  surrounding  tissues.  As 
to  IcK-aliiuition.  they  may  he  anywhere;  in  the  brain,  ciird,  nieilulla, 
pons,  cerclM'lIum,  the  ro«its  of  the  cranial  or  sjiinal  ncrvi-s.  within  the 
ojitic  ncr\'e  itiielf.  As  a  rule  they  are  found  in  Iwith  brain  and  sptnal 
fonl,  and  seem  to  have  a  spiN-ial  fondness  for  jilaces  particularly  rich 
in  ncuntplia.  arnl  there  is  a  certain  grade  of  as^Tnmetrical  sjTnmetry 
in  tlicirl(K*alization. 

In  the  cnrd,  the  median  line,  and  the  pyramidal  tract  region  an; 
favorite  localizatioiks.  and  in  the  white  matter  more  than  the  gray. 
Ccnlml  gliosis  .seems  rare.  In  the  nieilulla  the  olivary  region,  the 
floitr  of  the  fourth  ventricle,  arul  the  p*»steriar  asfjects  arc  favorite 
sites,  while  in  the  c-crebellum  the  dentate  nucleus  b  usually  moat 
often  implicated. 

Histologically  the  iiatchcs  arc  made  up  of  ma.<ucs  of  glia  fibers. 
There  is  no  areolar  ctmiposition  and  the  glia  nuclei  do  not  apirear 
prnniiiient.  Small  holes  may  be  found  within  the  plaqnirs,  im>utid 
which  the  glia  fil>ers  cluster  as  about  a  liliMtd vessel.  Bielschtiwsky 
prcjiarHliuns  sliow  the  partially  intact  nerve  axones  passing  through 
the  glia  masses  in  much  reduced  numbers:  the  rne<|ullHry  sheaths  are 
partly  utiHiinc-d  in  their  qualities.  Charcot  first  culled  attentiuiL  to  tJie 
IM-rsisting  axisH-ylinders,  The  immciL<te  ma-s?  of  glia  fibrib  is  an 
entirely  new  gntwtli,  apparently  not  to  take  the  place  of  dejitroyed 
nen-oiw  tissue,  but  a  pure  addition  product,  a  proliferative  inflamma- 
tion, in  which  one  finds  the  almost  normal  elements  still  present,  for  a 
time  at  least.  Secondary  degeneratiun  outsiile  of  tlie  plaques  is  not 
usually  pri-sent.' 

•  ^t^  tHmvm't  thf.  Ht.)  mmiilrti*  but<4»|untl  atuily. 


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402 


LSSIONS  OF  THE  SPiNAL  CORD 


What  relation  the  disease  has  to  the  vessels  Is  still  far  from  clear, 
but  it  seems  certatii  that  primary  disease-  of  the  vessels  is  nut  a  part  of 
true  multiple  sclerosis.  The  present  trend  Is  to  view  the  process  as 
related  to  a  iion-piiruleiit  eiifcphaloniyelitis,  allied  to  a  poliomyelitb*. 
rabies,  Bonia's  disease,  ett*.,  the  exciting  agent  bein^  !«»me  sfx-cific 
orgiinisra  as  yet  not  isolated.     (Spielmeyer,  loc.  cit.;  Schol.') 

Dawson's  monumental  study  .'teems  t-o  show  that  the  sequence  of  the 
jMtliologifal  professes  in  the  disease  is  somewhat  aa  follows:  (I)  A  com- 
mencing degeneratiim  of  the  myelin  sheath  and  a  simultaneous  reaction 
of  the  glia  in  the  imnicdiately  adjacent  perivascular  tisyiie;  (2)  an 
increasing  glia-<^ll  proliferation  and  a  commencing  fat-granule-cell 
fomintion;  (:i)  tlic  stage  of  so-callefl  "fat-granule-cetl  myelitis;"  (4)  a 
commencing  glia-fibril  formation;  (5)  an  advancing  and  (6)  a  wmplete 
.sclen)sis.  Histolngieal  study  has  given  overwhelming  evidence  that 
.selerotio  areas  in  the  disease  arise  on  the  basis  of  thisevoliitii>n  through 
a  stage  of  fat-granute-eell  formation,  and  Dawson  eoneludea  that  the 
underlying  pn>eess  is  a  subacute  disseminated  eficephalomyelitis  which 
terminates  in  disseminated  areas  of  actual  and  complete  sclerosis.  There 
is  much  to  favor  the  view  that  true  disseminated  sclerosis  is  due  to  a 
s|KTiiir  morbid  agent;  other  diffuse  affections  of  the  central  nervoua 
system  urteriosclerosis,  sjphUis,  acute  enceplialomyelitic  processes) 
may  give  rise  to  a  clinical  s>-mptom-oomplex"  ver>'  like  that  of  dis- 
seminated seleroais;  ihey  diifer.  Iiowever,  in  the  eha racier istif^  remis- 
sions and  relapses.  Arcording  to  Dawson,  the  anatomical  expression 
of  tliese  n-nvissioiis  must  naturally  be  the  gradual  clearing  up  of  the  cell 
exudation  and  a  sclero.sing  of  the  tisiue  with  a  retention  of  the  axis- 
cylinders.  There  is  no  adequate  evidence  to  distingiiisli  betwwn  u 
micmbic  and  a  tnxie  agent.  It  is  p<>ssibly  the  latter.  'J'lie  cau.sal 
agent  is  probably  of  the  nature  of  a  soluble  toxin,  wbieh  is  conveyed  to 
the  nervous  tissues  pmbahly  through  the  hloisl  channels.  The  sugges- 
tion made  is  that  the  restriction  is  in  some  way  related  to  tlie  selective 
aetionrjftlie  toxin  in<'er(aitinreasof  the  bl<HHl  supply,  or  that  unknowii 
factfirs  determine  an  irregularly  distributed  paralytic  dilatntioii,  with 
an  increa,sed  infiltration  through  the  vessel  walls.  Remissions  and 
relapses  necessitate  the  assumption  of  the  latent  presence  of  the  morbid 
agent  in  the  body — either  the  intermittent  evolution  of  a  toxin,  or  its 
a<(UTnu!atLiHi  from  deficient  elimination. 

Tills  whnle  picture  suggest-s  the  vegetative  control  of  the  spinal  cord 
metabolism  is  primarily  at  fault,  whi(h  in  part  woidd  aid  in  the 
understanding  of  the  market!  influence  of  psychogenic  factors  of  this 
disease. 

The  difTcrentialion  front  <lisseminated  myelitis,  encepbalomyeHtis 
and  other  secondary  affections  which  may  give  rise  to  partial  multiple 
.sclerosis  pictures  must  be  sought  in  special  works  on  paihology. 

Prognosu. — In  general  the  disnrder  is  progressive,  yet  there  are 
many  stniidnnry  cases,  and  some  few  that  apparently  recover;  these 

>  CIrauUHcli.  t.  Nnttirf.,  ])r«adi*u.  F«l<raarx  2-1,  1914. 


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MULTIPLB  SCLERatlS 


■ttJ3 


are  possibly  nn'^^takes  In  diaguosis,  but  sueli  mistakes,  in  view  of  th« 
grenl  nunsber  of  .'iiniiliir  afr«'tinns,  npe  almosl  impossiblf  to  avoid. 
Many  patients  oxtrt-im-ly  ill  and  bed-riddt'ii,  following  one  of  the  acute 
advances  of  tlie  disease,  recover  almost  compIetMy;  but  usually  there  is 
another  acute  advance,  and  then  others.  The  time  between  advances 
or  the  length  of  remissions  cannot  be  stated;  they  have  varied  from 
six  months  to  ten  years;  some  very  rare  observations  show  a  period  of 
twenty  years. 

A  few  patients  die  rapidly  of  the  disorder  (six  weeks  to  six  months) 
— acute  multiple  sclerosis  of  Marburg,  Frankl-Hochwart  and  others — 
but  the  majority  live  for  many  years,  and  die  usually  of  intercurrent 
disorders,  pyelitis,  tuberculosis,  pneumonia,  etc.  Muller's  average 
was  four  years;  Charcot  s,  six  to  ten  years. 

Therapy. — .SjKicific  therapy  is  not  yet  known.  Pn>phylaxi.s  also 
seems  difficult  to  grasp  since  no  definite  exciting  cause  is  known. 
Helative  prophylaxis  in  the  shape  of  advising  against  marriage  for 
young  affectwl  individuals,  or  against  child-bejiring  in  the  married  is 
necessary.  Childbirth  would  seem  to  be  an  exciting  cause  for  an 
active  exacerbation. 

Kest  in  bed  is  more  than  desirable  in  acute  stages,  it  is  imperative. 
The  rest  must  lie  absolute,  and  should  include  eye  rest.  Active 
remedial  treatment— massage,  hydrotherapy,  electrotherapy — are  all 
disadvantageous.  Warm  baths  for  short  periods  are  not  contra- 
bdicated.  Definite  motor  quiet  and  sensory  quiet  as  well  Is  desirable. 
Counter-irritation  in  those  cases  which  show  sharp  myelitic  symptoms 
is  to  Ix'  tried. 

I'harmacotherap>'  has  not  yet  devised  any  si>ecific  reme<iieft.  Arsenic 
is  use>d  on  empirical  grounds  and  because  of  the  possible  relation  of 
the  toxin-producing  agent  to  a  spirochete  (positive  Was.semiaun  in 
some  cases,  non-syphilitic)  and  in  combination  with  quinine,  ergot, 
stPpchuinc  and  iron  does  some  ser\'ice. 

Mild  work  in  tlie  open  air,  gardening,  etc.,  is  advisable.  Psycho- 
therapy is  never  to  be  forgotten,  and  a  healthy  optimism  helps  these 
patients  enormously. 

Some  ver>'  anotmdons  and  extraorrlinarily  rock!  re.sults  have  followed 
tile  opening  of  the  .spinal  canal  ( Klsberg).' 

'  tJelwrc:    Suncn?  uf  the  Hpi lull  l.'ord.     Sauuden,  lOlH. 


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CHAPTER  VIT, 

LESION  AT  THE  T.FAT.L  OF  THE  MEDri,I,A.  I*ONS,  BHAIN 
STEM  OR  MIDBUAIN. 

I.ESTOxs  involving  lliviiiLxIuIla.  pons,  hraiii  stt-in  nr  Tiildhmiii  do  not 
differ  essentially  in  tlieir  kind  fruiii  tliose  already  discussed  as  involving 
the  spinal  cord.  Softening  and  hemorrhage,  however,  arc  more  frequent 
from  lesions  of  the  vertehrals,  basilar  and  rirelo  of  Willis  ves,<*els  and 
their  hranehes.  As  has  Im-ou  pointed  out,  many  of  the  syndromes,  sueh 
as  for  instanee  tJKise  known  as  nmlti|>le  si-Ierosis,  as  s\Tingoniyelifl, 
poliomyelitis,  s^pliilis,  ete.,  may  involve  the  entire  cerebrospinal  axis. 
This  involvement  may  be  mure  or  less  instantaneous.  Such  is  the 
ease  in  poiiomyelitis,  whieh  in  one  patient  may  develop  a  meningitis 
(ecrebral),  a  ehorei>-athetoid  movement  fmidbraiiO.  an  eye  or  other 
cranial  nen'e  palsy  (meilullal.  paralysis  of  some  of  the  mu.sclcs  of  the 
arm  (cervical  spinal  eordj.  atrophic  changes  in  skin  and  bone  of  any 
extremity  (sympathetic  of  spinal  eorri),  ami  finally  a  palsy  of  (me 
or  more  leg  muscles  llumliar  corrl).  On  Tlie  other  hantl,  in  tlie  ease 
of  a  syringoencephnlomyelia,  a  midtipU*  sclerosis,  or  a  eerebnispinal 
syphilis,  the  complete  syndrome  may  need  ten  to  twenty  years  to 
reach  a  complete  development  from  brain  to  lumbar  cord. 

Furthermore,  certain  of  these  processes  may  limit  themselves  entirely 
to  one  group  of  structures.  Thus  a  pontine,  meftullary,  miilbrain  or 
fourth  ventricle  tumor,  a  midbrain  iirteriosclerosis,  a  medullary  polio- 
myelitis, a  tjnadrigeminal  sypliilis,  or  tlialamic  arteriosclenitie  softening 
may  limit  the  syndrome  within  narrower  coidines.  In  such  an  event 
the  topical  as  well  as  tlic  etiological  factors  become  paramount. 

The  present  chapter  intends  to  deal  with  some  of  the  more  important 
problcni.s  chiefly  with  n'ference  to  localization.  These  locaiizing  signs 
are  extremely  intricate  and  proper  diagnosis  can  be  arrived  at  only 
through  a  complete  knowletlge  of  the  anatomy  of  these  parts.  Such  an  i 
anatomical  knowlecJge  can  be  gained  only  by  study  of  serial  sections  o$i 
these  regions.  By  reasi>n  of  the  cumpiicttiessof  the  struct uri-s  the  many 
<'omplicated  cdinicctionfs,  and  the  as  yet  irniM'rfectly  analyzed  dynamics 
of  the  UKf-hanisms  witliin  the  pons,  brain  steam  and  mi<lbrain,  the 
study  of  disturbance  in  these  regions  is  particularly  fascinating  and 
fruitful.  Here  competing  dynamic  forces  are  represented  at  a  ma.\i- 
mnm,  sn  far  as  sensorimotor  fimctions  are  concerned.  While  they 
are  infinitely  less  complex  than  the  ctHnpeting  symbolic  dynamics 
handled  by  the  cerebrum,  yet  they  are  sufficiently  complex  to  make 
this  field  of  sens(frimotor  neiuvlogy  most  bewildering. 


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MEDULLARY  SYXOnOXtBS 


465 


The  Anfltomiral  plotting  of  most  of  the  fiber  tracts  and  the  chief 
syiiiipses  are  known.  They  are  givnt  for  the  most  part  in  various 
chapters  in  this  work  and  ehiefly  figiirtii  In  plates  VI,  IX,  X  and  in  the 
gn>u|}  of  figures  given  in  the  pages  immediately  foUowing.  All  of  the 
eliniciil  pietures  resulting  from  lesion:i  in  these  regions  cunnot  possibly 
be  given  in  a  work  of  this  kind.  Iierti-eoiily  those  most  fretpiently  met 


/tiff  1^  ma/^tmii  cwidPA'iffiiin  .  taptriijf 
fiarl  %■/  ^mt»ain-j /rynlat  fwi  rvtiirlon. 


(iir/.m   •■/ j4rif  ^runliFl  (ixiivlu'ltin: 
iJ7»T  )«  rf  j/ ,iif  fi,-iulal  roanvluf  Ian 


part   •-/  urtiiW  nrfaet  tif 


Am.  frtMl  mmiWbIIiiii 


pxrl<>f  mp  pariittti  tV'ixttlHn 


Sni^raMuriniial  gf**  Jlitl  Imp. 
eoitinJ*tiifiii  part ^  ittnmj  Itmp 


[  ['nfianlt  gynn   [ 


OtapUaL 


#/  oaijntai  IcbK. 


Aip^  mufatt  ^  tirtb/OuiL 


Aul-  bonirr  a/  in/.iurfatf  , 
Iff  cr'ibtllum. 


^^^-  'V.  C!iT«6<il,jr 


fit/,  mtrfaereferriitatiiti. 


Fmj.  202.— Oirrleol  WillH  aaci  ljrao<-b«».  wiib  indi^stion  tif  dial ril union*.     tloiikiiM 
A,  B  iiioit  frwitlcnt  nitcs  (or  lipmorrhttio.     (Gr«^tiiirre.  from  Furwwi,) 

with  in  practice  are  taken  iijj.  while  a  tabular  summarj'  of  these  and  a 
nnnilMT  r»f  others  is  |t:iven  at  the  end  of  this  chapter. 

Medullary  Ss^dromes. — I^^sions  of  the  medulla,  usually  depending 
njion  vascular  disorders  of  the  bnmeiies  of  the  vertebrals  and  basilar 
produce  marke<l  initial  symptoms  of  an  apoplectiform  nature  and 
definite  residual  signs  <]eiK*nding  u|M)n  their  UK-ation. 

Among  the  initial  signs  are  the  usually  nipid  and  severe  onset  of 
coma  fnmi  cutting  off  of  the  cerebral  fjathways  (diaschiais).  ^ot 
uifrequently  there  are  generalized  tonic  coavulaive  oiovemeiita  of  the 
30 


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406       LEHIOS  OF 


:M  or  MIOBHAIS 


extremities  uikI  often  uf  llie  fin-ial  uiust-ulature  witii  the  exception  of 
those  Qiusc-les  wliusc  Duclei  may  be  impliejiteci.  Klatfidity  of  the 
lower  extremities  from  dia.s(-h).sj:s  of  the  p\TamiHal  tracts  with  initial 
loss  of  joint  n'Hexcs  which  later  are  increased.  Involvement  of  vege- 
tative imthwuys  may  cause   vasomotor,   rtwpirutory,   piipilhiry   and 


W, 


w 


■MUiUWISMHIS' 


Vs' 


n' 


.NOCUUS  Of 


Flti.  203. — The  craiuitl  ucrvc  nuclei  s(-liL'tn)ilioull.v  rvprovuutcd  iu  u  suppooedly 
Irniuipiuvnt  lirniii  bUmii,  doranl  vkw. 

If  astro-intestinal  symptoms,  vomiting,  diarrhea.    Profound  sensorj'  loss 
also  may  he  present. 

Tlu'  rt'finhtol  symptoms  will  vary  Ki^atly  nrcnrdinR  to  the  area 
destrr>ycd.  If  re^Tivcry  takes  plm-e.  which  is  companitively  nirt'  in 
lesions  at  the  level  of  llu*  pyraiiiidfti  (KTUssHtiun.  at  least  thive  separate 
clinical  picturea  are  rccognizahle.     If  the  lesion  oL*cupies  the  lower  side 


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MEOVLLARY  SYNDROMES 


4i>: 


of  the  meHulIa  implicatinfi  the  pjTamidal  tracts  one  observes  a  more  or 
less  coiitinnfHis  spastir  paralysis  of  all  four  ^-xtrfmittes  ii.sually  mure 
marked  on  the  side  oppusite  tlie  lesion:  if  it  impinges  further  forward, 
involving  the  nueleiis  of  the  spinal  acressory,  there  is  added  to  the 
s|Hisitif  di|ilc'Kii  a  flaccid  palsy  of  the  muscles  of  the  awTssorius.  Such 
eilinicji]  jMftures  result  from  arterial  lesions,  chiefly  of  the  anterior  spinal 
just  Ih'Iovv  tlie  juncture  of  the  vertehml  arteries  tn  form  the  Imsilar. 

A  lesion  at  the  side  ()f  the  mcfjulla  here  (meninf^itis,  tumor.  Kiunuui, 
tuberculosis)  involving  the  tractus  cerebellospinal  is  would  cause  a 
cerebellar  ataxia. 

Ix^sions  slijijhtly  higher  up  in  the  medulla,  at  the  level  of  the  olive, 
fnr  example,  and  involvinj^  the  lemiti.-w-iis  rn)ssinn  fibers  prndurc  a 
dissociat«l  disturbance  of  scri.satiun  uf  the  entire  hulf  uf  the  body 
omittinfi  the  trigeminus  regions.  If  the  lesjun  is  below  and  impinging 
on  the  pyrHUiidal  rt'fjton  (Fig.  21VI)  lliere  is  a  s]iHstif  ]«in'^ts  nf  the 
opposite  half  of  the  htxly  with  atniphic  pjiralysisof  the  siinic  side  t>f 
the  tongue,  which  shims  filirillary  twitching,  deviates  to  the  nrm- 
paralyzcd  side  and  ^Wea  rcJidiuii  of  degeneration. 

Following  Ic^iions  of  the  anterior  spinal  artery  the  lesion  may  impli- 
cate a  loHf;  strip  up  and  tlown  the  uicdulla.  Thus  in  the  piitienl 
(Fig.  JiU)  inferior  alternate  hemiplegia  from  anterior  pyramidal  and 
interoli\'ary  lesions,  the  pictures  just  descnhed  rtccurs.  with  addi- 
tion of  a  hemianesthesia  of  the  same  side.  There  are  no  deep  sensi- 
bility signs  (heniianalgesia)  nor  hemithermo-anesthesia.  Should  tiie 
lesion  cut  ofT  the  circulation  on  both  sitles.  us  it  not  infre^piently 
happens  in  anterior  spinal  artery  occlusion  fnim  vi-rtelind  thnmibi,  the 
picture  seen  in  Fig.  'H't't  nccurs.  Here  there  is  h  dmiblc  hemiplegia 
andheniinnesthcsia  with  alteriwlcpantl'.'>.i.s()f  the  tongue,  more  marked 
on  the  left  side.  There  is  atrophy  uf  the  right  1ml f  of  the  tongue  with 
fibriUar^"  twitching  and  reaction  of  degeneration. 


QkKKKAL  LeUBNU  ABItHKV]AT]n\H(ir  Mi:Dr[.L.MIT,   PovnNB,  PBOCKtn}I.All,  AND 

MtnnnAiN  8rxt>RouK». 

Ill  nil  t<r  Uxiti'  [M*iiiL|ili*giH  in  ImliraUtcl  li)'  itli]i(|tii-  llaeK;  huiiiiannittu^i^H!  by  ibiti,  mill 
AllvroaU;  parubots  t>y  xray  aviv-ork.  The  looions  involve  tb«  ixrelirsi  pt-JuDcka  aud 
ihc  |H)r»t  at  iliftcrfrit  Ivvrls. 

AiiBiiEviATtQMt.  Aq..  witiedtiirt  rif  Sylvius;  BrQp,  poilanclf  of  piMl^rinr  corinia 
(lUBilriitpniiiium ;  Cnt,  roriju^  rwtifonuv  and  inlericir  c^relirlliii  pediiui'le;  Frc.  ccalriU 
icKnifntal  tract;  Fe*.  inu>niul  BomiiirrulHr  filwrs  o(  the  rpn*l*lluiii ;  Flp,  tynsterior 
lunjotudiniU  ranriiiilus;  Fl'fi,  FPofi.  niiUTior  ncxi  pu»terior  tKiiitiiiv  fit>i-n>;  HV,  cvrv- 
Mlur  ]ii?inu|ihi.'rc:  Lc,  Iticua  t«ru]«u«:  LN,  Iticiu  nJRpr;  Lia.  linsulii  of  auperior  ventiis 
fit  reMwIliim;  .ViJ.  1]niu>T«'  nudviiN;  -Vp.  iiurli-i  (if  \^>n»:  SR.  red  iiui:U>iu:  SRI,  nurlcu* 
ill  lMl«niJ  U>i:iiuBcua.  Srt.  retiriUar  imrleilfi  ol  iJie  (vKiDviitiun;  Sill,  nurlci  o(  tliird 
ri«r%'p;  A'niV.  iniit»r  fifth  Huclni.i;  -V*!',  M'nm>Ty  fifth  iiui'li-ii.i;  SVl,  nu<-li>u.i  rA  sixth 
ncrvf,  SVll.  imtkufl  i>I  Ihn  ftK*ial  iiervi-,  W'tii,  uut*wi»r  uudeiu  «[  tb«  ii*^«imUc 
(oiifhWrj ;  Or.  ivrclirlliir  itlivi-;  ftx.  Mi]M-ri<ir  or  |ia>riliiii'  olivr;  F.  Iiiwor  nLoci*  of  rrrr- 
linil  |i«1uiic1p:  J'cm.  ntiddlc- r^robctlitr  p«<tunoli*:  /V*.  »uf*rior  Co[vlK>llftr  pMlunclo;  Pu. 
pyramidfil  tr.ir-t  in  ilj(  tn-'liLii<-ij|ii|H)rttirii-  rafcioiK  V".  niriniK  (|iiiiilrigfiTiiiitmi  nnli^rittr; 
r,  rnp)ic:  H"'.  Iiic^inli  IruiliihriiA;  A/,  InttTiil  Iciudihi-uh:  ."^.I^.  Rra>  .<uiliittiiij''P  of  the 
ii<)uivlitrt  <\t  ."iylviiic;  Sifft,  KutjMtiiiiiv  '•(  Itoluiidii;  '/>'.  tenia  iX'tiUn;  7'r,  trii|i<-»i|'l  lindyj 
I'l.  (iiufll)  vi'tiinHv;  t'H.  su|>crii>r  vrmiL''  nf  (Ik*  •'t^ivlielliini:  V'l'',  viUvc>  of  X'iMiHMMUi; 
111,  moi  filrrt  »i  the  lliird  n«tvr;  I',  triitpniiiiua;  I'c.  ■Ji-vi-imdiiiic  motor  nxtt  of  the 
filth;  VtU,  d4i«rci»Iiti«  sfUMorj-  root  at  the  fifth;  I'/,  foot  fitx-rs  iit  tho  sIxUi.  Vtl,  rVlI, 
itxjt  Fibenof  the  faciAl;  VUg,  Imoi.-  (if  Um  faciftl.  VHtt.  vnuliuliu-. 


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468       IBSI0\  OF  TJIE  POyS,  BRAIS^  STB^f  OR  MIDBRAIN 

Lemons  of  the  vertebral  (usually  thromboses)  which  invfllve  the 
anterior  spina?  artery,  and  the  posterior  rerebellar  arteries  produce  an 
iiiv(vlvcm<'ii(  of  must  nf  (me-h«lf  of  themithillu  ( Fif,'-  2<il>).  This  L-auses 
the  Mwalleti  Syrnlrmiir  nf  Arfllijt.  Tile  pHtictil  shciws  the  usual  aiMi- 
plcctic  initial  symptoms.    The  rr^iduaU  shuw  a  hemiplegia  and  hemi- 


NCB 


Fit 


Kxn - 


Fit 
f-Oi 


*^.//^ 


N< 


«i 


Nor; 

No. 


XII 


^Q,  884.~Aiit<i«i-inl<"mn!  butbar.  Sytirlrfiiiir.  Allftrnalc  hrniiploKiA  I'f  tl">  liypo- 
sIdsiuii  hy  tbmiiilKXiiiior  the  loflnikti'rint  niiiuul  nrtwry.  The  leaiun  iiivtilvm  the  anterior 
pjTsmiil.  ihr  n'fi'niliu-  frtrmntjnn  »( thv  biilli.  tbc  root  filiora  »(  thp  liypnRltNwiu,  but  ut»t 

UU!    Xlt    IIUL-k'UH. 

On  the  ngf't  ""''■  thi-ir  in  hcniitilccia  nf  the  pxiri-niiiim  und  henii&twsthmia  i*ppri«lly 
of  drrt)  M-nMt)iilit>',  willimit  b4.'iiiiaiiiiliii,-4iit  or  liomittvi^rmi'-njii'^thcMu. 

On  ihe  fe/l  xitlr.  there'  is  Ikpniiiitroiihy  nf  tin.-  toDUUo  with  R.  I>.      (Deipritie.) 


anesthesia  on  the  side  opposite  to  the  lesion  and  a  palsy  of  the 
tongue  on  the  side  of  the  teslon.  There  is  a  trigeminal  anesthesia  of 
the  involved  side.  Oeulopiipillary  signs  are  prewent,  narrowing  of  the 
palfwhral  fissiire  oti  the  side  of  the  lesion.  There  is  also,  from  implica- 
tion of  tlie  ecrebcllar  putliways,  a  cerebellar  asynergin.  There  is  also  a 
paralysis  of  llie  st>ft  palate  and  voc-al  cord  of  the  same  side  aa  the  lesion. 


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This  Hinicat  pk-ture  may  be  enconntprod  also  in  ayrin(jom.vclia, 
multiple  sclerosis,  or  talie^  where  it  is  of  gradual  <IfveN»|>merit. 

Partial  clinical  pictures  of  the  syiiilmine  of  Avellis  Imve  been  termed 
the  sViidroines  of  Schnii(it  and  of  Jaekscm.  In  the  Syiiihtnne  of 
Schmi'lt  there  is  a  uiiiluteral  paralysis  of  the  soft  piilate,  of  the  vocal 


*^.A? 


Pto.  365.— Antcni-intcnml  Iiwlhar  symlruitio  from  ocoIimod  of  \Ik  anlerinr  <pituU 
UttttT  from  th^  right  vi^nr-tirn.  There  rpmli«  n  double  hpmiplpiriii  wJili  nllcrnntc 
pSMl>'ii!«  of  the  liypoRlomaua.  Tlip  leaoD  more  ninricnl  on  iln-  riiilit  «ide  i]i\-iiK'«^  txH.h 
pyimmid&J  trurin  lPj»)  in  t\w  >m!b,  the  interoUvury  pulhs  {Km)  »ii(l  ihp  tttrmnlinTetifu- 
larit  IrCl,  Cat.  On  the  riKhl  nido  the  I»xti>n  rtita  ofT  iIm>  r(H>t  ^^fi*  of  the-  h>-pi>R)>iwun. 
ThtHf  is  tidniiiiloKBri  imil  hKiiiiniK'Hihmin  o(  all  tour  limhfl.  mure  marked  in  tlw-  Irjl  »uir. 
Ilie acinic  r>f  pajNtiuii  ta  »po<'ialLy  involved.  On  the  rioh'.  tulf  there  is  heintiintnial  ■in>|)hy 
with  R.  D.     (IX-jt-riiw.) 

cord,  of  the  sternocleidomastoid  and  of  the  trai»ezius.  The  spinal 
va^Ls  nucleus  and  the  spinal  accessory  nucleus  or  radicular  libcni  arc 
involved. 

In  the  Sytifirtime  of  Jm-kwin  there  is  a  hemiparesis  of  the  soft  palate, 
the  vocal  c-ord,  the  stt-niiicleidoma^toitl.  with  heini|iuresis  uf  the  tuiif^ue 
with  atrophy. 


L-'IIJUl^KL'  0_v' 


.ooglc 


470        LESrOS  OF  TUB  PONS,  BUMN  STEM  Oli  .XtiDliRMS 


V 


L\ 


'/' 


cu.. 


KB :_  _     C9 


mi 


} 


»*      lU*^' 


X 


I4CB 


»■,  Kii 


MO 


WXIL 


ru 


Cr.l: 


)r 


Vit 


»>.( 

^7.. 


A 


n 


*<:*?■ 


3 


u  -     Nar.' 


XII 


Flu.  260.— ^tlo(n>-oliviiiy  biill>iir  cyndrompo.  HomiaofvthQftin  of  HyrinnDmyclic  typ? 
wilh  nltrmale  pan»ty«i»  of  the  descend Jiii;  root  n(  the  iriiwrniima  mntl  of  tlve  m^"*' 
vninu'  (s.VDdmme  of  .\vi-lli»)  and  hvnupiirpvifl  (if  tbo  pluin'iiE^I<>iO'»tl^^vH(>-|iat<itiiic 
wilh  (a)  or  witbnut  [b)  oniU>|Mii>il1nr>'  voKPtiitivc  .liitnH;  withntit  (n)  nr  VkHtli  t'>^  •viii- 
f<n>nit»iit  altvnuitv  psnUy»U  of  ih*  XSI,  uml  of  ttie  Iowm  prrljonp  of  ihe  ,V/  piiiim 
(nyiidroiiin  of  JnHuian).  Tlwre  in  hIhu  iHirnijiiilMiiii,  ivn')M>lli)r  lit'iiiiiilniin  atiil  lirmi- 
Aoyitorsia  fn>iii  tmion  of  the  bulbofvtrrt-cttivury  ivimipi) Itiit)  nf  iUe  rinlil  "idi?  »ui>t>lied 
liv  tlti>  iufi^riirr  mid  iMwrerKir  ri>n'l)fl1iir  iirt<>n'.  Tltrrv  ik  iin  iTHxm*!!  li^'miiilcKiit  of  ihv 
litiitm  iirir  laHilo  nnr  d(<-p  hmiianMit bmin  1«<-ttU>«  of  ih<*  iuiOKrit.v  nf  ihv  pyrnmkU 
nnil  iif  tlit>  rvtimlar  firrnialiun,  and  tMiriicnlnrly  ci(  Ihc  iuu-rolix-nry  pulW 

Oil  the  it/t  nidr  ihn^  U  riniilgff^n  and  therm' j-snentheais  nf  lite  piiir«niiiie<i.  lA  thl| 
iici-k  utid  tbf  burk  of  thai  bond  fruni  IcMvn  of  tbv  cru«¥«d  Kcwudttry  wrwory  (hiIIm 
thp  rutjo-olivarj'  r«'li<^lar  formMlnti. 

Oti  the  right  ihvtv  is  heuiiutaxiu  and  Ii»iiiia4>-D4mriii.  morft  nurkvd  ill  tha  lower  vstmn- 
ily  «lth  iNUvrkpiilsion  fmm  exiMuaoii  of  the  Ictu^^n  1o  \hc  rratifo'irn  hndy; 
Lurrtiizo-volopjiLaUne  palsy  from  loaion  of  tlie  aptbol  voous:  oiiMthNUi  of  ilte  fac«  ttot 
Ir^iikn  of  thr  (immndinc  mot  nf  thr  trigt'oiiniiH. 

Il)  ri  tli^rv  atv  veicvlAlive  o«-ul<jpupitlAry  »\gyn  froni  invulvvtnent  of  the  s>iiipNth«(i(] 
rUtcra  in  llir  ImU'toI  rplii'uhkr  fonuHliidi  iim)  trtKriiiiiiUM.  In  h  ilie  nynipiithptir  lil 
UK  uut  iiivolvinl  liut  the  XII  5l)ors  aro  iii>pticat«d.  tieoce  the-  poralyuii  and  aUopt 
<»f  the  uminii?:  rstptidini  biwrr  down  in  the  mudulln  ttw  infn'iiir  spiitul  orrpKMiry  fiti 
bfiuiE  CAUtclit  ill  the  l«jilon  tbon>  IH  panilyaia  of  the  mctoronl  bntM-b  fiippl)HnR  the  Inpctliiii 
Mnd  «lentiirh'i([i>iitiuiloi'[|.     (Ileiorine.) 


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^tEDVLlARY  .sr.vn/w.vffs 


471 


liMse  bulhar  [wLsics  are  observed  in  vascular  le^iuas,  in  tabcH,  pro- 
gressive bulbar  palsy,  multiple  sclerosis,  sjTingomyelia.  and  occasionally 
in  poliomyelitis. 


.^^    W* 


1 


/' 


V 


NCB 


Cr.t..., 

nt 

o;  I 


Hxri 


NXa 

Nlta 

■CX 


^f.//^ 


He 


N. 


Xll 


n;» 


Flo.  267.— AnU>rrwintvrnjU  mm^Wnry  bulfwr  ayndromp.  CmHocI  favmiplcftla  nnd 
hemiaDMtliMia  with  n]u>ruHt4>  puralynia  of  the  ttypogloMUa.  ihe  dnccndinn  fiflli  (syn- 
dftwnc  nf  AvellM).  onil<iiitipilhir>-  v<>ip>lAtivr  iIkim,  nrrehell&r  hcmianyncrKtn  from  tlimni- 
bom>  of  iho  lv(t  \'«rl«bruLl  Lcfuix'  ilu-  luvtmc  ofT  i>(  llic  auterior  «|)inul  mud  iitf^^ridr  tiitd 
pottterinr  (vrcl>cllnr  iirlenn>. 

On  the  ri<>hl  ■>(!«  l.ture  m  rros^cd  tttTniiplojcLt,  pon[tn»-bull>ar  type,  of  lh»  Inink  nnd 
the  c-xlrriiuiim  frnm  pyminidnl  Ivxioti;  hpituArmUimiii.  Ujt  nil  lorm*  uf  >«u»i)iilUy. 
rs[>wiBlly  ("r  pain  nnd  hent.  of  ihc  tniiik.  nock,  pxtppmiiiw  and  hnclc  of  the  hi-siH  fmm 
IrswMi  of  ihv  n-hriilMr  fommtioii  (Hfn,  rCi)  whilo  and  (Hit)  (my. 

Oil  lhi>  itfl  ilifTv  is  r«rt>lM?lli>r  hemiasyiiercia  nith  laWnipulBioii  and  hctiiiBtaxiii. 
Tlioro  It  lion Lilinmi 111  ntroptky  trom  Imioil  of  tin'  muc  fib(*r«  of  ttw  lij'poaloMiu,  phar>'nito- 
laryn^-vclii-ptvlatine  palny  (^>iidraine  of  AvcIUh).  wiih'dyaphaitia,  dyspbonin.  rouitli- 
••tiina  utid  I"BB  of  vniM  from  lemcMi  of  tli«  rw)\  fihem  and  antorinr  DURlmm  of  th*  K[HDa] 
VHKUfl  (XXa),  ui.x'nMS  and  iiarruvtinic  of  tho  palpebral  rianiire  from  ajriipalhoiiL*  octUo- 
pupillary  fibon  in  the  Intcral  n-ti^ilar  (ormatinn  (SR);  homiaiKMithniiit  nf  th«  fiu*<i 
fraiu  dvaoodina  ftfUi  Imtiitu.     (Dujeriu«.) 

A  related  sjTidrome  due  to  lesions  in  tliis  general  repion  is  that  of 
IJahiiLski  and  Xageotte.'    Tbesc  patients  show  acute  or  subacute 

>  N'tiuvrUo  Iran.  df>  la  fliUpHri£n>,  I1VJ2.  xv.  492. 


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472        ISRtON  OF  THE  FONS,   BRAIS  STF.\J  OR  MtOlHiMX 

involvement.  If  not  ccunotose  then'  may  lie  ilizzlnrss.  'l"^lie  resulual 
pit'ture  is  that  of  a  crosse*!  lieitiipHre^is,  lieiiiianestliesiit  with  iUh-jj 
sensory  tosses,  and  difficulty  in  swallowing  (Fig.  2f)7)  These  patients 
have  to  he  su])portefl  when  they  walk  witJi  lejfs  widcispread.  Tliere 
lA  marked  eerebellar  a-^ynergia  with  laieropnlsion  to  tlie  side  <»f  the 
lesion.  The  abdominal  ^efle^ps  are  not  apt  to  lie  involved.  The  other 
reflexes  follow  the  usual  heniiplenic  type.  Irre>;idarity  of  tlie  pupils, 
myosis  of  affected  side,  cnophthalnios,  syringoniyelie  (|]»»H'iation  at 
times  (K-e-ur. 

f 'estan  and  ("henai.s  have  descTibed  a  variant  which  is  u  e<jinbimi- 
tion  of  this  syndrome  with  the  palatovu^-al  palsies  of  the  syndrome  of 
A  veil  is. 

Lesions  of  the  Pons. — Softenings,  hemorrhages,  tumors,  gummata, 
multiple  st'lerosis,  svTingorayelia,  poliomyelitis,  tabes  produce  isolated 
or  roni|ilirating  lesions  of  the  pons,  whirh  varying  witli  their  loi-Htion 
and  size,  give  rise  to  a  liewlldering  array  of  eljnicol  pictures  whi<h 
merge  one  into  another  and  almost  defy  analysis.  A  careful  stmly  of 
the  motor  nuclei  and  of  the  motor  and  sensory  tracts  will  enable  the 
student  to  diflfcrentiate  these  jwntine  syndromes,  wliich  when  due  to 
lesions  implicating  the  seventh  nene  nuclei  or  structures  below  <tr  of 
its  branches  cause  the  various  typical  inferior  alternate  paralyses. 

The  most  classical  of  these  .syndromes  are  those  of  Millarfl-Giibler, 
Foville  and  (Jubler-Weber  combinatiiius, 

Ueference  to  I'late  1  shows  that  the  pontine  fillers  commence  to 
cross  about  the  upper  level  of  the  terith  and  twelfth  nerve  nuclei.  The 
syndromes  just  described— Schmidt,  Avellis.  Babinski  and  Xageotte— 
result  from  lesions  just  below  this  general  area.  The  course  of  tlie 
corticonuclear  fibers  is  extremely  complex  throughout  the  whttle  pontine 
levels  and  can  best  be  tracer!  from  Hate  \\  and  the  series  of  crosa-i 
sections  of  the  various  syndromes  of  this  chapter. 

The  sensi>ry  pathway.*!  are  likewise  extremely  complicated. 

So  long  as  the  sensory  paths  were  in  their  spinal  route  they  were 
capable  of  a  i-ertaln  amount  of  isolation  either  as  they  entered  the  cord 
and  made  tlieir  first  synapses,  or  as  tliex  continued  up  the  cord  in 
primar>"  or  seeon<lary  paths,  liut  as  these  paths  converge  to  enter 
the  brain  stem  they  become  closer  anatomically,  disease  processes  ar 
apt  to  ()vernm  many  |)aths.  and  thus  the  analysis  becomes  increasingly] 
difficult  up  to  the  entering  of  these  paths  into  the  optic  thalamus. 

The  most  searching  analyses  of  Head,  Holmes,  May,  Itothniann  and 
others  and  their  researches  tend  to  show  that  the  impulses  iinderlyingj 
sensations  of  pain,  hent,  and  cold  seem  alone  to  run  unaltcret!,  eitlierj 
directly  or  by  intercalated  fibers  associated  with  the  ganglion  cx-ILs  of  tlie 
formatio  reticulari.-s.  between  the  upper  end  «f  the  spinal  cord  ami  tliej 
optic  thalamus.  I  lere  are  received  the  regroui>ed  .'si'condary  impulses] 
from  tlie  fa^-e  which  cross,  then  join  the  sjiecific  paths  for  pain,  for] 
heat  or  for  cold.  The-se  jMitlis  are  so  situated  that  they  can  In*  intcr-l 
rupted  without  disturbancT  of  any  other  form  of  sensation  of  the  bi»dy, 


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iSIONS  OF  THE  POS 

and  the  aii.ilKi>siu  uiul  thprnii»-aiii*.sthesi»  so  prdihiccH  rt'.senible  in 
finality  tlie  Utsu  of  .seusatiuii  ti)  pain,  heat,  and  mid  raiiseil  Uy  a  li^iiiii 
in  tlie  spinal  t-ord.     (.See  Plates  I X  ami  X.) 


Ji 


%. 


W 


SR 


Rr 


V^ 


ff^&C . 


Fto.  'i^ — Anterior  cvphulk'  p'ltiliiio  KyniJmiRO.  H«nu[)l(«ia  of  rarpbral  13-1*0  duo  lo 
Utfombaaa  of  Uw  upper  part  of  (ho  )jaailar  trunk.  The  li«inri  i»  uniIai<vtU.  ikn-uiij  ing  llu! 
C^habld  part  rJ  Ihr  pojm.  ur  lh»t  nnlMHor  i»orti"n  nf  llw  riRht  {tonx,  dMtrriyiim  thrro  iho 
■•orlJMiHpiuul  pynmiiiliil  rilx.Ts.  the  i-ortimniidrar  fitwTs  of  iln-  riiriitt.  the  Hmctinit<>r«, 
nnd  th<-  hy\<rttiftf^.  U  <J*>f»  noi  involve  ihc  wnmrntiinn  nnr  th«?  rout  tilierw  i>f  iho 
cnuiml  ut-rvvs. 

On  the  left  ndp  ihorv  m  s  rrvMiMl  hotm]>l«-|[ia  nf  tliP  tnink  nnil  pxtremiliM  willi  i»n- 
tniotur««  ai»il  oxtim[«nitioa  of  lf»  «*flu«oj>.  Lt-fl  inlurior  tm-inl  lii-niiplrion.  tiiiM  »iip»'ri">r 
hcmifafini  pnrcwiK,  sJieKt  wktciiiiiit  of  the  piiliiptiraJ  fiMiire.  sliuht  (Iroopmjt  of  iIh'  cst^ninl 
Imrdrr  i4  ih"  h-it  fyrl>ri.w.  slitdit  iiupuiniifiit  vt  iadvpootlintt  ckunitw  of  the  py«f.  homi- 
pareeia  af  ihp  iniuitrulurfe.  rapfruklly  of  Uip  internal  pteO'lP'iti-  HcmiiumMia  ol  thii 
loncUf.    Iittciiriiy  >j{  i-^KCtriiMl  rctK^tiituf. 

By  muH>u  of  thi-  iinnli uDlnAnc-t-  of  the  iiniaplM  im  Uie  s(iun()  aide  tlH>  lifH  am)  jrw  ar« 
(Iruvrii  l'>  ihf  ri)(ht  mid  >iii  (inilniointi  nf  tho  tiMifoip  it  puinbt  t»  llu!>  pnndyiiod  mUiv.  cluv  to 
urtinn  ol  thw  nxhi  itt^iingtinnuB.     (l>i>jerinc.> 


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47(»        LB.VON  Of  TUB  PO.WS,   BRArX  i^TE.M  OR  ytlDBRAfff 

pressure  jilpmnctcr  ti(rt\-  Iw  riiistil  on  tlic  analnrsM-  siilt'.  In  thr  samr 
way  the  atrtH-ltii  area  i(f  tlic  IiimI,\  iiijiy  In'  Insi-tisitiw  t(i  iill  i]t'>:ryes  of 
heat,  ami  tu  ull  stiiiuili  CHpabU'  eiF  rvukiiiK  iinniialiy  a  scMisntiim  of 
t*ol(I.  In  tlif  nic'lnlla.  huwever,  in  disthuiinn  frnm  lesiims  of  tin-  i-ord, 
thf  crossiT  form  of  pjiiii  inid  discninforl  may  Iraverst*  ntlifr  pnths  if 
the  usual  f>in-s  ure  cliiscd,  wjit'rfus  in  the  eon!  ull  jjaiiiful  iiupiilses  are 
blorketl  by  a  uniftn-al  lesion. 

At  the  medulla  and  pontine  levels,  moreover,  all  three  forms  of  sen- 
sibility may  be  atfec'tecl  together  or  any  one  may  escape  or  be  alone 
involved. 

These  intpiilses  of  pain,  heat,  iiPid  roM  all  rnii  n|)  in  (lie  lu-ii^ddinrhnnrj 
of  the  fifth  ner\e  nueleiis.  and  in  eases  of  ocelusitm  of  the  postero- 
inferior  eerebellar  arterv  and  from  other  destroyiii(t  lesions,  the  paths 
are  usually  implicated.  This  same  accident  may  occu.sion  a  di.xMic-ia- 
tion  of  the  iinpulsi-s  underlyinjt;  the  appreciati<m  of  posture  iiiiil  passive 
niovenieiit  fmni  those  concerned  with  spatial  discrimiiialion. 

A  summarj-  of  the  findings  which  may  ocrur  in  the  lesions  which 
cut  oH'  the  sensory  pathways  between  the  nuclei  nf  tfie  pjosterlor 
coliuuns  and  the  optic  tlmlaitiu»  luis  been  stated  by  Hentl  and  Ilolmc-s 
as  follows: 

1.  The  impulses  for  pain,  lieat,  and  eo]d  continue  to  nni  up  in 
separate  secondary  paths  nn  the  opposite  .side  of  tht*  ner\'ou.s  system 
to  that  by  whieh  they  entereil.  They  receive  accessions  From  the 
regn»u):ed  atferent  impulses  from  the  nerves  «if  the  head  and  upper 
]y»n  of  tfie  nwk. 

Althouj-h  these  paths  are  fretpiently  alTecteil  together  they  are 
independent  of  one  another,  and  any  t>^  the  three  qualities  of  sensation 
may  be  dissncinted  from  the  others  by  disease. 

2.  lA'siodN  of  the  spinal  c*>ril  tend  to  diminish  simulUuieoiisly  all 
forms  of  paird'ul  sensibility,  but  with  dLsease  of  the  brain  stem  the 
RToss  forms  of  pain  and  discomfort  may  iiass  to  consciou-sne-ss,  although 
the  skin  i.s  anal^'wic.  This  applie.s  not  only  to  painful  pressure,  but 
to  the  discomfort  pniduced  by  excessive  heat. 

'A.  *I'hc  iuipijsfs  conci'rned  with  postural  rerontiilion  part  company 
with  tliose  for  spatial  discrimination  at  (he  posterior  column  nuclei. 
l*p  to  this  point  tliey  hove  travelled  together  in  the  same  column  of 
the  spinal  cord,  but  as  soon  as  they  reach  their  first  synaptic  juucticui 
they  separate.  Above  the  pfiint  where  they  enter  secondary  paths  the 
power  of  rr<'ognizins  [xwtnre  and  passive  movements  can  be  affected 
indepeudetilly  of  the  discriniinatiim  of  two  points  and  the  appn^iation 
of  .size,  shape  and  form  in  tliree  dimensions. 

4.  Tt  would  seem  as  if  those  elernenl-s  which  underlie  the  (M>wer  of 
localizing  the  sjHd  touched  or  pricked  beeouie  separated  i>tf  fnim  (heir 
associates]  tactile  impulses  before  they  have  actually  come  to  an  end 
in  tlic  optic  tJutlannis.  The  loti^  coimection  of  localization  with  the., 
integrity  of  tactile  sensibility  is  here  broken  for  the  first  time. 

.Ml  the.se  changes  are  jireparatory  to  the  great  regrouping  whicl 
takes  [)htce  in  the  ojitic  thalamus. 


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J7.S        LESIO.V  OF  TUB  POSH,  OltAIV  STEM  OR  MIDBRAIN 

Inferior  Alternate  ParalysU.— Anterior  and  I'osterior  Pontine  .S>'n- 
(irunies.     Millanl-tiuliler,   I'^ille  S^Tidronnis. 

Rcferenoe  to  J*late  I  anti  Fig.  273.  p.  479,  shows  the  site  of  a 
lesion  which  prcwiuces  the  Millard-Gubler'  lype  of  inferior  ulteniate 
jmralysi-s.  The  le^sion,  a  softetiitig,  henu'rrliapt:,  tahes.  Isoljiterl  tuhcrele, 
syrinjjuniyelia.  hulhar  piilsy.  gumma,  p(>h()eiu'ephahMnyelitt.>>.  rarely 
rc<'urrent  yAUy  in  mijjraiiious  vaseular  disturbance,  in  the  anterior  imrt 
of  the  pon-i  low  down  at  the  emergence  of  the  VI  nerve  ami  internal  to 
the  peripheral  exit  of  the  \\\  nerve  causes  a  partial  paralysis  of  the 
linihs  and  trunk  on  the  op]Hisite  side  of  the  hixly  to  the  lesion  and  an 
inlertml  strahisnuis  of  the  eye  tif  the  opposite  side.  There  is  (o)  no 
fuc'ial  pal.sy  and  no  sensory  luss — hemianesthesia — the  lemiiiseus  [Rm) 


l'\M.  'JT2. — 1  k-inorrliime  nf  ii^nia. 

"beiiiK  spurevi  in  this  lesion.  If  this  lesi<m  extends  laterally  (h)  to  im'hidc 
the  (Krniiheral  \'1I  there  in  a  facial  palsy  nn  the  side  of  the  lesion.  The 
sixth  ner^e  fialsy  tm  the  sann;  side  of  the  lesimi  eauses  an  Intenml 
strahismus.  The  seventh  nerve  palsy  is  of  the  peripheral  type  (set-  6). 
There  is  reaetion  of  def^eneration,  atrophy  of  the  facial  museiilaturc, 
lapuphthalmos  Fwin  levator  f>al.s\'.  the  aiifile  of  the  mouth  droops. 
Tiiere  are  rai  sensory  disturlMUiees. 

A  lesion  lying  internal  to  the  peri]»h<Tal  rniernenec  of  the  \'I  nerve 
can  cause  an  ordinary  hemiplegia  indistinguishahle  from  a  cerebral 
pal.ty.     It  wtjuld  have  to  be  a  very  small  lesion,  however. 

A  still  rart^r  delimitation  by  a  lesion  involving  the  VI  and  VII 
(between  a  and  b  peripherally  In  Fig.  273)  at  their  convergence  at 

'Oilblcf:  McntiiiKiiiiirl'henti(ilcgiQalt«!rD»,Uiui.  liolxl,  l8M'186fO.  P(vvt»t;  Thteft 
tJo  Pnha.  180S. 


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480       LESmX  OF  TIIS  POSf?,  BRMS  fiTEM  OB  MtDBRAIX 

this  level  will  c-au!K'  a  fKciul  palsy  with  an  intertial  strabismus  hikI  iio 
otliLT  symptoms.  Tlifse  are  usually  due  to  meninfjcalsyphilittf  lesions 
and  several  cjims  Jiavt-  come  iintitT  obsiTvatton.  Two  siuli  [Mitients 
have  hail  two  recurrences  of  this  comhinalioii  at  a  year's  inten'al. 
There  have  been  no  niigraine  artat-ks  in  either.  J  ii  one  the  Wassemian  n 
test  was  -f-f  -f  + ;  in  another  it  wa.s  ni*gative  and  tt  hepinnlng  multiple 
Hclenwis  wa**  suspected. 

MiHiirff-duhb'r-Fin'iHr  Sytidmnifi. — This  syndnime  was  originally 
described  by  Foville.'  The  lesion  wliieli  uiay  be  any  of  the  types 
already  cited  for  the  Mitlard-dnbler  .\vndrome.  but  is  more  apt  to  be 
vascular  (throndtu.s  of  vcrtel)rals,  basilar  involving  the  mitldlc  pontine 
ve.'isels),  occupies  not  only  tlte  anterior  stage  of  the  pons  but  lies  along 
the  central  rfl])he  In  thi>v  region  tif  the  pons  (Kig.  274).  Thus  the 
median  h-niuiseus  (fillet)  (flm)  fibers  are  involved  in  addition  to  thtv 
pyramidiil  fibers,  the  fibers  of  the  reticular  formation,  and  even  the 
pusleriur  longitudinal  fa.sciculus  {Flp).  Thus  to  the  crossed  hemiplegia 
there  Is  uihlt^]  a  i-ntssed  hemianestliesia  and  a  paralysis  of  the  asswi- 
ated  eye  muscles.  'I'he  internal  rectus  of  one  side  (III  pair)  and  the 
external  rectus  of  the  opposite  side  (VI }  cannot  functionate  syncrgUtic- 
ally.  This  <x'ulogyric  palsy  may  involve  one  or  the  other  sitle  accitrding 
to  the  site  of  the  Ie^ion,  the  eyes  iK'ing  turned  away  fnitn  the  site  of  the 
le-sion  (see  VXaW  II).  It'  the  ri>ot  fibers  cjf  the  faciiil  art*  imulvetl  (6), 
as  (hey  usuulK  are,  there  is  an  inferior  facial  palsy  of  the  same  side. 
This  tyi>e  of  paralysis  is  illustrated  in  ?'igs.  n  and  h  of  Fig.  273.  In  [h) 
the  facial  palsy  is  figure<l.  In  ia)  the  lesicai  lies  internal  to  therucial. 
The  hemianesthesia  involves  deep  sensibility  of  the  body  and  fa<'e. 
I'ostural  .'*ense  is  also  invnive*!.  The  losses  in  sensibility  are  more 
niarkeil  tu  the  face  than  iu  the  e.\tremitie.s  and  there  is  no  marked 
affective  overresponse. 

Puxfrritir  Piml'nir  Sj/nifn.nii-.^. — Lesions  at  this  >.auie  level  (VI  and 
\'II  nerve  level — sti'  I^latc  I)  f>y  lying  in  the  tegmental  or  posterior 
[Mirt  of  the  pons  and  behind  the  c<trticoiuielear  and  corticospinal  fibers 
produce  a  nimbi  nation  syndnane  if  the  lesi(ni  lies  internal  to  tlie 
cori>us  restiforme.  a  more  extended  syndr»>me  when  encroaching  upon 
this  structure  and  the\'III  nerve. 

In  this  more  limited  posterior  pontine  sNtidrome  (usually  softening 
or  lienuirrhage)  there  Is  a  partial  crtissed  hemianesthesia  frtim  inltiimal 
(illet  1,/^")  in\olvement,  alternate  paralysis  of  the  \'I  and  VII  nerves, 
anesthesia  of  the  trigeminus.  The  anesthesia  is  a  syringomyelic  dis- 
sociated type  if  only  a  part  of  the  fillet  is  implieattxl.  Tactile  sensi- 
bility, sense  of  position,  and  stercognostic  seiise  are  inta<-t. 

A  more  extensive  le.sion  (tubercle,  multiple  .sclerosis,  gumma,  soften- 
ing (Fig.  271,  p.  477)  produces  a  much  greater  degree  of  crossed 
hemianesthesia  b\-  tuitiplcte  cutting  !)t!'  of  fillet  fibers  {fim).  There  is 
alternate  \'I  aii<l  \'n  nerve  ]wilsy.     Thea*  is  conjugate  palsy  nf  the  HI 

■(.jnuael;     I{«viie  Ninir»lr)|[iqu<>.  IVQO.  viii,  5(f6.  cUtt,  Fovillv.  .Society  AiuilDiniiiiM. | 
166S,  IU  hnvtiiK  KJvcn  Uut  lint  clear  tlaacriiiikiiL  ur  diu  ayiictniiiic. 


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Fi«.  274.— Pontine  »)-iidrrttnc.  Mil  lard -CuliIer-FoviH*  ayadnmit.  H«niipleina  of 
c«rel>ral  lyp«  Kith  heniiuiifr-ttimiii  i>l  Die  i>xtfiTnil.in>  imd  nf  the  head  at  the  nido  opposite 
iiiitt  lUtomHU^  ptinilyjiin  mny  be  of  thiv  (I'/i  «.nly  i«]  or  of  iho  Vf  and  1'//.  (fc)  by  throtn* 
bosis  ol  the  iitfuriDr  portion  of  Uie  ba»iiliir  nrlvr^'.  iu  v>^tirular  nf  tlio  tnecltan  pontine 
url«ri<>9  of  thr  left  ndo.  Thp  Iraion  or^upi^s  the  nntpnor  port  of  tlio  ponn.  (l«Mtmyii 
th#  pyrAmi^lnl  trart  (^v)  vxlfiifU  lo  the  teBnirntum,  Motions  IKp  mpdun  l^nmiHciia 
(ibKD!  (Am),  the  fibon  of  tlip  rati^-iilBr  formittioii,  tiie  pcwtcrior  loncitudinal  fiuirtnuliLt 
{Flp),  iho  root  fi>ierii  of  the  V/  pair.  In  f'>>  iho  niori'  mtWimlvii  Icwon  dMlmyo  in  ad'li- 
tion  tho  root  Qbcn  of  the  fariiil  and  thp  tiunki  uf  the  I'i  and  VII  and  the  filx'ra  of  rhu 
lateral  port.inu  nf  (ho  ri>ri4'iil»r  {orrnniioD. 

On  the  riii/jl  Uiere  ut  iTiit ralal^raJ  iietitipleiiia  uf  tho  ci»r«I>nir  type — extreiiiitim  iiiid 
interior  fticja),  tiy  Ii-mdu  nf  the  rortinonpiiiiil  pyniiniilnl  filwry  and  of  the  conJ«o-nucleo- 
facifil  (uKTmnt'iiiedtillo-poniiiie  Sben).  Uemiauievihtwia  of  the  extremitiM  mid  of  ifae 
fnc«  in  <n)  invnlvirut  putjculnrly  the  iJtrtiLr  Nciiutnlily  itnd  potttuial  mdm.  and  in  (6) 
nil  OH'tlrs  of  «fii»itiility.  Ihent*  bcinjt  hkii*  tuarkc)  in  ihu  hmwJ  ihan  iji  ihi-  «xtremitic«. 

On  thv  It/l  Mv  there  is  pitrulyaid  of  the  exteriial  nftim  (I'/)  internal  strabianiiia.  Co 
which  there  is  added  in  i.b(  a  p^nlyma  of  the  Ur'ud  { VI Ji  mfenor.  mperior.  and  of  the 
pinlyvtna  myoidm,  lnit<>|ili(hatniui,  droopitut  uf  thv  oiisIp  of  the  innuth.  ftHttviuns  of 
the  faHiil  lines. 

Furthernn'»re,  (her*  it*  purnlyniK  of  lateraJ  movenwim*  of  the  eyca  townrd  thp  left  l»y 
Eeaion  of  the  lofi  poslrrior  looiptudinal  faecicuJus  (Fip).    By  reaaon  of  tlie  predoimiianee 
of  tho  antAgoni»u  the  p«tient  looks  toward  the  ri^t.     (Dejerine.) 
31 


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482        LESION  OF  THE  PONS,  BRAIN  STBM  OR  MIDBRAIN 

and  VI  with  turninff  of  the  eyes  away  from  the  side  of  the  lesion,  fntm 
involvement  of  the  posterior  longitiirJinal  faseicuhis  {Ftp).  Kiirther- 
morf .  there  is  a  rerehcllar  heniiataxia  from  the  euttinR  off  nf  filM^rs 
going  To  the  cerebellum  {Cr.if).  Involveinetit  of  the  spinal  vagus 
cau.ses  u  palsy  of  tlie.  ipsolateral  vocal  cord,  cutting  off  of  the  VJJI 
causes  deafness.  N'estibular  tiystagnjus  also  oeeurs  from  cuttinjc  off  nf 
vestibular  fibers.  Soft  palate  palsy  is  also  present.  Tumors  of  the 
pons  give  rise  to  a  very  varicil  syndrome.' 


<K: 


'/.: 


/a 


I'lii.  2"!'!. — ^Ui'iifrrlint!!!;- <■!  imji.-.. 


Po-siero-infcrior  Cerebdlar  Hyiuhome.' — 'I'he  «crjiisi<»it  4>f  the  pn*- 
tero-inf crier  cerebellar  arter>'  h  prone  to  produce  a  wulespread  jiontine 
Hyndrome.  It  forms  one  of  the  apoplectic  bulbar  palsies.  The  initial 
symptoms  are  apt  tt»  be  acute  dizziness,  occasionally  with  transitory 
unconsciousness.  There  Is  slight  usually  passing  paresis  oF  the  opp(»- 
site  extremity  with  iiuiy  he  transitory  motor  l<iss  tif  fifth  of  the  same 
side.  Crossed  hemiane.sthesin  to  piiin  and  tempeniture  and  ipsolateral 
trigenunus  sensory  impainnent  of  tin*  first,  second,  or  all  tliree  brancji 
distributions,  ipsolatend  }iemiataxiu  with  tateropulsion  to  the  side  of 
the  lesion.  Bilateral  nystagiims.  wors*'  on  side  looking  towanl  lesion. 
Revolving  vertigo,  sometimes  headai-he  and  vomiting.  AvelHs  syn- 
drome of  palatal  and  laryngeal  paresis  on  tJie  ipsolateral  side^  causing 
dj'sphBgia  and  a  whisfiered  speech,  sometimps  ta.ste  impairment  in 

>  Vnrri:     TliJbv  <lc  Pari».  \mh. 

)  fipiUer:     Jotir.  Ncrv.  and  Mcnt.  Dis..  IBOS,  uolv,  36&. 


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PEDUNCLE  SYSDROMES 


483 


the  anterior  two-tJiirds  of  the  tongue.  Occa^iton&Uy  ipsnlatcral  sixth 
aTid  seventh  nerve  palsy  from  extension  of  the  sitftening.  lixsolateral 
myosis,  narrowing  of  the  imlpehra!  fissrire,  anhydrosis  ami  eriophthdl- 
n)08.     Oeea^iionally  Ipsulateral  loss  of  henring. 

The  eireulation  nf  these  portions  of  the  cerebrospiiml  axis  is  subject 
to  Diueh  variation.  The  postero-iiiferior  ifrelH-llar  is  usually  given 
off  from  tlie  vertehrals  about  2  cm.  from  their  basilar  union.  The 
anterir)r  spinal  is  given  otf  internally  just  below.  Tliis  latter  enters 
tJie  raphe  and  is  distributed  along  the  raphe  (see  Fig.  265.  n  and  b) 
to  the  aiiten Mil i vary  Itodies.  piisterior  longitudinal  faseiculus  and 
twelfth  ner\*e  ntielrns  lirst  on  the  fliMir  of  the  fourth  ventrirle.  The 
pii.<ten»-iiiferior  rerelH-llar  artery  is  ehiefly  distriluited  to  the  [itti-ra! 
parts  ttf  the  iip|M*r  iiuHJulla  and  lower  |joiis.    Branches  go  to.tJie  corpus 


I^.  276.— Wriww'a  •yndromc. 


Flo.  377. — Webwr'n  syiidfome. 


restiforme.  (See  Fig.  271,  Cni.)  There  is  so  much  variation  in  the 
arteries  of  tliis  region  that  it  is  practically  impossible  to  state  always 
wht'ther  a  rlinirjil  symptom-oi>mplcx  is  due  to  vertebnd  or  to  inferior 
cerebelUir  artery  disease.' 

Pedimcle  Syndronies. — I^*.sions  in  the  region  of  the  upper  level  of 
the  pons,  lower  bonier  of  quadrigemiiia,  exit  of  III  nerve  (aee  Plate  I), 
give  rise  to  »  very  characteristic  group  of  clinical  pictures  variously 
tenned  (iublcr-Webcr,  \VelKra?id  Benedict  syndromes. 

Wehff'f  Sytuirome.— Superior  alternate  |:»aral\sis.  CJubler-Welter.^ 
These  pu.tient.H  are  taken  acutely  ill,  are  eomatose  or  uncouseious  for 

'  nrvwr:UK3  M^rUtrf.  OlKfvuiuer'n  Arl>wiwt,  1002,  in,  IHl ;  Kliii>kl»uni;  Jour.  iUtatpt. 
N'our.,  1907,  ivii.  VM;  XJunl:  Afchiv.  >1«  Chnnul.  uunn..  1873.  97;  WnllimtMrc:  Arrti. 
t.  Vivh.  «xrii.  30f 

'JwUiffo:  *ipor»oi  Allonuito  Hi'iiiii>l«i*.  Gublet-\Vo)>OT  Tj-p*.  Itilcrainiv  Mnljoiil 
Jouninl.  lUUH,  sv,  No.  0;  CmliUr:  Uil«cU«  hubdmiwiBinr,  It^V:  Wvlivt:  Mctl.  ClUr. 
TnuuMtiow,  19B3> 


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484        LBSIOff  OF  THE  PONSrsiUlS  STEM  OR  MIDBRAI.V 


a. 


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7$//ttr. 


m/rtr. 


Piti.  278. — Aiilcriiir  iierliminiliu'  dytitlnmii'.  Wclior'ii  iiyti(lroiiii>.  Hu|M>riiir  idlrmalc 
hpniipt«iaii.     Pnidurpd  bj*  rcroKiral  pedunHp  aod  ///  rmit  fiber  Imnnn. 

Oil  till-  nijAf  ntif,  uitii train tvnJ  homtplociu  nf  tlH>  tniiik  ii»<l  cxUvmilic*  fioiu  Ivmun 
of  the  (xiMirospinnl  pyramidfll  fibon.  Fiifin]  hcmiflr'ciB  infcnnr  bmnchm.  hrmipnrpsu 
of  tbv  ti>i)K\ir  fn.>iii  Icatoii  of  the  i-articvniiclror  filx-nt  ni  tho  h.vpi>iili.>«vui<.  lit  (»>  the 
iMdoii  iiivoIvM  only  n  portion  of  tbt-  forliMU([uniil  and  (■oniroimilwir  fibeni.  Id  (6)  iho 
Imoii  ioduclvb  ull  of  tJiv  pyrnmidiiL  (■4>rti(M?Hi>uiiLl  mid  <^urtityiDUirLriu  &bcn.  <'v«n  tboao 
whii-h  111  tliw  rfpoii  fomi  the  Mipprfiriiil  uikI  rtcrp  pra  kniniiwiui  fihtwu.    (Sw  Flute  I.) 

Iij  itddiliou  lo  th«  cyinptiKiin  ninmioti  Ut  |n|  amj  <'i)  iiidii-ulml  in  tlie  ill  lut  rat  inns,  tM 
bImi  nhfiwn  u  futijiigiilr  dl>^'in■iull  of  iho  linul  ntul  the  oymt  (nmi  n  ItM'in  of  \hc  nirtlpsl 
iiculorulary  fiticni  di^tinMt  to  nn  to  Uie  nucl«i  of  ihe  oculooiutoriiu  and  ftbducecu 
(f/f^r/l;  ilidtnillii*)!  in  invilji-jiliim  fniru  luduns  nf  Llir  iiiutor  nortici^triiciinutiui!!  (ilM^n; 
difliruUiw  ill  «i«'Altow'uiK.  of  pl)r>utttioo,  nnd  of  iirtivulalion  fruni  iMioufi  of  tbc  rortioo- 
nurlcfu-  fiboni  of  ttw  xpinol  vmtiis. 

As  M  resiUi  of  th4>  prodnniinnD<v  nt  the  antaconiat*  of  the  <iound  nido  Cl't^ft)  ii>  (A)  «nd 
(A],  thurp  can  Iw  olncrvcd  n  di>\inth(>n  uf  tlir  mouth  ifa<-iiil},  and  nf  |hv  jitw  (nuMticuton) 
lowant  tht'  l«ri.  ft  (i^'WntiAii  of  the  fitijcitu  tii  t.bc  iuirnlyi«d  atdo  <tu-tlon  of  mund  Rcniiv- 
llJintiUBl  and  iu  (b)  furtliH'  a  vutijuoalo  dwialiou  of  tiw  hoad  aiid  uf  tbo  «yca  mranl  Ifao 
Infl  (nrtion  nf  thp  cxtM-rinJ  linitich  nf  (he  opiiml  orrrKimry  and  of  tlii'  kvorotary  o<-iilar 
Rliers)  iinij  a  ilfviiition  of  the  uvtUu  tonarJ  thw  Ml  (spiTud  vafitut). 

Oil  ilip  /*■/(  (■ide  thiirp  in  n  tMn'ft  pumlysiB  nf  the  third  {III)  iiorvp  witli  fitoitis,  divvrsmt 
ptnilnMiiiw,  wtib  01'  without  Diydriavia  aud  pupib  whi<^h  do  not  rMict  oi(b«r  lo  lifht  ot 
oonvenc^nrc  arrarding  to  the  gmde  of  dcaLTUClkm  of  Hk  rruit  liljpre  of  tlio  nntloniotoKua 
(///>.     tDrjfriiifO 


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*BmmclE  SYNDROMSa 

tlie  nvKit  part,  uct-usioiuilly  as  in  l.uU)ir»ra!H;  (carliost  nfionUi!)  tlierc 
is  nn  loss  of  coiiscMHisncss.  If  the  patient  recovers  the  residiuil  pitralyses 
sluiw  thriH selves.  These  will  vary  somewhat,  tieiK-udirij;  ii|>i>n  the 
extent  of  the  drstniriiidi  in  the  pciiuncles. 

Midpeduncle  Syndromes.  'I'hesc  occur  from  lesions  similar  to  those 
juat  disciifwed.  'I'hromboses  chiefly  of  the  basilar,  tumors,  poUo- 
cnreplia litis,  etc. 

Wlieii  the  h*sioii  extends  alonj;  the  central  raphe  (as  in  Fig.  208), 
usually  frmn  arterial  disease,  an  acute  upoplcelifonn  palsy,  often  with 
transitory  or  complete  uucojiseiousiiL'ss  re:^ults.  Many  of  these  lesions, 
csiKfially  when  extensive,  result  in  sud<ien  death.  lu  the  milder  forms 
the  various  multiform  after-pictures  manifest  themselves.  The  (frave 
implication  of  the  intersperse*!  corllrospinal  fibers  causes  a  contra- 
InTernl  lieinipleKta  with  increased  tendon  reflexes,  clonus  and  Habinski 
phenomena.  Involvement  of  the  corticofacinl  fibers  causes  a  contra- 
lateral tower  facial  palsy,  paralysis  of  the  tongue  muscles,  and  of  the 
Tniitor  fifth,  deviation  of  dun  to  the  sound  side,  protrusion  of  ton^rue  to 
the  paralyzed  side.  Hemianesthesia  i>f  the  sauie  side  as  llie  hemiplegia 
is  also  present.  It  involves  the  sease  of  position  as  well  as  all  other 
types  of  sen.^ibility  on  the  entire  half  of  the  body.  In  middle-lying 
lesions  the  trigeminus  may  he  spareil.  In  niDre  latcral-lyinu  ones, 
posterolateral  pontine  syndmmes  (270),  the  syndnmie  i>  less  extensive. 

Ill  (27S,  a)  the  lesion  4Kvupiesthe  middle  third  of  the  right  pe<luiicle, 
cutting  oil  only  a  portion  of  liie  corticospinal  and  corticonuclear 
pathways.  There  in  a  crossed  hemiplegia  of  the  entire  side  of  tlie 
ljod,v,  the  extremities  from  the  cutting  otf  of  the  corticospinal,  the 
inferior  branches  of  the  facial  from  the  corticonuclear  fibers.  There  are 
no  atrophies  and  no  rejiction  »>f  degeneration,  the  paralyses  being  of 
the  cerebral  tjpe.  The  tongue  protnides  to  tfie  paralyzed  side.  In 
the  early  stages  of  a  severe  attack  with  coma  or  market!  somnolence 
there  may  be  no  hj'pertonicity  of  the  involved  hemiplegie  side,  hut 
later  The  increased  kjiee- jerks,  ankle-clonus  and  Babiiiski's  phenomena 
ap|>ear.  The  lesion  being  confined  below  the  locus  niger  gives  rise  to 
no  sensory  symptoms.  In  certain  cases'  (Grnenewald,  Cestan)  the 
lesion  involves  lemni.scus  fibers  (Benedict  syndrome  types)  and 
hemianesthesias  appear. 

On  the  same  side  nf  thi*  lesion  a  III  nerve  palsy  apiw^ars.  There  is 
ptosis  and  external  strabismus.  When  the  K-sion  extends,  occupying 
two-thirds  of  the  cerebral  pe<luncles,  additional  symptoms  appear  (6). 
Thus  there  are  added  further  corticonuclear  involvements.  Thus  tliere 
is  a  conjugate  deviation  of  the  hem!  and  eyes,  the  head  turned  away 
from,  tlie  eyes  IcMiking  toward  the  side  of  the  lesion:  there  are  motor 
fibers  involved  causing  difficulties  in  chewing,  and  further,  palsies  of 
the  soft  palate  and  phar^'nx  cause  dy.sphBgia.  The  uvula  is  deHocted 
to  the  sntmd  side  (side  of  the  lesion).  Then*  may  be  total  mydriasis 
with  loss  of  light  and  arc(»mmodation  reflexes. 

<  Jdtiff«:  On  Liwioiia  of  iKo  MiiJIiraio.  with  Sperjid  Rffcmn-i'  Ui  Uio  UnnMlict 
iiyuilroiiie.    Intn^uu  Medical  Journal,  Itill.  x^-iii.  No.  S. 


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486       LESION  OF  TUB  FOSS,  BRAIN  STEM  OR  MIDBRAIS 

Sonir  iir  tlicsf  ji;ilic-nt>  iiutko  a  Tiiirly  cuniplolc  rcvdvcry,  syjihilttir 
arteritis  witli  liciiiDiTlmK''.  '*"*  ""«^'  ^li'>"'  nsiiluulsaml  iisimlty  tli-veJup 
further  Rttacks  wlik-li  K-a^l  to  ck-Jitli. 


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R«J 


Fio.  279. — I*o«iMior  pedunriibr  Hyodrome.  ContrulaU'ml  Boncdiirt'a  ttjtidroim. 
HoRiiaiiraUmda  with  oborvo-BlhoUii'l  inovenuntfi  Aiid  alUiraat«  pnral>-<iis  of  Ui»  Ihird 
xmrvf  {IIS)  My  roiMAn  of  iMlon  uf  ibo  rifihl.  pontine  tcipiinnttim. 

On  thv  left  fidif.  I'linlralBteial  hpiiLuuii>)!ii.hi!(ua  of  the  cxtrociiticw  miJ  of  ibc  iuiot  fmni 
lesinn  n(  ihc  «c"iTitli»r>-  rfi>t(i«rfl  wtwriry  pnthwA}'^  (ftm  witl  .S'ff).  Chmwi-ath^iUiid  m'tv^- 
iiifuU  iiikI  nl  titii«<n  ireimm  fioiu  Uwiun  uf  tlic  red  imcleua  and  of  ilii<  .iuii«rior  m^bellar 
IMxIuiirlo  </*m)   IitImw  l.ho  (trc-iMnntJon. 

Oil  till'  naM  Kiido  por^yau  of  tint  tJiird  nerve  (///>.  with  ptosiit.  oxtcroal  atrahiaiitiu 
(noo-reBatance  to  ntt^riinl  recliis).  uitli  t>r  wtthnut  mydrinris  nnd  piipilii  inim<)hi1e  to 
lisht  Bud  oauwrBBncT-,  dupetidiiix  o»  tlie  vxtvut  of  ih«  Iniuii  of  tliv  ruot  lilipn>  i^f  th* 
onikNnoiDriuB  (if/).    (Dcjehni!.) 

UrnedirVit  Syndrome, — Benedlft  first  dcscrihed  tliis  in  IS72.'  Tliese 
pjitictits  usuhIIv  sltow  nil  npoplwtifonn  oiist't.  Hftnwlift**!  first  case  was 
frradiml  in  <ievflopme!it  (muUiple  tuberck-s).    TJiey  may  show 

'  JvllilTi*:  \jtii:  ril.;  fttumlirl:  Ner\'eMi>iitlinlr>gi(%  \M'2. 


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(*0rPORA  Qf'AliRlORHtUfA   .?VA*?)flrtA/R<! 

typk-al  Wi'Im^f  JH*mi|]lrr;Ii<  hihI  fnissttl  (Itin)  ihtvc  |»ul.sy  t«  wIikIi  Ls 
jii|»l»'(l  a  lir-ttiianostlH-Kiii  mid  h  r-IiMrtu-iitlu'tniil  like  (rcrnor.'  Wlii-n  (Iir 
lesion  fjiils  to  reucli  tin'  forti<'o;iphml  vr  cnrticomirlcHr  HI)er:>  iii  the 
]jcrlunclcs  there  may  be  no  hemiplegia. 

Thus  ill  the  ease  illustrafwi  (279)  rheiv  is  ti  ((iiitrahiterul  Henediet 
syndrome  without  any  lieniiplegiiu  'Utere  h  a  complete  hemtaiiesthesia 
from  impli<atinn  of  thi*  leninis«iis  (ihers  (I{m\.  'I'heve  is  ptosis,  external 
stnilii-snuis  and  pupiDury  iinnmhiliiy  (eomplete  or  imrtial]  fruni  iii- 
volvi-ment  of  the  III  nerve.  The  ehorei>atlietoiil  niovpmcnts  result 
from  euttiiiic  off  of  rubrospinal  (ytm  Monakow)  and  rubrwen-lx'llar 
fibers. 

These  cases  are  due  to  hemorrhage,  softening,  tuberele,  multiple 
sclerosis,  s\7>hilis,  poiloeneephalitis.  etc.  The  course  and  treatment 
will  depend  upon  the  causative  lesion. 

Corpora  Qcadrigemina  Syndromes.— (Jeneral  lesions  of  the  corpora 
quaflrigeniiiiii  bring  aliont  a  syndrome  often  called  Nothnagel's  syu- 
droQie.  Here  tlie  most  chara('teri?ilic  pathological  agents  arc  tumors, 
either  of  the  corpora  quadrigemina  themselves,  or  of  the  pineal  body. 
Vihcn  the  roof  of  the  midbrain  is  involved,  tliere  is  usually  headache 
and  vomiting  frtrtn  increased  intracerebral  pressure.  Optic  nctmtis 
often  ilevelops.  Dizziness,  staggering  and  rolling  gait,  with  irrt^gular 
fonns  of  ocuiomotur  pul^y  are  present.  The  conjugate  vertical  move- 
ments of  tin;  eye  an*  fn-iiuciitly  involved,  ami  not  infrefpiently  there  is 
nystagmus.  The  pupils  are  usually  wi<lely  dilatiHl,  or  shnw  anomalous 
reactions  to  light  and  accomniiMlutiou.  Hearing  is  inwiifiei]  if  the 
posterior  quadrigeminal  lH)die3  are  involve*!.  Tumors  of  the  pineal 
body  (see  Pineal  Syndrome)  offer  special  features  for  consideration. 
These  have  been  studiwl  particularly  by  Bailey  and  Jellitfe,-  and 
consist  of  (I)  general  sjTnptoms  of  intracerebral  pressure,  (2)  oculo- 
motor palsies  witli  disturheil  pupillary  reactions  and  other  signs  of 
involvement  of  the  corpora  iiniKlrigenilna.  and  (3)  mctalKilii-  symfv 
tonis,  due  either  to  the  disturbed  pineal  itself,  or  to  Infundibular 
hydrops  and  pivssure  u|>ou  the  piiuilju-y.  The  metabcUc  symptoms 
are  interesting,  often  consisting  of  adiposity,  sexual  precocity,  with 
pn'mature  (le\elopmenl  of  sexual  characteristics,  and  occasionally 
cachexia.  lesions  anterior  to  the  midbrain  involving  the  thalamus 
give  a  si>ecial  s,\TnptnDiatologj'  wliieh  is  discussed  under  the  head  of 
Tiialamic  .Syndrome  (7.  v.). 

CoUimitiit  Stijftrivr. — Tins  is  also  known  as  tlie  anterior  quadn- 
gemlnal  body.  The  general  to|Migraphicnl  anatomy  has  been  discussed. 
The  finer  anatomy  of  the  superior  colhculus  shows  it  to  be  a  highly 
complicated  structure.  .  It  is  arbitrarily  iH?i>arated  from  the  lower 
ittructures  of  llie  midbrain. 

'  Jpllilft-:  Oo  Somo  Oberiirc  TmnoiB  Diw  to  Itlidbmin  Lcsuma.  Post  Gniduatc, 
lOH.  750. 

1  TuoKtn  lA  Uii>  I'iiieal  Uoily,  Arrhivn  nl  IntmuU  Mcdiclns,  1911;  Kidd:  Hvviow 
ot  Nonroloo'  oiul  Pi^rhiRtry,   lOl'i.   l&i:i. 


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P0?f8.   BftA/N  STEM  OR  \(iDBRAIN 


A  swti(»n  at  !Ll>mit  tlm  coritnr  c»f  tho  iiiiillirfiiti  shows  flip  rullitvx'int; 
slnitliirrs;  (1)  A]i  miliT  white  layer,  the  stratum  SMJimle,  miule  up 
chiefly  nF  fibers  lieriveJ  fnini  the  iiptif  tract.  There  ure  alsn  filters 
friini  the  superlur  qiuulrigernintil  lirjielnu  and  small  horizontally  lying 
ntTve  eelLs.  [2)  A  gray  layer,  .-stratum  cincreuni.  made  up  cliiefly  of 
gangliou  colls  whose  asis-c-ylinders  proceed  inwar<i.  These  are  cells 
inakin;;  up  the  synaptir  jimotiirea  of  the  nptic  tract  fibers  and  are 
concerned  witli  establishing  oipllateral  a-ssot-iations  with  other  nerv^e 
pathways,  fhiefly  the  (M'lilnntotor  i>atlivvHys  to  the  nuclei  of  tlie  eye 
muscles  and  also  to  those  of  the  neck  itn<i  bo<ly.  (3}  A  layer  of  white 
fibers  contai]iing  the  greater  mass  of  the  optic  tract  fibers  which  arc 
temiiiiatiiig  ab«mt  tlie  ganglion  cells  of  the  tliird  and  tlie  fourth  layer. 
(4)  A  middle  gray  layer  of  cells  or  collatcnd  associHtion-s.  (5)  The 
lemniscus  layer  made  up  probably  of  fiber  of  tfie  median  and  lateral 
lemniscus.  ()>  and  7j  Layers  of  ganglion  cells  with  axones  passing  to 
the  opposite  side  or  passing  ventrally  to  the  atjueiluft  and  central  gray 
which  deenssftte  and  funii  the  tectobulImpoiitospiiiHl  tract  going  to  the 
anterior  columns  for  hcafi,  neck  and  trunk  associations.  Fibers  from 
the  spinothalamic  tracts  and  from  tlie  temporal  and  occipital  cortex 
arc  ulso  present. 

This  whole  structure  is  part  of  tlie  pathway  for  t!ie  mechanism  of 
sight.  It  is  in  connection  with:  («)  Ontripetal  pathways:  (1)  From 
the  nptic  tract  through  theantcriiir  brachium  of  the  superior  colliculus. 
(2)  From  the  spinal  eonl  thn>ngh  the  posterior  colimins,  their  nuclei, 
and  median  lemniscus.  {?,)  With  the  spinal  cord,  lateral  eolumns, 
tractus  spinotectal  is.  (I)  Occipital  lobes  through  the  internal  sagittal 
layers. 

ib)  Centrifugal  pathways :  ( 1 )  To  the  occipital  optic  cortex  by  means 
of  thearitenor  bnichium.  (2)  To  the  medulla  and  spinal  ettrd  by  means 
of  the  tectobulbospinal  tracts.  (;j)  To  the  nuclei  of  the  oculomotor 
muscles,  light  reflexes,  etc. 

Thus  the  reflex  ci^llalerals  in  the  su]wrior  i-oUieuhis  are  homologous 
to  tlitise  in  the  inferior  collieulus,  the  former  serving  to  join  up  light 
stimuli  with  the  rest  of  the  body — ^with  vegetative,  sensorimotor  and 
psycfiical  levels,  llic  latter  subserving  homologous  functions  for  sound 
stimuli.  The.'^e  reflex  collateral.*!  do  not  .subserve  any  optical  func- 
tions, properly  speaking. 

Fnini  these  anatomical  considerations  it  follows  that  a  complicated 
symptomatology  may  result  from  colliculus  lesions  which  will  vary 
aetrording  to  whicJi  tracts  or  groups  of  cells  are  involve*!.  Minute 
lesions,  as  in  |K>liomyeIitis,  encephalitis,  cysticercus.  small  tubercles, 
miliary  aneurisms,  may  cause  very  few  syndromes,  isolated  reflex 
di.^turban(Ts,  whereas  gross  lesions  from  pressure;  of  tumors  —pineal, 
tubercle,  sarcoma,  etc.,  may  cause  more  widespread  s^Tnptoms.  One 
of  the  more  roughly  grouped  of  these  Is  the  so-called  Xothnagel 
syndrome  just  descriljed. 

lesions  limite<l  to  the  stnictures  of  the  superior  Mdliculus  do  not 


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COnPOttA  0trADH!GBMISA  SYWDnOMUS 

causr  liliiiiiiiesM  nor  hemiaixtpsiA.  Thr  li^sioii  must  extt'iul  us  fur  ns  the 
geniculate  Ixwiios  tn  rearli  tlnw  t*\it\c  trnct  fibers  wliiih  urtM-oiitiiimfU 
farlluT  Uick  to  tUv  m-cipital  cortrx  us  si(;lit  HIhts.  .\lthouj;li  KIhts 
may  an  fnnii  tin*  tiilliculiis  In  iht-  <i<-cipit!il  lulifs,  just  whiit  rt-latinnsliip 
they  Imvf  tn  "wring  is  still  unccrtaiii.  Tin-  cliirf  ilisturbunct's  nf  pure 
coIliniUis  suix-rior  dist-asc  art'  in  tin-  pnprllar\-  reflexes,  eye  movements, 
and  balancing  funeiitms  tlirou^'b  eye  rnc>\ement. 

The  putliwuys  taken  by  tlie  pupillary  fibers  lire  not  elmreH  up  ciim- 
pletely  ns  yet.  1  Iiey  pass  witli  the  traftus  in  its  middle  i)ortion.  pass 
through  the  braehiuni  anteriiis  collifuli,  also  in  the  pulvinur  surface, 
and  end  in  part  in  the  sn|«'rfii-iHl  ;;ray  layer  of  the  sui>erior  colliciilus. 
Here  a  synaptic  jiLiiet ion  takes  plaee  loeonneet  up  with  tbeoeulomotor. 
Lesions  limited  to  these  pathways  may  cause  inequnlity  of  the  ]»upils, 
possibly  the  Arjj\  Il-Uobertson  pjienonienun.  !5nch  may  follow  traimia, 
alcuholiion.  or  syphilitic-  meningeal  infiltrative  processes.  The  over- 
whehning  majority  of  siieh  lesions  are  syphilitic. 

A  group  of  peculiar  assiK-iatwi  eye  iialsies  are  found  in  le.^ions  aiTect- 
inp  the  collicuiuji  itself  or  its  connections  witli  the  eye-muscle  uuelei. 
Thus  a  break  ii]  llie  connections  betwwri  theabducensand  the  collieuUis 
will  result  in  a  palsy  of  the  rectus  interniis  on  looking  to  one  or  the 
other  side  or  of  only  one  side  witJiout  any  palsy  of  the  abdiicens.  I  iiter- 
nus  associates]  palsy  witliout  loss  of  convergence  may  occur  (Fischer, 
Bielschowskyt.  The  precise  anatomical  details  are  as  yet  lacking. 
Conjugate  |>alsy  has  Ix'cn  frequently  describe*!  as  mostly  due  to  tumors 
pre.ssing  upon  the  eollicnlns  or  involving  it.  Here  the  eye-s  may  be 
directed  to  right  or  left  but  caiinol  be  raised  or  lowered,  or  only  one  of 
these  capacities  is  lost.  In  lo«»kiiig  down  (he  eyelids  do  not  follow. 
Most  of  the  describetl  lesions  are  so  gross  tiiat  it  is  difficult  to  IocaIi/.e 
the  precise  mechaiiisms.  Lewandowsky  regards  these  palsies  as  due  to 
a  break  in  tlie  pathways  going  from  the  cortex  to  the  oculomotor  nuclei. 

The  chief  proilucing  le.sions  are  tumors  (gumma,  teratoma,  sarcoma, 
al>scess,  cysticercus,  etc.),  multiple  sclerosis,  encephalitis,  arterio- 
sclerosi.s  etc. 

Mo^e  extensive  eye-miLscle  palsies  are  n'fernble  to  eollieulus  disease, 
especially  if  the  lesion  piTss  farther  caudad  towanl  tlie  nuclei  them- 
selves, or  involve  the  posterior  longitudirnd  bundle. 

Ataxias  are  similarly  present  in  disorder  here  fn)m  implication  of 
the  cye-umscle  functions  of  linrizimtal  vision  but  they  do  not  give  a  |»ic- 
ture  of  pure  colliculus  disease,  neither  ore  the  complex  motor  disturb- 
ances of  choreic,  paralysis  agitans.  or  athetoid  character  such  as  have 
been  dewrilKii  in  a'oii  Monakow  imd  other  classics.  These  are  ihie 
more  particularly  to  (Trebellar  and  vestibular  pathway  disturbances. 

Tiiat  the  superior  colliculus  is  associated  with  otlicr  motor  rellexus 
is  certain,  but  no  precise  localizing  sj-mptomatology  is  knon-n.  The 
reflex  collaterals  with  the  vegetative  permit  the  fear  reactions  tbrtnigh 
sight  -and  all  of  liie  considerations  concerning  the  relation  of  the 
psyche  mentioned  in  the  paragraph  on  inferior  culliculub. 


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400 


LB.VON  OF  Tti\ 


6RAIS 


MlbBHAlS 


i'oifirtihiji  liiffrior. — A]s4Aiiown:is(he[H>slcriorini;i(lri^(.'niin;iI  IiimIx-. 
Hcchtcrew  (1NS5)  was  ainon^  the  i-arlirr  iiwestj^ators  of  the  inferic*r 
ciillinihis  Ifi  ,sIio\v  its  rflittions  tn  tin-  cm-iilwir  ijorliiiiis  uf  tlif  accMistk- 
iitTW  iijid  liP(K-i*  it>  ini|iortanci'  in  [icnriiin-  I''nr  the  ijn»st  |»iirt  the 
rcsiills  (il)tjii]ifil  Ii>  liiiti  ill  Fkrlislg's  lalinratury  lm\i'  been  verilicd  imtl 
Hinplified  by  tliewiirkof  HcM.Viin  Gehuchten,  I^wundowsky,  Winkler. 
Spit/XT  ami  Kiirplus.  TJit-  iiifericir  cttlliculus,  in  part  with  the  nie<liaii 
geniculHte  bo<|y.  form  tJie  twc  chief  secoiidary  synapses  of  the  auditory- 
piitliwjiy.    The  neimms  of  this  pathway  are  jus  follows: 

Kirst  Npumn:  Sensory  rereptor  in  <'nrtt's  organ,  gangllnn  spirale; 

(a)  ventral  6(iehlcur  nueleu-s  and  (h)  acoustic  tubercle. 

Ser-'ond  Neumn:  (n)  AVntml  eorhlearis  nucleus — corpus  trapezoides 
superior  olives — ventral  nnd  dorsid  lemaisfus  nuclei  of  opposite  side; 

(b)  acoustic  (id)ercl«'  and  slriie  acousticie,  superior  olive  of  both  sides. 
Tliirti  Ncurun;  Superior  olive.  lemniscus  nuclei  (lateral  lemuiscua). 

colliculus  inferior  (posterior  quadri^niina). 

F()urtli  Xenron:  Inferior  rol lieu] lis,  arm  of  colliculus.  median 
geniculate  borly. 

riftli  Neuron:  Median  ^'niculate—  teniporiil -auditory  ciirtical  area, 
("ajal  iLSsumes  that  the  cells  of  the  inferior  eolliculus  are  not  direct 
but  eullHleral  synapses  for  shunting  auditory  stimuli  (reflexes)  to 
other  mechanisuis.  ear  movements,  Head  nuivements,  voice  production, 
eye  uio\  emeiits  in  part.  Anatomy  teaches  that  tlie  pathways  f(kr  sound 
arc  crossed  and  uncrossed  as  ai"e  other  sensory  pathways,  heiic-e  a 
lesion  of  one  colliculus  causes  no  rnurked  deafness,  althou>;h  inteKering 
somewhat  with  hearint;  and  more  espe^'iaJly  many  hearinfi  reflexes. 
Kx|KTimeutal  stimulation  of  tlie  inferior  eolliculus  has  brou^lit  alniut 
dilatation  of  the  ](npil  of  the  opposite  side — raisinn  of  eyebrows,  pn>- 
trusion  ()f  eyeballs  (autonomic  stimulation  fnun  fear  reactioiLs  from 
sound  >itimuli  in  normal  physiology),  turning  of  the  head  up  toward 
tlie  non-slunulated  »ide,  nlo^-eJnent  of  ears  (in  animals)  and  a  number 
of  lar>'nReal  ami  respiratory  siimuli  causing  voice  produetiou  (cries, 
grunts,  etc.).  Terrier,  who  performed  a  number  of  such  experiments, 
rame  To  believe  that  a  psychical  center  was  reveale<l.  I*rn.s  oliiAine<l 
somewhat  similar  results,  which,  with  the  information  available  from 
the  studies  in  the  vegetative  ner\'ous  system,  wontil  teml  to  show 
that  the  auditory  synapses  in  the  inferior  colliculus  constitute  a  large 
factor  in  psychical  reactions  to  sound  stinnili  as  expressed  through 
the  autoncmiic  (vagus)  diKtrihtitiou.  Coeuinization  of  these  bodies 
caused  clonic  convulsions,  raising  of  the  heiid,  movements  of  the  eyes 
to  the  opposite  side,  dilatation  <if  the  jiupils,  exophthalmos,  eardiac 
eninij),  and  loud  crying,  i.  r.,  typical  epileptiform  pheimniena.  Prus 
interpreted  tJie  results  as  showing  a  motor  center.  Seen,  however,  from 
the  view-poitit  of  vegetative  neurnlc»gy  it  would  appear  that  disharmonie 
vugus  activities  come  into  activity  (Lewandowsky)  through  cutting  off 
of  psychical  (thalamic  homologue)  control,  i.  e..  thalamic  ovcrrcsponsc 
oivurred  in  the  sense  in  which  Head  has  deseribed  it  for  the  thalamic 


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nMiiss 

te!iioii8  in  wliirli  tactile  sensilntily  was  iiriiler  (lisi'ii».siiiii.    Tlie.st>  ri'llfc- 

tinli.s  Wiinlil  Irjul  f«i  ;i  ri-vicw  of  thf  >iillijri't  nf  tin-  ]>syrhnm'llK'  flictitrs 
ill  (-crtaiii  fjjili-ptir  HttJicka  asstn-iated  witli  iiifaritilt*  fear  shock  aiiidi- 
tintied  b\'  auditory  impressions.  In  this  ci>uiurtioii  OppeiilR'iin's 
statement  tJmt  overrt'sponse  to  sounds  ts  seen  in  dipletrias,  inijiht 
have  a  wider  aiunificanre  that  he  seems  to  pive  it.  Furthermore.  tJie 
problem  of  tone  production,  as  eontraste*!  with  tone  perception,  ac{(iiires 
wider  sipnificance  ihan  that  piven  to  it  hy  tlie  nriKi'inl  llelinlioltz 
peripheral  hypothesis,  since  tlie  reflex  aetivities  tif  the  tens<ir  tyni|>ani 
are  apparently  involved  in  rolli<"nlus  inferior  disorder.  fJeeht^'rt^w 
has  further  shr>wii  that  tlie  genital  apparatus  (erci-tion.  contraction  of 
uterus,  stimulntiiin  of  niilk  secretion)  is  also  refJe\ty  aftV-eted  tlirough 
the  inferior  c<>lliculus.  As  the  aiitononiii-  pelvic  functions  are  lionio- 
loffues  of  the  va^us  autonomies  this  .seems  loRicaJ,  and  contributes 
further  light  on  the  psychonnaiytic  hypotheses  of  repre-ssioji  of  the 
sexuality  and  eertaiu  rpilejjtic  attacks  (Maeder).  Frnm  the  reHex, 
somatic  siile,  a  >tH(ly  liy  Krey  and  Fuclis  i.s  of  interest  on  thf  subject 
of  jeflex  <'|)ilepsy  and  ear  and  nose  disease,  also  the  i-lassieal  ri']iorts  of 
Tlu>:lilin^  .Iack.s<in  and  (MnenMl. 

Clinical  ncurolojry  still  lags  behind  the  anatomical  and  physiolopical 
correlations.  Charcirt  has  not«l  a  tabetic  with  deafness  in  whom  the 
inferior  eollicuhis  was  involved.  KIech^ifi  has  reeonlwl  hallucinations 
of  hearing;  and  \\'eiiihiiid  hascalliil  attenlioii  to  disttirbancesof  hearing; 
from  lesions  of  the  inferior  n>lli<-ulus,  and  possibly  incorporating  other 
geniculate  fibers.  The  relationships  of  disturbed  autonomic  functions 
to  eollieular  disease  liave  not  reecivt-d  sufficient  attention  fnmi  neurol- 
ojjists  and  otologists.  The  literature  on  deafness  witli  dumbness  has 
not  been  gone  into.  TJie  tinnitus  of  neurasthenia,  of  the  psyeho- 
neuroses,  the  great  importance  ascTihed  to  .sounds  in  many  psy- 
ehoses,  hallueinations  in  seliizoplirenics,  in  manic-depressives,  have  as 
yet  reeeiveil  no  satisfactory  analysts  fnini  either  Uie  neurological  or  the 
psychiatric  diseiplirars. 

RABIES. 

Uabiea  is  an  acute,  specific,  infectious  disease,  \vhich,  after  the 
symptoms  have  ap|tearef!,  is  almost,  if  not  (piile  always,  rapidly  fatal. 
While  the  disease  may  occur  in  any  manimat.  it  almost  always  results 
in  man  from  the  bite  of  the  dog.  The  vims  travels  from  the  wounil 
along  the  nerve  trunks  eiVi  the  si)ipHl  ciml  to  the  medulla  and  brain 
nuich  in  the  same  way  as  dws  the  tetanus  toxin.  It  Is  ronlainerl  in  the 
saliva  of  the  rabjii  dog.  For  these  reasons  wounds  upon  the  exposeil 
portions  of  ilio  body  and  those  containing  a  large  nerve  supply  are 
most  dangerous. 

The  iueiibaturfi  i>eriod  varies  within  wide  limits,  but  in  man  on  the 
average  it  is  »l>ont  forty  days,  though  it  may  lie  prolonged  for  a  number 
of  ntuntlLs. 


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497 


t 


iiitfstinal  tmets  of  hcrbivora,  partieularlv  of  horses  iiiwi  cows,  and 
also  of  man.  It  is  a  sporc-formiiiK  orgfliiism.  The  sport's  arc  extrcmely 
resistant  tn  destrnctivc  apnint-s  and  arc  found  in  the  soil.  t'spiTJally 
soil  wlii<'h  Ikfis  btfii  contaminated  by  the  fen's  of  horses  and  of  man. 
The  symptoms  of  tetanus  are  due.  not  to  the  bacillus  directly,  but  to  a 
toxin  rlahorateil  by  it,  which  travels  up  the  axis-cylinders  of  the  nerves 
to  the  cord  and  brain. 

The  incubation  period  varies  within  ronnlclerable  Hmits,  frnm  three 
or  four  days  up  to  as  many  as  twenty  <l8ys.  the  severity  of  the  infittioii 
beiiif?  fnirl>"  well  indiratcfl  by  the  earhness  of  the  oaset  of  symptoms. 

Symptoms.  -The  symptoms  of  the  diticase  are  essentially  thase  of 
tonic  spasmodic  contractions  of  the  voluntary"  musculature.  The 
muscles  involved  at  Krst  feel  stiff  and  are  sulwequently  thrown  into 
convulsions,  particularly  the  face,  giving  rise  to  the  characteristic 
risus  sardonicm.  Later  the  trunk  muscles  are  involve*),  producing 
severe  convulsions  and  liending  of  the  iMidy  towani  those  most  affecte*!. 
The  muscles  of  nia.sticatit>n  are  early  involved,  while  the  spasm  of  the 
muscles  of  respiration  aiul  of  the  krynx  interfere  with  breathing  anil 
hasten  exlmusliuu  and  the  end.  Fai-ial  paralysis  is  an  occasional 
complication  when  the  point  of  entr>'  of  tlie  infection  has  been  the 
face.  The  mind  remains  clear,  as  a  rule,  and  there  is  no  temperature, 
except  toward  tlie  end.  The  convulsions  are  excited  by  slight  stimu- 
lation, such  as  noises,  much  as  in  strychnine  |>oisonin|!. 

Course  and  Diagnosis.^ln  the  severe  forms  death  generally  eventuates 
in  three  or  four  days.  The  disease  must  be  differentiated  from  strych- 
nine poisoning,  tetany,  hysterical  anti  epileptic  tyj)es  of  convulsions, 
liydropliohia,.  and  meuinj^itis. 

Treatment. — llie  prophylactic  treaitment  is  largely  surgical,  involving; 
the  prrnper  treatment  of  wounds,  particularly  punctured,  contused, 
and  infected  wounds.  The  bacillus  appears  to  thrive  especially  in 
mixed  culture,  and  so  infecte*!  wounds  arc  especially  dangerous.  The 
specific  treatment  is  by  the  u.se  of  tetanus  antitoxin,  which  sluiuld 
he  administeri\l  after  any  suspicious  wound,  without  waiting  for 
sjTOptoms.  k  prophylactic  dose  of  about  1500  units  may  he  given. 
.\s  soon  as  a>Ti;ptoms  appear,  however,  the  larger  dose,  about  20,()00 
units  should  he  administered.  It  is  well,  too,  to  inject  some  antitoxin 
into  the  large  nerve  trunks  leading  from  the  wound,  and  dry  teUmiis 
antitoxin  may  Iw  dusted  upon  the  wound  itself.  As  the  antitoxin  is 
eliminated  in  abinit  two  weeks,  if  further  effects  are  desired  fntm  it, 
additional  injcitions  will  be  necessary,  .\fter  the  toxin  has  cimibined 
with  the  motor  nerve  cells  it  cannt>t  be  displatx^  or  neutralizciJ  by 
antitoxin.  The  antitoxin  can  only  neutralize  the  free  toxin.  CJood 
results  have  ht^n  re|)orted  by  the  inlravenou.-)  injeclioiLS  of  inagnesiura 
sulphate,  in  eonjumlion  with  the  use  of  antitoxin,  and  also  by  the 
hyp«xlermir  use  of  magnesium  sulphate. 

The  priiffiinjfi.'r  has  been  materially  improved  since  the  advent  of 
antitoxin  treatment. 
32 


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CHAPTER  VIII. 

PARA1,VS1.S  AGITANS,  CHOREA,  AND  RELATED 
SYNDROMES. 


FABALYSIS  AGITANS  GROtTP. 

History. — 'ITie  flinirians  of  the  times  inmialiulely  prcwiling  Parkin- 
son grniipp*!  the  pjiralysis  a^tans  rases  of  the  present  day  in  several 
different  categories.  Galen  had  noted  the  characteristic  tremor,  and 
the  class  of  tremors  of  this  kind;  the  "tremhlement  palpitjuit"  of 
Preysinger  was  part  of  the  earHer  pafmo/t  of  (!alen.  Prancls  dc  la 
136e  was  shrewd  enough  to  notice  the  difference,  afterward  forgotten, 
between  the  treraor  produeed  hy  attempts  at  motion  and  the  tremors 
present  whih*  the  linh^  were  at  re^t,  am)  his  term  trfijtwT  coacfwr, 
for  the  tremors  of  paralysis  ngitans,  was  utilized  up  to  Parkinson's 
time.  Juncker  had  also  descrih<'d  a  paralytic-like  tremor,  trevtorrJi 
paralt/ioidei ,  whicli  included  some  of  these  patients. 

Not  only  was  the  tremor  appreciated,  but  the  clinicians  of  the 
eighteenth  century  ((Jaiihius,  17.t1)  had  called  attention  to  the  pro- 
pulsion of  these  patients,  and  Sauvages  groups  them  in  his  choreas, 
as  Scelotrjhe  pre<ipitee  (l)an.se  de  St.  Ciuy  precipitee,  L.t. 

Parkinsiiii,  in  his  famous  thesis  on  the  "Shakiiij;  I'alsy. "  London,' 
1817,  made  a  synthesis  of  several  of  these  conditions,  and  erected  & 
new  clinical  fonn  to  which  he  >[avc  tlic  name  shiikiiiK  palsy  (paral.\"sis 
agitans),  and  gave  the  following  short  and  striking  description: 
"  Involuntary  trcrauh)us  motion,  wMth  lessened  muscular  power,  with 
a  propensity'  to  bend  the  trunk  forward,  and  to  pass  from  a  walking 
to  a  ninning  pace,  the  senses  ami  the  intellects  being  unimpairo<l." 

All  of  the  ca.se  histories  cited  hy  Parkinson  were  jinihably  true 
cases  of  our  present-day  paralysis  agitans,  Init  the  gnrnp  as  iIm-h 
understood  still  contained  certain  of  the  chronic  choreas,  and  certftin 
cases  of  multiple  sclerosis,  possibly  certain  thalamic  cases,  etc.  which 
later  clinicians  have  agreed  to  separate.  The  chronic  choreas  were 
definitely  excluded  by  the  wt)rk  of  tlie  Gemiain  S6e,  lN*>t,  and  the 
researches  of  H.  Cohn,'  Ordenstein,^  and  ('liarcot  finally  separated  the 
multiple  sclerosis  symirome. 

Since  the  appearance  of  Charcot's  studies  the  monographs  of 
Wollenberg.  Heiniann.  Manschol  (\Vinkler)  (ItKVI),  /ingcrle  (1910), 
and  of  Mendel  (1911).  contain  the  cliief  steps  maile,  showing  the 
steadily  advancing  trend  to  reganl  the  dis4>rder  not  in  the  light  of  a 


Wicu.  Ried.  n'l-liiuftlir.,  No.  18. 


>  Ttv^w  do  I'flHu.  1868. 


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PARMTfifS  AGITANS  OHOVP 

funirtioiinl  dii<>turbancp,  as  Charcot  taught,  but  as  an  soDiatirt^ymlromt*. 
and  affcctinn  either  rircurasrrilMNHy  or  more  diffusely,  eerluin  rerc- 
bellar.  thalamic  and  kntinilar  pathway's,  and  certain  synnpsts  in  the 
lar^re  inot<jr  cells  of  the  ^Inhtis  pallidus.' 

Etiology. — 'Ihe  ilian^cs  nf  age  seem  to  be  the  mast  striking  etiit- 
logieal  factom.  The  majority  of  the  patients  are  between  fifty  and 
seventy — although  r-ases  of  patients  of  nlnetirti,  fifteen,  twelve,  ten, 
and  three  years  of  ape  are  reeorded.  some  of  wliidi  have  heeu  pussilily 
faultily  diagnoseil.  the  vast  majority  of  these  being  multiple  sclerosis, 
emt-'phaiitis  or  poliomyelitis.  Ilereditarj'  fu(t«)rs  may  play  a  role, 
pn>bably  through  vascular  disease.  Berger.  (Jowers,  Borgherini, 
Clerici  and  Medea  and  others  have  reponed  eas(*s  oeeurring  in  two 
generations  or  in  more  timn  one  member  of  the  same  generation,  ami 
Krb  rejjorts  that  in  In  per  rent,  of  his  eases  the  parents  or  gruiidiiarenta 
suffered  from  the  same  ilisoase.  ("otieerning  indirect  hei-edity,  the 
least  said  the  letter,  as  the  studies  available  are  entirely  too  am- 
flirtlng.  and  for  the  most  part  inapplicable. 

Emotional  di.sturlianee.'i  are  held  acciiuntable  by  many  writers;  it 
is  difficult  to  determine  here  whether  one  is  concerned  with  cause  or 
effect.  Sorn>w,  worry  and  emt>tional  distress  are  sueli  universal  all- 
pervailing,  envin>nmental  factors,  that  Ukj  rnueh  stress  must  not  be 
placed  u|M>u  them.  Sudrlen  shock  may  perhaps  stanil  in  an  ac-cen- 
tliating,  accidental  relationship. 

Trauma  stands  in  a  p<»ssibly  closer  relationship.  It  is  higlily  improb- 
able as  a  direct  cause,  but  it  may  be  a  sufficiently  exciting  cause  to 
bring  the  symptoms  of  a  slumlienng  paralysis  agitans  to  the  surface. 
or  lliose  of  a  mild  case  rapidly  to  a  severe  stage.  In  the  recent  great 
war  shell  sluM-k  has  been  pnilifie  in  bringing  certain  paralysis  agitans 
and  multiple  sclerosis-like  tremors  to  the  fore.  All  of  thest^  have  not 
l>eeu  tremophobias  as  Mcigc  has  termed  them,  nor  hysterias  as  iliag- 
nosod  by  others,  but  prolwiHly  many  are  the  results  of  somatic  lesion:^. 
Physical  stress  is  a  factor  which,  iHiiring  upon  arteriosclerosis,  may 
be  an  accompanying  factor  in  certain  caites.  Toxic  factors  of  them- 
selves are  not  known  to  play  any  neeessar>'  role.  Their  coincidental 
occurrence  is  frequently  reported;  the  same  may  l>e  said  of  infections. 
Cold,  exposure  to  wnt,  and  other  factors  are  probably  more  ae<-idental 
than  vital;  they  may  augment  the  action  of  an  underlying  factor,  as 
yet  unknown;  they  may  represent  purely  coincidental  features. 

Arterioselt^nisis  is  the  chief  fat-tor  in  bringing  aUmi  the  presenile 
syndnune.  The  central  features  i)f  the  syndrome  are  matters  4»f  liKali- 
zatioti  in  the  implication  of  certain  patliways  by  the  sclenxsing  proc-ess. 

The  hypotliesis  that  the  distirder  is  due  to  a  h>T>erfunctioning  of 
the  parathyroid  iLimdborgJ  is  still  purely  suggestive. 

Symptoms. — These  develop  for  the  most  part  verj'  idowlx',  although 
iX'CBsionally   i»atient.s  are  seen   who  show   fulminating   types,   and 

>  llunl.  J.  H.;    TmnMurtiDim  Am.  Nvur.  Awn.,  t01»;  Brnin,  1U17. 


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501)     /M«.4/.V.S/.S  AOlTAMi,  CUOREA  ASU  RELATED  SyXDItOMBS 

attlioiLKti  atypical  devt'lopments  are  known,  the  regularity  and  uni- 
formity ill  the  Hevelopment  is  wry  strikinji. 

The  vast  majority  of  the  patients  show,  on  close  analysis,  profiromnl 
sjTnptoms  whieh  an*  ehieHy  seusorj',  in  contrast  tii  tlie  sensurimotor 
symptoms  of  the  mure  ailvanceil  stJi^es  of  the  pii-lurc.  The  more 
chnrnctersstic  of  these  priH^rtmiatn  iut  fugitive,  irrej^iitar  pains  of  a 
?flian>.  laiicifiatiiif;  chanu-t'CT.  fn'quent!\  found  in  the  extremities  first 
|to  be  affected  by  the  motor  disturbances,  ami  usually  ceasing  as  these 
latter  advance.  Paresthesia  are  also  frequent,  eausinj;  sensations 
of  tickhnR.  <'oM  si>ots.  hot  spots,  pai^tric  distress— almost  crises-like 
attacks,  with  diarrhea  an<l  cidlck;'  <nsturhances  in  the  lar^e  intestine. 

Cieneral  malaise  with  heaclat-he,  sweating,  mild  vertigci.  palpitation, 
sialorrhea,  anxiety,  pressure  of  blood  in  the  lieoil,  easy  excitabiltt;\% 
are  general  symptoms  accompanying  many  senile  and  presenile 
conditions,  but  are  mt  frequently  found  as  forerunners  of  the  motor 
synipttims.  and  persist  with  sucli  marke<l  increase  of  severity  through- 
out the  disorder  that  their  appearance  is  to  be  regarded  as  more  than 
coincidental. 

T!ie  symptoms  of  the  more  elassieal  syndnime  may  be  groupwl  hn 
follows:  (1)  The  main  group  of  sensorimotor  ihsturltauces,  varying 
in  intensity  and  location  in  rlUft-rent  individuals.  (2)  A  mmiljer  of 
sen.sory.  vasouiotor,  trophic  and  secretor\'  disturbances  already  indi- 
cated as  often  in  part  occurring  as  prodromes.  {3)  Psychical  s.vniptoms 
which  are  snmiewhat  variable  and  possibly  not  essentially  relate<l  to 
the  disorder  per  w. 

The  sensuriinotor  dLsturbanees  are  pn-itominantly  inen-astt  of  mus- 
cular toniLs,  with  rigidity  and  resulting  contractures,  and  motor  dis- 
turbantx^  with  tremor,  compulsory  gait,  fuit-e*!  attitudes,  forced 
movements,  and  loss  of  niinietU"  expre^sitin. 

An  iacreasi-  in  the  muM-ular  tonus  is  u  most  fundamental  feature 
in  the  cnnrrept  paralysis  agitans.  As  a  result  of  it  there  follows 
the  rigidity,  the  mask-like  countenance,  and  the  contract urtv.  The 
increase  in  the  muscle  tonus  usually  is  a  ver>'  early  sign,  although 
positive  traces  of  rigidity  may  not  appear  until  later.  It  is  practically 
always  found,  wheniis  tliere  are  some  [wtients  who  have  little  or  no 
tremor'  and  yel  the  name  paralysis  agitans  is  properly  uacil.  Assti- 
ciated  witli  the  hyjuTtonus  anil  the  rigidity  there  is  a  slowness  of 
moveuienl,  and  a  steadily  Increasing  stiffness,  and  alst>  retardation 
of  the  motor  and  ideational  impulses. 

The  mus<ular  rigidity  varies  widely  in  its  situation  at  the  beginning. 
Practically  the  symptoms  (irst  become  manifest  un  one  side  of  the 
biMl.x",  and  the  s*'verity  of  the  symptoms  usually  preilotninates  on  one 
.side,  it  may  In*  for  years.  In  the  weHnteveloiM-d  syndnane  the  rigidity 
involves  the  muscles  of  the  neck  and  trunk;  jwrticularly  the  patient 
assumes  the  bent-over  attitude,  such  as  one  naturally  a-ssunies  when 

*  I'ttrntner  el  ■!,;  sec  itiiiBPrle. 


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PARALYSIS  AOtTASS  (JROUP 


501 


»hiveriii(;  fnjiii  the  <-m1i[  au<l  t)ie  fiice  is  inusk-liki!  t<t>rruKHtors)  und 
stariitg,  the  eye  mujH-les  als<»  stuiriii^  in  tlif  ripwlity  with  Stelnag's 
bigii. 

Whereos  the  musclfs  iS  the  iiwk  ami  Ijiii-k  iirt*  most  aflVvteil,  almost 
any  group  of  musi-U's  may  U-  iiivtilvtHl.  The  anus  ami  h'jfs  are  almost 
always  iinplit-atwl,  and  so  also  are  tlie  muwk-s  of  iht'  faee.  Occasion- 
ally there  is  ptosis,  or  the  patient:^  open  tfieir  eye>  with  difficulty  aftiT 
dosing  tiieni.  One  of  us  has  seni  lliis  a.s  an  initial  svinptoni.  The 
pati^its  read  with  diHieulty  because  of  the  stiffness  of  the  ocular 
movements.  Ocular  palsies  may  result— |>s«'u<Jo-ophthalnioplpgi}is. 
Slow  pupillary  rear-tioiis  an*  occasii»iialI>  found.    The  pluiryiiKcal  and 


Fio.  2Sa— Attitude  oi  par 


'iticnt.     ^TiJne.v.i 


laryngeal  muscles  being  Involved,  as  otliers  in  the  body,  results  in 
shtw,  difficult  speech,  bwHHiun};  fainter  and  fainter  as  the  years  jjo 
by,  until  finally  tJie  patient,  in  addition  to  bciuK  uiiHble  to  move,  to 
dress  himself,  eat  without  help,  finally  is  unable  to  talk  or  to  swallow. 

The  hyiHTtonus  and  rigidity,  hviwever.  is  not  aswK-iated  with  the 
usual  increitsed  reflex  signs  of  pyramidal  tract  involvement,  the 
n^flaxes  are  either  normal,  or  only  slightly  exai^gerated,  no  clonus, 
Babiatki,  Oppenlieim,  etc.,  an<l  the  coiitractiu^s  may  he  easily  over- 
come by  pflssivc  movements,  in  marked  contrast  to  the  contractures 
of  psyclutnuitor  cortical  origin.  The  muscular  power  is  also  not  so 
involveii,  the  patietits  show  nniscular  weakness,  but  not  paralysis. 
There  is  a  striking  contrast  between  the  strength  of  active  movements 


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PAHALVSIS  AOITANS.  CHOREA  AWD  HELATBD  SVyDROMUS 

mid  that  of  rcsistamt"  mnvcnieiits.    Tlie  former  arc  weak,  the  Intter 
rnrely  less  than  iiornml. 

A  few  ca,se?i  of  cxteii;H)r  riKi'lity  are  remrtlwl,  but  the  iiivulveiiUMit  is 
prwlomitmntly  of  tho  flcx<>r  muscles. 

With  tlu-  riKiditv  tluTc  {>>  it  feoliiiK  of  teus'ion  which  the  patients 
dislike  iisunliy  much  more  than  the  alim»st  universal  tremor.     This 
^csuscb  tht'in  to  feel  as  thoujfh  thi-y  weiv  iHiutul.    Their  motor  Impnl.Ke 

:ins  interfered  with.     Tliis  may  even  involve  their  uritmtinn  ami 
defecation,  and  their  deglutition. 

Altiiiiflr. —'i'hx'^  us  llmt  ivf  a  decerebellate  rijiiHity  in  contrast  to  a 
decerebrate  rigidity. 

Tremor. — In  the  innjfirity  of  the  rases  thi.<i  ohjeetivo  sign  seems  to  be 
the  first.  altluiuKl^i,  in  reality,  vasomotor  signs  preeetle  as  a  nde.  It 
was  the  s\nnptoin  first  noted  by  (lalen.  It  is  cliaraeteri/^I  by  its 
unifonnity  and  steadily  iner wising  severity,  botli  in  itoiiit  of  advance 
of  tlie  disease,  and  also  during  the  movements  themselves.  It  is  a 
tremor  that  Kraneiscus  Sylvius  first  noted  was  present  while  the 
limb  was  at  rest.  It  ceases  during  movement.  es(>eeially  if  the  move- 
ment i.<<  rapid,  an*!  in  the  beginning  of  the  dt.sease.  In  the  later  stages 
it  iHf'oines  c-nntiniuMis,  and  Mime  patient.s  v\ith  ]>arulysi.s  agitans  show 
some  uitentioii  tremor.  Again,  a  eertniri  rmnilR-r  of  |)Htients  show 
little  or  no  tremor. 

The  tremor  is  characterized  by  the  miifonnity  «f  its  excuRuons. 
which  are  at  first  ismall,  slow,  and  rh\"thinieal.  They  average  about 
three  to  five  in  a  second,  according  to  the  uuisdes  involvcKl.  Tremor 
in  the  muscles  of  the  thumb,  whicli  is  often  an  early  sign,  gives  rise  to 
the  well-known  "pill-rolling"  movements.  Similarly,  one  has  the 
nioveiiicut  of  "Iwiting  the  drum,"  and  other  attitude  types  when  the 
larger  muscles  of  the  arms  are  iniplicatttl.  The  muscles  involved  in 
the  early  tremors  vary  considerably;  usually  the  upper  extremity  is 
involvwl  before  the  lower,  the  hand  particularly;  but  with  tlie  prog- 
ress of  the  diseas*'  the  tremor  tends  to  l>ecome  widespread,  almost 
universal;  most  diverse  localizations  arc  on  record,  anjtiiing  is  to  be 
expected.  There  i.s  no  great  preponderance  of  one  hand  over  the  other, 
although  there  Is  a  marke<l  tendency  to  disproportion  in  the  severity, 
and  a  bcmiplcgic  type  of  onset  and  persistemt-  is  frtsjuent,  if  not 
characteristic.     Monnlimbic  typi-s  are  enctiuntered. 

At  first  the  tremor  is  absent  durLug  sleep,  but  in  the  advanced 
stages  it  frequently  persists  and  constitutes  one  of  the  factors  in 
sleeplessness  which  finally  exhausts  the  patient. 

Motion  tends  to  diminish  the  tremor,  as  also  does  attention;  emo- 
tional disturbances  and  cold  incTease  it  markedly,  (irasping  tlie 
tremulous  member,  touching  it,  or  changing  its  position  results  in  a 
temporary  cessation  of  the  tremor.  The  resllessuess  of  these  {utients 
is  largely  dependent  upon  the  constant  and  continual  shifting  of 
the  body,  in  order  to  obtain  comfort,  i.  e.,  before  they  become  too 
rigid. 


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Statistical  stiulics  aliow  that  tremor  may  be  absent  in  us  IukU  ua 
3.1  ]M.T  cent .  of  tlnMiiscs  -a  miicli  jircater  proportion  tliaii  show  absence 
of  riKHiitv',  uhicli  alM>  nmy  Ik-  absent  or  scarcely  noticeable.  'Hicse  arc 
variatiims,  in  |n-<^^ise  patlnviiy  blocking;,  the  lesions  sltitwini;  slight  vari- 
ability in  liK'nli/.ttti(Mi. 

Piiturljanctii  iif  iCqulUbriiim. — I'mpulsiim,  which  apparently  was 
first  noted  by  Ciaiibius  (1751),  is  one  of  the  raitlinal  symptoms  in 
Parkinson's  uriginal  definition.  The  patient  on  walkin^^  tends  to  fall 
forward,  and  in  his  effort  to  keep  his  etjntlihriuin  yoes  faster  and  faster, 
until  he  either  falls  or  stops  liimself  by  gras^pia^  a  support,  Ijitero- 
pulsioii  and  retropulsion  are  also  present.  These  arc  due  either  to 
the  stifTncsa  with  the  slowness  of  muscular  niovemeat,  or  to  a  central 
disturbance  of  equilibrium,  which  latter  is  perhaps  the  preferable 
explanation,  since  exquisite  examples  of  gait  disturbances  are  known 
without  any  marked  stiffness  or  rigidity.  In  »  few  cases  the  los*  of 
equilibrium  in  one  direction  alters  to  that  of  another  during  the  course 
of  the  disease. 

Secretory,  V'oJtunwtur,  Trophic  DtJituTbnvces. — These  make  up  the 
second  category  of  sj'mptoms  almost  universally  found  to  a  greater 
or  less  degree  ua  paralysis  agitans.  As  nutetl.  many  arc  prodruma] 
symptoms.  What  relation  tliese  symptoms,  all  of  whielt  liave  some 
definite  rclaliun  to  the  vegetative  nen'ous  structures,  possibly  at 
lenticular  levels,  bear  to  the  almost  universally  present  arteriosclerosis 
is  not  yet  apparent. 

'Vhe  most  important  of  the  secretorj-  changes  are  increased  perspira- 
tion— sometimes  unilateral,  increased  salivation— one  of  the  most 
distressing  of  the  symptoms — and  pt>lyuria,  with  oecasirmally  diarrhea. 

Among  the  vasomotor  changes  are  rushes  of  hUKwl  to  the  head, 
reddening  of  the  face,  cyanosis,  tachycardia,  acroparesthesia,  with 
hot  and  cokl  sjwts,  alteration  of  temjierature — sometimes  unilaterally 
diaijoseil,  and  dermographia,  which  is  almost  constant. 

Trophic  changes  in  the  skin,  such  as  atrophy,  thickening,  edema,  arc 
among  the  rtiriT  findings. 

Psi/chic  Dislurbanc€Ji.~ThGse  probably  do  not  coiLstitute  an  essen- 
tial part  of  the  disorder,  but  represent  almost  normal  i>s>-chologtcal 
reactions  to  a  most  <listressing  and  hopeless  situation.  Depression, 
anxiety,  ideas  of  self-destruction.  sct>mfulness,  savage  raillery,  sarcastic 
pcsstmisra,  euphoric  compensjition  and  sublimation,  resignation  to  the 
will  uf  tjod,  etc.,  lhe,se  are  but  a  few  of  the  innumerable  attitudes  which 
these  patients  show  at  one  or  another  lime  during  their  loi^  period  of 
almost  uulxmrable  suft'ering. 

Parkinson  sind  the  "senses  and  the  intellects  are  not  iinjwiire*!," 
and  intelligence  tests  bear  this  out.  In  some  patients  one  naturally 
finds  a  senile  deterioration,  and  for  most,  in  the  later  stages,  the  mental 
signs  of  an  arteriosclerotic  deteriorating  process  are  present.  Acute 
cxluiustion,  delirious  states,  often  close  the  sad  clmpter;  but  these 
are  not  a  part  of  the  paralysis  agitans. 


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iOITANS.  CUOHRA  AM)  RELATED  .SYNDROMKS 


Sinxiiri/  Siiiitjititm-t. — 'I'lictllr,  tluTiiuil  nr  |iiiiii  ilistiirlwiwrs  urc  liut 
iK'fiiiiti'.  Tlifv  nrv  iint  nfteii  strikiirjj  ffiitlirt's  (if  tile  (lis«»r<itT.  Tlic 
early  puim  arc  usiiully  furtive,  atui  upurt  froni  the  dull  aiitl  mnst 
oi>i>ri-ssivc  sonsjitii)ii  due  t(j  tlw  u-iisiim  imd  sr-itTiu'-ss,  iwin  is  not 
])r<innucnt.  IrreKuIar  anesthesm*,  hypereHthesia*,  part^tJiesiiK  are 
frequently  found,  l>ut  are  so  inconstant  timt  one  can  say  tliat  deKnitc 
sensory  HiAhirhanet^  rarely  helnnj;  to  the  jmralysis  af^itans  picture. 
When  present  tn  striking  fashion  tliey  are  probably  due  to  leiitieular 
or  tlmlamie  inviilvenient  nf  deep  sensibility  pathwHvs. 

The  re/ir.rcji  are  not  umrkedly  di^turhwl.  Tonsiderablc  variation 
exists,  but  there  is  no  constant  picture  as  yet  known  which  is  pathog* 
nonionie  of  the  eivndilion.  UeJIex  activities  <iiie  to  ])yraniidal  tract 
invoivenicnt  are  occasionally  found.  Increased  knee-jerks,  clonus,  aiid 
Bal>inski  phenomena  are  at  times  found,  but  they  are  not  constant, 
and  represent  mcasinnal  rather  than  essential  features. 

L<isN  of  the  Achilles  reflex  is  a  not  infrequetit  symptom,  the  sl^ifi- 
CRiice  of  which  is  as  yet  not  definitely  placet]. 

Tlie  alHlointitiil,  cremasteric,  epifjastrtc,  and  anal  reflexes  are  not 
involved. 

Otiier  clinical  findinp*  are  ittc(nistant.  The  blo«>d  practically  shows 
notliinp,  some  anemia  at  times,  but  nothinj^  striking;  the  cerebro- 
spinal fluid  is  praetieally  negative.  The  urine,  apart  from  a  fre(|uent 
jKilyuria.  shows  no  (piantitative  or  <|uiditative  anotnahes.  beyond  tlic 
excessive  phosphate  elimination,  which  is  indicative  of  the  exhaustion. 

Course  and  Progress.— lUidimenttiry  forms  are  not  unknown.  Many 
senile  patients  show  conditions  closely  approaching  the  milder  gra<les 
of  paralysis  agitaii.s,  and  intenne<liary  stages,  with  muscular  stiffness, 
slowne-ss  of  movement,  retardation  of  motor  impulses,  etc.,  arc  not 
mfrequent.  Certain  stationary  cases,  non-progressing  for  twenty-five 
years,  are  also  known,  and  infrecpiently  patient.s  make  partial  recov- 
eries. These  are  possibly  syphilitic  cases  showing  tlie  symlrocne. 
But  the  usual  course  of  the  more  frequent  arterioscJcrotic  cases  is  a 
long.  slow,  and  gradual  progression,  lasting  over  many  years  with 
fumoyaiiee,  ineonveiiience,  discomfort,  distress,  and  agony  until  life 
bc(.-omes  a  burden.  Renusslons  and  cxaccfbatiotu  belong  to  almost 
e\'ery  case. 

Patients  with  little  hypertonus  and  muscular  rigidity  seem  to  pro- 
gress less  rapidly,  ami  many  cases  beginning  in  younger  individuals 
do  fairly  well.  Kmotional  disturliaiices  act  ba*ily,  almost  invariably 
causing  marked  progress  of  the  disease. 

Tlic  majority  of  the  patients  get  worse  gradually.  The  intTcasing 
weakness  and  stlfTness  limits  them  more  and  more  in  tlicir  work,  until 
that  becomes  impossible.  Then  the  walking,  to  which  they  are  uncon- 
sciously attrattte^l,  b«-omes  more  and  more  difhcuit.  They  are  then 
confined  to  tlieir  chairs  for  a  few  years,  or  to  bed,  and  finally  come  to 
lie  helpless  invahds,  who  must  lie  fed,  turned  over,  altcndiHl  to  like 
living  rigid  s-tatues,  which  in  tiie  presence  of  relativelj'  Intact  intelli- 


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gciK-f.  tlioiigh  rolilntl  of  the  iwwer  uf  t-xpre^sinti.  rtwlliifc,  writing, 
even  pjinttmiime.  a>n'<<itute^  one  nf  tlic  nuist  jjliastly  Hniiclitms  in  the 
entire  realm  of  iier\()us  4lis»)nlers. 

Decubitus,  pneumonia,  exliaustion  delirium,  iind  stiirviitioii,  are  the 
usual  precursors  to  the  end  of  a  disorder  whose  ])rogiu>sis  is  bad. 
Hwtiverie5  there  are  none,  although  stationary  eases  are  otxa-'sionally 
seen. 


Flo.  281. — Primary  K(TO|)by  uf  ihu  palLidai  nyaletu.  PruKmnre  atrufliy  <'l  tbe 
tf obiut |>alltdu0.  Jiivoiiilc  pfirniysi*  agitBiiA.  fUcrtioa  thnHigh  tho  globiM  jisllidiu,  obow- 
tuft  fetrophy  and  dirainutiou  uf  the  Iutrv  iiiulvr  cvlU  of  the  sivbav  pallidu<.  witii  iiH^rvniw 
of  s)ia  Luclri.     (Kanuay  Hunt.} 

Differeotial  Diagnosis. — The  diagnosis  Is  rarely  difficult.  The  atti- 
tude, gait,  facial  expression,  and  tremor  are  so  cliaraeteristic  as  to 
stamp  the  patient  at  once.  In  the  initial  period,  before  the  stiffness, 
tremor,  pulsions,  etc.,  have  developetl,  the  diafrunsis  may  he  iliffieult, 
but  after  its  classlcAl  development  it  cannot  he  mistaken  for  uuythhiK 
else. 

Hysteria  sometimes  comes  into  review,  but  here  the  character  of 
the  liyjiertonus  i.s  quite  different,  the  tremor  is  rarely  eiasHieal,  and 


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50G     PAIIALYSIS  AOITAm 


lA'/)  miATBD  SYNDROMES 


(':iii  Im-  more  reatlily  irillmnn-d  hy  ilivcrsimi  ilikI  ilistnu-titm.  Tlii* 
exafigcmtion  nf  a  pHralysis  agitinis  \viit|itom-pii.-tim>  is  fharHC-tcTislic 
(if  till"  hysterical  typr. 

Multiple  sclirosis  iif  the  rfn-U-IIur  ty|n.-  frttiui'iilly  slumji  (In-  diissiral 
parulysLs  agituiw  piclun.-.  plus  tJie  evtili-iife  of  pyramidal  tract  involve- 
ment. n>'staKnius,  bulbar  spcvth.  etc..  of  t3us  disease.  It  is  ii»ually 
presi'tit  in  younger  individuals.  Some  of  the  so-rjilled  juvenile  Park- 
inson ctwes  are  t-erebellar  types  of  multiple  sclerosis.  Hunt  lias  dcseribet] 
a.  true  juvenile  ty[je  of  the  syndrome 

Senile  iinrt  presenile  trentors  have  been  lueatione*!. 

Coinplicutiiig  diseases,  such  a.s  tabes,  hj-steria,  multiple  sclerosis, 
hemiplegia,  cxophthatnuc  goiter,  etc.,  are  known. 

Pathology  and  Pathogeny.  A  doKinatic  pre.se ntat ion  of  the  cat 
for  paralysis  ugitans  is  not  yet  available.  The  trend  of  opinion  is 
ttiat  it  represents  a  senile  or  presenile  iiegeneration  of  certain  mid- 
brain pathways,  and  these  are  mostly  concerned  witliiii  the  cerebellar, 
thiilamic,  and  lenticular  mechani.sms.  Whether  they  arc  confincil  tu 
the  niitlbrain  regions  is  nut  prove)] — neither  are  these  uieclinnisms — 
but  the  evidence  points  in  that  dirertimi.  The  iiierenscd  tonus 
resembles  ecrelMjllar  und  not  cerebral  tonus.  Tlic  rigidity,  attitude, 
slowness  of  motor  impulses,  tremor,  has  its  aiiulogics  in  disorders  of 
the  frontocercbellar.  cerebello-rubro-spinal  and  thalamic  systems. 
Hunt'  would  Im-alize  this  motor  part  of  the  s\iidronip  to  disease  of 
niutur  cells  ill  the  globus  pallidii.-*,  a  view  cli«.sely  related  to  that  t>f 
M'inkler  elaliorated  in  Manschot's  thesis  (l!K)l).  The  disturbances  of 
eqijililjriiira  nrv  distinctly  of  the  CTrebellar  ty|K;.  The  viisomotor.seere- 
tory,  arnl  trophic  symptoms  represent  eentral  vepetiitive  dis<inlers, 
which  are  referred  with  greutcs^t  prol)jibilit>  to  those  lateral  thalamic 
nuclei  utluT  tlmn  the  nueiei  which  are  kmtwn  to  be  the  synapses  of  the 
clucf  sens«iry  pathways.  Thus  tlic  automatic  propritK-eptive  tontis 
impulses  passing  over  impainvl  cerebellar  pathways  are  not  counter- 
balanced by  the  bifluence  of  the  eorticome<iullary  pyramidal  systems. 
Ilecausc  of  tJie  lesions  in  the  globus  pullidiLs  with  the  degenenitions  in 
the  ansa  lenticularis,  there  are  mit  etumgh  centripetal  cortex  impulses 
to  act.  The  rigidity,  foK-eil  attitude  of  the  head  and  trunk  po8»bly 
may  be  so  interpreted. 

The  recent  review  of  Zingerle  {loc.  ctV.),  JelKersmu,"  and  of  Hunt 
brings  these  features  to  the  fore.  Few  <'omplete  scries  of  microscopic 
sections  through  tlie  cerelwlluni  and  midbrain  n-gion  have  as  yet 
been  studied,  \o^  of  motor  cells  in  the  globus  pallidum  and  distinct 
atrophies  in  the  ansa  lenticularis,  in  thalamic,  and  lenticular  regions 
are  present  in  those  cases  studied  by  the  serial  section  methofl. 

The  muscular  hypotheses,'  wliich  are  many,  arc  totally  inadequate, 
as  is  also  the  parathyrokl  hypersecretion  tJieory  upheld  by  Lundljorg. 

•  J.  H.  Hum:  lew.  vit. 

1  JntSCTfnna:  Verb.  d.  GmM<]l«chaft  Dnil.  NnKirromrhor..  1008,  SO.  ii.  p.  383. 

*C'aDip:  Jour.  Am.  Mod.  Awa..  IVIO. 


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DYSTONTA   MUSCULORUM  DBF0RMAK8 


B07 


As  to  the  nature  uf  the  pntcessi  thjit  brinf^s  almut  tiic  dcgi'mTatiutis 
in  the  re^'ions  involvwl.  science  is  still  in  the  Hark.  Arterittsrlerosis 
is  the  chief  fiictor  ihns  far  nbservrtl. 

Therapy. — Notwithstanding  the  (rlofunv  uiitlmik,  much  cuii  he  done 
to  relieve  the  iwtienLs.  They  must  be  ^nnhtd  ngninst  eold,  and  as 
fur  as  possible,  from  eniutiunul  disturluintx's  and  incntid  and  physicul 
stniiii. 

They  shoulfl  live  iu  warm,  dry,  simiiy  riwuis  if  |><i»sible,  be  much 
in  the  open  air,  eAt  a  Full,  mixed  diet,  and  possibly  a  minimum  of 
purin-<-<intiiining  substances  is  needed.  Akrohol  and  eofiVe  may  be 
UHed  in  nuHliriition.  Tobacco  Is  not  necessarily  tabtK);  two  or  three 
cigurettcs  or  cigars  a  day.  The  regime  should  under  no  circumstances 
be  w>  Mtrictly  adhered  to  as  to  cause  the  patients,  alrea<iy  sutlering 
from  irritating  conditions,  to  become  further  amioyed  thereby.  Diet 
lias  reiatively  little  power  to  modify  the  trouble  and  fussy  dietaries 
are  superstitious  nonsen.st:  for  tJie  most  part. 

The  preatest  relief  from  rigidity  comes  from  the  regular  use  of 
passive  movements.  I'he  Zander  apparatus  cim  be  utilized.  Working 
with  Carpentry'  or  garden  tools  is  often  %'ery  helpful.  Meat  is  grateful 
and  helpful  and  pjissive  motion  combined  with  warm  (not  hot)  batlis 
is  particularly  gratifying.    A  few  patients  react  badly  to  baths. 

Such  attempts  at  occupation  therapy  must  he  carefully  dosed. 
Fatigue  must  be  avoided.  Five  tu  ten  miimtcs  is  sufiicient  in  the  early 
stages.     Sueh  therapy  \s  solely  uf  value  fn>m  a  psychical  staiul-point. 

IJnig  therapy  is  at  times  of  doubtful  scr\ice  in  ctintrolling  the 
tremor.  The  remedies  are  those  with  markeil  iictii)ri  on  iiicmniiig 
nerve  impulses — notably  the  alkaloids  of  the  helljidnnna  gt^'nP)  of 
which  hyoseine,  duboisine,  scopolamine  and  atropine  arc  the  most 
available.  In  view  of  the  chemical  micertainties  conctTnliig  the 
alkaloids  of  this  group  one  should  obtain  good  prmlucts  and  try  the 
different  derivatives.    The  dosage  must  be  tested  witli  each  case. 

The  analgesics,  ])articularly  in  combination  witli  salicylates,  are  use- 
ful in  relieving  the  muscular  soreness  and  pain  of  tension — phenacetin, 
aspirin,  acetanilld  combinations,  etc. 

For  .sleep,  the  best  fonn  of  hypnotic  is  not  yet  known.  BromidcH 
are  at  times  available,  at  other  times  the  alcohol  hypnotics— trionol, 
sulphonal,  again  urea  substitutes,  ns  veronal — arc  useful.  One  should 
avoid  morphin  as  much  as  possible,  particularly  bearing  in  mind  tliat 
the  emotional  h,vperactivity  may  luve  little  real  feeling  behind  it. 
It  is  often  mostly  mimicry  which  is  uncontrollable  because  of  the 
motor  defect. 

DTSTONU  MUSCULORUM  DEFORMANS. 

'nder  thi^  term  Oppenheim  includes  u  peculiar  syndrt^ne  6rst 
callpil  attention  to  by  Ziehen  as  a  tonic  torsion  neurosis.  Flatau  and 
Sterling  term  it  a  pnjgressive  torsion  spasm.       It  is  preeminently  a 


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PARALYSIS  AOITASS,  CUORRA  ASD  RELATED  SYNM 

(ILsiiiiitT  (if  rliiliippii,  niitst  uf  tho()l»siprvpil  putu'iits  luiviiit;lii-4'ii  Ix-twifn 
nslit  him!  fiHirtiTii  vi-nrs.  iind  almost  nil  tif  tin*  Jirwisli  rnrr.  A|i{Kin?iitl,v 
tluTf  iirv  mi  s*-?i  (!iirt'mHfs.  Oppt'iilieiin's  rust's  ilid  not  It'jul  liiin  to 
utiy  lijilit  "11  ih*'  ilisnnliT  as  n-jjiinls  lirrtility.  'niivr  ^f  Zii'Iirn's  i-aNffs 
were  brutht'rs  hiuI  sisters.  Kxcitinp  or  otlicr  rnu.s«tivf  fm-turs  arc 
not  knttwn. 

The  illness  c-omes  on  apparently  gradually  ami  subtly  in  one  arm 
or  in  \nit\\  arms,  iKfn.sii)iniIly  first  in  the  lejjs  or  in  the  spine,  but  iii 
prni;n^ssiiiti.  'I'hf  (mtieiit  twists  the  spine  in  n  periiliiir  fashion,  tilting 
the  |)e!vis.  and  hringiii);  ahinit  u  tnarkeij  torsion  of  the  entire  vertebml 


Kttis.  282  bikI  'J83. — AUiludM  in  dyHtouin  tntweulonint  i-om.-^.     iFlalau.) 

AXiH,  with  lordoHls,  scoliosis,  and  tilting  of  the  pclvi^t,  the  arms  and 
|eg»  miiving  in  a  peculiar  manner.  'J'he  mcKle  of  pn)>;reitsion  at 
time:*  rescmhies  tliat  of  astasia  abasia.  The  whole  musenlature,whcn 
in  action,  h  extreEiicly  stiff  and  hypertonic;  when  at  rest,  hypotonia 
is  apparent.  In  the  general  attitude  uf  the  patient  in  walking  one  is 
inclined  to  regard  the  whole  matter  as  one  of  extreme  suggestibility; 
a  psychogenir-hystcrifonn  affair.  The  movenieuts  of  the  hip  are  very 
typical.  It  is  tilted  or  tlu-ust  forward  or  backwanl  in  an  awkward 
manner.  Oppenlieim  has  likened  it  to  a  dromedary  in  some  of  the 
positions  iLssumed.  Walking  seems  to  fatigue  the  patients  greatly. 
They  |»erspire.  get  red,  and  show  signs  of  fatigue,  getting  out  of  breath. 


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PFifiCHESSIVE  LENTICULAR  DECENS RATIOS 


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anri  one  of  our  (J.)  patients  gnmt«l  involuntarUy.    One  uf  Op|>eii- 

heiin's  pufirrity  roiild  walk  ImckwHnI  licftrr  than  Iir  foiiM  walk  fnr- 
wanl.  On  sitthi};  <lnwri  or  lyitiE  ilouii  the  niovt'inftits  ccjisf  (Hii'litig's 
case),  or  are  riUK-li  rcchicccl  in  frfi|iicncy  anfl  in  cluwiiishiicss.  Ziehen's 
cases  wt're  at  times  t-ontinuulh  Jii  motion,  and  hud  to  he  kept  in  a 
speciul  h«I.  aK»iiist  which  they  frequently  hruiswl  themselves  hy  their 
impulsive  movements.  The  ])e(iiliar  activities  come  iiitii  play  as  soon 
as  there  is  an  attempt  to  make  any  voluntary  movement.  Writing 
beenmes  diffic-ntt  or  im]nwsihle.  There  Is  no  paral^'slt.  Oppenheim 
speaks  (if  »  dystuniB,  Ziehen  of  a  h\'jjertonia.  The  movement-s  are  not 
athetoicj  nur  ehoi-eie.  They  are  wide,  irrepiliir.  »nd  yet  partake  of 
the  nature  of  bcith,  and  at  times  resemhie  those  uf  IIiintinKton's  choira. 

Tonic  and  clonic  extension  of  the  muscles,  particularly  uf  (hi-  hieeps 
and  rotators  of  the  thiph.  were  marked  in  Opjjfnbeim's  eases.  Thus 
there  is  an  alterimtinn  in  lonieity  of  the  muscle. 

The  knee-jerks  are  apt  to  he  niuclt  diminished,  coming  out  in 
Oppenheim 's  cases  only  by  Jcndrassik  reinfurcemcnt. 

Tlie  relationships  are  difficult  to  state.  Hysteria  should  be  excluded. 
I'oiible  infantile  atheto.si.s  shows  a  similar  picture.  These  cases  have 
been  studied  especially  by  I  ewandnwsky.'  f'eeile  A'opt  and  Oppen- 
heim hiive  repiirtrti  on  infiintile  iweudohutbar  pal>*y,  which  also  is 
to  be  consitlemi  in  this  conniftion.-  The  patients  apparently  hold 
their  own  h*?  some  lime,  and  but  little  is  kjiouri  of  the  development 
of  the  disorder.  As  yet  nu  |>athological  reports  are  available.  No 
known  methiKl  of  treatment  seems  useful.  SuftK<^tion  is  of  no  value, 
nor  are  biiiniides.    The  niovunients  L-ease  during  sleep. 


PBOORESSIVE  LENTICULAR  DEGENERATION. 

Wilson^  has  ck-scribwl  this  syndrome,  to  whirh  he  applies  the  tertn 
progressive  lenticular  degeneration. 

The  disease  is  familial,  in  the  sense  that  frecjiiently  more  than  one 
memlwr  of  a  family  is  affected  with  it,  but  it  is  not  bereilitary;  it  may 
also  occur  sporadically.  It  (K'ciirs  in  young  people,  either  in  an  acute 
or  a  ehrrmie  form.  As  far  as  is  known  it  is  pnigrt^^sive  and  invariably 
fatal,  its  duration  ranging  fn>m  si\  months  or  a  year  to  as  long  us 
fotir  or  five  years. 

Symptoma.  ITie  clinic-al  symptoms  consist  of  involuntary  move- 
ments, nearly  always  a  bilateral  tremor  of  U>th  up(R'r  atal  lower 
extremities,  the  head  and  trunk  also  iK-ing  stmietimes  hivolvcd.  The 
tnmior  is  nsimlly  rhythmical  but  e)cca.^ioually  irregular,  atid  increiLs- 
ing  with  volitionid  movenietit;  there  is  pronounced  spfisticity  of  the 
limbs  and  of  tJie  fa(«,  tlie  latter  Ijeing  usually  set  in  a  s|>astic  smile, 

'  DriiUir'lii' iViiKrb.  f.  Ncrvwilirilk..  mxU.  UHIS. 

*  Joiimfil  f ,  Ni>tirc>lnKic.  xviii,  IfU  I . 

*  PraicnMuvr  la'iitM'iiliir  DnKuuprnlian.  \  Fftoiiltiil  Ntnvunt!  IMp^mM.',  .\NHot-iulMl  wiih 
CirrhoKU  of  t hp  tJv(>r.  Hntin,  11)13. 


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510    I'AH.\LrSlS  AUITASS.  CHOHEA  AND  tOSLATBD  SYSDROUBS 


while  in  the  latter  staRes  contractures  of  the  limbs  (K-velop;  there  i.s 
dysphapa  anil  dysnrthrla,  the  latter  eventually  rlegenerating  into 
complete  anarthria;  there  is  also  spasmulic  laugliiiig  bikI  emotional- 
ism.    As  a  result  of  the  extraordinary  deprec  of  stiffness  of  the 

iijuscnialure  there  is  cousiderahle 
ditfirulty  in  maintaining  etiuilih- 
riiim.  Little  or  no  true  paresis 
or  jiaralysis  ncriirs,  however,  inas- 
niiich  Hs  most  orfliiiaTV  movements 
i-!in  lie  exwut«'<l,  although,  it  may 
he,  slowly  and  ffel)ly.  In  spite  of 
the  itreat  degree  of  motor  weakness 
and  helplessness,  in  a  pure  case  the 
abdominal  reflexes  are  present  and 

II  dcfublf  flexor  response  is  obtained. 

III  ot  her  words,  tills  jdTect ion,  whei^ 
it  occurs  in  an  unitimpHcated  form, 
is  an  ex  Ira  pyramidal  motor  dis- 
ease, the  importance  of  which  is 
apparent  by  reason  of  tlie  light  it 
sheds  on  such  a  process  as  paralysis 
agitans, 

Pathology. — The  cliief  patholngi- 
ral  feature  of  thediseaseis  bilateral 
syuunetrienl  degeneration  of  tlie 
pnlamen  and  globus  (Mllirlus.  in 
I>artic-nliir  the  fonner.  This  degen- 
eration is  a  sc<)ucl  to  the  selcrtivc 
ciperalioii  of  some  morbid  agent  on 
the  cells  ami  fibers  of  the  putameu 
and  lenticular  nucleus  genernlly. 
The  caudate  nucleus  is  often  siMue- 
what  degenenite<l.  hut  never  to 
the  same  extent,  while  other  large 
ci>Iiecti(ins  of  gray  matter  in  the 
imme^fliate  neighl>orhoo<l  of  tlic 
lenticular  nucleus — t.  g.,  the  optic 
thiilamiis.  which  has  partially  the 
hnmrblond  supply — iin*  not  afTected 
Hi  all  ill  ii  pnn-  case  unless  it  l>e 
indirectly,  and  lo  a  very  ^liglit  ex- 
tent. The  morbid  agent  is  possibly 
le  fonn  uf  toxin.  A  constant  essential,  and  in  all  probability  primary 
feature  of  the  pathology  of  the  disease  is  cirrJHwis  of  the  liver,  not 
syphiUtic  or  ahroholic;  it  is  multilobular  or  mixeil  in  type,  8lwa>'8 
pronounced,  but  presenting  a  var>ing  pathological  picture  of  neoiosis, 
fatty  degeneniti^in,  and  regenenition. 


V 


\ 


Fii!,  2-M,— Pni^iwwivo  Innlidilnr  lU-iwii- 
imilioii.     Cnini-y.) 


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It  is  probable  that  the  toxin  is  associated  with  the  hepatic  cirrhosis, 
ami  may  be  penerateiJ  in  cniineptioii  therewitli.  An  important  iinalopy 
may  be  drawta  troni  the  ncciirrence  of  "  Keriiiktents"  iit  c-ertjiin  rases 
of  familial  icterus  gravis  neoniitonim,  where  in  spite  o(  the  tiniversal 
bile  stniniiig  ut  the  tissues  i)f  the  hody  certiiin  cdllectiuiis  only  of 
gV&y  matter  in  the  brain  shew  a  niarkeij  avitlity  for  the  circulating 
stain,  while  others  do  not.  The  parts  that  are  stainetl  deeply  are  in 
particular  the  nucleus  lenlicularis  anil  the  corpus  Luysii  (among 
others),  while  the  optic  thalamus,  for  instance,  ts  scarcely  stained  at  all. 

DYSSTNEBOIA  CEAEBELLARIS  PROGRESSIVA— CHRONIC  PRO- 
GRESSIVE CEREBELLAR  TREMOR.' 

As  dj'ssynergia  ccrebellaris  progressiva.  Ramsay  Hunt  bus  de^>cribcd 
a  chronic  progressive  tremor  disturbance  of  ccreMlar  origin. 

'ITiLs  affection  ii*  characterised  by  genrrali/eil  intention  tremors, 
wliirh  begin  as  a  lucal  manifestation  and  then  (inniually  involve  in 
varying  degree  the  entire  voluntary  muscular  system.  The  tremor 
which  is  extreme  when  the  muscles  are  hi  action,  ceases  entirely  during 
reliixation  and  rest.  This  dis«trder  of  motility  is  associated  with  dis- 
turbances of  muscle  tone  and  of  the  ability  to  measun',  dirrtrt  and 
associate  iniisi'ular  movements;  the  clinical  manifestations  of  which 
are  dyxstftifrgui,  difsmetria,  hyi^oionia,  adiadokoicinesis  and  antknt'w. 
All  of  these  s>'mptoms,  includiug  the  volitional  tremor,  which  is  an 
extreme  expression  of  the  underlying  disturbance  of  mascle  tone  and 
synergy,  imlicate  a  disorder  of  midbrain  and  cerel)ellar  mechanisms. 

These  cases  are  further  distinguished  by  the  absent.-e  of  true 
nystagmus,  objective  vertigo  cerebellar  fits,  vestibular  seizures  and 
disturbances  of  eqnilihruun,  sjinptoms  which  are  so  fret|ueiitly  ass<i- 
ciatwl  with  gross  lesions  of  the  cerel>elluni. 

The  clinical  picture  is  strictly  limited  to  a  progressive  disturbance 
of  synergic  control,  the  most  striking  characteristic  of  which  is  the 
ataxic  intention  tremor,  which  accompanied  any  movement  of  the 
atTcctcd  part,  whether  volitional,  rcflcv  or  automatic. 

Pathology.  The  pathology  is  as  yet  unknown,  but  the  progressive 
tendency,  ctironic  i-ourse  and  welUiefined  cerelK'Har  symptomatology, 
would  sufjgcst  an  organic  disease  causwl  by  liegenemtion  of  certain 
.sjieirial  structuffji  of  the  wrel»ellar  mechanism  which  are  eonifnied  in 
the  regulation  of  the  tonus  and  s>-ncrgies  of  muscles. 

Differential  Diagnosis.- — In  gcnend  appearance,  the  motor  dlstnrbaiur 
which  chanicteri/.es  the  progressive  (freln-llar  dyssyiiergia  is  similar 
to  the  intention  tremor  of  multiple  sclerosis.  It  differs,  however,  in  the 
slow  and  gradual  manner  of  progression  and  the  strict  limitation  of  the 
symptomatology  to  tremor  and  its  associated  d>'smetria,  dyssynergia, 
hypotonia,  and  intermittent  asthenia. 

'  Bmtn.  Itfl4,  xuvi. 


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512    PARAIA'SIS  AOn-ASS.  CIIORSA  ASP  HSLATED  SYSDHOMES 

All  other  s>inptoms  of  multiple  sclerosis,  such  as  nystaRmiw. 
objective  vertigo,  pyramidal  ami  sensory  tract  symptoms,  temporal 
pallor,  hemipleftic  ftttacks,  forred  lauRliter,  alterations  of  the  reflexes 
are  aliseiit;  so  that  n  eercWIIar  type  of  this  nffeetioii  miiy  he  exclufled. 

The  pseudoselerosis  of  \Vestplial  may  also  Ix-  fliriiiiiated  by  reu^uii 
of  the  strict  Hiuitation  of  the  symptomatology  to  the  volittonal  tremor, 
together  with  the  absence  of  mental  deterioration,  pigmentary  deposits 
and  the  other  sjiiiptoms  which  rliararterize  the  recorded  eases  of  this 
obscure  affection. 

The  tlieory  of  a  functional  disturhanee,  in  the  nature  of  lij'steria 
or  the  traumatic  neurosis,  is  not  tenable  in  the  ahsem-e  of  an  uile<piate 
etiological  factor,  and  the  mental  and  somatic  symptoms  which  clmr- 
acterize  these  affections. 

The  rare  tremor  ty]w  of  Parkinson's  disease  may  likewise  he  excluded 
b.^'  reason  of  the  nature  nf  the  tremor  and  the  existing  hvpntonia  and 
dyssynergiii.  wliit-h  ditter  fuiulanientally  from  the  musele  nmnifestatioii» 
that  characterizf?  this  affeetion. 

Huntington's  chorea,  athetosis  and  myoclonus  multiple\  are  readily 
ililTerentiate'l  h\  the  chnracter  of  the  motor  disorder  and  persistence 
during  niuseulur  relaxation. 

Of  especial  imi)ortanee  from  the  diagnostic  stand-point  is  ihe  group 
of  the  so-called  essential,  hereditary  or  family  tremors.  Progressive 
dyssjTiergia  is  not  a  true  trfTmor,  but  a  synergic  dlsturharice  which  is 
evident  only  when  the  extremity  is  in  action,  and  consists  of  coarse 
irregular  mnvenients  in  which  the  constant,  vibrati>ry  characteristics 
uf  true  tremor  is  almost  entirely  lacking. 

PropiosiB.— The  pnjgnosis  is  unfavorable  but  like  other  sj'stem 
iliscascs  the  affetrtion  is  eompatihle  with  many  years  of  life.  The 
whole  course  of  the  di.-iease  is  chronic  and  sk)wly  progressive,  and  the 
mot^ir  life  becomes  more  and  more  restricted,  so  that  the  jjatients  in 
time  an'  almost  entirely  dejiendent  u[)on  the  care  of  the  nurses  or 
relatives.  Onee  established,  the  tremor  never  disapjiears,  except  during 
rest. 

There  are  days,  and  sometimes  Inngcr  periods  of  even  weeks,  during 
which  the  tremor  sutlers  temporary  exacerbatitms.  After  the  sub- 
sidence of  these  crises  of  tremor  there  is  a  return  to  the  usmil  chronic 
condition. 

THE  CHOREAS. 

The  somatic  choreas  are  due  to  definite  but  mually  recoverable  brain 
c<mditinns,  chiefly  located  in  and  almut  the  cerebral  and  cerebellar 
cortex  and  the  static  nuitor  i>ath\vays.  Menhigitides,  encephalitides, 
new  gr«)\vThs.  sexere  t'nnciis.siiiiis,  heniorrhagirs,  toxemias,  and  niarkiil 
faligues,  ell-.,  are  among  tlie  causative  faetors.  They  are  a  vast 
conglomeration  of  conditions,  certahi  trends  of  which  have  been 
separated  out  under  a  variety  of  types. 

The  detailed  histor>'  of  this  sorting  process  would  lead  too  far.   The 


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bepnniriK  of  the  present-ilay  grinipiniirs  «re  to  be  round  in  tin*  t-lassie  of 
(icrmain  H^  (1S5()).  The  chief  trends  center  alMmt  the  ^Uv\y  of  the 
ninveniients  which  are  present.  Tliese  are  of  three  main  fonns:  (a) 
spontaneous  nio\'ements,  (ft)  coordination  disturbances  and  <c)  dis- 
ttirbanres  of  pnTposefuI  movements.  In  most  choreas  the  three  forms 
are  present  Init  in  xarviiiR  pniportions. 
The  chief  nosological  entities  which  have  heen  created  are: 

1.  i'hiirrii  Mumrur  Sydcnham'ir  Chart'.n. — The  most  widespread  and 
frequent  of  the  trends,  usually  found  in  children  or  yomiff  adults, 
which  is  usually  recoverable  and  hence  erroneously  spoken  of  as 
functional.    Only  psychogenic  choreas  may  thus  he  termed. 

2.  Chorea  Chronica.— A  .stationary  form  of  the  Former,  or  when 
occurring  in  old  age,  chorea  senilis. 

3.  CkfiTcn  lluntintfftmii, — A  ehnmic  proRre-saive  tj-pe  with  certain 
definite  herwljtary  factors  and  one  showing  a  vast  variety  of  other 
choreic  anomalies  in  the  "  nnn-IIuntingtnn  chorea"  members. 

4.  Chim-n  iffijritpraiiji  of  lirhmiuil,  (K-curriiig  as  a  result  of  presenile 
breakdown  in  unstable  neuropathic  individuals. 

6.  Chftren  rUririra  uf  Ihil/int,  an  acute,  usually  fatal  dlsturhanw, 
often  occurring  with  epileptlfitnn  attacks,  paralysis  and  death. 

ti.  Cfinrt'it  eirrtrica  of  lirrtji'nm  und  lirruvfi,  occurring  in  young  per- 
st)r]H,  seven  to  fourteen  years,  with  rhythmic  lightning-like  nioveinents 
of  the  neck,  shoulders,  and  upper  arms.  It  has  allies  in  certain  cpilepti^^- 
like  chnreas. 

7.  ChoTta  epiUptioa,  continuous  with  the  preceding  or  related  to 
cortical  epilepsies.    (.See  Kpilepsy.) 

8.  Choreat  t,f  general  jxiresin,  in  which  spontaneous  choreiform 
movements  occur.     (See  Paresis.) 

9.  Chureaa  of  many  Patfchnnc/t. — Motility  psychoses  of  Wernicke, 
chiefly  schizoplirenic  individuals  in  whom  Kjeist  has  endeavored  to 
show  an  involvement  of  the  cerebro-rubro-<'ortical  tracts. 

10.  Chori'fvt  of  Congenital  or  Infantile  Cerebral  Pahi^. — (See  Hemi- 
plegia, Ttialamic  Syndrome.) 

11.  Chorea  Postapoplectica.  Posthemiplegic  Choreas. — (See  Hemi- 
plegia.) 

12.  Chorea  Thahmica. — (See  Thalamic  Syndrome.) 

i:{.  ChorroJi  due  to  Dimrder  hirohing  the  Superior  Cerebellar  Ped- 
uriclejt. — (See  ('erehfllar  Syndromes.) 

14.  Cht*rfa.i  of  Cerrfn^UtiT  Origitiir. — (See  Cerebellar  Syndrome.) 

IT).  Churrn  fubica  in  tabes  witli  choreic  crises  with  or  without  pain. 

10.  Pirych'tgrmc  Chorrnn.—(iriev  Psych i.nieu roses,  Hysteria,  Com- 
pulsion Neurosis.) 

Chorea  Minor  (Spdeu ham's  Chorea,  St.  Citus'  Dance)  is  the  most 
frequent  of  these  disturbances  of  spontanci>us,  purposeful  am!  coordi- 
nating movements,  which.  (H-curririg  in  <'hildrer,  nstially  reeoverit. 

Itife^tion  and  maldeveiopmcnt  are  the  most  frequent  etiolo^al 
factors.  The  most  widespread  infec-ting  agents  are  various  strep- 
93 


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514    J'AHALYHIS  AGITASS.  CHOREA  AND  liELATEO  SYNDItOMi 

Xw*>iv\  (tonsillitis),  inftx-tious  diseases,  measles,  wh(«>pinp-<-(iiiKh,  ctr., 
heuce  tlie  frequent  complications  of  infectious  tirthritides,  erHiocarditis,^ 
with  a  mild  meningitis  which  is  usually  present- 
Girls  are  apimreutly  less  resistant  fcillawing  these  infections, 
hence  show  a  higher  percentage  of  choreic  attacks. 

Symptoms.— Tliese  show  eonsidcniUe  variatiun.  ranging  from  sliglit 
niotiir  unn-st  and  irritahility  to  marketi  motor  disturbances,  witK, 
corn'siKdidinp    modifications    of   conduct    and    emotional    response 
The  latter  at  times  are  so  severe  as  to  constitute  a  psychosis  (choreic 
mental  disease,  q.  r,).     The  motor  sjTnptnms  are  l>esl  grtiupe<] 
pyraniidid  or  extrapyraniiiinl  tract  hthI  ccrehellar  disturhances.  either 
or  hdth  iKH-urring  in  most  pHtienty.    They  arv  the  results  of  definit^^ 
irritations,  occasionally  of  defect  (diaschisis)  lesions.'  ■ 

The  aponUmcuus  movements  arc  quick  and  show  comparatively  wide 
excursions.    In  the  distal  extremities  cramps  of  single  muscles  or  gr«Mii>» 
of  muscles  CKTur.  with  complete  rest  following  the  nnivements.    There 
is  great  irregularity  in  the  alTec-ted  groups;  there  will  be  one  or  tw^_ 
movement,-!,  which  are  followed  hy  opposite  muscle  action.  ^| 

In  mild  cases  these  movements  ^re  limite<l  tu  the  face  ami  to  sinja;!^^ 
muscles.     In  the  ntore  severe  ihics  the  entire  Imily  musculature  ts 
involved. 

The  arms  are  flung  about,  the  legs  are  wobbled  and  pulled,  walking 
is  impossible,  the  larynx,  lips,  and  eyes  are  in  activity.    The  patients 
gasp,  snort,  atid  groan.    In  the  mild  cases  the  movements  may  cea.s<^ 
during  sleej);  in  the  more  sevei-e  ones  the  movements  are  continuous.^ 

Any  sensory  stimulus  may  Increase  these  s]>iKitaneous  movements. 
They  do  not  bclmvc  like  wille<l  movement^.     Hence  extra py ram idaij 
systems  are  also  involved. 

Ptframiilo!  Tract  Difitnrhattceji. — rertain  eh<in,'ic,  jerky  movement 
are  observed  apart  fmrn  tlic  more  usual  ataxias  and  incoordinate  movt 
mcnts.  The  latter  diminish  with  rest,  quiet,  and  relaxation;  tl 
former  do  not  se*>m  tn  diminish  aa  masele  activity  is  withdrawn. 

.\  gnnip  of  nnnfir  signs  a])iiear  on  close  examination.    One  of  these  ii 
the  Uubinski  hand  sign  (dysmetria;  see  Fit;.  2!)1).    When  the  choreic 
patient  >limly  raist's  the  arms  in  front  nf  ihr  ImhIx,  pahu  duwn,  on< 
.side,  that  most  affected,  has  a  tentlency  to  sag.    Or  if  the  hands  ar( 
hanging  by  the  side,  the  more  affected  hand  shows  a  positioTi  half-wa] 
between  prountion  and  supination,  whereas,  since  the  normal  musel 
tomis  is  greater  in  the  jironalors,  the  more  hc;»lthy  side  is  held  more' 
pronatcd.     This  is  in  aceonl  witli  the  gi-nend  tendcnc\   for  one-half 
of  the  iMMly  to  In*  nuirc  affci-teil  than  the  uther.     The  iilTectetl  side  in 
In-potonic;  the  shiiulder  dnwips  more.     There  is  apt  to  be  exMggerated" 
Hexion  or  extensiun  of  the  arms.     In  the  lower  extremities  hj'per- 
flcxions  of  the  leg  on  the  thigh  occurs.    Since  hypotimieity  is  char- 
acteristic   of    underdeveloped    pdychomot<>r    integration,    younger^ 
children  do  not  bring  these  contraata  into  relief. 

'  FAwt<T:  Vollan»na  Klin.  Vort,,  383. 


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THE  CHOREAS 


f)15 


If  the  patient  lies  Hat  u|x>u  the  Imck  and  attempts  to  sit  up.  the 
arms  being  folded,  the  leg  that  is  most  affected  is  flexed  on  the  thigh 
and  raises  from  the  hed,  the  healthy  side  remaias  Hat.  (liabinski 
thigh  sign — ^Hoover).  Siniihirly,  if  the  |M»tieiit  lyin^  on  the  back  raises 
the  legs  simidtaiieously.  the  sound  side  rises  higher  than  the  <ither, 
or  if  oue  leg  is  raised  and  tlieii  the  dther.  the  stjund  su\v  is  raisci I  luglier 
and  the  choreic  side  also  falls  more  readily. 

The  Hoo\'iT  prtH-eihire  hy  measuring  the  pressure  of  the  leg  on  the 
lifcl  during  the  iiuiveuieuts  jusl  mentioned  sliows  dimiiiLsheil  pressure 
on  the  weak  side.    (See  sjTierpi.'itie  test-s  in  chapter  on  Kxamiiiatioui).) 

Korster  sliowed  that  iu  ehomes,  [mriicularly  in  tlie  more  uiidateral 
ctMA,  the  closing  of  tlie  fist  of  the  sound  side  called  forth  an  associated 
cloflUre  of  the  fist  of  the  affeeteti  side,  Imt  not  vicr  verm.  Sinulur 
assmnated  abdnctor  or  adductor  movements  usually  ocnir  in  the  lower 
limlis. 

The  IJahinski,  Oppenheim,  (ionlon,  and  Cliaildork  great-toe  exten- 
sion sign  is  very  frecjuent  in  eliorea,  and  shoulrl  Ik*  looked  for. 

Striim]>cirs  contTactlon  of  the  tihialis  anticiis  oc-curs  when  the 
patient,  lying  on  tlie  back,  attempts  to  flex  the  leg  on  llie  thigh  agiiinst 
passive  resistance  applied  to  tlie  thiglis.  The  foot  assumes  the  eciuinu- 
varu-s  position. 

The  tendon  reflexes,  patellar  and  Acliilles,  are  apt  to  Ite  variuhte  and 
often  delayed. 

These  signs  are  all  suggestive  of  mild  types  nf  hemiplegia,  and  have 
iH-en  cullec1«l  hy  l/IIeniiitte  umJer  the  title  of  the  "Little  Signs  of 
Hemiplegia."'  Some  one  or  all  may  he  present  in  even  mild  cases  of 
ehorea,  eapeciiilly  when  the  disturhamr  is  at  its  height  and  partii-nlarly 
in  the  severe  infectious  types.  Their  disappearance  often  takes  place 
with  the  stage  of  recovery.  Mild  cases  may  show  only  tlie  most 
passing  signs,  or  ver>'  mildly  developeij  ones. 

Cerebellar  Siy/w. — These  are  chieHy  adiadokokiuesia  and  asyibcrgia. 
The  fonner  is  frequently  found,  esixKrially  on  Uie  more  hyiwtonie 
side.    It  is  sometimes  er>mplieated  by  the  choreic  movements.' 

Asynergia  is  the  usual  c^ioreic  type  of  movement.  There  Is  a  jerky, 
irregular  movement  of  the  muscles  which  fail  to  perform  weli-atlapted 
movement.  Tlius  the  ]»atients  drop  things,  lurch,  stumble  or  fall, 
spiEl  their  fiHHl.  or  speak  in  a  jerky,  at  times  nnimbling,  niauner.  Tliey 
are  incapacitated  fnjni  writing,  playing  on  the  piano,  or  for  making 
■uy  finely  adaptive  movements.  The  finger-nose  and  fingcr-fiuger 
tests  show  this  asyncrgia  by  the  overshooting  of  the  mark,  pseudo- 
ataxia.  Attemjjting  to  grasp  an  objetrt,  the  <*horeic  opens  the  affected 
hand  over  widely;  the  pencil  test  also  shows  similar  overshooting. 

l^uko<">'tc3  ivK  iBually  increaffcil  in  the  cerebrospinal  fluid.  (See 
Meningeal  Inflammation.) 

>  J»lliffe:  Little  Higiu  of  HomlpltviK,  Pmc  Uraduitte  Mnliool  Journal,  111  IS. 
*  Grmet  et  LoubM:  n«v.  Nour.,  Uer<uiuber  lb.  1912,  |).  032. 


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RVSTTS'GTOS'S  CnOliEA 


51 : 


hyiKitontiK  Is  IcMS  lialilt 


callL-d  I'lmrfii'.  Imt  in  Iwrtli  Iiystcna  ami  in 

to  show.  There  is  a  jrrcjitcr  likclih^KKl  thjit  siM-jtlled  hystm<'!il  mo\T- 
ineiits  will  turn  out  tn  ln-chorfji-s  than  thr  reverse,  rs|M'cialiy  in  yonndcr 
chihireri.  In  oMer  chihlren  or  in  younK  ailulls  the  uppdsilo  niwy  lie  mure 
scrlomly  enttTtaiiieth 

Treatment. — The  best  treatment  is  rest  in  bed,  with  jMirtial  isolation, 
no  pla.\'inK,  Jural  treatment  vf  infifted  thmat,  tonsils,  teeth,  full  diet, 
with  inerea.se(l  fatty  ingreilients  Imilk  ami  eggs). 

The  rest  in  lied  shijtdd  be  pruetieally  iJiMilute  for  six  wivks,  ami  if 
aneniiii  is  present,  and  it  usually  is,  Inm  an<l  arwenie  are  useful. 

One  may  start  with  milder  anncnic-al  pre|MratioiLs  in  less  severe 
attacks,  and  in  those  where  sudden  disprajjortitmatc  pnnvih  seems  to 
play  a  lurger  role,  KowUt's  solution  lH  v-x  or  the  aeidi  arseiio,-.i  may 
be  usc<l,  either  alone  or  in  pleasing  vehieles. 

In  severe  and  pmTraite<l  <-ases  the  intravenous  use  of  doses  of  0.05 
to  0.2  gm.  of  salvarsaii,  awordinR  to  a^e,  r)nee  a  week  fi>r  four  week.s, 
is  advantageous. 

Most  of  the  rnild  cases  recover  on  prolonged  rest  in  bed.  without 
nu'dieatiiin,  if  on  a  full  diet  with  nillk  and  egjpi  in  ahnndantv. 

Huntington's  Chorea.— This  is  u  disorder  of  the  nervous  .system, 
iiuined  after  (leorge  Huntington  (Iwrn  1JS50),  an  .\mcriean  phyyieian, 
who  gave  the  first  essentially  eiiniprehensi\'e  and  ilisliiictive  deserip- 
tkni  of  the  disease.  Huntington's  grandfather  aial  father  had  observed 
the  disorder  in  one  of  its  American  foci,  Easthampton,  IxinK  Island, 
and  chiefly  through  their  studies  of  several  generations  of  atHicted 
families  the  essentially  hereditary  nature  of  the  malady  became 
apparent. 

Huntington's  chorea  has  \w  relationships  to  Sydenham's  ehurea, 
that  essentially  infautUe  disturbance  of  cerebrocercbellar  tract  coor- 
dinations following  so  fretiuently  upon  infectious  disease  or  exhaustion. 
Hnntington's  chorea  is  essentially  hereditary  and  chn>nie,  oi-curring, 
as  a  nde,  in  adults  from  thirty  to  fifty  years  of  age. 

The  condition  did  not  escape  earlier  olwen'crs.  Iliilenius  gave  a 
report  of  a  case  apparently  as  early  as  IHlCi,  Rufs.  another  in  1S,'J4. 
Waters  made  his  striking  comment  in  1S41.'  r*r.  Cliarles  G.  Gornian, 
of  Luswme,  Pa.,  wrote  an  inaugural  thesis,  in  1S4S,  <in  this  affection, 
which  has  been  lost.  Dr.  Irving  W.  i.yon,  while  house  physician  at 
HeUevup  Hospital,  wrote  a  paper  on  "Chronic  llereditarj-  Chorea," 
which  was  published  in  the  Americnn  Mrdintl  'Urnes  in  l^ihi.  Hunting- 
ton's pajier  appeared  in  the  Medicai  am!  SitTtfical  liejMtrter,  Philu- 
deljjhiu,  ill  IH72.  Since  this  time  a  rich  bibliography  has  accumulatal, 
which  in  the  Huntington  number  of  Xcuriuiruiili.t,  eilited  by  Dr. 
William  Hrowiiiug,  in  IIU'S.  mounted  to  2D()  titles. 

EtiolOKy-  ^o  far  as  is  known  the  disorder  is  hereditary.  From 
eugenic  studies  of  Davenport,  Muneie,  and  Jellitfe.^  the  chief  4ieter- 

'  t>iuild>')"Ti's  Pnirtii-c  -^f  Medicine,  ii,  312. 

■  Anw>ri<-au  NeuntlntQrnI  AKWu-inlion,  1913;  Muni-ie  and  DiiVQDport:  .Vtii.  Jniir. 
lufluQity,  lOtn. 


Digit 


zedbyUoOgle 


518    PARAr.Ysrs  agitans.  chorea  axd  related  syxdromrs 


lie 


niiriHiits  Hj)])e]ir  to  th'liavr  ii»  MeTidfliiin  <liiii)iiiaiiti!.  Ileilbroiincr  hitifl 
said  th»t  tlie  (ILsiinler  a|)jH'ars  at  liiti-r  iutiTviils  in  siic<'iHHlinp  priicra-^ 
tiniis,  hut  cvklence  from  cxteiitdve  I'liKfUK"  stuHies.  which  iiu-lMile  t\w 
shtily  itf  HHK)  nises  of  n»iiitinpton's  chorea,  liniitc*!  to  a  few  fitniilk-s, 
sliows  that  it  appcHrs  at  enrlicr  years  in  sucrwdiiijr  generation;*.  The 
data  here  indicated  tliat  the  disease  behaves  as  a  complex  in  whicli 
ajje,  motor  disturbances,  and  mental  defect  behave  more  or  less 
independently  one  of  another.  When  nil  thret?  faetors  combine,  the 
result  is  Huntington's  chorea.    No  other  etiology  is  known. 

Symptoms.^As  it  is  not  pittsihle  in  a  short  rfsuuif  to  discuss  tl 
separate  factors,  the  older  lines  of  description  which  r^^ard  the  di 
order  as  a  unit  will  be  followed.    Thus  one  speaks  of  an  lasidious  onset, 
usuall>'  coming  on  between  tJie  years  of  tliirty  nnd  forty.    'I'he  earlier 
si^nis  »rf  either  slight  clianges  in  character,  irritability,  moroseness,^ 
eicentricities,  or  the  choreic  movements  be«onie  prf)minent  in  theV 
pictiin*.      The  facial,  neck,  iiml  upper  cNtreinity  nuiscles  are  nsunlly 
involved  first.     Tliere  are  involuntar,v,  jerky  movements,  usuull\'  of  _ 
muscle  gi-oups,  not  of  niuscle  fibers.    Tlie  excursions  brought  about  arel 
massive,  *'.  r.,  excessive,  loose,  and  hypotonic.    The  hand  is  thrown  to 
one  side,  the  whole  arm  sweeping  outward;  the  neck  Is  jerked  liack* 
ward,  the  hea<l  bowed  forward  in  a  quick,  loo-se-jointed,  jerky  ftirt  of 
way.    The  motor  unrest  spreads  over  the  entire  body.  m 

The  patient,  after  several  years-  for  the  motor  disturbance  advances^ 
slowly — becomes   jerky,    ainl    idthough    for   ii    long    lime    voluntary 
movement  is  able  to  check  the  excessive  motion,  Knally  control  is  lost 
and  the  patient  is  confineil  to  a  cliair  or  his  biil,  making  Ids  peculiui 
broad,  jerky  movements.     During  sleep  the  motions  cease. 

Nearly  all  of  the  voluntary  muscles  may  be  involved.    The  eyi 
movements  seem  to  resist  to  the  la-it.    The  sjicech  becomes  explosive, 
or  gnmt-like,  very  incohen-nt  at  limes  by  reaiion  of  the  involuntaryj 
movements  of  longiie,  lips,  diajihragm,  and  chest.    Kven  swallowing] 
is  involved  in  tlie  later  stages.     Writing  stH>n  Incomes  impossible  by 
reason  of  the  jerkiness  nf  the  hands  ami  anus.     ^Valking  becomes 
successively   more  and  more   misteady   until  the  patient   becomes  | 
bed-ridden. 

There  are  few  disturbances  of  .seiwibility  and  these  are  ob3er\'ed  oiilyj 
late  in  the  deteriorated  phases.  The  knee-jerks  are  active  or  imiiwj 
volvcfl;  tliere  are  no  atrophies,  nrir  paralN'ses,  nor  hypertropliies. 

The  mental  changes  may  develop  apart  from  the  motor  ones,  and 
in  choreic  families  mental  choreics  are  to  be  rccoguizctl  who  perhaps' 
may  ne\'er  slu>w  motor  signs  or  those  who  show  cJioreie  movements 
very  late.  This  h  the  basis  of  1  >iefcndorf 's  coastitutionally  defec- 
tive group.  These  |>aticnts  even  in  cliildhood  may  l>e  excessively 
nervous,  irritable,  anri  excitable.  There  are  often  diflicult  cliildren  to 
manage.  Their  eccentricities  become  more  and  more  marked  with 
advancing  years.  Some  show  markeil  grades  of  feeble-mindedness  and 
occasionally  are  boni  choreic  and  defective. 


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519 


P 


In  Uif  urt'ut  iimjority  of  the  fuses  llic  iiisidiuus  and  slow  ilcvclup- 
iiu'iil  of  (ircjit  instal>ilit\'  hihI  irast-ihililv  slum-s  itself  <TiiiicuU-iit  with 
ur  ftilldwiiin  thf  fhtirfiftirrn  riio\'niu'nts.  Auiiry  <ii[tl>ui>ts  mikI  »U*strur- 
ti^'t'  impLilsi's  <K'c  ur.  olU'ii  followed  or  prwtnled  hy  piTiixl^  ol'  timrkfil 
uiun>seness  and  dpsiMinHency.  'Hiis  depression  nr  eUxmi  may  l»c  a 
forerunner  of  suicide.  Diefendorf  remarks  that  this  despondeney  is 
not  due  entirely  tn  the  realizatinn  of  having  tJie  eJisease.  With  some 
patients,  however,  the  sukide  i*i  to  lie  Iraee*)  to  the  knowledge  of  the 
taint.  Suspieiousness,  paranoid  iileas  luid  jealousies  are  not  Jiifn'- 
queut  mentJil  sigiLs.  Kmotioiml  deterioration  follows.  The  patient 
loses  nil  interest  in  his  work,  his  appearance,  his  home,  ete.  Some 
bet'ome  trnmiw.  IntempenuK-e  hihI  free  sexual  artivities  may  show 
themselves  with  lliis  gradual  tleteri oration.  Indifference  sliades  off 
into  absolute  ini'ii|iaeity  and  deterioration  iK'comci*  profound,  always, 
however,  showiufi  itself  in  the  affective  sjihere  more  prominently  than 
in  tlie  intellet-tual  capacities,  although  these  latter  are  not  free  from 
gross  ejefeet:  the  {Mitients  being  forgetful,  poor  in  ideo^,  disonlerly 
in  thought  and  weak  in  judgment. 

DiefendorF  speaks  of  a  group  in  xvhicli  the  mental  symptoms  (levehij) 
somewliat  similarly  to  those  seen  in  the  heljephrenie  types  of  dementia 
precox,  'j'hcse  patients  eoniplain  of  insomnia  and  general  maliiise. 
They  often  then  develop  ideas  of  reference,  anxiety,  suspiciousness 
anil  ideiis  of  infidelity.  In  stmie  of  these  impulsi\'e  Activities  show 
themselves.  Homicide  has  taken  place.  K'racpelin  cites  an  illustra- 
tion of  a  choreic  father  who  killed  his  three  ^mall  children  by  hanging, 
as  he  feari-d  he  could  iwi  support  ihetii,  then  cjuictly  t<M>k  a  walk  and 
was  quite  unconcerned  alwut  tlie  affair  at  a  judicial  hearing.  The 
eating  is  often  impulsive  and  ravenous.  In  some  (if  these  eases,  as 
with  the  inferior  group,  the  mental  sjTnptoms  may  develop  long  I)efore 
the  choreic  ajmptoms,  and  the  diagnosis  of  a  katatonic  schizophrenia 
may  be  made  as  the  motor  sjTiiptoms  become  nmnifest.  Here  the 
diagnostic  difficulties  are  very  definite, 

It  would  appear  from  Piefendorf  and  the  studies  cit«l  tliat  the 
mental  and  motor  traits  are  more  or  less  independent  one  of  the  otlier. 
In  inheritance  they  seem  to  sliow  as  such.  Some  patients  have  shown 
choreic  movements  for  twenty  to  thirty  years  without  mental  signs. 

Conrse.  Tliis  is  subject  to  great  variation.  Often  the  patients 
suddeulv  develop  great  motor  unrest;  the  mental  signs  augment 
rapidly,  and  the  patient  dies  in  exhaustion  five,  ten  or  fifteen  years  after 
tlie  onset  of  the  symptoms.  I'sually  the  disorders,  i.  <?.,  motor  and 
mental,  are  progressive;  rarely  they  may  diminish  after  reaching  a 
severe  grade.    Many  die  of  intercurrent  disease. 

Pathology. — No  unitary  interpretation  seems  yet  possible.  The 
mottir  and  the  mental  symptoms  are  liest  eonsideretl  sepanttely. 

A  number  of  autopsies  have  shown  a  variety  of  findings.  At  times 
there  are  ebronic  meningeul  thickenings,  again  generalized  brain. 
ntroph>'.    This  reduction  of  the  cortex  may  show  to  a  uuirkeil  degree 


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520     PARALYSIS  AOtTASS,  CHOREA  AS'D  RELATED  SVXDROMBS 

in  tlie  liKM  of  wlls,  pmticiilftrly  of  tlit  thin!  layer.  Tlicrt*  is  a  ti>n»pen- 
iuitnry  inrrcH.sc  ii)  ncun>glia.  In  snnic  imticnt:^  urtcriosi'ltTiiisis  Uim  been 
prt-scnt,  in  others  not.  The  older  patients  showed  the  arteriosclerotic 
rhanpi's.  These  cortical  celhilar  ehangcs  are  apjmrentJy  nmre  fn^iient 
in  the  frontal  an-A.^.    They  are  rorrdatwl  with  the  mental  defects. 

Tile  pathology  behind  the  motor  manifestations  is  more  obscure. 
TluMiretlt-al  eousiderations  as  well  as  imthologieal  findings  point  to  an 
iniplinition  of  the  rubro-tlialunio-eortii-al  extensions  of  tlie  fcrebellar 
jHithways  as  chiefly  responsible  for  the  perverte<l  movements.  K'U-ist, 
Zingerle,  Jelgersoia,  and  Wuikler  adduce  oljservations  from  various 
sides  which  tend  to  show  that  thc*e  mechanisms  are  involve*!.'  Numer- 
ous autopsies  show  clmnges  in  the  Icnticntar  regiou  which  may  Iw 
taken  to  support  these  contentions.  Thus  the  motur  signs  liave  a 
iwithology  closely  relatwl  tn  that  i^een  in  paralysis  agitaus  and  other 
m-flbrain  tremors.     'I'he  putamen  region  shows  distinct  losses. 

Therftpj. — There  is  no  efficient  therapy.  Many  patients  need  hos- 
pital care.  I'rophylaxis  i.s  important,  ^lemlelian  tlominanee  aiding 
for  certain  fHctors  at  least,  that  these  patients  should  not  procreate. 
The  percentage  of  chanee  of  escape  for  Huntington  choreics  is  about 
one  in  four  at  the  best.  Some  branches  esciipe.  and  a  branch  oiic« 
free,  is  always  free.  OnJy  a  few  exceptions  to  tlus  iu"e  fouud  in  the 
Davenport-Muncic  series. 


■  Roueay  et  rHcnoitU:  i^rchives  d«  Mddioin.  1915. 


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CHAPTER    IX. 
CKHEBKLLAU  SYNOUOMES. 

Defect  or  disease  of  the  eereWllum  itself,  or  of  its  chief  afferpnt 
um\  ftfercnt  patiis  j^xvfs  rise  to  »  iiuiiiIkt  of  fairly  definite  syiulronies. 
These  may  l)e  referred,  with  a  certain  depree  of  accuracy,  to  the 
struetures  involved.  There  are,  furtheTmore,  other  disturbances  in 
or  about  the  rerebellum,  the  precise  mechani.sni.s  of  which  are  still 
iinsatisfa<-torily  analyzed,  altlioiif^h  it  is  rerognize<l  that  thecerebelliini 
or  its  pathwiivs  ure  rielinitely  involved.'  - 

These  syndromes  may  lie  the  result  of  defect  or  ijisonler  of  the 
organ  itself,  or  uf  its  i-onnwtioiiH.  or  tliey  may  be  due  to  or  ciHnpli- 
cated  by  the  position  that  the  cerebellum  itself  occupies  with  reference 
to  contiguous  struclUFfs  in  the  pusterior  cerebral  fossa. 

The  cereWllum  uccupies  tlie  posterior  cerebral  fossa,  is  separated 
from  the  occipital  Iol>es  of  the  cerebrum  by  the  tcutoriuni.  and  rests 
uptm  the  pons  and  mwlulla,  funning  part  of  tlie  upper  boundary  of 
the  fourth  ventricle.  It  is  connected  with  the  rest  of  the  nervous 
system  by  the  anterior  metluUary  velum,  the  superior,  middle,  and 
inferior  lerebdlsir  |Kiluni-le.s  and  po.ste.rinrly  by  the  posterior  iiiedulliiry 
velum.  The  tela  clionmlea  forms  the  posterior  continuation  of  this 
latter  structure^  ami  serves  as  a  roof  to  the  posterior  part  of  the  fourth 
ventricle. 

Being  so  ultimately  connecter!  with  structures  in  the  midbrain,  the 
red  nucleus  and  tlie  optic  thalamus,  with  bulbar  and  pontine  centers 
and  with  the  cord ;  lying  above  important  structures,  and  containing 
important  nuclei,  the  dentate  nucleus,  Deiters'  nucleus,  niideiui 
globosus.  nucleus  embnliformis.  tcctal  nuclei,  etc.;  with  a  multiplicity 
of  afferent  and  efferent  tracts,  the  possibilities  of  sj-mptomaUilopy 
are  very  nuniermis. 

The  cerelK'lhnn  Is  the  central  organ,  composed  of  groups  of  synapses 
for  the  coordination  of  the  reflex  system  of  the  proprioceptors;  tlmt 
is,  those  sensory  impressions  coming  from  re«*ptors  tlimughout  the 
entire  Iwdy.  It  thus  represents  the  entire  liody.  1'^ese  receptors 
receive  impressions  of  thernnil,  tactile,  gravity,  weight,  pain,  chemical 
and  otiier  sthnuH,  and  by  uiean^  of  afferent  paths,  transmit  tliem 
chiefly  to  tlie  cortex  of  the  cerebellum.  Many  of  these  patiis  arc 
definitely  known;  otJiers,  ])artieularly  tliose  connected  witli  the  vistvra, 
are  stUl  under  investigation.'    The  chief  functions  known  are  relateil 

'  L6wL>tki<tcin;     Zcooli,  f.  N.  u.  P.,  rvt.  vol.  v. 

I  'l*hoinu:  The  Corebellum,  Nervous  and  MeDlBl  DUeawt  Monograph  Series, 

'  Uechterew:  Vin  FutiXtioimii  Uot  NorvBOveatn.  ItMM.  ii. 


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CKHBBBLLAR  SYSDROMBS 


tn  the  lot-aliTJitioii  of  ilu-  IxNly  in  sfnux',  aiul  statk*  traiic  mc 
iniicrviitiiii). 

Krum  the  r<>ri*lM>llur  cnKex,  which  may  tlius  be  liHikerl  iii'mui 
chiefly,  if  not  rxcUisively,  sensory,  thtse  impulses  pass  to  tlie  viimii 
niirlei  of  the  eerebellum.  Hiitl  are  there  reili.strihute<l.    It  wnuM  ap[ 
thut  tlitsc  iutriiisic  cerebellar  nuclei  are  mainly  motor.'    The  iiiovis 
menUt  of  ibc  head  Iwinp  cluefly  referable  to  the  intrinsic  nuclei,  tl 
of  the  tnmk  and  limb«  to  the  paracerebellar  nuclei. 

Tliii  chief  afferent  or  receptor  patlis  arrive  liy  way  of  the  thi 
cerel)ellar  peihincles. 

Bechtcrew  (/oe.  dt.)  Heserihcs  seven  (jatlis  as  pa>^sinj:  throuj^  I 
mferkfT  cerrheUar  jiedvnck.  or  restiform  hotly.    These  are  in  part: 

1.  The  clorsospinoeerehellar  tract  of  Flechsig,  which  pa-vsrs  up  the 
lateral  ventral  .side  uf  Uic  lateral  coluiiui,  originating  from  cells  ia 
("lark's  (Hiluinn,  from  the  npi)er  lumbar  to  tlic  upper  dorsal  scpuent^. 
This  tract  passes  up  through  the  inferior  cerebellar  peduncle  (corpus 
restiforme),  and  is  thought  to  be  distributed  to  the  middle  lobe  (rfj 
the  vermis  and  the  ventrolateral  lobe  of  the  lobus  <-entnili£ 
(Mott). 

2.  The  posterior  colunms  of  GoU  and  Burdach  send  Bbcn*  froi 
their  nuclei  in  the  medulla  by  way  of  the  restiform  biKly,  dorsally 
and  uiicroftoed  to  tlie  inferior  vermis,  ventrally  and  crossed  to  tliftj 
siiju'rior  vermis.     (Many  autliors  claim  tiiat  these  bundles  have  i 
coiitii-^-lion  with  the  cerebellum.) 

;i.  Tlie  olivoccrehcllar  tract,  which  originates  in  the  cord,  ends 
the  inferior  olive,  fnnn  which  it  passes  direct  (?)  to  Inciters'  nuclei 
au<l  crosses  to  the  Mi|)erior  vermis. 

4.  >'e8tibul<K-crebellttr  |Mitb  from  the  vestibular  ganglion,  which 
sends  its  central  filwrs  lo  the  nitcleus  vestibularis,  and  to  Deitenj' 
nucleus  in  Uic  teginentuui,  and  from  tlience  to  tlie  inferior  vermis. 
(The  iletails  of  these  pathwaj-s  arc  given  in  the  chapter  on  the  vcstin 
bular  functions,  also  in  IMates  IX  and  X.) 

These  pass  up  through  the  lateral  part  of  the  restiform  body, 
the   median    portion   there  are  two   groujis  of  fibers:  One  contaii 
sensory  fibers  from  the  cranial  ncrvt-s,  the  trigeminus  ami  vestibular. 
They  form  tlie  direct  cerebell(»r  sensor>'  patli  of  Edinger.    Other  fil 
connect  the  nuclei  of  the  cranial  sensory  nerves  to  tlie  cerebellum.' 
Hnth  of  these  bundles  end  for  the  most  pjirt  in  tlie  tegraental  nuclei 
Tliis  traclus  nuclaHcrcbeilaris  is  an  indirect  [with."  M 

In  the  niifidh:  crrebcUar  i>e(ivncle  incoming  fibers  come  from  th<ff 
nuclei  of  the  jjontine  reticular  formation  and  the  ventrolateral  pontine 
nuclei,    <Vr(«in  of  these  fibers  are  in  relation  to  fibers  ct^imiiig  from 
the  frontal  area  to  tlie  jKintine  nuclei  and  form  part  of  a  frontocen'hellar_ 
reflex  patli  (Fig.  2X1).' 

>  Hundi-y:  FuDcti<jiiu  <>t  Uw  Cittvbdluii).  Bniu.  1906,  xxix.  -HO. 

*  M<iiml«i-hri(t,  1M»1,  i,  KM.  ■  Bwhtcnw,  ii,  MU. 

*  Srlittflcr.  Cerebell»r  PyrtimidBl  FiWre,  SEtw^r.  (-  N,  u.  P..  vol.  jei*ii. 


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523 


The  filMTK  iMtssiiig  t(»  tlu'  ivrflit'Iliirii  liv  iiil-uiis  nf  die  nujirrior 
rrrrMhir  imlunrJr  are  four  in  niinilnT,  Hccurtliti^;  tn  H«ihti'rt*\v.  Tlie 
best  known  nf  thttse  Is  (lowers'  tract,  whidi  pusses  iritu  tlie  cerebpllmn 
by  means  of  the  superior  cerebellar  ijcdiincle.    Aeeowlmg  to  Kdinger 


C9_, 


r- 


cs 


fa 


f}. 


:7Sir 


ra 


rp 

Tia,  3B6. — TIm;  fiber  traiMs  u(  the  ijuttloriut  ccnboUnr  pudundp.  ra,  anterior  inotag 
rp,  poAeiior  toitl»:  /c,  [XHlcrior;  /c',  ventral  pon-bollap  tniri«:  fi,  abpmnl  pynti 
ftbtTB :  fO,  ootiinin  of  Ciull;  /B,  Dolumu  of  Burdxch;  /</,  iJv9><vn<)iiiic  tract  from  Driioni' 
niirlms;  I'lJIe.  v€»Xtl>ulaH&;  ^.  fibcn  from  Jat«ml  nui-lei  of  truHliilU:  fi/e,  /be,  ciiri>l>KtlKr 
Blwrii  fr<»m  t>o!tori<;r  r>.>Luitiii  nuclei;  jjc,  p;n,  liitcn>vi>n(mJ  and  donioiue'lian  imitiitio 
niirln;  nl),  Dcitcrv'  nurlfiLs,  tir,  vcatihiiliirit  iiiii^Ii?um;  d,  ilwrtfriilinn  hundlr  nf  rni-diim 
IKirUon  of  i>ottl*rior  i:«ret>ollar  ppdunde;  a,  HacpiiJiiiic  fibeiE  of  v eat i hula ru .  nJ,  rci-liU 
nuclH:  eo.  diwmuliiii;  imlh  fnnti  irrL/il  ntirli'j  Ui  nii]icriiir  cillvo;  rx,  miperinr  r4irt>hc4l&r 
peduDcIo:  m,  uu<.>leu9  retroU'Dticuluris ;  fi,  fitwn  from  Deitcn'  uut'k>iu>  tu  po«t«nor 
loocilu<liniil  hiindtr:  im,  •iiiji^riur  ulivo:  fa,  Mien  fnim  ftciociJiu  Ut  wrmis:  em,  median 

>'MnibvU«r  pvdtiiicio:  /f,   fiwdcuius  v«rticalu  iionlin;  /cf.   reutrul   tvf(uii^»uU   tract;   oi, 

!  iofonoT  olivn;  /o,  olivary  lascioiilud.     (Bccliterew.) 

and  Hursle.v  this  tract  in  distributed  to  the  entire  cerebellar  cortex. 
Fibers  from  the  thalamus,  from  rjie  red  uucleus  and  colIaterHla  from 
the  uucici  of  the  e>e  luu-'cli's  have  olsti  been  traced  through  the  superior 
cereWlar  iK'dniiHes. 


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Kiij.  2K7.  —  Deni-Piiriiiia  iioDtJiie  and  wreliellar  traeta;  Vt.  rooljt  filwn  nlidumnHi  ep. 
coriicnpnjiliiiP  fillers;  trp,  fitipw  fmn  pono  to  ficrplx-Iliim;  it,  dentate  tiurlcuii:  /(J.  eoi*- 
bvllu-Dritvni'  fibum;  /»,  U-KEnQUtu-uli\iiry  libvr);  ft,  fitxTs  Isvtu  vortuiit  Cu  t<^itnM)iital 
aurl(!i:  ff.  c-ortical  EuwwmliuD  fitter*:  Wl.  Bbdim>i»i  nui-ItMio:  nd.  Die^t-n'  nurU^a: 
Xot,  uilerivr  wUvp;  nl.  U-stOMiUil   nuvki;  ow,  im[»uri'ir  ulivo;   ra,   aatniot   ni'il    filx-t*. 

The  cerclicllum  therefore  forms  an  important  sensorimotor  station 
ill  ft  complicated  scries  ttf  rcHcxcs  whU-h  work  for  the  most  part  nuto- 
maticiLlly.  The  cerebellar  cortex  acts  a*  the  priiiuirj'  reception  center, 
the  impulses  coming  from  the  rord  and  brain  stem  traversing  the 


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52n 


CBREBELLAK  SYMiHUSfEfi 


patJis  just  enumeratet!,  piviiip  iiifnniiation  chiefly  concrrniiitf  tnr 
states  of  tension  of  the  musciilHr  apparatus  of  tlie  trunk,  tliu  extremi- 
ties, and  tSc  hraci,  and  the  states  nf  pres.sure  in  the  joints  and  tendonajl 
The  reflexes  t'oinhiiie  to  regulate  the  eoiwtjintly  iiltering  positions  of™ 
the  entire  body  in  space,  and  also  possibly  of  the  visrera.  The 
ivreliellum  therefure.  in  this  sense,  acts  as  a  regidntlng,  cooniinoting 
organ  for  ttie  estiniatiiiii  of  the  h<-)dy  in  space.  To  the  spintil,  miilbmin, 
cerebral  reflex  ares  there  are  also  added  f rout o-py ram id(>-ponto-l)ul iM>- 
cerebellar  arcs  which  contain  invohmtary  as  well  as  xoluntary  regula- 
tory coiirdinating  impulses,  acting  to  orient  the  bcwly  in  practically 


\<m 


Pw.  288  Fio.  280 

>'iUB.  288  and  2K9. — Tlu-  ]>pi'uLiar  itjitiun  nrtil  luiil  i)f  cotvliclliir  aUuk.     (ThomM.) 

all  of  its  sjMitiid  relations.    (\von  adds  that  therefore  the  cereWlliim 
\s  intimately  concerned  with  the  niatlicmatieal  sense  in  its  ohie<'tive3 
space  relations^ 

Symptoms.  — The  gcnend  syinpionis  of  ren-lH-Ihir  litscasi-  tbererore] 
otfera  niultitudinoiis  complex,  the  details  of  which,  and  their  una toniico-j 
pathological  correlations,  arc  .still  being  rapidly  uilded  to.  Ainontfj 
these,  however,  there  are  certain  t,vpes  which  are  capable  of  partiaTj 
differentiation  at  the  present  time,  and  to  which  attention  will  \>t\ 
direct  e«l. 

Cyou:  Dm  Ohrlabj-riDll).  ItKKI. 


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CercheUar  Ataxia. — 'Vhis  complex  of  (ii»turl>ance:s  is  one  of  tlie 
classipal  signs  of  cerebelliir  diaorder.  It  consists  in  a  disturbanc*'  of 
t-he  onorrlination  of  the  larger  nmyfular  jjrmip  actions,  principally  of 
tlie  trunk  and  lower  extremities,  althuugli  the  hi-ad,  eyrs.  and  iipiH-r 
extremities  are  not  uninvolvcd.  Thiis,  standing,  walking,  and  tlie 
making  of  fine  coordinated  movemeuta  are  interfered  with  in  the 
absenc-e  of  signs  of  distinct  paralysis. 

In  walkinR,  the  wobbling,  side-stepping  gait,  so  well  <IescribeH  by 
early  Krench  anthors  (Ducbenne.  of  lioulopne)  as  the  drunken  giiil, 
is  chanicteristic.     \n  severe   grades   of  cerebellar  ataxia  standing, 
and  e\'en  sitting,  beeimies  impossible. 
In    milder    grades    one   sees   the    same 
type  L)f  disturbance  in    many   cliorrns, 
in  paralysis  agitans,  in  general  paresis, 
multiple  sclerosis,  etc. 

A  partial  study  of  the  cerebellar  gait 
has  shown  two  charaeteristic  trends  <>f 
disturWnee:'  first,  staggering  (latenipul- 
sioris)  toward  the  afT'ettted  side,  at  times 
^o^^'a^d  or  backward,  according  to  loca- 
tion of  lesion  in  vermis  (or  dentate 
nucleus).  The  |Mitifnt  feels  as  though 
shove<l  to  one  side  antl  in  the  attempt 
at  restitution  overeon-ects  (asynergia  of 
liabiiLski)  and  thus  sways;  seeoiul.  the 
entire  orientation  in  space  is  uifluenccd 
and  the  patient's  movements,  as  a 
whole,  swerve  in  tlu*  direction  of  the 
affected  side  (menagerie  movements,  as 
seen  in  whirling  white  mice;  tumbling 
movements,  as  seen  in  the  tumbler 
pigeon). 

Coiwcious  attempts  at  forrectii)n 
{froiitiK-erebellitr  (mths)  produce  the 
larger  -/ig-iuigs  Jn  the  general  course  of 
the    progression.     Forward    and    back- 

wanl  nioveinetits  liavc  their  sjM-cial  localizing  signs  to  l>e  siMikeii 
of.  From  the  anatomical  considerations  tliese  ataxias  may  R-snlt 
from  involvement  of  the  spinocerebellar  patlus  (FIcchsig.  (towers 
— vestibular  .systents),  as  in  llie  Friedreich  and  Marie  ataxia  group; 
front  invcilveniigits  in  the  cerebellum  itself  (tumors,  cysts,  agenwes, 
scleroses);  in  afTwtiiins  iu\o]ving  the  su|M'rior  cerebellar  peiiunclcs — 
from  bulbar  and  pontine  iuvolveiuents  nf  these  patLs,  and  also  from 
implication  of  the  cerel>eIlorubral,  cerelwllothalamie,  ami  fronto- 
cerebellar  paths.  Typical  crrt'bcllar  ataNias  arc  thus  seen  in  some 
frontal   tumors,  with  classical   int<ixi*!ition   gait. 

>  Stowiul  and  Ilolmvo:  Brutu,  l(KM. 


''K^T^ 


FtD.  20(1. — rcrch«liMrKnitntlitiidf. 
(Tliouis».) 


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SYMPTOMS 

as  In  walklti);.  Visual  aid,  or  its  lack,  has  little  or  no  iiiflueriCL*  on  the 
ataxia,  as  tested  liy  the  finger-mwc  test  and  fingei^finger  test,  and  the 
ataxia  b  a  cuiislant  one,  non-inm>a»iii^,  tis  in  an  intention  tremor 
(with  varying  gradati<)iw,  for  certainly  the  intention  tremors  of  mul- 
tiple sclerosis  are  often  due  to  iiiterfereiicc  with  eercbellur  meelianisms). 

Adiadokokuie^is. — Originally  dp»cril>«I  by  Hahinski  aa  character- 
istic of  cerebellar  disease,  this  symptom,  consisting  of  a  disability  in 
the  iH-rfi>rniaiice  of  rapid  movenieiit-'>  involving  the  alternating  actions 
of  agonist  and  antagonist  muscles  (see  Kxanunation).  is  not  invariably 
found  nor  always  clearly  indicative  of  cerebellar  disorder;  \ct  it  is 
so  frequently  found  as  to  merit  special  attention.  It  is  iu  part  a  variant 
of  ataxia  brought  out  by  a  special  test.  Mere  tlie  timing  sense  that 
is  regulated  by  tJie  cerebellum  Is  at  fault.  In  the  absence  of  paralysis 
it  usually  is  indicative  of  cerebellar  path  involvement.  It  is  frcf.|uently 
nbusent  iu  extracerebellur  tumors  in  which  there  are  other  well-niarkctl 
cerelnillar  signs,  as  iii  frontal  tumors. 

J'ertigo. — As  the  cluef  organ  of  orientation  in  space,  severe  disturl>- 
ance  of  certain  of  the  cerebellar  reflex  paths  causes  vertigo,  wliich 
is  apt  to  be  a  prominent  and  a  fairly  constant  sign.  The  vertigo  is 
of  a  mtatorv'  character.  The  patient  may  not  only  feel  himself  revolv- 
ing in  sjMice,  but  objw-ts  may  go  around  from  right  to  left  or  from  left 
to  right;  more  rarely  the  vertigo  lias  an  up  or  down  character.  Kacli 
of  these  two  characters  is  to  be  closely  inquired  into.  Here  the  chief 
IcsioiLs  are  connectetl  with  the  vestibular  patlis,  as  the  labyrititli  is 
the  chief  cephalic  gangli<»n  in  tlie  whole  propritK^eptive  system,  of 
wliich  tlie  cerebellum  constitutes  the  coordinating  center.  Thus 
labyrinthine  di'*ease  itself,  as  well  as  disease  of  its  extracerebellar  or 
intracerebellar  paths  may  give  rise  to  the  s.xTnplom.  Hy  means  of 
the  specific  tests  devised  by  Uarany  I  see  chapter  on  Kxaminatinn)  a 
separation  of  luhyrinthitie  tliseases  of  extracerebellar  origin  is  usually 
possible. 

Furtlier.  enough  expi-rientr  lias  awumulati'd  (Stewart  and  lluluu's. 
htc.  cif.)  to  show  tlint.  In  genend.  objects  rotate  from  the  disea.sed  to 
tlie  well  side  for  intracereliellar  as  well  as  extracerebellar  a(Tectiun.s, 
whereas  the  siibje<'tive  sense  of  rotation  is  usually  from  the  diseiused 
to  the  well  side  in  intracerebellar  involvement,  and  the  reverse  in 
Lextniivn*l)ellar  involvement  of  the  paths.  This  generalization,  ii 
Flittle  too  hnwd,  is  in  neeil  of  further  stvidy,  am)  of  more  accurate 
Iot*al!  nation. 

Xtfstaguitig.  ,\  fourtli  sign,  rarely  absent  in  cerebellar  path  ilis- 
tiu"bancc,  is  ti%'stagiiius.  It  is  also  closely  relatwl  t**  the  vestibular 
rellex  system.  an<i  may  result  from  extracerebellar  involvement  a.s 
well  as  from  intracerebellar  implication  of  the  i>atlis. 

True  vestibular  nystagmus  is  almost  invariably  a(x-ompaiue<l  by 

vestihiilar  vertigo  and  ataxia.    Vestibular  n>'stagmus  itself  is  usually 

modified  by  the  pttsiliou  of  the  head,  hence  every  (terstKi  with  uys- 

tuguuis  niu»t  be  examined  with  the  head  iu  three  pUiies;  a  patient 

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CEHEBBLLAR  SYNDHOSfES 


w'itli  vestibular  nystag^nus  tends  to  rotate  witiiin  the  plane  of 
nystagnius,  and  iii  tlie  direction  opposite  to  that  of  tlie  quick  iiystugiui 
movcnitnt. 

A  patient  with  vestibular  n>'sta(fmu8  then,  who  bends  liis  liead  foi 
ward  at  5J0  degrees  will  rotate  in  a  direction  directly  opposite  if  he  bei 
his  hoad  backward  flO  decrees.    The  laws  of  intracerebellar  nystajjinius,' 
apart  fnuii  aitiia!  vestibulHr  disease,  ivtnain  to  be  invt*stij,Tit«l  ((thi- 
Jiiyate  di.'viations,  skew  deviiiti'ins.  and  i>tlirr  eye  disiplacemcnts  ore 
to  be  iiiterpreteil  in  the  light  of  forced  rini\'<nu'riis  hnrint:  tln'Ir  mml- 


Fiu.  2d3. — Aeyiivntin  <'(  KiibiiiAki  ili-vi'l- 
(>)M>d  on  Mtoinpting  in  t«ke  hold  of  a  kIiui«. 
The  fiuscn  ore  lidd  v«ry  fur  opoo.  (Tliutuiu.) 


i'lo.  2M.— Asyoccflm  of  Babinski. 
(Sehaller.] 


ojries  to  n>-stapnus,  and  are  considered  in  the  chapter  on  Alidbratn 
Disease.     See  illustrations  of  rtmjugate  palsies;  also  b  chapter  on_ 
the  Kye  l*aths.   See  plate  of  (x-ulnnrtarv  and  cephiilorntar\'  mei'haiusnisA 
(Plate  VII).  ■ 

Closely  associated  with  disorder  of  the  vestibular  system  are  pain 
in  the  nmseles  nf  the  neck,  nausea,  vomitin^c.  amblyopias,  and  loss  nil 
consciousness.  ■ 

Cerebellar  Uypoionm. — Palpation  of  the  muscles,  testing  of  reais- 
toncc  movements,  and  looseness  in  the  performance  of  passive  movi 


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meiits,  reveal  a  type  of  muscular  hypotonus  iii  cerebellar  alFw-tions 
which  is  usually  homolateral.  Tlus  hypt)tonia.  or  atonia,  is  usually 
accoinpanipd  by  nonnal  or  even  exajiKt^mtetl  tendon  reflexes  in  con- 
tract to  that  of  peripheral  neuritis  or  tabes.  One  feature  of  this 
hypotonus  noted  by  Stewart  and  liolmes  is  striking.  If  a  resistance  to 
a  (iofiiiite  moveiTient  be  suddenly  relaxed,  iii  tlie  normal  flexing  of  the 
arm.  for  instance,  there  is  a  sudden  flexor-jerk,  followed  by  an  extensor 
rec-oil.  In  a  cerebellar  hy|Hitonic  reni-tion  tiie  flexor-jerk  ts  excessive, 
and  is  rare]\  followed  by  a  recoil. 

Aittheniii. — A  paresis  or  asthenia,  usually  homolateral,  is  closely 
related  to  cerebellar  hypotonus.  Its  presence  in  cerebellar  disorder 
has  usually  l>een  interpreted  as  due  to  a  lesion  of  the  pyramidal  tracts 
by  continuity;  unquestionably,  however,  it  is  a  true  cerebellar  symp- 
tom. It  is  chiefly  present  when  tlie  corebello-vestibulo-spinal  and 
rubroitpinal  tracts  are  affected.  Since  the  rubrospinal  trac-t  is  to  be 
interpreted  as  an  auxiliary  to  the  pyramidal  tract,  the  different  opinions 
nf  various  authors  may  find  a  common  adjustment. 

Vrrfhrilnr  Aarjnergia. — Deseril^eid  by  liabinski'  as  a  sj>ecial  sympttmi 
nf  cerebellar  disease,  this  s^Tnptom  is  in  reality  one  of  the  components 
of  cerebellar  ataxia,  but  in  the  anteroposterior  plane,  rather  than  Ju 
the  lateral  planes.  It  consists  in  the  |>atieut's  inability  to  Ijidance 
himself,  whereby  lus  legs  either  walk  away  from  under  him,  or  he 
pitches  forwani  without  their  following.  It  is  a  severe  grade  of  retro- 
pulsion  and  propulsion,  us  seen  hi  parnl>'sis  agitans,  and  due  in  both 
instances  to  sucilar  pathological  foundations. 

Cerebrltar  fits—  Originally  described  by  Jackson'  as  tetanus-like 
ctinvulsive  seizures,  with  characteristic  holding  of  the  body  in  extended 
rigid  position. 

Forced  Motrmrnts. — These  are  present  in  the  neck  muscles,  muscles 
of  the  eyes,  and  np|>car  as  irritative  or  as  defetl  symptoms,  due  to 
disease  of  the  hcniisjilieres  or  of  the  middle  cerebellar  iH*duncle.  (See 
Diseases  of  Midbrjtin.) 

Sprrch  Disiurfiajtcff. — Dysarthrias  usually  indicate  the  same  type  of 
ataxia  as  fomtd  in  other  muscles  of  the  body,  adiadokokinesis.  Thej* 
are  usually  present  with  defet't-s  of  the  cerebellum,  and  may  indicate 
general  defect  of  tlic  entire  apimratus,  disease  of  the  bulboeerebellar 
tri\ft>  or  pressure  upon  the  bulbar  nuclei  from  contiguous  new  growths. 

Chief  Ssmdromes.-  In  discussing  disorders  of  the  cerehetlum  it  is 
convenient  to  take  up  first  aiTections  of  the  peduncles,  although  very 
rare,  then  of  the  cerebellum  itself,  and  finally  diseases  of  extracere- 
bellar  location,  which  latter  occupying  the  posterior  f(»Ksa  implicate  the 
ceri'hellar  niM-luinisnis,  and  th*isc  of  its  ti>ntiguous  structures,  the  pons, 
mcilulta,  and  fourth  ventricle. 

Inferior  Cerebellar  Peduncle— Corpus  Reatifornie.^ Isolated  disease  of 
this  structure  is  rare.    Pressure  <lue  to  bulbar  and  pontine  disease  b 

■  Rpv.  Mea».  Inl.,  Ma>.  IKUU. 

*  Brittfili  Med.  Joui..  Novraibirr  4.  1917;  Rcpiinl,  Binin,  1000.  p.  43A. 


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not  um'ominon.  The  most  characteristic  s\i«ptonis  are  moclifioatim 
of  the  eye  movemont-s.  cnnvtTjjcnt  and  divergent  strflbismus.  even 
skew  de\nation,  forced  p^isitions,  tnniiiifi  of  hmly  t<)WHnl  the  site  of 
lesion,  ftiid  vertigo,  with  tendency  to  fall  in  the  (lirection  of  the  side 
of  the  Ic^iioii.  The  chief  mechanism  invoKitl  is  the  trrelK'Ho-vestibuIo- 
Spinal  tract.'     (Si-i-  MIdhrarn  I.esidns.) 

Lesions  of  the  Middle  Cerebellar  Peduncle. — l^cse  cause  rolliug  move- 
ments of  the  biCMly  on  Its  vertical  iixis,  skew  deviation  nf  the  eyes. 
Magendie-Hcrtwifi  syndrome  consisting  in  one  eye  being  higher  than 
its  mate.  The  patients  !>ehave  as  though  they  hail  bilateral  vestibular 
diwHM",  enuring  llie  rnlling  matioiis;  the  eye  syniptntiis  deix-ml  on 
lesiims  of  the  fii.seieiihis  antenmiHrgiiialis.  fillers  to  the  [nwterior  longi- 
tudiiiat  Iniinile,  and   interference  with  the  fibers  to  the  abtiuceiis 

lUK'IcitS. 

There  are  few  uncomplicated  cases  ou  rccctrd.  Poutine  lesions 
often  give  rise  to  symptoms  from  implication  of  the  middle  peHiinrle. 
(See  Midlirain  Sv-ndromcs.)  ' 

Lesions  of  the  Superior  Cerebellar  Peduncles. — Isolated  lesions  of  these 
|«'iiiiiicle.s  arc  rare.  The  symptoms  are  usually  choreic,  t»r  paralynis 
agitiins-liko  tremors  on  the  same  side  <»f  the  lesiiin — pi)ssibly  due  to 
implicatiiHi  of  the  cerehellri-ruiiro-spinal  bundle  in  (he  traetiis  i-erehello- 
tognu'iiti.  Koreeii  posltiinis  of  the  IicjhI  to  the  side  of  the  lesiim  have 
been  descril)cd.  Ocular  implications  rarely  occur,  althougli  nystagmus 
lia.s  been  ohserved.     (Sec  IVIidbrain  Lesions.) 

Lesions  of  Cerebellam  Itself. — The  most  important  of  the^e  are  age- 
neses  nr  aplasias,  scleroses  or  atrophies,  hemorrhage,  softening,  infiam- 
mution,  abseesses,  Hiid  tumors. 

Aplasias  of  CercbeUum. — Tliese  are  iHWi^iiilal,  and  represent  a 
vast  array  of  dilTcreiit  conditions;  total  lack  of  irerebelhim,  alwence 
of  the  lateral  (in  old  sense)  hihes,  absence  of  vermis,  unilateral  loss, 
irregular  <lefects,  and  general  congenital  smnllness  of  the  cerehellura 
and  cerebrum.  A  consistent  syni])tonjat()logical  grouping  is  not  yet 
possible.  Mingazziiii'  has  attempte<l  it.  With  the  newer  studies  in 
localization  by  Horsley.  Uolk,  and  others  the  entire  study  of  cerebellar 
reprcsentntinn  will  see  marketl  advance  in  the  near  future. 

Minga/zini's  groujiing  of  the  ennditions  is  as  follows: 

1.  Pure  unilateral  agi-neses  and  atntphics. 

2.  Pure  bilateral  agencses  and  atrophies. 

3.  ("erebeliar  atrophies  associate<I  with 

(a)  Disease  of  tlic  cercbnuu. 

(b)  Disease  t>f  the  spinal  cord. 
1.  UnihiU-rnl  loss  of  a  lateral  tin  old  sense)  lobe  may  be  present 

without  an.\"  s.\Tiiptoms  according  to  present  devrfoped  modes  of 
testing.    Few  of  these  ca.ses  liave  been  tested  by  more  recent  metJiods. 

■Adlor:  Ilic  8yn)|ju>iiuiU'li>'Kic  dor   KlciiihiraorknuikunitDD.    WiaabatUni,    ItHK).   luu 
■  Mooatachr.  (.  Neur.  u.  Paych..  1W6,  i.viii.  76. 


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?'io.  295, — Middlo  pnriliav  nyiidromo.  I^emoii  uf  the  ■■U-r&I  p»n  o1  ihv  left  pontio* 
Mgmentuni,  involt-in^  the  nuclei  of  the  trigirtuiakL!!.  ihe  croHacd  sevondar}'  mnttory 
pntha  <if  the  loKiKi^rttiini.  {.iitrl ially  involvinK  llic  mipcnor  ncfi-hcll.ir  pcHunHc  il*e$} 
mt«i  the  itiedini)  li'iuuiAi.'u.i  {lim),  aud  taut  iiivolvuuc  ttie  uutviiut  portiou  uf  ihe  puos. 

On  ihn  riichl  ihvn  U  hemUriMtJioaia  of  the  piircniiUni  of  ttu  syiinicumydic  typo, 
ubovo  n]l  fur  ptiiii  acid  teiupentura  Moae. 

Od  tho  left  Uipnj  M  poralysu  of  the  miurlm  of  mMtivatMin  (pterj'Buid.  niiuwieUT, 
temponJ)  by  Ictioii  of  the  motor  nud«u«  of  tlio  Uigvmitiiu.  There  is  Alight  anoatheaiA 
iu  tho  iriKttininuj)  reitiuo  (wtiBury  nijc]>eua  V)  and  rhureu-ntbolotd  muvoniciilji  uf  ibiT 
uxlremilici  from  invo[v<.'m«ttit  of  th*  miperlor  *ercbel1ftr  pediinele.     (Dejwitjej 


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affw.'twl  hemisphere  is  jitniphie;  if  the  atrophy  involves  a  part  of  the 
vermis,  slight  motor  sigus.  swh  as  slowing  af  the  gait,  have  been 
ubservetl. 

2.  I'urr  HUntfrid  Atjt'nrsh. — Iti  wime  tif  tin*  fast's  rfjKjrUi!  iu»  sl.^Ilp- 
toms  have  lieeii  (iliserved  {old  cases).  The  commonest  symptoms  are 
diffirulty  in  staiiditig  ami  walking.  Tlie  patient,  in  high  gra<les  of 
atrophy  or  aplasia,  is  unable  to  stand,  or  sometimes  even  to  sit;  in 
the  niil(!(T  ffraties  the  station  is  wobbly,  the  feet  pliiceiJ  far  apart,  and 
walking  is  possible  only  with  assistance.  The  gait  is  then  the  classical 
drunken  stagger.  There  is  marked  asynergia  of  the  trunk  and  lower 
extremities.  Tremors,  ataxias,  inciHinlinatiun  (asynergias)  of  the 
upper  extremiti(*s  are  also  present.  Hyp<jtonus,  muscular  weakness, 
slow,  irregular,  hesitating  or  explosive  speech  are  also  present.  X,\-s- 
tagmus  may  or  may  not  \)v  prt-seut,  there  is  usually  adiudukokinesia. 
the  knee-jerks  are  usually  normal,  or  even  slightly  exaggerated  at 
times,  even  in  the  presence  of  liypotonus.  Bilateral  atrophies  show 
similar  sjTnptnms. 

It  is  evident  that  untit  the  newer  knowledge  regarding  cerebellar 
localization  is  <i«»nlinatitl  with  the  older  arwl  newer  fintlings  the 
studitw  wliieh  have  ap|x^ared  up  to  the  prestiit  time  will  lack 
precision. 

Combined  AjAasitiJi  of  the  Cercbclhnu  and  Brani.— ComlK'ttcs'  (old 
period)  patient,  with  absolute  absence  of  the  cerebellum  had  from  birth 
epileptiform  attacks,  was  able  to  walk  but  fell  often.  Many  of  these 
patients  are  idiotic  and  imbecile,  and  show  shrilar  s>-mptoms  to  those 
enumerated  in  the  previous  ])aragraph, 

Mingaz/.ini  includes  the  olivo-pouto-<¥rehellar  atrophies  here,  but 
tiiesc  tire  discussed  later. 

Holmes'  calls  these  cases  "congenital  smallness  of  the  central  nervous 
s>'stcm,  with  ct-rebcllar  symptoms." 

A  number  of  conditions  may  be  grouped  here.  Some  of  Marie's 
so-called  hereditary  cerebellar  ataxias  are  best  referral  here.  Irreg- 
ular staggering  gait.  Romberg,  disorder  of  si>eerh,  nystagmus,  and 
ataxias  of  limbs  are  the  chief  symptoms.  These  patients  have 
shown  small  cerebellums  with  apparently  intact  tracts  in  cerebellum 
anil  con), 

Ofiw-j)ontn-cerebe}lar  .Uwphi/. — Tliis  t>  pe  was  iles<Tibed  by  Thomas 
and  shows  a  fairly  definite  syndrome.  Anatomically  there  is  atPopliy 
of  tlie  cerebellar  cortex,  of  the  bulbar  olive,  and  of  tlie  gray,  matter 
of  the  pons.  There  is  total  degeneration  of  the  middle  cerebellar 
peduncles,  partial  degeneration  of  the  inferior  cellcbcllar  peduncles, 
and  a  relative  integi'ity  of  the  cerebellar  nuclei.  It  is  not  necessarily 
hereditary,  familial  nor  congenital.  It  comes  on  at  an  advanced  age 
and  progresses  slowly.  Clinically  there  is  great  defect  in  equil'bration 
in  standing  and  walking^runkcn  gait.    Romberg  's  absent.    Some 

•  BraiD.  1907.  p.  MO. 


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CEREBELLAR  SY.WOmJMES 


irrc^utar   intention   trctnor,  usually  iiystagiuiis,   and  also  scanninf; 
speech  is  present. 

CereMlum  and  Cord  Atrophies  or  Aplasiaa.* — Ha^  also  a  motley 
fTTOup  is  nil  rer<»rd.  These  casea  will  van."  pre'itly  ii  pro]X)rtion  to 
the  varyiiin  ileyrw  uf  the  Icsiun  In  the  cerebellum  ftiiii  in  the  <iini. 
MarirV  hrn-d'tiiry  fe-rclR'JInr  atrophies  bclmiK  here.  Some  inithors 
arc  <lis|KJse<l  to  refer  Frieilreieh's  disease  to  this  gniijp  alsu,  and  tn 
Lhiiin  that  between  these  two  disorders  one  finds  every  gradation  frrwii 
tlie  Friodreieh  type,  witli  mostly  eord  and  Httic  cerebellar  change,  to 
Marie's  type,  -Rith  more  cerebellar  and  little  corti  elianpe. 

The  rhief  signs  here-  are  ataxias  of  the  leg,  arm,  facial,  ocular,  heatl, 
laryuReal,  ai\d  pharyngeal  muscles.  Cerebellar  reeling,  no  Koniljerg. 
Later  paUies  and  contractions.  Exaggerated  tendon  phenomena. 
In  most  of  tiiesc  cases  the  disorder  is  predominantly  in  the  cord. 


Fiw.  2ftS. — Hiinr>tr!ioec  of  cMcbollum.     (Larkin.) 

In  otiier  cases  with  degeneration  of  tlie  spinocerebellar  tracts  with 
normal  or  only  small  cercbclhiin  one  finds  patients  with  stagpering 
gait,  scaiuung,  exp!o^ive.  slow  sjicpch,  nystagmoid  jcrkings  of  the 
eyes,  muscular  cramps,  fatigability  of  muscles,  normal  nr  exaggerated 
knee-jerks.  As  mentioned,  Friedreich's  <ltscase  pnjpcrly  belongs  to  tlus 
rubric. 

Primary    Parench/viatoua     IJrgnjeraltfm. — Holmes'    has    deseril 
this  condition.     It  usually  .sets  in  about  middle  age  and  progreases! 
slowly.    Staggering  or  reeling  gait  is  an  i-urly  sjTiiptoni,  then  asynergia 
of  the  upper  extremities,  and  later  hesitating,  scanning,  or  explosive 
articulation.  n>stagmus,  tremor  of  the  head  and   limbs.     Tendon 


■  HmIrim:  Brain.  1W7.  loc  cji...  for  llt«nitiir«. 
'  Hrawn:  Brain.  1803,  xv.  250. 


*  Drain,  IWfT,  p.  460. 


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reflexes  are  nomial  or  slightly  exnggprated.  Nu  doims,  no  babiiiski. 
Spliiiu'ttTs  iiitin-t  and  riuniml  i>syche.  Must  uf  llie  i*ases  linve  shown  a 
fnniilinl  t'hanu'ter. 

fitmorrhage  of  Cerebelium. ^  -VcrcheWar  iK'inorrluige  is  prolwiMy 
extremely  rare.  Its  siTnptomatologj'  nil!  ilepeiul  largely  on  ila  sixe 
and  tlie  liK'atioi)  of  the  effusitHi.  The  superior  cerehellar  arlerj*  is 
ofletiest  iiivolvetl.  thus  imi>licatiii);  i-crTani  jmrlioiis  of  the  dentate 
nuclei.    Kxtensidn  iiit<i  the  fourth  \  i'ntri<'le  Is  to  he  huriie  in  miml. 

The  onset  of  ihe  sj-niptnrns  is  nsnally  sudden,  or  prec-eded  hy  pain 
in  tlie  hack  of  the  head,  with  slifjlit  giddiness,  or  fun-ed  position  of 
the  head.  Tliere  is  usually  marked  vertigo,  reeurring  on  atlenipts 
to  move,  and  usually  fK'r<istinK  in  non-fatal  eases.  ("erobellHr  gait, 
forred  position  of  heatl.  depending  on  location,  nystaginiiB,  e.s]KTialiy 
on  lateral  movements.    Operative  uilerferenee  is  generally  useless. 

Ci/fih  itf  CfTrhplluiii.''~('yst!i  and  eystie  tumors  are  not  alwaj's 
distinguitthable.  Ti>gether  they  fonn  a  small  part  of  limior  formatitms 
m  the  forebelluni  i.3  to  10  per  cent.).  The  >ymptoms"of  (Trehellur 
cysts  are  practically  identical  with  tliose  of  c-erehcllar  tumor,  Init  the 
operative  outlook  is  much  Ix-'tter. 

Cetehf.llar  Tnvwrn}  Before  dlscu.<wing  tlie  subject  of  tumors  of  the 
cerel>e]liim  projier  and  their  s\Tnptomatology  a  word  may  he  suiil 
regarding  the  questibu -of -cerel>ellar.  iucalization.  The  resenrrhcrs  of 
Uolk,  and  others*  in  c^iniparative  Hnali_)my.  and  of  Horslcy-'  Imve 
served  to  make  fairly  certain  that  both  in  the  cortex,  and  in  the 
iutrmsie  nuclei  there  are  definite  localizations,  the  former  witli  refer- 
ence to  seiLsory  representations  from  dili'crcnt  jiortions  of  the  l>ody, 
the  latter  with  reference  to  nuitor  represenfjitions. 

With  reference  to  seiiaory  representation,  studying  practii-ally  only 
the  terminations  of  Gowers'  tract,  Horsley*  concluded  that  there 
twas  no  evidence  of  difTercntiiition  of  the  cerebellar  L-ortex  into  locatized 
rivuig  stations  for  the  Injpres^ions  (nuiseular,  arthritic)  which 
ascend  from  the*  arm,  trunk,  or  leg  muscles,  joints,  etc.,  respectively. 
This  autliur  hoUls  that  the  results  of  tlie  work  of  Bolk  and  others 
did  not  guard  sufficiently  against  lesioiu  of  the  adjacent  nuclei. 

While  this  may  be  true  for  the  distribution  of  Gowers'  tract,  it  is 
not  true  for  the  distribution  of  the  oliviMiTebellar  traH.  Stewm-t  and 
Holmes^  ha^■e  shown  tlmt  fibers  from  certain  i«>rtioiis  uf  the  inferior 
olive  pass  to  definite  regions  in  the  contralateral  cerebellar  cortex. 
The  function  of  these  olivoeerehellar  pntks  is  still  in  question.  As 
to  definite  localization  for  other  receptor  patks  ichenueal,  etc.),  exact 
knowledge  is  absolutely  wanting  at  the  i)rcsent  time. 

So  far  as  localization  of  motor  functions  in  the  nuclei  is  concerned, 
this  seems  to  liave  receivefl  definite  confirmation  by  the  work  of 
Horsley  {loc.  eit.). 

'  Starr:  Medicnl  Record.  M&y  2.  1609. 

>  WillisnvLm:  Kcvibw  uI  Nvurolosy  ood  I'kychialjy,  March.  lOIO.  for  titcrature. 

*  Htew«n  and  HoIhim:  Brain.  IWH,  xxvii.  522. 

*  8m  Vnn  ttyritwrk.  Kmebaise  d.  fhynol.,  1W7.  *  Rraio.  1008, 

*  IMtl.,  1009.  '  Ilud..  1008. 


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CtUBF  SYSDIiCtMES  63d 

Tlie  cluL-f  f^eiiernl  symptums  (»f  i-en-lM-ll.nr  tmiiors  art-  headiK-lie, 

usually  severe,  nrxnpital  or  frontal,  ami  apt  tti  In-  ■ctniiirefi  to  a  sagittal 
plane;  papilledema  ami  lat*T  ojitir  atrophy,  whii-li  is  rapidly  progres- 


'W 


Flo.  301. — Tumor  of  cerebellum.     (GoodhAM.) 

sive;  voinitiiiK,  verti((o,  and  tendeniess  to  ijercusniuii  over  the  omput. 
Tumors  hi  the  hemispheres,  not  iiivdlviiif;  the  t-eiitral  tniets  or  the 
tntriiisif  iiuck'i,  may  pive  rise  to  no  liK-aliziii}^  sytiiploni^.  But  theie 
LH  usually  an  iinplitiitioii  of  these  contiguous  structures  with  added 
symptoms. 


Ktcj.  303. — "SkfriT  (l(>vjatioir  uflcr  n-iiiuvAl  ul  a  tiurxjr  rruiri  riti*  Ivfl  lateral  l»lie 
f>f  the  rercMliiniT  thr  loft  ey«  in  dirccUfd  tlownwanJ  aiid  iuwin),  ili«  rfjtht  eya  upwnitt 
and  oiHwan),     (tlolriicv  and  ^Iwwarl.) 

These  are  tJie  elassiral  cereWllar  .syudrnmes  of  pait.  and  attitude, 
asjuerpia,  ataxia,  and  adiadokokiuesia  of  the  same  j^ide.  with  hypo- 
tonia of  special  character  already  descrihed,  and  motor  paresis  of  the 
same  side.    To  tliese  are  u-sually  addeil  nystagmus  and  eye  deviations 


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tiltrndy  noted.  Thi-  iivsta^iiuis  is  upt  to  be  pronouratxl  only  on 
ItHikiiig  to  the  uffei-'ted  side,  and  is  4C<uii]l.v  slower  and  eoarser  than  the 
nj-stBpniiis  of  l»t)yriiithiiie  orijrin,  or  of  involvement  of  the  vestibular 
trut'ts.  As  these  latter  are  frec|iifntly  iini>inffwl  upon,  it  is  useless  to 
insist  npon  too  tine  ttislinctioas  in  the  character  of  nj-staginus.  rnless 
tile  pjTamidal  tracts  are  inHueneett  by  pressure,  the  ami  and  leg  tendon 
rcflexe-s  are  not  markedly  exaggerated,  nor  are  they  lost,  uiul  the 
HiiUin-ski,  Oppeidu-iui,  Sehavfer  and  Remak  signs  of  pyraiuiflitl  tract 
ihVuKcnieiit  iire  not  present.  The  aWoniinal  reflexes  are  usually 
umnodified. 

As  the  tumors  increase  in  siae  there  are  added  sjiinptoms  due  to 
eucroadunents  or  pressure  upon  eontiKUoas  stnietures.  These  are 
usually  tJie  sign.**  of  involvement  of  the  pyramidal  tracts,  eye  palsies, 
and  of  the  cranial  nerves — from  thr  fifth  to  the  twelfth.  These  all 
show  on  tlie  opposite  side  of  the  body.  The  two  lower  branehes  of 
the  facial  are  involve],  the  (uuguc  protrudes  to  the  paralyzed  side, 
and  is  witliout  atmphy  or  H.  D,  Oecasionally  the  medulla  is  pressed 
upon  and  one  find>>  all  brunches  of  the  facial  involved,  willi  atrophy  of 
the  tongue.  Homolateral  anesthesia  of  tlie  cornea  may  be  present, 
due  to  trigeminus  involvement.  Homolateral  affections  of  the  ears, 
deafness,  buzzing  and  homolrtteral  pain  to  pressure  on  the  mastoid 
may  aid  in  diiignosis.  I'ercussiori  should  never  be  neglected.  Oppen- 
heim  has  caileil  attention  to  (he  eracked-pot  sound  often  present  in 
cerelH'lhir  tiitnors. 

rrulateriil  signs  arc  apt  to  pass  over  into  bilateral  signs  as  the  pressure 
increases,  with  dysarthria,  dyspluigia,  continued  vomiting,  and  finally 
canliac  and  respiratory-  signs. 

hunibar  puncture  may  give  important  information  in  clearing  up 
a  diagnosis  {tf  meningitis-serosji  or  hydrcx^phalus. 

Crn-beilar  Abecess. — These  nre  relatively  frequent,  and  originate 
mainly  from  middle-ear  infections,  either  by  way  of  the  temporal 
lobes  or  the  mastoid,  and  wounds,  from  trauma,  wliich  hitter  may 
have  occurred  a  long  time  previously.  Occasionally  alwcess  may 
result  from  thrumhi  due  to  abscess  of  the  lungs,  ulcerative  endocar- 
ditis, etc. 

These  alwees.ses  vary  considerably  in  size  from  that  of  a  pea  to  an 
apple,  and  their  development  is  either  acute  or  chronic. 

The  cliarnct eristic  symptoms  are  headache,  usually  occipital,  and 
radiating  into  tlu:  neck  region,  prtHlucing  marked  stiffness  of  the 
neck,  at  times  resembling  the  pain  of  a  cerebruspinal  meningitis. 
General  unrest,  nau-sca,  vomiting,  and  stupor  are  present.  Hji^er- 
themiia  may  !«■  addeii,  but  a  cerebellar  absi-ess  may  ruu  a  course  of 
several  mouths  without  temperature.  Of  special  cerebellar  s.Mnptoms 
ataxia,  njstwgmus  and  rotatory  vertigo  are  characteristic.  This 
vertigt)  is  usually  rendered  worse  and  vomiting  is  induced  by  move- 
ment of  the  body;  hemiparesis  and  hemiasyncrpa  are  usually  present 
on  the  side  of  the  lesion^  but  these  are  not  constant  signs. 


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By  ail  increase  in  the  size  of  tlie  abscess,  s.vmptoms  of  pressure, 
prccis<'Iy  similar  to  those  iin'iitionwl  iintier  Tumor,  may  rlevelop. 
Papilledema,  with  optic  atrophy.  Is  lurt  infrequent  in  lurge  abscesses. 

Hrain  puncture  hy  speeiai  aspiration  nce<l!es  Is  advisable  to  clear 
up  tiie  diagnosis  in  coiiiplicat'tl  cases,  t.umhar  puncture  is  useful  in 
exchiding  menin^tis. 

Associated  Posterior  Tosaa  Compile ationa.^(-Vci//i ft;?  hjhi-s. — These 
may  !«■  pressed  \\\»m  antcnisuperiorly  hy  a  foreign  body  growinj?  upon 
or  within  tiie  superior  lobe  ()f  the  cerebellum.  Hemianojisia  anrimiml- 
hlindness  may  then  occur. 

t'otpoTn  Qundrigeviiiui. — OciiiaT  palsies  of  a  nuclear  character  «Krcur, 
first  on  onv  side,  tlieu  up<iii  the  other.  The  iK-uIumotor  and  abdureiis 
arc  i)flencr  involvcil  than  ibc  trochlear.  Their  Is  less  apt  t"  he  a 
paralysis  of  accommtxlation  or  changes  in  the  pupils,  and  the  loss  of 
conjugate  motion  of  the  eye  is  rarely  found.  Implie-atiriu  of  the  [his- 
terior  corpus,  and  of  the  uuildle  geuiculute  causes  deafness,  usually 
bilateral,  hikI  if  the  lateral  geniculate  be  pressed  upon,  amblyopia, 
ivithout  iiapilledeuiu.    Pineal  tumors  may  cause  the  same  picture. 

Cerehral  PedundfM. — If  these  structures  arc  markedly  inipingtxl 
upon  the  Wehcr-(iubler  symlromc  of  altcniatc  hemiplegia  and  (m-uIo- 
niotor  palsy  may  be  foun<l.  From  milder  irritative  pressures  one 
nbtains  the  Eeneflict  sjTidrome,  oculonnrtor  pal.ny,  with  tremor  of  the 
ifp|aisite  sirle.  If  the  lemniscus  is  imjutired  then'  is  erosscd  anesthesia 
and  ataxia.     (.See  Miilbraln  Syndromes.} 

Pmt*. — Here  one  finds  a  uiiniber  of  syndromes  added  to  the  initial 
cvrebellar  symptoms.  Crossed  hemiplegia  with  facial  pal.sy  iMUlard- 
Guhler)  and  U.  H.  ()eca.sic)rmlly  from  a  inure  anterior  pressure  there 
may  be  homolateral  facial  palsy  without  It.  D. 

Crossed  Ihviipkgia  m:d  Jliditccnx  Pahy. — Both  are  usually  asso- 
ciated with  hypoglossal  involvements.  Conjugate  deviations  to  the 
oppositesideof  the  lesion  arcol)served  in  these  cases  when  the  al^Mluccns 
nucleus  is  involved,  .'^uch  ronjugnte  palsies  speak  more  for  tumors 
within  the  pons  {q.  r.).    (See  Midbrain  Syndromes.) 

(.'rossed  hemiplegia  and  Trigeminus  involvement  are  occasiunnlly 
found,  and  also  altenmte  hemiplegias  with  cijchlearis  symptoms. 
Here  the  hearing  defect  is  due  to  tleslruclion  of  the  intrap(»ntirie 
fibers  of  the  cocldearis;  or  to  prcssun-  mi  the  tulicrculuni  acousticum. 

Twnurs  of  the  Fourth  Vcuincle.  -These  may  be  considered  here 
because  of  the  tvrcbellar  s.Miiptoms  induced.  These  tumors  are  for 
the  most  part  glioma,  sarcoma,  psammmna,  carcinoma.  They  give 
rise  to  symptoms  due  to  pressure  »ni  the  int'<hilla  and  pons  an<i  almost 
always  cause  a  marked  hydrewephalus  with  advancing  »titiM»r  and 
ciHifusion.  Cysticercus  may  also  he  found  here.  Bruns  has  calleil 
attention  to  the  following  features.  Alternating  periodicity  of  heail- 
ache,  naiiM'a,  viiuuting,  vertigo,  changes  in  ]»ulse  and  breatliiiig. 
with  sudden  let  up  of  all  these  syniptoiiis.  The  vertigo  aiul  vomiting 
are  set  up  by  changes  ui  position  of  the  head;  sudden  moveiuent  i^i 


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CEBEBELLAH  HYNDHOMES 


the  heAil  mA>'  cau^e  immediate  unconsciouttneM.    Cerebellar  A1 
irilH  nystapmus  nnd  ocrasionaily  diplopia  are  other  s\gns. 

One  iiiiire  wcinl  may  Ik*  said  alxiut  cerehelhir  tumors  iind  then 
diflgiiiwis.  They  nmy,  in  the  presence  of  few  signs  only,  he  mistaken 
for  afftftions  of  the  frontal  lobes  (frontocerelK-llar  path!>),  pnrietal 
lobe^  (iniplicatii»ns  of  central  sensory  eomponeiita)  and  of  the  opjm 

In  fnmtal  lolte  tuinurs  siHtial  intellipenie  tiefert*  are  usually  found. 
if  c-arefiilly  exuniincd  for  by  llie  methods  of  Ziehen,  Sommer, 


Flu.  SOS'^Tumor  (iteuiofibramal  of  ecrebeUopoiiliuc  ttiucEe.     (Larluit.) 

Kraepelin.  The  tremor  is  apt  to  be  vct>'  fine  and  rapid,  iiemipareai^ 
if  present,  is  crossed,  and  shows  spastic  phenomena;  the  speech  d]fl 
turbance  is  nphemir;  the  conjugate  deviations  are  irritative  and  nor 
paralytic.  Then  unosniiii,  apraxia,  witzclsucht  anil  aphasia  arv  often 
added.  Skew  deviations,  and  hypotnnus  arc  not  knonTi  for  frontftl 
tumors. 

I'arietal  lobe  disease  only  occasionally  offers  difficulties,  while 
chanR-teristic  sensory  disturbances  and  central  pains  of  optic  thalat 
involvement  should  exclude  this  structure. 


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CrrdirihinmiiTu-  Att^le  Tumors} — These  should  Ix*  (Hwiisst-d  here 
betause  of  the  a\inptomH  of  cerebellar  pressure  and  of  vestibular 
involvement.  Two  main  types  of  tumor  come  under  review.  Those 
from  the  pia  of  the  cerebellum,  and  those  growing  on  or  about  the 
eighth  nerve.  Fibromata,  myomata,  and  sarcomata  are  the  most 
frequent. 

These  tumors  press  upon  the  pons  and  middle  cerebellar  peduncle 
and  the  symptoms  var>'  slightly,  according  to  the  variations  in  pressure 
oil  these  Two  structures.  The  eighth  nerve  Ls  usually  involveil  ciirfy; 
buzzing  and  deafness  are  observed.  Facial  palsy  is  usual  with 
corneal  anesthesia  fmm  pressure  on  the  fifth;  trigeminal  jMiiiis  are 
frequent.  Ptosis  may  appear.  I'ressurc  on  the  cereljelluin  causes 
the  typical  gait  and  the  ataxia,  homolateral  paresis,  and  hypotonus. 
A  contralateral  pjiresis  frtim  pressure  on  the  pyramidal  tracts  usually 
develops.  This  gives  the  usual  signs  of  a  pyramidal  tract  involvement. 
Homolateral  static  tremor  is  frequent,  also  a  sense  of  subjective  rotation 
towani  the  side  of  llie  lesion. 

Treatment  of  CerebeUar  t'oTH/((ion5.— Gummata  must  be  attacked  by 
the  usual  antisyphihtic  treatment,  othcnvi.sc  surgcrj'  offers  the  only 
i»pix<rtuuity,  and  this  Is  limited  to  the  attack  upon  cysts  which  may 
give  fortunate  results.  The  results  of  operations  for  abscess  are  im- 
proving, as  are  also  those  for  tumors.  But  as  each  case  is  a  law 
unto  itself,  it  is  futile  to  generalise. 

'  Hwwhcn,  F.:  IVhisr  GpjtchwQUiui  derlunWron  KchitdnlKriibff  im  lipsMind^ivrfM  Kl<>in- 
htmbmckcnwinkels.  lUtl.  for  full  ]it«ratun>  to  dalo:  uLm  Kiislifili  litoraluK-.  FTscitkei 
Jtnd  Hunt  MrHirat  R«Mtrd,  IQWi,  and  MonHenl  St^vni,  IWM;  Stownrt  and  Ilnlmtts: 
Brniu.  IttO-l:  Wvioeulwrs.  Jour.  Am.  Mv<cl.  Awn..  1008;  SUrr:  Jour.  N«rv.  nad  Mnit. 
Dw.,  1910;  LowimtlowHky :  Hnmllnn-h  dcr  Nwiiml'iKM'. 


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CHAPTKil  X 


DlStL-^SKS  OF  TIIK  MKMNGKS. 

IIkkf.  <IIsi'n.stti  of  the  rlura.  the  urfiehnoul.  tiiul  the  pia  are 
refo(;iuz*xi.  rmler  tlie  first  various  types  of  mciiinp-al  hcniorrliaifC 
and  itiflaiiinmtioii  iHieliymeniiiditis  -  are  found.  I'ikUt  the  latter 
various  forms  of  Icptonicmnpitis  and  eerebrospiiial  meningitis. 


DURAL  DISEASE. 


J 

•I 

lint 

4 

icn 


1 .    Meninge&l    Apoplexy      ( Traumalir.     yfen'mgeal     Urmorrhagf. 
Fractun   nj  thr  ShiH}.-  Etiology. — 'rmunia  from  blows,  intstnimeti 
vii>lence  of  various  kinds,  causes  t'itlier  a  rupture  of  the  branehes  of  t 
niiddlr  nH'iiIuKcnl  artery,  the  veins,  nr  of  the  rcrehral  Minuses.    .Sut 
lieniorrliuges  luiiy  l>c  found  at  the  site  of  the  injury,  or  at  the  point 
opposite.' 

The  lieinorrliage  umy  be  extruiiural.  between  tlir  pia  and  du 
epidural,  or  between  the  pia  and  cortex,  arachnoidal  hemorrhai 
The  blii'i>tlinj;  may  be  diffuse  or  eireunis<Tiheci.  At  childbirth  sncl 
lienmrrluiges  with  partiitl  destruction  of  tlif  brain  sul>stanee  it.scif 
are  extremely  fpetpient.  Here  the  bleeding  is  almost  always  excliwively 
venous. 

Pathology--  M'leroscopieally    such    heuiorrhii^ces   resemble   hemor- 
rhagic pachymeningitis,  but  mienweopieally  they  differ,  especially 
the  abscHi-e  of  new  elements— vesseb,  plasma  cells,  etc. 

Not  infrequently  in  severe  fractures  the  brain  substance  is  a 
invtib'ed. 

Symptoms. — These  will  vary  according  to  the  severity  of  the  cAusiiii; 
Icsiim,  the  amoimt  of  blo<Hl  thrown  out,  and  the  site  and  extent  oF 
(hcbjcc^lijiy.  In  se^e^e  injuries  there  are  signs  of  shock  and  nmcussidti 
in  addition  to  the  symptoms  of  pressure.  I'nctuisciousness  becomes 
increasingly  deeper,  the  pulse  is  slow  iu  the  beginnuig,  then  hastetLs, 
vomiting  takes  place,  urination  and  defecation  arc  involuntary', 
irregular  respiration,  with  increasing  temperature,  and  death  6fteti 
results  unless  operation  relieves  the  prej^sure. 

In  less  severe  lesions  the  initial  symptoms  of  concussion  witli  varjffl 
ing  grades  uf  xtupor  partially  clear  up  for  an  hour  or  more,  eve^ 
twenty-four,  ur  a  few  days.*    Then  c^nnprt-ssion  symptoms  develop, 
with  signs  of  excitement.     Irrituliun  and  paralytic  signs  appear. 

•  A.  Mfcyor:  Zonllil.  f.Oyn..  ISIfi.  No.-l«. 

■  Coniiwll:  Ftw  lau^n-kl  iu  UeiuDgfial  HcnuinlMCM,  BunC-  Gyn.  and  OfasUI.,  Mueb. 
IBM. 


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515 


There  may  be  spasms,  epileptifurrn  i'(jn\nilsi«ns.  often  of  Janksonian 
type,  ninnnplej.'ijts,  IieinipIeKias,  the  arm  often  sufferliin  tlic  worst. 
The  heiiiiplciiiii  is  usually  on  tlie  side  tipposite  to  the  site  of  injury, 
but  in  about  5  per  cent,  of  the  cases  is  found  on  the  side  of  the  lesion 
(uncrossed  p>Tarai<ls  or  <-ontra  ronpi.  Aphjisias  are  not  infnfpient  in 
left-siHed  injuries.  'l*he  tendtHi  reflexe.s  are  asiuilly  increased  on  the 
paretic  sltle,  while  the  skin  reHexes  are  nsually  diniinishiHl.  The 
Itahinskl  [ihenoineaon  is  frequent  on  the  [Miralyzed  side,  iiiid  iM-i.Tision- 
ally  present  on  tlie  side  of  the  hematoma.  Oeeasionnlly  hemianesthesia 
and  hemianopsia  can  l>e  made  out. 

Bleeding  at  tlie  base  may  show  involvement  of  the  cranial  nerves; 
occasionally  choked  disk  is  present. 


FlH.  804. — P(N-arM<hiu>{cl  hi-mrtrrhaup  fr«nt  (■•)iitr»  i-oiiji.     (t^rkiii.) 

'llie  pnpilK  vary  flatly.  Wiesnuiim  has  shown  in  70  ea.ses,  tliat  in 
3!)  iNith  ptijiils  were  ililatfil  and  iumidhile.  in  20  there  was  dilatation 
on  the  side  of  tlie  hentorrlmne.  in  7  lnnh  pupils  were  small,  and  in  4 
there  was  ililatation  on  the  siile  opjM^site  llie  lesion. 

In  birth  lieniorrhatfes,  Seitz  ha.*^  shown  tint  subtentorial  lieuior- 
rhani"?-  lleha^■c  (litl'crcntly  fnfln  convexit>'  lienu»n'!iage.s.  In  the  fonner 
the  children  l'riH|iit*iitly  >how  no  sign  of  asphyxia,  then  after  a  few 
hours  respirjitnr.N'  disl  urbances  set  in,  the  breathing  het-onies  irregularly 
quickened,  with  s|MisinK  and  cyiiiiusiH.  Then  s|>asms  of  the  eyeballs 
ueeur,  h-ss  ofleti  faeial  spasms.  If  the  pressure  Is  directed  downward 
tnwan!  the  medulla,  opisthotonos  ami  nniscuhir  rigidity  develop,  and 
not  inf  reel  lien  tly  prinpisni. 


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DISEASES  OF  TIIK  MENINOBS 


In  convexity  Iiemorrhaj;cs  the  child  shows  coiisiderahle  restlessness, 
refuses  to  svii'klf,'aii»l  thfii  develojjs  signs  of  brain-pressure,  pressure 
in  the  foutauelles,  respiratorj'  disturbance,^,  drowsiness  to  uncoiwcious- 
nftss,  with  some  slowing  of  the  pulse.  Localizing  symptoms  may  then 
show  themselves,  spasms  of  the  opposite  arm  and  leg,  increase*!  tendoD 
reflexes,  and  sli^;ht  hypertoims. 

In  children  tlie  hitc  results  bring  alwut  various  Hymln»raes.  \\"hen 
the  hemorrhaitt?  and  destruction  tRX-upies  the  motor  areas  alune,  the 
t>'pe  of  Little's  disease  is  present.  Slight  variations  In  l<K*alization  of 
the  hemorrhage  and  destruction  bring  abunt  varijuit  furins  of  Little's 


Fi<-    3i'.3,     Truuiiiutii' HupnultiRil  hcniorrhuci*.     (Lnrkin.) 

disease  with  sensory  nivolvement.  Cerebellar  localizations  bring  about 
HMoniiilons  (rrclM-IIar  diplegic  t>'pes.'  According  to  localization  of 
hemorrhage,  llien  tin-  following  wrebral  types  of  birth  p'llsy  may  be 
distinguit^hcd: 

1.  Atonic  ty|)es  witl)  mental  defect— frontal  lobe, 

2.  Spastic  t.x-pes— Little's  disease,  motor  area. 

3.  Sensory  ty|)cs-spcech  defects,  posterior  central. 
•    4.  I'sendiibidbar  palsies. 

5.  CcreliellHr  diplegic  tyi>es  (Batten,  Clark,  L.  P.). 

t  Cl»rk,  Ih  P.:    Journal  of  Nervciw  ftMl    MtnlMl  Dii>e«M.  lUIS;  Trano««tioiia 
Nciir.  8oo„  1010:  Hunt,  J.  R.^  Lcc.  dl.;  DsUvn:  Brniii,  1913. 


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DURAL  DISEASB 

Diifnosis.^Tt  is  extremely  difficult  to  determine  whether  one  lias 
to  deal  solely  with  a  pure  menin|i;cnt  apoplexy,  or  whether  there  is 
also  intracerebral  disturbance.  If  there  is  a  definite  free  iiiten-al  after 
the  initial  signs  of  conc-usstun,  with  the  gradual  or  sudden  onset  of 
wimpression  signs,  the  probabilities  are  for  heraatonia  (SO  per  cent.). 
ITie  length  f»f  free  interval  offers  no  certain  criterion  as  tft  site  of 
hemnrrlmjiP,  Choked  disk,  iiften  transitory,  also  speaks  for  hematoma. 
BIikmIv  ;ipiiial  fluid,  wlurh  dues  not  clot,  sjjcwks  for  intradural  licmrtr- 
jrhage,  occasionally  eslnidural.  Neisser's  hraui  puncture  and  liindmr 
[procedures  often  help  in  dcariiifc  up  a  diagnosis.  Long  intervals 
speak  for  abscess. 

Therapy. — This  is  surpcitl  and  sluuiltl  be  immediate.  The  exact 
prnrpiliire  must  be  dctermineil  britcly  by  the  .sv-mptoms.  Even  the 
iiitnicnmiid  hciniirrhHj,^'s  of  cbilrlbirth  tna\  he  controlled  by  skilled 
surgical  meaNures.  The  results  of  surgituil  interference  are  tliree  times 
us  g<-HKl  as  leaving  the  patients  aloite. 

Tmuniiitic  lute  apoplexy  b*  a  special  variety  in  which  degenerative 
prucesses  complicate  the  picture.  The  patients  may  develop  tlic 
signs  of  liemorrluige,  usually  intracranial,  even  montlts  after  the 
injur>\  Such  cases  are  to  be  diagnose*!  with  much  caution.  Senility, 
pronoimred  arteriosclerosis,  and  s.^'philis  should  be  e-icciuded.' 

2.  Inflamniation  of  Dura  {Pnchymetiingitia). — (,^}  Pachyroenuagitis 
Externa. —  Folluwlng  severe  traunia,  purulent  priw-es-ses  of  the  frontal 
sinuses,  the  middle  car,  mastoid,  erysipelas,  caries,  or  ostconiyciitis. 
one  occasionally  ttljserves  an  iiiftainmaliun  of  tlie  external  surface  of 
the  dura  of  the  cerebrum.  It  is  usually  localized.  A  ifimilar  process 
may  be  present  in  the  spinal  dura. 

Symptom,^. — These  are  usually  hidden  in  those  of  the  causative 
lesion  and  varj'  with  the  acuteness  and  extent  of  the  process.  I.ocalizeil 
cerebral  or  sjiiiud  ]min.s,  muscular  twitching,  sjui^mi^,  markc<l  .scalp 
tenderness  to  percassion,  and  slight  rise  in  tempcralnre  arc  the  chief 
signs,  At  timi.*H  symptoms  of  Walized  pressure  of  the  cerebrum  or  of 
the  cord,  rescndiling  tumor,  are  ofjserved. 

Trmtmtnt.—'VUe  treatment  is  that  uf  the  causative  factors. 

(li)  Pachymeninritifl  Interna  Simplex. ~ This  may  com^ist  of  a 
kK-ali/ctl  or  circimis^-ribed  punilent  exudate,  giving  in  the  main  the 
s\*mptoms  of  a  brain  abscess  or  a  brain  tumor.  In  rare  instances 
(pneumonia,  etc.),  a  sec-ondary  pseud  onu-in  bra  nous  prwluctive  iiiihuii- 
miLtion  occurs. 

(C)  Pachymeningitis  Inleraa  Hemorrhagica. — Tins  ransists  of  a 
chronic  inflammation  in  tlic  internal  layers  of  the  dura,  associated 
with  extnivasution  of  blood.  It  is  by  no  means  infre(|uent^  and  gives 
ris«  to  chronic  [wychoses  of  an  ill-defined  type. 

UiMory. — Morgagni  noted  the  affection  in  the  eighteenth  century. 
Baillarger'  followed  the  older  autliors  in  assuming  it  to  be  a  primary 

>  S^aflclninnn:   IVtil.  nii»(l.  Wrhtuirhr.,  190.1;  Altro:  Jour.  N>rv.  und  .M^nl.  Dia.,  IIHI9. 
*  1) lurk  bum .  (iovemnipnt  Ilofpilal  Katapsy  R«part&. 


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urna- 
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hemurrhitjj;e,  witli  ih*w  meml imiie  tissue  formatioi].  Ilcsi-bl  niul  Vir- 
chow'  iirst  [Hiiiiteil  out  the  inflammatory  imture  nf  the  |)rf»c]uc-ti\T 
infiamniatinn.  and  tlic  consequent  hemorrhage  due  to  the  rich  forma- 
tion of  new  bloodvessels.  Jorea  and  modern  autliiirs  supjiort  th« 
views. 

Orcurrfuce,    I^athnkfjy.—VamiWy    a    disorder    of   advanced    y< 
liemorrhafjic  parhxTneiiinnitis  may  lie  found  tti  children.' 

It  is  extremely  frequent  in  general  paresis,  and  HIaekbum 
found  it  tn  cause  chixuiic  excited  and  chronic  depressed  states  i^T 
patients  rmuiiuj;  n  course  reseinbltng  senile  dementia.  It  is  fre- 
quently un  alcoholic  complication.  It  is  seen  in  some  chronic  choreic 
affections.  Tuberculosis,  nephritis,  leukemia,  scorbutus,  Harlow's 
disease,  and  hemophilia  have  seemed  to  stan<i  in  causal  relations  ta 
some  instant^s. 

In  the  initial  stages  a  pnKluctive  inflanmiatiori  causes  the  formatM 
of  a  thin,  delicate,  yeIle»wish-brown  membrane  on  the  inner  surfa 
of  the  dura.  The  base  is  ranly  ufTeeted,  the  tempomi  regions  mi 
often.  New  bloixlvessels  foi-ni,  wliose  walls  pve  way,  giving  rise  to 
extniviisjition  of  hloixl.  The  prtx-css  of  new  membrane  fomnition  and 
bleeding  gws  tin  hand  in  hand  until  the  whole  membnme  may  be  one 
or  more  centimeters  tliiek,  eoinpressing  the  brain,  with  which  it  is 
usually  closely  united  by  new  cunnective-ti-isne  formation,  and  new 
bloodvessels,  anil  causing  iitrupiru-s,  dcgeneratioiLs,  softening,  or  scie- 
nces of  the  near-lying  portions  of  the  cortex.'  The  process  may  extenj 
to  the  spinal  cord.  " 

St/mptvms.—'Vhe  disorder  may  be  present  for  years  without  symi>- 
toms.  Tu  paresis  it  may  not  add  any  definite  symptoms  to  the  under- 
lying disorder,  or  it  may  cause  a  numlier  of  couipltcating  pressure 
pictures.  ^Vhen  the  process  has  a4lvanceil  to  a  definite  extent  both 
general  and  local  s,vmi)toms  show  but  are  sn  indefinite  as  to  defy  diag- 
nosis, (inulually  increasing  head  discomfort,  headache,  often  severe, 
some  naiLsea  or  vmniling,  irregular  |jeriods  of  confusion  or  tlistresa 
in  the  head,  with  at  times  mild  <lelirious  excitement,  are  among  tJic 
more  characteristic  earlier  sigius.  M 

With  rapid  extravasations,  acute  pressure  symptoms  may  devclopP 
with  epileptiform  con\^llsions,  hemiparesis,  comatose  states  with  slow 
pulse,  apluLsias,  a-stasia-abasla.  h  is  very  characteristic  that  these 
may  Im^  transitory.  Persistent  nionofilcgias,  with  -Tacksimian  attacks 
involving  irregularly  dbtributeil  muscle  groups  may  Iw  eaH\'  signs. 
Often  persisting  stereotyped  muscle  movements,  chewing,  automatic 
arm,  hand,  or  leg  movements  may  be  the  signs  of  a  local  irritative 
lesion.  ("oiLstantly  putting  the  hands  to  the  head  was  eon.sideretl  sug- 
gestive of  pachjTneningitis  by  Fiirstncr.     It  is  a  fre<iuent  sign  in 


■  Wfinlnirci-r  WrliiinillutiKt^i,  IKfiR,  it.  UH. 

'  O'jppen;  Jahr.   1.   KiaJcrheilk.,    IWIO.  Ixj.  51;   PV«u>ul:  Mnnnl 
190»,  vii. 

>  JorpM  11.  tjiumtil,  ZfcjtWB  DniiriVitn.  xxn. 


t.   KliulcriiKnk 


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ytSSASES  OF  THE   AKACUNOID  AND 


549 


jMircsis.  'riic  vyc  iinis<-Krs  are  riircl\'  iiiv()I\f«l  (r»nijiit;iii»'  <Ir\i{itioiis, 
iiystjif^iuis),  liiid  still  more  nirrly  nut-  finds  iiivnlvcnifiit  i>f  tliu  ci-jiniai 
iKTvc:*  at  the  htan'. 

I'upillitis,  or  cliokcii  ili.sk,  is  ofu-n  pwsnit.  The  [lupils  art*  imt 
itifrftiiiontly  irregular,  otfasionally  myotic  in  the  (.-arly  sta|^,  ililated 
in  iconiji,  anil  at  times  immobile  to  light  and  accommodation.  Argj'll- 
KohtTtsi»n  may  l>e  present  with  or  wilhont  jKwitive  VVasseraiaiin. 
Increased  tendon  reflexes  show  the  presence  of  irritation  of  the  motor 
cortex,  cjomis  and  Hahinski  h<*in(t  occasionally  present,  and  at  times 
comuif;  ami  goin^.  Irregular  hut  iiK-onstuut  temijcrature  clmnges 
are  ofttn  present. 

Cmirxe.-  This  varies  ciiii.siderubl.\ ,  is  usually  chronic,  sliowa  remis- 
sions and  exacerbatioa'*.  At  times  the  patient  recovers  completely; 
again  the  disorder  is  progressive  and  causes  death  after  a  long  psychotic 
pcriiHl  of  irregular  exciteinent  or  deprerwioii. 

Diagnnsia. — It  must  be  separated  as  a  primary  aud  as  a  secondary 
Ijrocess  in  alctphoHsui.  paresis,  eerebn>si)inal  syphilis,  etc.  Brain  tumor, 
lbsce9».  hydrocephalus,  sinus  thrombosis,  leptomeningitis,  ajKJplexy 
are  to  \yc  home  in  min<i.  Traumatic  meningitis  must  be  excluded 
if  nn  ante<"edent  trauma,  even  of  mild  grade,  such  as  falling  from  the 
bed,  in  bath  tub,  hanl  crack  on  the  head  from  rumiing  into  door,  etc., 
should  have  oeciirred. 

Nelsser's  pr(.H.rdurc  of  brain  pmicture  is  often  desirable  in  those 
patients  that  give  signs  of  UraiTi  tumor,  brain  abscess,  etc. 

TkcTayy,—\i\  acute  progressions,  local  bleeding  is  advisable.  Hydn>- 
therapy  with  stimulation  of  eliaiinution  is  useful.  IJrain  puncture  luts 
been  of  service,  also  lumbar  puncture  in  children.  Abstinence  fmni 
alcohol  is  ImiMTative.  Mercury  in  the  |x*sitivp  VVassermann  cases 
is  Indicated.  The  pains  are  often  relieved  by  analgesics,  and  by 
warm  baths. 


DISEASES  OF  THE  ARACHNOID  AND  PU.     LEPTOMENINGITIS. 

1 .  Acnte  Leptomeiiingitides  [Cerehrospinai  Me7} tngiiidcx) .— 11ie 
studies  of  recent  years  have  shown  a  host  of  causes  f<ir  adjte  inflam- 
mation of  the  cerebral  and  spinal  arachnoid  and  pia.  These  vary 
very  widely  as  to  severity — sim)>le  meningism  to  the  gravest  fonns  of 
general  meningeal  involvement — epidemic  cerebrospinal  meningitis, 
epidemic  polio-myelo-cncephaUtis.  general  syphilitic  meningomyelitis, 
etc.  It  becomes  Itnpussiblc  to  present  a  logical  classification  of  these 
disorders,  either  fmm  the  etiological,  pathological,  or  clinical  stan<l- 
'  point.  In  general  only  tlic  more  circumscribed  types  of  meningitis 
will  be  considered  here.' 

'  Recent  moaitempha  are  )>y  .MrbulUe  fNoilinaicel}  uid  Ffiikclittnirg,  HsiKlhiirh  d. 
Neunilone,  ii.  lOWt,  in  UxJt  at  whWi  rnmtilfl<>  tiiMiitffrnphitat  an  lo  li»  fniinil. 


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DISBASES  OF  THE  ^(ENfS'OBS 


Caoses,     Tht^tt-  »«■  iiuiny.     Tniuiini  is  oik'  tif  tin.*  iriost  irii|M)i 
Such  trauma  may  ni-l  cUIiit  thnniKli  ilirtri  inratitiii,  ;lk  l>y  iv>nip(>ui| 
frarlitre,  ur  .stTotulRrily  brinfj  about  a  septic  meninj^tix.   throi 
hemorrhage,  thronibosijt,  aiul  siibse(|Uetit  itifetrtion. 

Traumatic  early  and  late  ineiiingitidtsiapijear.     Many  tubeix-ult 
leptoiiieiiinj.'itwles  anst*  frotn  trauma.    Occasionally  one  meets  w» 
late   purulent   meniiiKitides,   due  to   old   erica psultitcil  abscesses,  ol 
prfijcclilus  (bullets,  splinters,  etc.),  old  fractures  of  lamina  cribrosa. 

Infection  from  suppurative  processes  in  the  netfthborhood  is  ti 
of  the  most  frequent  causes  of  the  ty[)c  of  rii en ingi tides  under  coi 
sideration.  and  c-!iief  nf  tliesc  is  otitic  meningitis.    Suppurative  fititis 
may  lead  to  intra-  or  extracranial  abscess,  siuu-s  phlebitis,  thronilHisis 
direct  infection,   infection  through  laybrinth,  thr»Hi|jh  mastoid. 
Serous  ireniiinitis  may  also  have  an  otitic  origin. 

Nasal  and  frontal  sinus  infectiftn  gives  rise  to  a  small  number 
these  meniiiKitiiles;  ibey  may  be  purulent  ur  seroa'?.    Operations  upon 
the  nose  are  frequently  complicated  by  meningitis. 

Facial  cnr'sipelas  occasionally  in  a  cause;  rarely  facial  furunrulosfiH 

Specific  organisms  give  rise  to  specific  typo-s  of  meningitis.  .Vmon^ 
these  are  measles,  scarlet  fever,  varicella,  typhoid,  <iiphtheria.  The 
ijiHiicnza  bacillus  is  an  extremely  important  organism  in  this  respect, 
often  giving  rise  to  severe  epidemics  of  meningitis.  Malaria,  yellow 
fever,  nntlirax,  leprosy,  actinomycosis,  pneumonia,  whooi>ing-tiough 
each  may  be  the  exciting  factor.  Septic  extension  fn>m  acute  articular 
rheumatism  is  a  factor.  TuWrciilosis  is  a  large  item.  The  cpideniie 
tjpe  due  to  the  D'lplococcus  intraceiluhris  is  one  of  the  most  character- 
istic of  the  types.  Old  absces.s  formations  in  the  lung,  liver,  bladder, 
gonorrhea,  teeth  pockets,  etc.,  all  may  give  rise  to  a  meningitis. 

Occasionally  one  ascribes  certain  meningitides  to  chemical  poisor 
diahetys,  lead,  gout,  are  among  these.  _ 

STmptoms, — These  show  certain  variations  according  to  the  mo<le 
of  infecliou  and  the  type  of  infectuig  agent.    Since  simple  puulcnt^ 
meningitis,  tuberculous  meningitb  (usually  a  mixed  infection)  amfl 
epidemic  cerebrospinal  meningitis  are  the  chief  infections,  the  following 
description  will  apply  to  these  and  no  attempt  will  be  made  to  ci)ver 
the  symptomatology  of  the  entire  group.  J 

//fWflcAr.— This  is  one  of  the  earliest  signs,  and  is  frequent,  ttsuall^ 
increasing  in  Intensity  as  the  disease  prognsvscs.     It  is  mostly  diffuse, 
but  may  first  appear  in  the  occipital  region,  or  in  the  forehead.     Tfad 
slightest  niovement.  percussion,  etc,  increases  it.  V 

Stiftifss  of  iVfcA-.— This  is  a  ^^triking  s\Tnptom  and  develops  early, 
sometimes  preceding  the  headache.  Such  early  stiffness  may  or  may 
not  be  apparent  to  the  patient,  but  comes  out  on  careful  examiimtion, 
an<i  is  not  infrequently  accompanied  by  painful  pressure  points  ovelB 
the  cervical  vcrtebne.  When  well  develoiH-d  the  least  movement  ofl 
the  neck  is  painful  and  the  attitude  of  tlie  patient  on  movement  is 
.striking.     Ill  young  children  it  Is  not  infrequently  al»scnt,  and  i 


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mSEASES  OP  THE 


551 


ill  rhmni(!  cases.  It  is  a  ftirtlM-'r  dm  racier  Utic  ttiat  thjs  NtilTiiuss  and 
painfulness  shows  considerable  variation  even  during  the  twenty-four 
himrs. 

litjlHTF.stliniiti. — ^Tlie  skin,  the  miisclc-i,  ih*:  juiiit-s.  i-aii  luinlly  bear 
tlie  slipiitest  tuuch  or  pressure,  ami  wiwitiveness  U>  light  and  totiuund 
are  early  signs  of  meningeal  irritation.  Occasionally  the  sense  of  .smell 
is  abnormally  acute. 

XatiJtea  atid  romifiTij.— These  arc  common  initial  symptoms  (S(l  per 
cent.).    Oecasioimlly  the  vomiting  persists.     Kurly  vertigo  is  fretiueat. 

MerUal  Sytnpltmia. — These  occur  early,  j»articularly  m  cliildrea.  aiitl 
more  especially  in  luW'reulous  meningitis.  The  patients  become 
peevisli,  tlirow  tlieir  toys  away,  are  capricious,  tlieir  attentinn  varies. 
They  not  infrequently  have  uiild  tlcltrium  early,  especially  at  night, 
or  are  confused.  Very  young  children,  one  to  three  ye^rs,  often  show 
less  mental  involvement.  Older  |>atieiits  are  excite*!,  sleep  iMidly,  are 
restless,  mutter  in  their  sleep,  or  ha\-e  well-markej|  delirium.     I^ter  a 


F)o.  30Q. — T«(&peruturv  nine  shovriiuc  irreKiilarity  and  vriiln  oiiiuniiNui.     (Oiler.) 

semicoma  may  gradually  develop,  with  vurintiniis  In  intensity  from 
slight  confusion  to  a  coufusiil  delirium.  Marked  ups  and  ilowns 
characterize  the  epidemic  fonns.  hut  some  degree  of  confusion  or  coma 
is  more  <ir  hrss  ctmstant. 

Tnnjvmt II re. -'i'he  patients  practically  always  show  a  rise  in  tem- 
perature. High  temperatures  (104*  to  H)6°  K.l  usuiilly  characterize 
the  purulent  meningitides;  often  preceded  by  dull.  Such  tempera- 
tures may  remain  high,  or  not  infrequently  show  remissions.  The 
tuberculous  meningitides  nsually  show  a  lower  curve. 

i\futoT  Irriiatitm,  or  Purahjtic  Phrf'iimpnn.—('ami\vi  and  epileptiform 
con\-ulsions  ooair  more  often  in  the  early  staprs  with  children  tlian 
with  adults.  They  sometimes  iirc  very  persistent.  ("ircum?eribe<l 
si)asm8,  Jacksonian  in  t^-pe.  are  not  infrequent.  Occasionally  tiiere 
are  cliorcic.  athetoid,  or  tremor  movements,  which  come  and  go,  or 
arc  continuous. 

Muscular  rigidity  is  an  early  and  [>ertistent  -^ign.  showing  early  in 
the  neck,  later  in  the  Ixick,  with  oijisthotonos,  or  stilf  lonlosis  postures. 


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DISEASES  OF  THE  .SfEMXOES 


llicsc  miifw'iitsir  rij^lilitics  arc  nfttii  subject  to  ty>ii.si(lrnil)le  fliiPtiiatinn 
with  tin-  lU'RriH'  4»f  iiiteniiil  or  extcniiil  IiyHrmfiilmliis.  l.uniliar  pum- 
tiin*  often  iiiHiu-iuv-s  iIk-ih  i;mi)l> . 

KVriu>i's  sifi!!  is  frpqiicul,  iiml  is  ImisinI  u|Kiti  tliisj^i-iierallKi.^)  iiiusculiir 
ri^iility  (ri'flcx,  siMisiiimiif  itmtrartioii  uf  rt-L-tus  reinitrb). 

Paretic  si^nx,  tnonoplcjtia,  or  henii|jlcgiu,  lire  k-ss  frequently  met 
with,  imd  tlieii  more  in  tJie  late  stage,-?.  Such  indicate  luraliz^ 
imnilent  pmcesse-s,  with  abscess  fonnation  in  the  motor  area,  mid  are 
usuuily  iieeompunied  by  convulsions.  Spinal  pareses  (pnniplr^'ia )  art^ 
rnre. 

Speeth  disturbiiHces,  usually  eorticHl.  and  apliasia  are  occasionally 
oltserved,  inore  particularly  in  tidnTculnus  nieiiingitiiles. 

Cranial  Nfttc  Sipt-f.  PisturliaiiL-cs  of  the  cranial  nerves  are  amon^ 
the  mofit  characteriiitie  sipis  in  the  nieniiij^itidcs.  The  pupils  are 
iifleii  uaetnial;  fretiuently  markedly  myotic  in  the  be^nning.  they 
show  irrepiilnr  widening  later.  \Vith  increasing  coma  they  ustiall>' 
widen,  mid  reiurt  slu^^gishly  or  imt  at  all.  ( 'tmvergencc  reactions  art* 
less  easily  tested,  but  alstt  show  slowness. 

Kye  palsies  are  frequent.  Mild  jitusis,  tmilnterul  or  bilnteral.  diver- 
gent and  cojiverffent  strabismus  tlu-  nbdnt-eiis  is  particularly  prone 
to  dLsturbaacf  and  <loub!c  vision  is  often  present.  These  eye  jMiLsieK 
van."  from  hour  to  ln)ur  in  extent,  and  in  intensity,  beconunfc  perma- 
nent in  the  lon>;  protiarted  cases  particularly.  I'rotnision  of  the  eyeljoll 
is  a  rare  sign,  nystagmus  frw|uent. 

!*apillitis  is  very  frctiuent,  a,m\  eiu'ly;  optic  atrophy  is  eunimon  {18 
111  25  per  (Tut.).  IVnnanetit  blinilness,  however,  is  rare.  'Hie  trigem- 
inus is  rarely  involved. 

Facial  palsit«  arc  very  fretjuent,  but  are  usually  incomplete,  vary 
from  day  to  day,  and  are  rarely  permanent. 

Hearing  is  frequently  affected.  Complicating  otitis,  and  laby- 
rinthitis often  leave  these  patients  deaf.  It  is  a  frequent  coniplieation 
in  the  second  and  tliir<i  week  of  the  disease. 

ITiie  vagus  involvement  causes  pulse  and  i-espiratory  anomalies 
which  are  also  influenced  by  O'otral  proce,sscs.  The  pulse  is  initially 
hastened  in  practically  all  forms,  and  usually  reuiauis  rapid  in  the 
later  stages,  save  in  those  forms  of  less  acute  progress,  notably  in 
tuberculous  nientngitis,  where  it  is  often  slow,  especiall.v  after  the 
second  week  of  the  disease  (75  per  cent.-  Ileubner).  Marked  irregu- 
larity uf  the  cardiac  rhythm  is  conspicuous. 

The  respiration  is  also  irregular  and  Cheyne-Stokes  type  is  rre<]uent 
in  tiie  seven'  purulent  and  tuberculous  types  ttiwani  the  end. 

Kejirres. — The  tendon  reflexes  are  usually  somewhat  exaggerated, 
particularly  in  the  early  stages,  but  may  be  missing  from  the  begin- 
ning (meilullary  and  ventricular  ijrcssure).  Witli  the  advance  of  the 
disease  they  may  be  missing.  Marked  variations  and  irregularities  are 
to  be  expected,  thus  lost  knee-jerks  may  be  aiwociated  with  ankle- 
clouus  and  Hidiitiski.    This  latter  Is  a  very  frufpient  early  sign  and  later 


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niSKAsBs  OF  rnn  ARAcnrroiD  a^^d  pi  a 

•li-iiip[Kr«rs.  It  shoiiltl  lie  rcniembcifil  tluit  it  is  iiornially  ihvshmiI  in 
\oiiiiK  rhiWrcii  lip  to  six  Ut  fiplit  imiiith.s  of  ajti*,  itiui  licncc  is  to  U* 
lu't^lcctcfl  in  ([ia(fn»K<is  in  younjr  chiUln-ti.' 

l.uiiilmT  I'utit'turr.  'Hiis  is  nl"  |irininry  ini|iorTi(ii(f.  Tlir  pn-sstirc 
us  initially  iucrouscd.  ],ii1er  this  is  tuil  iniirki-d  jus  thr  Miii<l  is  piiriiletit. 
In  the  ordinurj'  purulfiit  ineiiiiigiti<lfs  the  fluid  is  UHUully  doudy, 
snnu'tiiiirs  only  iiurnist-tiplrHlly  so,  Ht£aln  intirkci!l\  punilmt.  in  whicli 
the  specific  urjiiuiisnis  may  hv  found  by  pmiKT  nietiuKis.  In  tnber- 
c'uluu:i  meningitis  tlie  fluid  is  less  apt  to  be  cloudy,  esijccially  early, 
but  by  proi)er  twrlinic  the  bacilluK  is  found  l^W  per  cent,  ejirly  slaves, 
50  per  cent,  with  pressure  sipis,  UM)  per  cent,  in  puralytic  staf;^ 
— Pfftundler). 

C'y1oInKii*Hlly'  one  finds  that  in  purulent  nieiiinftitis  there  is  a  pre- 
poudcnince  of  polyiiii clear  Iciiki>cytes,  while  in  tuberculous  meningitis 
the  iyniphoey  tes  are  iniTcased.  This  i.s  not  an  absolute  rule  and  there 
are  variatioius  during  the  cour.sc  of  the  di.sense.  Tlie  cytological  fiiidinj^ 
should  \tc  cheeked  up  witli  the  clinical  ones.* 

Irr/'fjiilar  Sifmptoinx. —  Merges  is  not  infrequent  (75  per  cent.,  save 
in  young  cldldren)  in  the  epidemic  form,  and  usually  appears  within 
the  first  week  (two  tt)  five  ilays^.  It  is  most  frcipient  ainiut  the  nose, 
lips,  and  forehead.  It  di«s  not  i>erst.sl  Ioiik  as  a  rule.  Other  skin 
eru|itions  are  tiut  infrequent,  especinlly  the  nise-colored  siM»ts  of  the 
diplucofcus  typi-3.  Kruptious  rcsendiling  measles,  scarlet  fever,  urti- 
caria are  occiisional.  while  erythemas  and  liemorrhagic  spots  are  rare. 

(Jaatric  disturbances  arc  frequent,  especially  constipation.  I  )iarrhca 
may  Iw  an  initial  symptom  in  young  cjiildren. 

Tonsillar  an<l  pharynyejil  re<hiess  an«l  soreness  are  not  infrequent 
ill  the  epidemic  tyju-s,  and  lirouchif  is  is  often  present  in  the  later  stjtge.s. 

Coarse  and  Prognosis. — Wliereas  most  of  the  types  of  leptoineiringitls 
show  much  the  same  general  symptomatology,  it  is  more  particularly 
in  their  developmental  course  tliat  the  dilfcrenees  appear.  Tiiese 
variations  may  Ih?  viewed  as  fundamentally  due  to  spwific  dilFerenccs 
in  the  microorganisms  in  question,  althnugh  it  may  be  said  tliat  in  a 
number  of  instances  the  only  ditferenrcs  observed  by  the  best  clinical 
obser\'ers  have  been  those  of  the  microscopic  slide,  or  the  test-tube. 
Ilenir  it  may  Ik*  stated  that  under  certain  cinnnnstjinces  the  ]mtholog- 
icu!  fact  that  the  patient  has  a  meningitis  governs  the  entirt-  picture 
and  all  fonus  are  precisely  alike,  but  in  the  main  it  is  true  tliat  specific 
variations  exist,  and  slioutd  be  sought  for  when  facing  any  particular 
ease  of  leptonieiiinptis. 

In  general  fairly  .'^harp  distinctions  can  be  made  between  (1)  the 
infectiousj  (2)  the  epidemic,  (3)  the  tuberculou.^,  and  (4)  the  serous 
forni.s. 

'  8cv  ncpiHMl  fitr  rmt'tul  jUitly  of  rvllexvn:  Klin.  Juhr,  xv,  42.1,  Bim^.  klin.  Weluuwbr. 
lUltt.  31.  2S. 

*  H<-)tatil)nm:  Klin.  Vnrl..  VH;  Mod.  Klin,.  I»»G.  p,  593. 

*  Caiutili  Ri<hni.  n.  HeholtniiUleT's  valunhlc  nlli»  of  rvrebroapinnt  Anid  lindiiiKR,  1013. 


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55-1 


brSSAHEfi  OP  THS  MEXIlVaRfi 


(1)  Itifcetiinut  Mrnfngififi.  -Uvn^  thv  iiiitiiil  ilistiirliiince  in  the  enr, 
mise,  iiiasliiiil,  fmntal  siiuis.  rrm-fuii',  t'tr.,  prtvi'ili-.  iiml  its  syrnptniiis 
oftfii  lii<lf  tliosf  iif  the  suppurative  iiK-niii|;iti.s  tliiit  follows.  The 
ciisi't  is  usually  acute.  Headafht'.  local  or  <liH'usf.  is  early.  The 
tfm|MTatiin'  usually  mounts  rapidly  t<)  HU"  K.  or  105°  K..  with  initial 
chill;  the  pulse  and  respiration  are  nipiil.  There  is  photophobia  and 
hyperaciisis  within  ii  few  days.  The  mental  .ligns  cume  on  soon.  Coii- 
fusioii,  souinoleucf.  or  iHinia  are  frequent,  often  puiictitatwl  by  active 
ilelirious  intervals.  Lumbar  puncture  usually  shows  a  purulent  (hiid. 
The  tendon  reflexes  niT  usually  increaset!  anil  the  cranial  nerve  signs 
are  nmrked  witliin  the  first  week.  No  special  shin  eruptions  are  noted. 
Neither  tache  c6rebralc  nor  dermo^rraphLsin  are  marked. 

\\'ith  irreRiilar  septic  temperature,  inrreasinR  coma  or  delirium, 
increasing  signs  of  local  pressure  or  de.struction,  convulsions,  and 
paralyses  the  more  .serious  oases  end  fatally  within  two  to  five  days  in 
children,  or  one  to  two  weeks  in  adults. 

Other  paticiits  show  less  grave  sjinptonis,  run  a  subactive  c*»urse 
and  recover  in  tliret-  to  four  weeks,  hut  in  general  the  prognosis  is  un- 
favorable.   Those  that  get  well  |)n)hBhIy  Imvc  a  eircumscri!w<l  process. 

(2)  Epidemic  C'erebrospitiai  Mfningitis.^Knov;n  for  centuries,  first 
recognised  as  epidemic  in  1S()5  in  Switzerland,  in  IHCMi  in  Massachu- 
setts, this  funn  h;is  been  extensively  observed  the  world  over.'  Its 
epidemii-  onset  is  usually  very  insidious,  and  spring  Vnd  winter  are 
the  months  of  predilectiuti  in  the  north  temperate  zones.  Il  is  now 
endemic  in  large  cities.  Children  under  ten  are  most  prone  to  the 
infection.  The  exciting  agent  is  the  Menivifociif'cu:i  intracelluUiris 
of  Wcichselbaum."  The  disease  is  contagious,  the  contagion  being 
po«.^ibly  carried  through  the  nasal  passages.  Abortive,  subacute, 
acute,  chronic,  and  fulminating  cases  are  recognised  with  every  pos- 
sible intermediarj'  tj'pe.  Recent  studies  among  tlie  armies  in  Kurope 
have  contributc<l  very  wiiicly  to  the  knowledge  of  the  passibilities  of 
this  disorder. 

The  malignant  or  fulminating  caste  may  end  fatally  in  twenty-four 
hours,  with  headache,  nausea,  vomitiug,  delirium,  coma,  convulsions 
stiff  neck,  high  temperature,  rapid  pulse,  C'heyne-Stokes  respiration 
and  death  from  acute  toxemia. 

AI>ortive  cases,  which  are  more  often  found  in  adults  than  in  children, 
show  rudimentary  meningeal  signs.  Ileadadie,  backache,  itausea  and 
some  vomiting  with  slight  stiiTiiess  of  the  neck  iiceur,  or  tlic  patients 
may  only  have  slight  vertigo,  malaise,  and  nausea,  and  keep  on  with 
Uieir  work.  ]'"ever  is  usual  ami  occasiomdty  dcafnc:>s  develops  in 
these  mild  attacks. 

The  usual  subacute  or  acute  types  show  a  latent  period  averaging 
three  to  five  days,  consisting  of  irregular  backache,  headache,  slight 

1 8tto  RepiirL  of  Htnt*  Rnanl  of  Health.  MabBactiiiwtU.  tSOS.  for  estccwive  rpvtcw  with 
lilernture  iu  that  dnto.     Arlirk-«  of  Finkl«nburit.  |r>c,  ctt..  for  later  liuntun. 
»  FnrtsrIiriMc  <l.  Mwl..  1877.  i>.  t\2'£. 


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DISEASES  OP  THE  AliACHXOin  AXD  PIA 


555 


\'eftij;t),  nml  swf^tiiig,  with  si}^n>;  nl"  a  imsi»phitrytipitis.  Tln^n  a  liiill 
with  HliRlit  rise  in  tcinpL-mtiiR^  iHr<niipiiiiie(l  l>y  vomiting  iiidicHti-s  lUv 
onsft.  OhiMrcii  lu'riiiiu-  rcstlpss,  cry,  and  arc  ver\'  irritable.  I'siially 
within  twt'itty-four huur^  mciimgwil  signs  uppetir  Stiff  iiet-k,  liwidiiche, 
mentjil  adifuMioii,  iirc  present:  not  iiifrec|ucntly  convulsions  nppear  in 
tliildrcji.  Pliotuphubia,  hypfrsicnsis,  excT^ivt'  .scnsitivencs.s  to  pn-ssurt-, 
and  hyj)ertonicity  then  sliow  themselves  witli  Kemig's  :<ipn  and  in- 
creased It'ndcm  reflexes.  The  eninial  nerve  signs  then  de^-elop.  Herpes 
labiaiis  is  frequent  from  the  second  to  the  fifth  day,  and  a  few, 
macular  eruptions  (spotted  fever)  may  appear.  Other  skin  eruptions 
(fleveliip  in  the  first  week.  Tile  {-erebrDspinid  fluid  shows  a  cliariiftcrls- 
tif  picture.  (.See  Itelun  and  SchiMtuniJIrr.  I  '\'\it^  blrt««l  HiuIiuks  aiTord 
some  clue  as  to  the  prognosis.  The  leukocytusis  is  cfwructerized  more 
or  leys  definitely  by  an  increase  in  the  |»olytnurphoneutrophile  ccllu 


I'^a.  307. — Tread  of  hlood  cun'e  io  cervbrtMpiuAl  nicoinHiiw    in  farorahlr   luul 
(infavorahtr  nuv*.    .V.  twiitrophilca;  L.  ]yTjiphnrji*« ;  K,  MMnnophiln.    (Hubca). 

whieh  in  the  patients  with  a  good  prognosis  tend  to  diminish  and  are 
aeenmimnied  hy  an  inrrcase  in  the  Iymphoc\nes,  with  a  slight  incrciise 
in  i-osiimphile  cells.  In  the  unfavorable  cases  this  crossed  curve  does 
not  take  place  and  the  eo-sinophile  cells  disappear  entirely.' 

Hie  eonui  ajntinues,  shows  coiisideraMe  vuriution  in  inteiLsity,  and 
the  patient  gradually  improves,  or  shows  increasing  signs  of  pressure, 
omvulsions,  palsies,  mid  die^  within  seven  to  fnurteen  days,  after 
ineffe^.'tual  attempts  at  maintaining  nourishment. 

Other  patients  show  a  much  more  chronic  course,  lasting  weeks  or 
months,  with  considerable  variation  in  the  intensity  of  the  headache, 
coma,  or  delirium,  with  eye  palsies,  mono- or  hemiplegia,  contriictnres, 
constant  emaciation,  and  variable  temperature  until  death  takes  place, 

>  Riucn:  Doiitsch.  Areh.  f.  klin.  MM.,  101 1,  im. 


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656 


OF  THK   MSyiXGES 


iiftrii  «itli  ItHTcasiiij;  size  i»f  llir  In 
L'linil 


Hm 


Inifrpluilus  Hiul  »igti 


,'Hst'<i  (rrfnnii  pn-ssim.-. 

In  otlit-r  more  favnrahit'  cases,  periods  of  cloMniess  or  of  iK'tUTOKiil 
iM-conu-  loiipT  anil  timn'  proiioiiiKiil,  iiit4Tiniiif;]r<I  witli  the  w^vcm 
•;,vthpt(llll^  ;ilrt';i<ly  ixitlitiei].  Thi.-  Viir'uihilhv  in  i-IIntii)l  ctmrse  h 
eiiornnnis,  Init  thi'  prnf^niisiN,  up  ti>  the  time  of  the  iiitrtMliictlnn  ol 
the  Vlexner  sfrtirii,  was  (iirtliiiftly  uiirHvuniMe,  the  rnnrtnHt>"  miigiDg 
from  50  t<i  HO  per  cent.  Ajipan-utly  mild  eases  ufteii  die  and  some 
extremely  ill  rhildri-ti  rei-<»ver.  Iteeovery  with  defect,  eitlier  ileafliess, 
blimhicss,  eraniHl  ucr\'e  pnUies,  munoplejpiiis,  hemiplegias,  or  iiienul 
defect**,  are  not  infrequent.  jM 

TTfntnif'it. — Since  a  *tpe<nfi('  antinieniniritie  serum  has  Iweii  elaw 
mted  by  Klexner'  the  prngnosis  has  heen  much  im]ir<ived.  The  mor 
tality  has  falh'ii  to  "i'l  imt  cent,  in  some  of  the  recent  epidemies.-  The 
Iwst  results  iire  ohlaliied  in  ehiUlren  nf  from  five  to  ten  yt-ars. 

The  etierts  i>f  serum  treatment  are  often  seen  very  soon  —twenty- 
four  hoiuT*  after  injeetion.  The  Keruig  si(;n  ami  slifTness  of  the  neck 
persist,  however.  The  attenuation  of  the  s\mi)t<>nis  is  vcr>'  marked 
in  many  of  the  eases,  as  weU  as  shortening  of  the  disease.  Lyxis  a 
the  usual  mode  iilf  recovery  of  non-senim-treated  aises.  Crises  occui 
much  more  often  in  senmi-treated  ea.ses  (25  jier  cent.).  Furthemiorc, 
thi-  pernmneiit  sec|urlii'  of  the  disease  :ire  markedly  reduced  hy  t^ 
senmi  trcatnieiil.  1| 

Tlie  geinTal  treatment  will  be  considered  with  tliat  of  the  otha 
forms  of  meningitis. 

(3)  Tubertnilatu  Meningitis.— 'Ihis  form  was  first  isolated  about  1S3C 
(Killiez  et  Hflrthez  and  Ilobert  Wh.rtte),  although  one  can  see  its 
chief  features  in  the  Xo.9oUi(fjf  i>f  Snurnfffjt,  written  in  1763.  In  this 
form  the  cjOM-t  is  eharacteristieully  Hubiieiite  or  chronic,  one  or  two 
weeks.  e.xceplioUHlly  months,  and  is  almost  uivariably  secondary  to 
tuberculosis  in  otlicr  organs.  General  s\inptoms,  such  as  loss  of 
appetite,  irritability,  loss  of  flesii,  general  malaise,  with  loss  of  desire 
to  play,  fretfulness  and  ready  fatigability  are  the  precursors.  Head- 
ac-he  and  dizziness,  witli  irregidar  fever  movement  is  then  observed, 
and  ocrasinnal  dreamy  states,  during  which  the  patient's  manner  u 
peculiar.  M 

Then  gradually,  or  suddenly,  the  patient's  manner  l>ecomes  mura 
changed:  inilii  ilehrium  or  coma  develojjs,  and  eonvulsions  appear. 
Tlie  piUieiils  lie  in  bed,  are  restless,  rolling  from  side  to  side  with  sharp 
cries  or  whimiR-rs.  and  frequent  placing  of  the  hand  lo  the  head. 
Passive  motions  of  the  head  for^vanl  invariably  bring  out  resistance 
and  pain.  The  sensitiveness  of  the  skin  to  pressure  or  touch  Ls  marked, 
and  hyjxTtonus  with  muscular  twitchings  and  Kernig'a  sign  are  present. 

The  temj)eratnre  ranges  from  102*  F.  to  104*  F.,  and  is  usually  less 
marke<l  tlmn  in  the  suppurative  or  epidemic  t>ijes.     Lumbar  punctua 

<  Juur.  Kxp.  Mii±.  lUUT.  fl 

>  FI«xQcr:  iDternntional  dimes.  1900;  Jour.  Am.  Mrd.  Ahu.,  OeU>bcr  3(1.  ISOO. 


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DISEASES  OP  THE  ARACUXOID  AND  FIA 


557 


in  till'  first  week  uswally  gives  a  dear  fluid  under  pressure,  with  ext-ep- 
tionally  the  tiihercle  Imnllus  ur  pns  elements. 

The  <.Tanial  nerve  signs  may  then  ilevelop  in  the  8eci>n(!  to  thin! 
week,  and  show  ninre  ups  and  downs  than  is  usually  present  in  the 
other  types.  l.(K'nlizcd  pressure  signs  with  liemiplegias  or  monopk'ciiis 
then  develop  and,  not  infrequently,  the  previously  intreuse<l  tendon 
reflexes  diminish  or  are  lost. 

The  patients  gradujilly  get  worse,  eonvidsions  are  Trequent,  and 
rigidity  is  foHoweil  by  flaceidity,  and  the  imtient  dies  with  signs  of 
market)  exhaustion,  stinietiiiies  with  agiund  risi'  nf  temperature  imme- 
diately preceding.  The  whole  attack  may  terniinate  within  ii  mtupura- 
ti^  ely  short  time,  two  or  threi'  weeks,  or  may  run  for  months. 

Atx'pical  forms  are  especially  frequent  in  lulults  such  us  apoplecti- 
Torni  onsets,  with  aphasia,  monoplegia,  or  hemiplegia.  The  picture 
may  be  that  of  a  toxic  delirium.    The  prognosis  is  bad. 

(4)  Serous  M  ni  i  luj  it  is.— Vict] .  in  l.s^d.  first  isolatwl  thistj-pe,  which 
is  of  uncertain  origin,  and  characterized  hy  varying  grades  of  edematous 
exudate  with  infiltration  of  round  tf\U.  'l"he  sN-niptoms  are  usually 
those  of  a.  mild  meningitis.  Ileadiiche.  stiff  neek,  marked  sensitive- 
ntt<s  are  eonsUint.  whereas  i-onvulsions  and  signs  of  pressure  arc  less 
frequent.  Again  the  di.wrder  may  Iw  anite  and  very  severe,  witli  high 
temi>eralure  and  signs  of  cranial  nerve  involvement.  The  usual 
course  is  less  stormy.  Papillitis  is  u  frequent  symptom,  and  shoukl 
be  borne  in  mind  in  those  patients  in  whom  the  serous  exudate  is 
more  or  less  eirciimscrilx'd,  giving  the  general  impression  of  a  brain 
tunmr.  Lumbar  puncture  shows  incn-jise  in  prtssure  with  some 
lymphocjies. 

In  the  seroa^  meiimgitis  of  ak-oholic  origin  (wet  brain,  meningo- 
encephalitis), there  is  usually  a  busy  delirium,  excessive  hyperesthesia, 
with  mi)rke<l  twitching  of  the  muwies.  Tliis  type  Ls  c<Hnparatively 
infrequent  but  is  s«'eii  often  lu  the  large  cities  Belle\nie  Hospital 
service  fwirticularly — in  all  drinkers  of  long  standing  iu  the  thirties.  It 
Is  seen  follonnng  n  very  liani  drinking  Hfiell  and  often  is  accimipanieil 
by  delirium  tremens  (7.  r,).  The  jnitients  hcttmic  snnitimsciinis,  In  a 
muttering  fairly  busy  delirium  with  hallucinations  of  sight  and  hearing 
which  ciHiu:  and  gi).  There  is  rnarkal  hy(K'rcsthesia  and  the  pupils  are 
contracted.  The  coma  is  apt  to  deepen,  the  temj)erature  rises,  the 
tongue  is  very  heavily  brown  eonted.  lnvohu»tar>'  evacuations  may 
occur.  Inen-asing  temperatiire,  104**  1'.,  rapid,  irreguhir  and  feeble 
pulse,  loss  of  tone  of  the  skin  and  muscles  all  point  tn  a  letlml  tenniiiu- 
tion.  Others  slowly  improve  and  reciivcr  v\ith<Mit  ur  ^^ith  (Korsakow) 
defect. 

(5)  Sifphilific  Maungitijf.^i?4x  Syphilis  f>f  the  Hrain. 
Differential  DiafnOBis. — The  chief  ilisordcrs  that  nuiy  Ik;  rorifoundeil 

with  the  meningitides,  wiMs-ially  in  the  U'ginning  of  the  disonler,  or 
in  mihl  cases,  are  as  follows:  liiternal  jmchymeningitis,  which  rarely 
gives  temperature  or  lumbar  puncture  findings.     Kncephalitls,  ami 


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DISEASES  OF  TUB  MENl.VOBS 


iptotns  develop  eai 


I'lKvphalniiiyt'liti^:  iii  tlie  fonner  IcH-oItzing  symptoms 
Hiid  the  spitml   i\nii\   is  clear;   in   the  latter  flaccid  [wlsies  rapidly 
(le\elop.  mid  ilie  fluid  is  not  purulent.     Brain  abKrcs.1  may  be  com- 
plicated by  meningitis,  or  localized,  in  which  latter  case  the  localizuufa 
sjTnptoms,  septic  ctjurse,  and  clear  spina!  fluid  are  of  aid.  fl 

Infectious  siniis  thrombosis  may  rc>einlile  meningitis  very  closely. 
There  is  a  proater  tendency  for  the  lower  cranial  nerves  to  1m?  involveil, 
particiilnrly  the  viijtns,  hypoglossal  and  v^pinal  accessory.  The  spinal 
fluid  is  usually  clear. 

Deliriuni  tremens  shows  an  active  occupation  delirium,  optic  hallu- 
cinations, marked  fine  tremors  and  little  temperature.  I  lA^teria  rarely 
shows  temperature,  and  many  of  the  organic  signs  descril>ed  by  e-arlier 
authors  as  found  in  hysteria  are  better  referred  to  as  organic  brain 
disea.se  with  hy.itcrical  epiphenciinena.  h 

Treatment.— Tliis  must  first  lie  jjniphylactie,  ami  involves  genenj 
hygienic  precautions  in  tuberculosis;  prompt  aural  trciitinent  in 
otitis,  mastoiditis:  surgical  asepsis  of  vvtiunds  in  all  head  operations. 
The  isolation  of  the  epidemic  types  is  advisable,  and  nasal  antisepsis 
imperative.  Quarantine  mea.sures  are  important  and  are  be,st  con- 
trolled through  culture.s  of  the  nasal  and  pharyngeal  mucus.  The 
active  treatment  is  surgical  fi»r  most  of  these  furms,  especially  if  the 
sympttnns  show  early  signs  of  being  circuui5crii)ed,  or  when  it  seems 
possible  to  get  at  an  initial  Focus  of  infection,  aa  in  the  various  septic 
infectious  forms  -ear  disease,  etc. 

tu  dilTuse  pcnernl  meningitis  tlie  responsibilities  are  great,  and 
is  dilhcuh  to  decide  in  the  individual  cases. 

Kpidcmic  types  arc  best  treated  by  scrum.  Surgical  treatment 
tuberculous  meningitis  has  not  yet  met  with  sufficient  succfss 
warrant  its  ndvocacy. 

l.uinliur  puncture  1ms  given  very  brilliant  results  in  some  patients, 
in  others  it  has  been  nf  little  service.  With  the  development  of  lu-nte 
hydrocci>halus  it  is  uidicaled.  and  it  is  iu  general  a  luinide^  prutttlure. 
The  punctures  may  he  made  frequently,  and  25  to  40  e.c.  of  fluid 
removed.  The  amount  removed  should  be  controlled  by  the  pressure. 
Hess  (/.  c.)  s])eaks  of  the  Kusca  leukocj-te  cur\T-  as  affording  a  criterion 
for  luinhur  puui  tnre.  'Ihe  drop  in  eosinophile  cells  and  the  failure  of 
the  lymphocytes  to  nn»nnt,  with  increased  fever,  these  are  indicatiot 
for  puncture. 

()f  the  serums,  the  Knlle-Wassennann  in  septic  cases  has  piven  gt> 
results,  l-'lexner's  serum  for  tlie  epidemic  tyijes  has  been  nienlione<l. 
In  u.sing  this  senuu  a  lumbar  pmicture  is  first  nuule,  and  from  10  to 
50  e.c.  of  fluid  allowed  to  ilrain  tiff,  the  amount  beiuR  determined 
largely  by  the  pressure.  One  dnjp  in  fmm  three  to  five  seconds  is  a 
general  rule  for  iletermliung  tliis,  Then  from  10  to  50  c.c.  of  the 
antimeningitic  -scrunt  is  slowly  iujectei!  by  gravity.  The  serum  may 
Iw  used  every  three  or  four  days,  (."ontrol  smears  of  the  organisms  in 
the  fluid  ttfl'ord  some  clue  to  the  frequency  of  use  of  the  st^rum.    Wit 


itic 

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559 


¥ 


numerous  bacteria,  adis'e  celtultir  exudates  indtcute  mort-  fre(|ueiit  ^l^f 
of  serum.  In  tJie  alcoholic  types,  prompt  and  thorough  ciitlmrsis 
-should  first  be  used.  Diophoresis  by  hot  packs  is  of  scn*ice.  Suppurt- 
inp  ftiid  tonic  treatment  is  then  rwjuired. 

General  treatment  consists  in  keeping  the  patient  quiet.  Bromides, 
chloral,  veronal  and  other  mild  hj-pnotics  are  of  .senire.  II\*pn<Iprmir 
use  of  morphine  or  hynwine  may  be  nec'es.s«r>',  hut  otlier  things  beintj 
equal,  is  undcsinihlc.  The  rontiniiuus  hot  hath  is  es(>prially  vahiahle 
in  delirious  patients. 

In  the  beginning  n  prompt  use  of  calomel  is  called  for.  The  room 
should  be  darkened  and  as  quiet  as  possilile.  Pain  may  be  controlled 
as  far  as  possible  by  analgesics,  and  local  counter-irritants. 

I*articuhir  uttoutioii  should  be  given  Ut  the  nouri^Uiment  ami  rest 
of  the  patient.  <"ontinnous  fussing  and  ovcrnursjug  is  to  be  avoided 
in  these  easels.  There  are  no  specific  remedies.  I'rotropin  in  large 
doses  may  be  tried,  as  it  is  partly  broken  down  into  formaldehyde  in 
the  cerebrospinal  fluid.    The  colloidal  silver  salts  are  disappointinjf. 

Ill  the  long,  tedious  convalescence  of  numy  of  tlie.se  little  patient.s 
one's  ingenuity  is  taxed  to  stimulate  the  H[ipelitr.  provide  the  proper 
amount  of  outdoor  play,  and  to  strengtlien  tlie  paretic  or  punilyzed 
mtiseles. 

2.  Chronic  Leptomeningitis.— Thin  is  usually  a  secondary  afTection 
in  (wresis,  senile  deinentitt.  chronic  lead  ptn-soning,  and  chronic  pachy- 
meningitis; it  is  rare  as  a  primarj'  affection  save  as  syphilitic  or  tulxr- 
culous. 

Chronic  tubercluous  leptomeningitis  is  usually  of  the  convcvity. 
usually  anterior,  involving  the  frontal  attd  motor  areas.  It  behaves 
a.s  a  low,  ntlM-grade  meningitis,  often  with  interniitlent  cjnum.scribt'd 
sj-mpTtinis,  ^iniidiiting  those  of  a  brain  tumor. 

Truimiatic  ai.ses  often  show  chronic  vo^tiK(^  paiii.s,  epileptifonn 
cunvulsions,  apha.sias,  nausea  ami  vomiting,  and  gradual  mental 
involveiucnt.  In  order  to  catiililish  a  iliagnosis  of  tniimui  tht-.se  signs 
should  stand  in  direct  relationship  tc)  the  injury,  antl  should  not  be 
conii)licattHl  by  signs  originating  at  a  distance  from  the  site  of  the  iniur>' 
or  from  other  causes  [Argyll-liolx-rtsou  from  syphilis,  for  iiistttutr). 

Chronic  meningeal  inflammations  are  occasionally  found  in  childn'n. 
giving  the  signs  of  a  posterior  basilar  meningitis.  They  are  often 
acfiimjKiniefl  h^'  hydroi-ephahis.  Opisthotonos  is  frequent.  Many 
arc  dor  in  s\  philis,  as  the  WjLssermann  te^ts  show. 

HydrocepluJus. — An  Bccumulatinn  of  fluid  within  the  cranial 
cavities  takes  place  in  a  variety  of  affections.  It  is  invariable  in  the 
acute  nK*ningiti<Ies,  in  greater  or  lesser  degree;  in  tuberculriu.;  menin- 
gitis it  is  often  extreme  und  comes  on  with  great  rapidity— acute 
liydroccplialus  being  practically  synonymous  with  a  tul>erculous 
basilar  meningitis. 

Kxtenial  hyciniceplialus  is  often  synonymous  with  serous  meningitis; 
a-s  an  entity  It  is  infrequent. 


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Hyrlrocephaliis  is  a  very  frec[uent  ((iniplinition  iti  tumors  of  tb* 
brain,  partit'ularly  in  tumors  of  the  third  vetitrit-h-,  the  piruTal,  the 
cor]Kirn  quadrigeiiilim,  aiul  those  causing  pressure  ujhui  the  aque^hict. 
These  conditions  are  rliscussed  uiuier  Bruin  Tumor.  Ventricuhir  hydro- 
cephahis  often  results  from  sueli  struc-tural  nnonialies  as  ccplialoc-elfc 
and  spina  hilida.  fl 

In  children  one  may  find  a  primary  c-hronlc  hydrwephahLs  of  ns  y^ 
unsettleil  pntliolo^y ;  hut  there  is  usually  a  cluroiiic  ependyniitis  jirescnt. 


FlQ.  308. — Shnvrins  markixl  hydDJccphiiliiK.     Clinii-ally  llip  puli<*iii  Hhaw«d  epileptic^ 
jitrjickn  iiimI  wiui  niarlMHlly  fM>l>]o-niiiiili>(l.     lMuii«r>it,) 

One  to  five  pints,  even  pillions,  of  fliiiii  may  lurunuilate.    The  fliiiil 
Is  eleflr,  sll^htl%'  alkaline  with  sp.  tpr.  (l.l(X)5,  eantarniait  the  earthy 
elUorides,  all)nmhi.  pho-spliates.  iiml  <H<'asi(inall>'  a  snyar-reihieinjj  suhH 
stance.     The   pn-servei'  nf   hi^U   pfrecutap's   of  alhiiinin   aiid   man^ 
celhilar  elements  iTidieal*^  a  nuire  active  iuHanunatiou.     As  a  result 
of  the  pressure  the  veutridi-s  \vi(h'n.  the  septum  lueidum  is  displaei 
the  cortex  thitis,  the  inftnidllniluin  dilates,  the  optic  chiasm  is  pi-essi 
upon.    Extreme  rlLstention  may  eoiivert  the  pallium  into  an  eunmioi; 


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DtSEASES  OF  THE  ARM 

pyst,  with  the  smallest  vestige  of  a  cortex.    The  tlwlnmus  may  be 
flatteiieil,  even  the  pons. 

The  (Tuninl  Umes  may  beeome  separateri.  'Hie  hetul  enlarges, 
ii:^iihIIv  syiniriflricnlly,  a1  the  viuiU  niul  nt  the  hnse.  In  (diler  i-hiiilren. 
however,  hydroeeplmlus  may  ext^t  without  these  clianges  iu  the 
|X)sition  <if  the  cranial  bouc^  taking  place.  The  avernge  cranial  cir- 
eiimferenrr  at  birth  is  fourteen  inclics;  at  one  year  eighteen  to  nine- 
teen incluw.  In  hydrocephalic  heads  this  ifi  incTea.se(l.  As  a  rule  the 
enngenital  tj-pos  show  the  largest  heails.  These  patients  are  rarely 
I«>ni  iilive.  or  they  live  a  short  time  only. 

Symptoms. — Two  or  three  or  more  montlts  after  birth  it  is  noteil 
thai  the  rhild's  hc-ad  is  IncreA^ing  in  sin'  with  mure  tliini  the*  usual 
rapidity.  Somnolence  and  lethargy  are  frequent;  tlie  child  may  not 
be  able  to  hold  the  head  up.  A  wliiny.  peevish  irritability,  with 
Impienl  sliarji  cries  is  tlie  rule.  Witl»  i'airly  rapidly  increasing 
internal  pressure  the  mnia  is  marked,  showing  great  variability, 
however:  vomiting  is  frequent,  the  hearing  is  affected,  also  the  sight; 
clicked  disks,  siiasticitics.  with  usually  ^_\^nrrH■t^i^■ully  increaseil 
n'flexcs.  The  pupils  are  usually  eontracted  and  sluggish  to  light  eiirly. 
Witli  severe  gmdes  of  prt^ssure,  there  may  In-  extreme  dilatation. 
Convulsions  appear  and  death  results  in  from  three  to  six  months, 
with  signs  of  emaciation. 

In  the  eases  of  nu>re  grailual  increase  f)f  intracranial  pressure  » 
niarkt-*!  degrt*  of  accommodation  takes  place.  The  s\Tnptoms  are 
those  of  dulness  or  stupidity,  the  children  are  usually  less  bright,  the 
choketl  disk  may  be  very  little  marked,  or  may  Iw  ext-essive  if  the 
bnnes  have  not  permltleii  distention,  and  may  be  followiil  by  atrophies; 
hut  many  cast's  recover  with  only  a  slight  degree  of  mental  reduction 
— weak-mintiedncss  or  only  stupidity.  There  h  a  proverbial  chccri- 
ness  in  these  patients.  S»me  few  make  total  recoveries,  and  may 
slmw  brilliant  mental  capacities. 

In  the  hydrocephalus  of  brain  tumttr  in  mhilts,  with  its  up-and-<lowTi 
course,  siimnolence  and  headache,  choked  db^k,  diluted  pupils,  some- 
what inactive  to  light,  are  characteristic.  A  cracked-pt)t  percussion 
note  is  often  very  cliaracteristic  in  the  young  and  also  in  many  adults. 

Ther&py.  Many  cases  ai-e  hopeless  from  the  onset.  .\  Wassermann 
test  should  always  be  made,  both  of  the  bliMid  and  cerebrospinal 
Huid.  for  the  double  purpose  of  detcrminiiig  syphilis  or  other  iuHani- 
matiiry  disorder.  Many  vusca  of  cpcndymitis  are  syphilitic  in  origin, 
i'or  these  prompt  mercurial  treatment  is  indicated;  salvarsan  or  eneso! 
are  useful.  InunctioiLs  are  also  valuable  In  the  less  rafiidly  advanring 
oases.     lodin  therapy  is  advantageously  aimbined. 

Cerebral  irritative  phenomena  need  hot  batlis  and  bromides. 

Tapping  is  fntiuently  of  ser\ice,  hut  not  always.     Puncture  of  the 
eorpiLs  callosmn  may  pnive  vahmble.     Lund>ar  puncture  is  not  prac- 
ticable to  relieve  pressure,  as  fre<|uent!y  the  aqueduct  of  Sylvius  i& 
bUK'ktNl;  a  dry  lundmr  tap  is  of  diagnostic  service. 
36 


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562  DISEASES  OF  THE  MENINGES 


SUNSTROKE. 


This  is  a  condition  brought  about  by  exposure  to  the  direct  rays  ol 
the  sun  or  to  great  heat  from  any  source. 

The  severe  cases  are  marked  by  profound  unconsciousness,  verj' 
high  temperature — 108**  to  110°P\,  perhaps  by  convulsions,  delirium 
and  death.  The  milder  cases  are  so-called  cases  of  heat  exhaustion, 
with  general  prostration,  little  or  no  rise  in  temperature,  and  frequently 
with  recovery.  These  patients  not  infrequently  show  marked  cardiac, 
renal,  or  other  organic  disease.  In  the  severe  cases  coma  is  profound, 
there  may  be  developed  paralyses,  hemiplegia,  or  other  s\Tnptoms  of 
focal  brain  injury — meningitis  or  encephalitis  may  follow,  and  if  the 
patient  lives,  convulsive  phenomena,  definite  psychoses,  neurastheni- 
form  conditions,  focal  disturbances,  ocular  disturbances  and  deafness, 
and  general  conditions  of  weakness,  may  eii-iue. 

Therapy. — The  patients  should  be  i)lacei!  immediately  in  cold  water, 
the  temperature  of  which  is  kept  down  by  ice.  The  drop  in  the  bodily 
temperature  will  determine  the  length  of  time  of  immersion. 


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CHAPTER  XI. 
DISEASES  OF  THE  BUAIX. 

ENCEPHALITIS— ABSCESS  OF  THE  BRUN. 

Encf.pihi.itis  refers  to  an  inflammation  of  the  brain  siibstanoe. 
There  are  ii  nuinlier  of  Tonus,  but  the  tenii  is  liere  restrictwl  to  the 
more  acute  proeesses,  due  to  hacrterial  or  toxic  action.  Primary  idio- 
patliic  enifphttliiis  docs  not  txist.  Gencnd  paresis  is  u  diffuse  eneep}i- 
alitis,  with  exudations  and  proliferation  of  new  f^lia  and  bloo<lvesslcs; 
multiple  sclerosis  is  a  type  of  disseminate<l  fuct'pluilitis;  cerebral 
pimmata  may  be  spoken  of  as  Im-alizeii  encephalitis,  et<*..  but  the 
di^ussiou  is  here  ]imite<l  more  particularly  to  acute  exudative  inflam- 
mations of  the  brain  substance  proper.  .\lis<-ess  is  a  freijuent  secondary 
result. 

Historical. — The  cucephalitifles  were  for  years  included  with  the 
niciungitidcs,  possibly  under  the  term  pivrenitis,  which  to  the  ancients 
meant  any  excitement,  aeeompanie<l  by  fever.  In  Hippocrates  the 
tj-pical  description  of  phrenitis,  however,  is  a  typlioi(]  <leliriijm. 
Traumatic  encephalitides  were  known  to  this  aut!i<»r. 

Just  how  long  this  conglomeration  of  <'erebral  afl'ettions  remained 
an  entity  in  nosoii>g.v  canmit  be  ilcterniine<l.  Separntion  tif  ty|«w  is 
going  on  at  the  present  time,  and  it  must  be  recognized  at  best  that  a 
heterogeneous  group  must  Iw  included  for  the  present  under  the  symbol 
encephalitis,  a  term  use<l  as  wirly  as  bo4  a.d,  by  Actuarius, 

Leaving  aside  the  older  works,  the  hist<iri-  of  enceplialitis  iiractically 
begins  with  the  works  of  Uostan  (ISiiUJ,  liouiilard  (bSUlii,  Lallcmand 

|[.(1S30J,  and  KucIls  (IJSSd)^  in  which  processes  of  s*>ftening,  of  an 
inflammatorj"  or  non-inflammator,'  character  were  commencing  to  lie 
recognized,  f 'ruvcilhier,  in  ls29,  di.stingulshed  an  jipfjplectic  ^M)ftetl- 
iiig,  suppurative  softening,  and  softening  with  disorganization  without 
pus  or  inflammation.  Virchow's  (1840)  work  on  thrombosis  and 
embolism  threw  much  light  on  the  subject,  while  the  studies  of  I>urand 
I'anlel    (IW9),  Haye  (1868),  and  Huguenin  (IXTC))  conmieneed  to 

[give  a  modern  toucli.  Then  Wernicke  (ISSI.i  descrilx^d  a  toxic  form, 
chiefly  alcoholic,  an<l  Striimpell  (IHS4}  opened  u])  the  large  study 
of  the  infertive  t>pes.  Finally,  the  miKlern  study  of  epidemic  polio- 
myelitw,  by  Metlin  and  Wiekmann,  the  recognition  of  syphilitic  tj-pes 
by  Kreud  and  I'laut.  and  the  work  of  Councilmann  aiul  his  sturlents 
have  served  to  widen  out  the  conception  of  tlie  infectioas  types  of 
Striiinpell.     Recent  monographs  of  value  are  by  Oppenheim  and 


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5(H 


DISEASES  OF  THE  ItRAIX 


Cassirer  (UX17),  Nopt,  in  I^wjindowsky's  Uaudbuch  drr  XeurrUoffie 
(19121,  and  Southard  in  ()s!er"s  Modern  MedicUe,  \9\ri. 

Etiology. — Infections  and  intoxications  are  many  and  various. 
Among  the  fdnner  iirr  found  the  organisms  of  influeir/a,  streptococtnls, 
typhoid,  DipfiJiiiccuji  tnniingittdi\i,  pnciiinonia,  scurlet  fever,  measles, 
tuberculosis,  syphilis.  trypano-wHiiiasis,  nialarin,  rabii-s,  poliomyelitis, 
etc.  The  commnuest  acute  forms  are  due  to  the  influenza  bacUlu5, 
pyogenic  organisms  (external  and  internal  infections),  indudinp  mas- 
told,  etc.,  poliomyelitis;  iimoiiK  the  mure  common  chnmic  tv-pes 
are  tuberculosis  and  s.v^jjiihs,  which  latter,  a.s  I'lant'  lia-s  well  shown, 
is  responsible  for  many  of  the  infantile  cerehrai  palsies.  As  for  the 
int<ixicHtii»ris,  iilmhol  [ilays  the  chief  role. 

Acute  Encephalitis. — Symptoms. — As  so  much  depends  upon  the  seat 
of  tile  iultiunmiUoi-y  process,  it  is  natural  that  great  variations  in  the 
clinical  jiidure  should  be  cxjwcted.  The  type  <tf  iufw-ting  agent  also 
intr<HbRTsa  variant.  The  infecting  agent  (tf  a  polioencejjhalomyeHtis 
is  different  from  tliat  of  a  ayjihilitic  encephalitis.  .Mthough  similiir 
strnctures  may  be  mvolved  and  in  a  manner  ver\*  closely  related  patho- 
logically, yet  nevertheless  tlie  mode  of  developnu'nt  wil]  he  different. 
I'nr  this  reason  some  of  the  more  pronounced  types  will  receive  separate 
eoiisideralion.  .\ny  attempt  to  generalize  on  the  whole  gnnip  results 
in  a  desf'riptive  monstrosity  untrue  to  any  cHiiical  type. 

I.  hiftiiertzo  l^nceithaiitix. — The  work  of  Wickmann  and  other.s  lias 
sliown  tliat  great  care  mnst  be  exercisc<l  in  not  confusing  tJils  with 
poliomyelitis.  In  the  trne  inHuen/al  t.\*pe,  the  disorder  is  apt  to 
develop  in  young  adults  some  day,  or  even  weeks,  after  an  acute 
infhicnzn.  Oppenheim  includes  other  infections  tjijes  here.  The 
"cold  in  the  head"  seems  to  i)e  clearing  up,  when  most  intense  headacJie 
^ofl<*n  in  the  ncci put— nausea,  vomiting,  apathy,  nr  drowsiness  com- 
mences to  indicate  something  more  tlian  the  u.suiil  depression  of  au 
influenzal  attack,  ijometinies  there  is  a  rigor.  Confusion  and  mild 
stupor  are  frequent,  the  patient  being  aroused  with  some  difficulty 
after  a  few  days.  S\Tnptoni.s  of  meningeal  irritation  are  not  pntminenr, 
and  a  clear  cerebrospinal  fluid  will  .seiwrate  this  condition  from  the 
closely  related  picture  of  cerebrospinal  meningitis.  There  is  usually 
much  febrile  irregularity.  The  pulse  is  very  variable,  lieing  not  infre- 
quently slow. 

Kncal  sxmptoms  develop  irregularly.  If  the  pynuniilal  region  Is 
involved  there  is  premonitory  weakness  nf  the  limbs,  then  paresis, 
then  paralysis.  ConviJsive  seizures  may  be  present.  The  extent  may 
l>e  that  of  a  monoplegia  only,  or  a  hemiplega,  which  may  not  show 
in  the  t-oma.  Various  aphasias  may  occur,  pseudobuUwr  palsies,  <ir 
occuloniotor  jwisics.  Sensory  anomalies  are  fretpient,  but  arc  dillictdt 
to  detect  because  of  the  mental  state. 

Manj'  [Nitienta  recover  absolutely,  otliers  arc  left  with  slight  motor 


I 


'  NenrauB  vad  M^Ia)  Owsmo  Muu*H[nLph  Scnm,  till  I. 


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B,KCEPUAUTtS-ABSCBSS  OF  TUB  BltiT^f 


mh 


defects,  ]i)nmjplt'gia.s,  ur  sevov  hc-DnpI(^gia.s.  In  a  few  ahscess  may 
develop.  Ill  others  there  is  a  cKinprKfttiiig  e[)endvinitis  with  hydro- 
cejihahis.  hikI  frequently  there  «re  psyi-hotic  eimipIwatMuis. 

'2.  I'nfuiencrpJi/ihniiyclUit  (Striinipell's  acute  eiiee])hjtlitis  nf  cliil- 
dreii  in  part).— This  has  been  discussed  under  the  eerebnd  forms  of 
jMiliocnceplialomyelitis  (Ileine-Mcdins"  dUeasc).  This  lUsorder  shows 
t!ic  usual  acute  onset  of  tlus  disease.  The  cerehrnspinnl  fluid  shows 
the  rharaeteri:^tic  hfKlie^  ilesrrihefl  hy  Hough  ami  Lafoni;  tlie  Wai^ser- 
niaiin  rejictioii  of  the  cerehrcjspinal  Hui<i  should  he  negative.  The 
residuals  here  may  he  purely  in  the 
cerebrum,  the  uiidhram,  )>ous,  uiedulla. 
and  spinal  eord  e?<'npinji  entirely.  Various 
fomis  of  int'anlile  palsy  (Ho-calle<l  Little's 
disease),  idioey.  imbecility,  monoplegia, 
etc.,  are  to  be  encountered.  Kpileptiform 
couvulsinns  are  an  infrefjuent  residual  of 
a  miitor  zone  focus.  T\\e  prognosis  is 
usually  gtHxI.  Many  ]3atients  recover 
entirely,  or  with  niild  residual.  As  a 
nile  there  are  pomine,  bulbar,  or  spinal 
complications. 

H.  Pi>!.iin'nf'f/thnhtiji  llrmorrhaffiat  Sujh'- 
rior.  —  Wernicke  calleii  attention  to  a 
special  form  of  difTuse  encephalitis,  with 
pro]n»nneeiI  involvement  of  the  midbrain 
(op)ithiihnople}£i]u>).  In  one  sense  this  i.s 
not  a  true  iidlammatory  reaction.  In 
the  alcoholic  and  syphilitic  patients  the 
course  of  tlie  atfection  resend)les  tliat  of 
the  Knrsakow  syndrome,  with  pronounce<^l 
eye  palsies.  There  is  usiiidly  an  initial  de- 
lirium, sometimes  appearing  hiter.  Ilead- 
aelie,  nausea,  and  vomiting  precede  the 
development  of  an  irregular  type  of  oph- 
tlialmoplepia,  ap{)areutly  nuclear,  possibly 
neurit ic.  Ptosis,  nystapnus,  irrcgidar 
pal.^ies,  optic  neuritis  are  frequent.  The 
gait  Is  ecrehellar;  the  s[)ec<'h  is  slurring: 

the  mental  disorientation  for  time  and  pla(«  and  confabulation  are 
marked.  Somnolenceantllossof  scnsi^ry  finictiiinsarealso  frequent, and 
point  to  the  involvement  of  the  thalanuis.  Tliere  is  no  fever,  no  leukn- 
cj'tosis,  and  a  doubtful  cerehruspinal  (hiid.  The  pulse  is  usually  rapid 
-SO  to  lAt  often  found.  The  nerve  trunks  and  muscles  are  usually 
tender  in  the  alcoholic  types.  Many  of  these  patients  clear  up  to  a 
marked  dc|<ree.  but  there  is  usually  a  residual  mental  defect,  showing 
in  a  lack  of  initiative  anfl  mitd  deteriorated  states. 

The  lesibns  are  those  of  a  difTusw  neuritis,  with  hemorrhagic  foci. 


Km.     ;fitti.  — Itiiiiijiili-     ■i-u'luftl 
pftUy.     <  KmiK'tiikuil.) 


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DISEASES  OP  THE  BRAIS 


\  non-alcoholic  variety  han  Itrrn  descril>e(l,  in  wlucb  stminolcnce 
is  more  miirked  than  delirium.  There  is  ptosis,  complete  ophthalmo- 
plegia, with  vertif?o  and  ataxia,  disorientation  and  fpetjuently  con- 
fahtilntinn. 

Occa^ionnlly  [wjisoning  by  muasels,  by  fish,  bromides  or  from  rabies 
shows  similar  clinical  pictures. 

4.  P}/f)genic  Tifpen. — Here  a  multiplicity  of  affections  is  to  be  rcrk- 
one<l  with.  Age  is  no  bar.  Traumatism  bulks  hifjli  in  the  percentage; 
also  ear  disease.  The  onset  is  usually  acute,  particularly  in  the  younger 
patients.  Tnuinia,  or  niiddte-ear,  labyrinthine,  sinus  or  other  pyogenic 
inrcction  is  fnliuwctl  by  malaise,  headache,  nausea,  and  vomiting  with 
advancing  stupor,  or  convulsions  and  increasing  coma.  GreAt  restless- 
ness, with  increasing  ilclirium,  usually  develops  within  from  tliree 
days  to  two  weeits.  Leukocytosis  Is  usually  pn,'setit.  l-imibar  puncture 
is  usually  negative,  except  when  meningeal  sympt<mis  arc  also  prcseul- 


Fiu.  310. — ParcaU  will)  Koraakuw  syiidroiiiei  Wcruiirkv'H  p<iUucDcnp1iatiii8  supmor. 

Topical  -iigus  arc  very  frcf]uc]it.  These  are  monoplegia,  hemiplegia, 
epileptiform  convulsiitns,  cranial  ner\c  palsies.  If  the  delirium  clears 
up,  one  may  find  aphasias,  pseudobulbar  palsies,  various  midbmin 
syndromes,  hemianopsias,  and  bulbar  palsies. 

Many  patients  die  in  coniii.  Others  rwover  with  marked  mental 
defect  (cerebral  atrophies  of  childhuod.  idiocy,  imbecility,  debility). 
In  i»tiiers  iJie  general  signs  of  brain  abscess  (i^.  r.)  become  apparent. 
Again  others  clear  up  with  hemiplegias,  mouoplegiu,  diplegias  (so- 
called  Little's  dtsoase).  Finally,  others  recover  entirely,  or  show  small 
focal  residual  lesions. 

Diagnoeia.^  It  is  im|>ossihlc  with  present  methods  to  clearly  dis- 
tinguish all  of  the  various  encephali tides.  Many  are  not  diiigiioscd 
during  life,  the  course  behig  so  rapid,  and  fncilities  for  laborHtorj* 
research  limitt-^l.  Oppenhcini  Iws  well  said  tliat  at  the  present  time 
(19II)  any  attempt  at  presenting  the  problem  is  only  jmtchwork. 

Wernicke's  type  is  characteristie.  It  is,  however,  frequently  reserved 
for  the  psychiatrist  to  make  the  diagnosis,  as  the  mentkl  symptoms  so 


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567 


the  ph.Viticnl  sixiis.  OphthalriKipIcfcia,  iieurltU.  dLsorientatioii 
fur  time  and  p]hiv,  with  tHitifabulation,  pn»firosi>ui^  lo  detirium  or 
coma,  the  almost  typical  far-ics,  closoly  rcst'mhlirip  tlie  Knraakow  fofiea, 
tiK'hycarHin  and  rw*  hyi»erlhermia  are  the  Imdinf;  features.  Here  the 
I'litirt'  series  nf  the  HlcoholiL'  Hyiidmrnes  must  he  reviewe*).  (See 
Ala)holism.* 

Foli(»fncephali)inyeiiti.'<  i^  t(i  Im-  susik'<*1«1  during  an  epidemic.    'I'lic 
aciUe  onset,  frequently  with  ^^t^o-inte:itinal  or  tiasal  resi>iralory 
predecessors;  the  frequency  of  spinal  and  Imlhar 
involvements;  usual  ahsemt- of  si^ns  of  neuritis; 
lost    knee-jerks,  spinal  fiuid   findings  are  sug- 
gestive. 

Meningitis  often  calls  for  diagnosU.  Here 
lumbar  puncture  h  of  gi-eat  service,  since  many 
of  the  initial  clinical  signs  are  i<lcntiral.  In- 
crease<l  pressure,  presence  of  cellular  elements 
and  pus  are  present  in  purulent  meningitis.  In 
epidemic  ct^rebruspuial  meningitis  there  U  the 
elumicteristic  organism. 

Herpes  is  usually  alisent  in  eui-eplmlitis;  the 
neck  and  muscle  hy[>eresthesiu  usually  less. 
Eye-muscle  palsies  are  often  absent  in  the 
pyogenic  types  of  encephalitis;  they  are  not 
infrequent  in  meiiingili?..  In  syphilitic  types 
the  Wassermnnn  test  is  of  gn-at  service. 

Tharapy. —  Priictifally  only  in  the  malarial 
and  syphilitic  encephalitides  is  there  any  specific 
therapy.  In  the  pyogenic  forms,  with  abscess, 
surgery  is  demanded.  The  i>oisoniiigs  require 
withdrawal.  Bromide  poisoning  is  not  to  he 
overlooked!, 

All  these  (wiients  require  het\  treatineiit  iti  a 
darkened  room.  The  toxic  cases  shniild  have 
h(>t  sheets  and  elimination  encuuragerl.  Ice- 
hags  to  the  head  gjvc  comfort  and  c^iuntcr- 
irritutioii;  they  do  not  alfcct  iiilenial  lenipem- 
turea.  Active  I'attuir^is  is  (lesiralile.  ca  lomcl  and 
salmes  being  advisable. 

In  tJie  inHucn7.al  types,  salicylates  are  hidicate<l.  Otiierwisc  the 
treatment  is  largely  symptomatic.  The  residual  symptoms  call  for 
their  HfHH-inl  thempy. 

Abscess  of  the  Brain.  -  History.— Brain  abscesses  have  been  recorded 
for  many  years:  Cniveilhier's  and  f'arsucH's  illustrations  are  classic. 
The  steps  tlial  led  up  lo  the  prcscnt-tlay  ciinccjrtion  of  brain  abscess 
are  partly  outlincfl  in  the  scctiipn  ()ri  Knceplmlitis.  The  history  of 
these  two  groups  is  almost  identi<-al  up  to  the  appearance  of  Wernicke's 
Uhrbuch  d.   Gehimkmnkheitpn,  1.SS3,  when  a  ilivision  into  infectious 


Fici.  an.  — lufouiiitf 

cntlutl.) 


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5fiS 


mSBASBS  OF  THE  BUMS 


and  iinn-inffctious  al)Sit*sses  wuv  forcsluidowt'ii.  Mat-Kweii's  H.'^iflS) 
studifs  gave  a  f^reat  impttus  to  the  understanding  of  the  ports  of 
entranrc.  wliile  Komers  (19()2  UH)S)  studies  have  set  in  rlfur  relief 
the  important-e  of  aural  disease.  Itccent  monographic  treatinent-s  are 
tlu'se  of  Oppeiiheim  and  Cassirer  (liHH)),  BrisKaud  ami  Schjuos,  in 
Houclmrd  and  Hrissaud's  TriiitfiU-  Mrdirlvf-  (1004),  ix.  LewHiidonsky, 
in  U-WHiiduwsky's  Uaiulhuvh  drr  Xfnrolgie  (1912).  Southard,  in 
Osier's  MoflfTti  Mi'tlicine  (1915). 

Etioloey. — Cerebral  abwress  is  alnioHt  exclusiwly  a  secomlary  pln'Mom- 
enoii  due  tcf  nift'ction.  Many  organisms  have  iwcx\  fiiund  in  i-crehral 
abscess.  They  are  derive<i  from  many  sources;  external  trauma, 
the  venoa'i  sinuse^j,  and  ntitls  media  being  among  the  eommiinest. 
Otitic  infection  supplii-s  about  a  thitxl,  the  usual  eninnuiidesitioii 
being  tlirungli  tlie  teginen  of  the  tintrum.  Metastatic  abscesses,  fn.»m 
]jyemin,  tnbereuli>sis,  osteomyelitis,  abstess  vi  lung,  empyema,  elc, 
are  not  infrequent.  Actinomycosis,  amebic,  and  oldium  infections 
arc  among  the  curiosities.  Streptocot'cus  pyogenes  is  the  most  fre- 
quently found  )>actcrium.    Multiple  infection  is  the  rule. 

Symptoma.^'Pht-rc  is  always  some  anteecfJent  disoMer,  although 
such  may  be  overlooked  or  silent,  the  acute  miliary  tuberculosis  of 
cardiac  disease  being  au  example.  The  symptoms  will  vary  greatly 
with  the  exciting  cause,  the  site,  and  the  size  of  the  abscess  or  abscesses. 
Certain  traumatic  abscesses  nni  their  fatal  ciiurse  in  tliree  to  five  da.\-s, 
whereas  some  recorded  cases  have  persiAted  for  years. 

There  are  enough  cases  described  to  show  that,  .speaking  in  general 
terms,  one  may  rea>gniKe  (1)  a  stage  of  irritation,  (2)  a  stage  of 
remission  or  latency,  and  (3)  a  stage  of  paralysis  nr  of  aeutr  pro- 
gression. 

1.  Prinifiry  Staije. — In  the  initial  stages,  general  rather  than  Im-aliz- 
ing  signs  predominate.  The  patient  usually  lias  an  acute  rise  in 
temperaturv;  it  is  frequently  slight,  insidious,  and  variable,  and  often 
absent  after  a  few  day.s.  The  puhc  is  often  slow.  Headache  is  rarely 
absent  but  is  very  variable  in  inteiwity.  It  U  most  frt»quently  dull, 
but  gives  a  sense  of  tension  in  the  head.    There  may  be  some  vomiting. 

.Such  a  tense  iieadaehe,  with  rise  in  tem|X'niture  and  slow  pulse, 
following  an  otitis,  after  the  discharge  may  have  ceased,  is  of  grave 
unport.  Tlie  pain  is  situated  usually  over  the  side  aflecteil;  but  is  ni>t 
infrequently  slight  or  absent  in  cerebellar  cases  {q.  r.)  or  here  may  be 
frontal  hi  eliaracter.  Movements  are  apt  to  increase  the  headache. 
Anxiety,  in.somuia,  restlesanea.s  are  tlie  rule,  and  in  younger  patients 
tlte  sleep  is  often  broken  by  loud  cries.  There  may  be  some  delirium 
or  stupor  in  these  initial  stages,  which  occupy  the  first  three  or  four 
days,  occasionally  a  week.  There  is  frequently  some  li-ukoc>iosis  in 
this  stage. 

2.  Stage  of  Hmtissiuti  or  Lafericy.-^A  perioti  of  depression  often  sets 
in  about  diis  time.  The  headache  diminishes,  the  fever  diminishes, 
the  patients  are  fatigued,  somnolent,  indifTerent.    The  pulse  is  apt  to 


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rc>main  slow.  IVpi'iisslon  nt  lliis  time  may  reveal  temlerness.  'Hu* 
Mntwl  ouirit  is  viiriiililc.  \vi(l»  h  (tiuJwicy  to  pulyuudoar  iinTease. 
This  sUige  shows  extraor<linnr>-  variution  in  ilitlVn-nt  cHSi-^,  st)iTietitnf8 
persisting  weeks  or  months. 

In  this  stage  betriiinini;  chokMi  disk  is  not  infrequent,  espe<.'ially  if 
tiie  disorder  has  lasttx)  over  a  week  or  ten  ilays.  It  is  apt  to  first  npfiear 
homohiterai  with  the  abscess.  There  arc  imlrfitiitc  signs  i»f  »  tf  n-hral 
ntreelii)ir.  vjiriablr  headache,  owasional  nausea,  vomitiTijr,  fainting 
attacks,  or  convulsive  seiaures. 

Thi-  jnipils  are  fivquently  luiequal,  if  there  is  pus,  and  the  more 
dilated  pupil  is  apt  to  be  on  the  side  of  the  abscess.  With  maxiinun) 
e(|iial  ilUatation,  the  jncaliz-ation  is  dilKcult  from  the  pupils  alone, 
and  such  dilatation  argues  for  a  large  abscess.  With  increasing  size, 
immobility  appears.  Contracted  pupils  are  found,  in  a  few  instances, 
towani  the  end  in  severe  eases. 

3.  iihige  of  Adnnicr.— After  a  period  averaging  from  one  to  three 
mouths  the  symptoms  of  an  advancing  cerebnd  pressure  nianifest 
themselves.  There  are  dehrium.  often  epileptiform  convulsions,  all 
of  the  symptoms  of  a  generalized  meningitis,  with  death. 

Occasionally  encapsiilatiun  occurs  with  no  s\Tiiptoms  for  from  ten 
to  twonty-eight  years'  (Nauwerck). 

Course. — The  course  just  dcscTilRt!  is,  statistieatly  spi-iikinj;,  the 
most  frequent,  but  it  is  by  no  means  universal.  In  ninn\'  cases  there 
is  an  acute  progressive  course,  without  any  intermission  or  remission. 
This  may  also  follow  a  latent  ixTJod,  ur  may  develop  acutely  after  a 
trauma,  or  following  a  suppurative  process  in  the  ear  ur  nose.  In  otliers 
there  occurs  an  acute  prf»gressive  (xiursc,  with  a  remission  which  is 
ineumplete.    The  chninic  course  is  as  desrril)ed. 

FormB.— The  most  marked  are  the  traumatic,  the  otitic,  the  rhino- 
gt-nie,  and  metastatic.  In  the  truumaiic  cast's  the  abscess  is  usually 
near  the  site  of  the  trauma,  and  the  symptonis  of  tlie  ahsei'ss  formatiitti 
are  apt  to  be  complieati-d  by  the  traumatic  incidents.  The  symptoms 
of  a  leptomeningitis  develop  early,  whereas  those  of  a  purulent  destruc- 
tive nature  usually  require  from  eight  to  foiirteen  days  (Hergmann). 
The  whole  development  is  lusually  gradual,  and  the  stages  far  from 
being  sharply  set  nlf  one  fn)m  another.  Ileadaelie,  fever,  vnniitiiig, 
vertigo,  confused  delirium,  tliese  are  iJie  prodnmial  signs.  The  focal 
lesions  occur  several  days  later,  either  as  an  eptlt-psy,  a  cortical  motio- 
plegia,  a  speech  or  otiier  motor  or  sensory*  defect. 

Traumatic  htc  abs<es.ses  arc  also  known,  weeks,  moaths,  even  years 
go  by,  Ijofore  the  full  truth  is  known. 

(Hiiic  brain  abscesses  are  frequent,  yet  in  proportion  to  otiti.**  are 
rare  (Jansen,  7  in  oflOO  rases).  Hero  the  original  disorder,  the  loeal- 
iiuition,  and  tlie  complic-atinns  are  of  moment.  The  development  1ms 
already  bwn  sketched.       It  Is  very  insidious  in  many  cases.      The 

>  Sim  Uppruheini,  loc.  rit.,  fur  literalun  uf  lb««e  nn  vwes. 


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DtStSASEfi  OF  TUB  RJtAtS* 

liicaliztttion  is  usually  i-Uher  tenipc)ri»spticiui»lal  <(r  ixTt'lK-IIar.  Ilnn- 
mun's'  study  of  SLS  iaR<«4  showe<i  that  thrre  were  .'il^9  cerebral  and 
279  fert'bellHr  'mvol\Tuieiits.  Of  Wo  carel'ully  studiwl  cases  the  loi-al- 
izations  wtre  as  follows:  Tcnipttral  '4^)b.  tcmpornl  nml  (nt-ipital  19, 
temporal  and  fnmtal  4,  ti-iup<}ral  and  fcrt'bi-llar  111.  <»tdpital  It.  fronla) 
3,  tert'bdlar  IHH,  others  scattering.  The  syiupionmtulojrj'  "f  riplit- 
and  Ifft-sukni  tenipimwpbenoida!  alwcesses  or  tumors  ('tTt'rc(insideral)le 
variations.  A  riphT-sidwl  absress  may  pursue  its  course  with  little  nr 
no  localizing  signal.  Left-sided  ones  often  n've  rise  to  apliasic  Ciiinple.xes. 
Pressure  upon  the  pyrnmidnl  tracts  will  pive  elmmiteristie  beniiplegic 
phenomena,  (here  are  apt  to  be  disturbanees  of  smell,  djreet  or  sul»- 
jet-tive.  olfactory,  or  uncinate  fits  (Knapp,  fuc.  rit.). 

lihiftogertic  abscts-Hcs  are  usually  lucatwi  frontally.  In  addition  to 
tbt  headache,  there  is  frequently  a  certain  degree  of  torpor,  often 
as.soriated  with  a  tendency  to  joke  (Witzelzueht),  t.solate*!  choked  disk, 
a  cerebellar  type  of  ataxia,  when  the  cerebello-rubrdcortind  filters  are 
ini|»Iicat«l,  isolated  tretnor  of  the  hjiiid,  and  olfactory  disturlwnces. 
When  the  abscess  nnu-hes  farther  back,  motor  synipt<inis  oL-eur. 

Diafnosis.^jVTany  ditTereiitial  points  arise.  The  etiology  is  the  most 
important  factor  to  Ik'ht  in  mind.  Traumatic  purulent  ineuiiigitLs, 
apoplexy.  late  apoplexy  (Bollinger),  pachymeningitis,  brain  tumor, 
tuberculous  meningitis,  syphilitic  meningitis,  hemorrhagic  encephalitis, 
meningitis  Hen>sa,  psycliogentc  headache,  sinusitis  and  sinus  thrombosis 
are  the  chief  disorders  to  be  reviewed.  The  last  often  runs  a  very  simi- 
lar course,  ami  is  often  8^sueiale«l  with  a  purnleiit  otitis,  as  a  fimda- 
mental  disi^rder.  Mere  the  fever  ts  apt  Ut  he  high  and  remittent,  even 
on  the  same  day,  rigors,  chills,  and  jjrofuse  pcr>])iratiori.  pulse  usually 
rapid  and  irregular,  convulsions  rare,  save  perhaps  in  children,  head- 
ache constant,  eye-gnamds,  as  iu  abscess,  usually  bilateral  neuritis, 
more  frequent  than  choked  di.sk.  Focal  symptoms  rare.  I'hysical  signs 
of  swollen  spleen,  ami  metastatii*  invasions  confirm  tlie  illagnosi.s  of 
thrombosis. 

A  purulent  meningitis  may  lie  mure  difficult  to  differentiate.  It  may 
be  caused  by  similar  factors;  it  is  usually  more  acute  and  stormy  in 
onset;  it  usually  nms  a  sliorter  course,  slums  higher  and  more  con- 
tinuous fever,  herpes,  the  pulse  usually  rapi*!.  irregular,  often  slow  in 
beginning  as  in  absces-s,  initial  unrest,  irritability.  ci»nfiisiiin.  delirum 
in  contrast  to  a  heaviness  or  c(tma  in  abscess,  headache  constant, 
vomiting  frefpient,  convulsions  common,  genera!  clonic  and  often 
muscular  twitches,  the  eye-gronnd.s  are  less  often  positive,  meningeal 
irritation  phenomena  (Keniig,  spasticity,  i-hnnis,  etc.),  coiunMin,  liM-al 
symptoms  more  con/lnetl  to  cranial  nerves  and  basal  >igns  rather  than 
intracerebral  f(K'al  .signs,  spinal  symptoms  fretpienl,  wheix-as  in  abscess 
they  arc  rare.  Furthennore,  the  cerebrospinal  fluid  is  more  apt  to 
contain  globidin  and  show  a  Iv-mphoc.vtosis  or  even  pus. 

>  Arch.  f.  nhreiihk.,  Ixxiu,  258. 


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ABSCESS  OF  THE  BRAIN  571 

FrogBCWis. — When  left  alone,  cerebral  abscess  almost  invariably 
causes  death.    Calcification  or  external  discharge  occasionally  occurs. 

Treatment. — ^This  is  exclusively  prophylactic  in  nose,  throat,  and 
otitic  work,  and  surgical  after  the  development  of  the  abscess.  The 
results  of  operative  interference  are  highly  satisfactory.  The  statistics 
v&ry  with  each  new  series  of  cases.  In  the  hands  of  competent  surgeons 
the  risk  from  operation  is  nil.  The  temporasphenoidal  and  frontal 
absces.ses  can  be  readily  reached  and  drained.' 

>  Starr:  Med.  Record,  1906;  Halsted,  in  White  and  JeUiffe,  Modern  Treatment  of 
Xervnufl  and  Mental  Diseases,  1013. 


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juca 

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CHAPTER   XII. 

DISKASES  OF  THE   BHAIK   (Continukd). 

TASCULAB  DISTURBANCES     CEREBRAL  APOPLEXIES. 

TriE  quantity  and  cioality  (visposity)  of  the  hlmw),  the  hi^art  acti 

ami  the  size  htkJ  activity  uf  tlie  liloiKlvcsst-ls  art-  tin-  chief  factors 
which  guveni  the  general  us  well  us  tiie  ecreliml  hlntKl  (low.  Of  aU 
the  bodily  structures,  the  brain  is  among  the  most  highly  vascularized. 
arguing  for  its  great  functional  acti\'ity.  Knrtlie.rmore,  there  is  marked 
plasticity  evi<)ent  in  the  compensatory  rcgutation.s.  Not  only  is  there 
ii  continuous  balance  maintainerl  between,  Hiil'erent  vascular  sy.stems. 
c-ijx'rially  Ijctwet'ii  tliose  larger  groups*,  such  as  the  portal  system,  the 
ves.sels  of  the  skin,  the  muscles,  and  the  brain,  but  within  the  brain 
itself  dilTerciit  Uiluncing  reactions  arc  constantly  going  on  Ix-tween 
speech  ureas.  >isual  arcjis,  auditor^"  ureas,  motor  systems,  etc..  wlucU 
are  thrown  into  use  at  different  times  in  specialized  occupations 
activities. 

The  anatonucal  structures  used  in  regulating  these  compensa 
me<'hanisms  are  partly  lt)cali7.eil  in  the  medulla  and  eoi-d,  as  di.seus.-^e< 
in  the  clutittcrs  ini  the  Vegetative  Nciirohig>'  of  the  \'jiscular  Appara- 
tus, hut  parts  are  \nthin  the  vascular  apparatus  itself;  at  times  within 
the  walls,  again  witluu  the  circulating  blood  (viscosity  disturbance).' 

The  smaller  cerebral  ves:4els.  in  uniformity  with  tlie  softness  and 
plasticity  of  a  dcvchipirg  organ,  have  less  rigid  walls,  hence  raoreeasily 
overfill  (congcstionj  and  contriut  i,l"»inting),  are  more  liable  to  i^ymn- 
taneous  nipture,  and,  furthermore,  many  differ  in  that  they  have  few 
or  no  anastomosing  branches.  Thus  special  problems  are  connected 
with  the  cerebral  circulation.  The  avenues  of  bitiod  intake  are  thniugh 
the  two  internal  carotids  and  the  two  vertebrnls.  The  cdurse  of  the 
left  iutcriial  carotid  is  mure  direct,  and  it  lias  been  taught  tliat  tlirombi 
are  therefore  more  common  on  the  left  side.  There  are  no  deci^ 
facts  to  bear  out  this  a  priori  conjecture. 

The  vertebrals  unite  to  form  the  basilar,  wliicli  bifurcates  into 
two  large  posterior  cerebral  vessels  which  supi>ly  the  tern ])oro-ocei pita' 
lobes,  the  cor[Kira  quadrigemina,  crura,  and  parts  of  the  optic  thalami. 
The  posterior  con nnuni eating  branches,  usually  small  aiul  synunetrical 
and  subje<'t  to  great  variation,  pass  forward  to  join  the  internal  caroti<ls, 
and  are  given  off  to  the  base  of  the  brain.  The  internal  wirotids  form 
the  iniiidle  cerebral  and  the  anterior  eerebnd  arteries,  an  ante 
communicating  branch  completing  the  circle  of  Willia. 

>  HiTBohfvld :  Zischr.  f.  N«ur.  u.  P^uh.  rfl..  W,  103. 


]ibi 

ital 


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VASCULAR  msrVRBAXCES-CERERRM.  ArOPLEXfBS     573 

Tile  mitidlf'  cerehral  artprit*s  lie  in  the  Sylvian  fissure,  pving  off  mimy 
tipMnrlK's  Ui  the  leiitirilliir  micleus,  the  ititenml  fapsiile,  yxirtioris  o( 
the  tluilitmiis,  and  su[HTfifially  irrigate  the  Itslaiul  of  lU'll,  Ilpsehl's 
convolutiim,  and  inudi  of  the  liitera]  us|>ect  of  the  hrain. 

The  anterior  fcrebrararteries  sui>ply  the  frrmtal  areas,  the  olfactory 
apparatus,  the  upper  margin  of  the  frojital,  parietal,  and  otripital 
lobes  on  their  niesitil  aspects,  uml  tntich  of  the  corpus  <:all(K«um. 


frOBf 


t^H  Iff  ma fpiim/  co'tvl 'I!'" .  nfrrior 
aiuF  nJiUb'/rimfjIconiuMfoiM.  itpptr 
jMirt  <f  mrtadatg/rv't-ol  nmrnfii lion 


turfaet  1/  /Inl  //vnlJV  rv*  n^Hliofi . 

Ufi)«rjijrf  of  aic./i.'ulal  n— m/uJu-ji, 


Ihini  fnml.  tuHrulutUim  iiMin 
part  of  <iftntal  taifaet  c/ 
•vilatietM 


AM.fnint  iVBraTuIlO'i 


.lir-  furiflal  onauafufi"*.  Uimt 
pari  of  mp.pariaoi  (uniuiufun 


Skjir«marp<iMl  ^rvj.  fii,t  trmp 
trnMi-vhHon:  pari  f^  meumj  Irnp. 


t'lteiMale  nrxt.  \ 


OeciptfBi' 


/■MET  oJiJ  mitwr  imr/ittn 
I  </  ectipilal  Alt*. 


Svp.  turfaet  0/  ernuaum. 


Atl  batttr  ^  la/.  turf  net 
of  ctr^Mtam. 


"-*.  W-  CirtbttUr 


Inf.  mitfaei  ^oerAtBaM. 


Ftn.  312. — Circio  ol  Willie  luid  brBnehe<.  wiilt  iiulicittiori  ul  dixribulioDs.     Heiooiu 
A.  B  mo«t  fmqiieiit  dtoa  for  hcmurrhaBai.     (tircD&Bcrc,  from  Fim&e.) 

The  rerelHJhini  flerivea  its  supply  from  the  vertehrttl  nri*l  hasilar 
arteries. 

Partial  compeiisatory  l>ulanee  of  the  ein-ulation  is  hroujjht  alwut 
chiefly  tliniugli  the  circle  of  Willis.  Tins  circle,  as  well  as  the  hnmches 
frotii  it.  shews  a  vast  lUiinlHT  of  anoinitlics.  and  these  tii  part  dctcriniiie 
many  aiionmlous  cerebral  disturbances,  possibly  relatwl.  as  Bluckburn, 
Windle,  linllen,  and  others  ha,ve  ahawn,  to  faulty  cerebral  development, 


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574 


tE  BRA  Iff' 


irucfl 


thenfby  iBviti^  tlit*  aiiatoniicul  foiiniiatioti  for  a  neuro.sLs,  a  psvchosis  or 
some  aberrant  vascular  disease;  (sriftening,  deterioration,  vicarious 
mcnstniatinn,  etc.).  Kitrthernmri',  surh  iiiifjniidies  are  of  great  surreal 
importance.' 

Tlie  chief  cerehral  arterial  ilisunlers  arise  from  in)  teniporun.' 
vascular  instaliijitv  (sluick  renctions,  cardiac  irregularities,  intcniaJ 
secretorj'  disturbances),  (fc)  protracted  rt'trressive  changes  (arterio- 
sclerosis, witli  or  without  miliary  aneurisms),  (c)  lieraorrhage,  (rf) 
thromljosis,  (e)  emboUsm. 

Venous  changes  arc  less  frequent  than  arterial  ones.    Sinus  thi 
boses  are  the  most  iinpurtant. 

(a)  Vascular  Instabili^. — Tliis  is  a  very  variable  factor  and 
been  discIl^^!rl^  uiidcr  ilic  sections  on  Vegetative  Xeurulog^v.  Vago- 
tonia luiil  viigntropin  in-cur  in  the  cerehral  vessels  as  well  as  in  die 
somatic  vessels.  The  results  were  previously  grouped  under  tht 
concepts  cerebral  anemia  and  ceri'bral  hyperemia.  Chronic  va( 
tCMiic  conditions  are  known.  They  should  not  he  called  cerebi 
congestions.  _ 

Anemia  (ShcK-k;  noci-a.ssociation — (Vile)  re-sults  from  loss  of  blcMxl, 
paracentesis,  surgical  handling  of  intestines,  canliae  weakness,  or 
from  marked  vascular  instability,  often  of  psychogenic  origin.  The 
symptoms  are  faintness,  flizzliiess,  black  spots  before  the  eyes,  buzzing 
in  the  ears,  and  it  may  be  loss  of  consciousness  with  or  without  luusea 
and  vomiting. 

There  may  be  partial  consciousness,  apathy,  or  semicoma,  wit]>  c« 
tracterJ  pupils,  and  cold  and  clammy  skin,  occasionally  lass  of  bladd< 
or  bowel  function. 

The  therapy  is  heat  and  bandaging  of  the  extremities,  the  horizont 
position,  camphor,  cafTein.  and  cardiac  stimulants,  alcohol  ai 
ether. 

Hyperemia.— i  lypereraia  may  Ije  active  or  passive.    The  former  mi 
result  from  vascular  instability,  ur  is  not  infrecjuent  after  excessiviT 
eating  or  drinking.    Sudden  emptying  of  the  peripheral  and  somatic 
vessels    may   occasion   it.     It  is  frequent    in    certain  th\Tnidisni( 
not-ably  in  exophthalmic  goiter  and  in  [laturut  and  artilieial  ment 
pause  states,   which  latter  often  are  aceum|>anied    by  changes  in 
the  organs  of  internal  secretion.    (Sec  Vegetative  Kcurolog>',  £ndo- 
crlnopathies.) 

The  s.vmptoms  of  hyperemia  are  redness  and  congestion  of  the 
face  and  eyelids,  {Kmrnhng  in  the  ears,  or  ne<-k  or  head,  headache, 
confusitai,  and  usually  contracted  pupils.    More  severe  attacks  may 
lead  to  acute  confasion,  ri.se  in  temperature,  and  the  general  picture  gta 
an  acute  meningitis.  1 

Signs  of  ciMigestion  of  the  face — flushing;  a  sensi*  of  fulnesis,  etc., 
must  not  be  taken  to  necessarily  mean  iri-ebral  congestion.    It  slioi 

>  I.  W.  BUokttura:  Jvat.  C^ms,.  Naur..  11)07.  xvli,  va ;  lOlU.  si.  lh&. 


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VASCULAR  DISTURBAS'CES— CEREBRAL  APOPLEXIES     575 

be  Wirne  in  mind  tliat  the  vessels  of  tJie  faw  and  those  of  the  hraiii 
arc  runlrolle*!  l\v  sepnnite  mwhniiisms. 

Passive  hypcremms  result  from  ineclmmewl  obstruction  to  the 
jugulars,  rliirflv  frimi  new  j^rowtlis.  enipliysenin,  and  loss  of  minjjeiLsa- 
tion  of  heart  disorders.  Pressure  of  the  head,  abnoruial  wakefulness 
or  sictpincss,  dizziness,  apathy  or  mild  confusion,  with  anxiety,  are 
the  chief  Hi^s,  eombined  with  deKnite  signs  of  passive  oonf^estinn  of 
the  skin,  face,  and  mucous  membranes. 

KtHeient  therap>'  consists  in  amelioratint;  the  cnusative  factors 
wliether  active  or  jjassivc.  The  hy[>ereniias  are  purely  secondarj'. 
Acute  states  may  call  for  bleeding,  mustard  foot-baths,  active  cathnniis. 

ih)  Cerebral  Arteriosclerosis. -This  is  a  wiilespread  disortler  occur- 
rinj;  chiefly  after  forty  years  of  age  when  with  incrensinj:  years  it  tends 
to  become  more  and  more  prominent.  The  arteriosclerotic  process 
differs  little  in  cerebral  vessels  fnim  those  located  in  iitlu-T  origins  of 
the  body,  save  in  a  temlenc^*  for  a  marked  pnxluction  of  miliary 
aneurisms.  These  are  larf^ly  conser\ative  formations  and  are  not 
til  lie  considercil  as  priMhutivr  of  beniunluige.  as  tiuiKht  by  Charcot 
and  Hnucliiinl.'  <'erebral  iirterioselerosis  is  tlue  to  the  same  causes 
that  produce  artcriuscleriKiis  elsewhere  (herc*<hty,  syphilis,  alcohol, 
clironic  adreiialemia  from  emotional  or  other  factors,  etc.),  and  may  be 
the  expression  of  a  jrcneral  disease,  4>r  may  be  sharply  dclimitc<t  to  the 
cerebnd  vessels. 

Symptoms.— The  symptoms  of  earh'  arteritwelerosis  may  be  Reneral 
or  locnlize<l.  The  chieHy  early  symptoms  are  sleeplessness,  restless- 
ness, headaches,  espe<-ially  if  there  are  dir/y  attacks,  and  renal  chaQges, 
neiind  fiitigiic.  itu-rensed  eniotioiiiihsin  and  irritability.  To  this,  at 
times  is  addeil  liclM-tiide,  ready  f»trKctting.  csjM'fiHlly  of  new  bnpres- 
sions,  iniTejiseil  bloiKl-prcssure.  These  signs  an-  often  loosely  and 
improperly  spoken  of  as  neurasthenic.  l/ocal  sifins  may  be  added, 
sucJi  as  temporary  lapses,  marked  sonniolcnce,  tingling  or  numbness 
or  other  signs  of  focal  disease. 

The  chief  neurolipgica!  intere~sts  are  ft^cussed  upon  the  di-stribution 
of  the  fi«al  lesions  anil  are  here  discussed  according  to  the  syndromes 
prcsenteti,  The  pM  eliiatric  features  are  only  mentioned  here,  as  they 
are  considered  in  the  sjjecial  groupings  under  the  senile,  presenile  and 
arteriosclerotic  p^yeho«.'s.  (See  Section  III.)  Thus  only  the  more 
distinctly  neurological  features  arc  accent«l  in  this  place.  (Sec  tables 
in  chapter  tui  Mi<lbrain.) 

These  chief  syndromes  are:^ 
I.  Disorders  due  to  disease  of  the  tvrig:i  and  terminal  branches, 
(o)  *  ortic-al    branches;     irritative    complexes,    Alzheimer's 

fiisejise. 
(i)  Meilullary  branches:  lacunar  complex. 
(c)  DifTu&e  types  (arterttfsclerotie  deiumitias). 

'  0M  JHck:  Bori.  IdlD.  Wvhiiwhr.,  Pobruitry  21.  1910.  p.  325.  for  bibUosnph) . 
)  Lwnbtn:  8utw  Hotpiul  Bull..  ivOS.  i.  I76. 


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576 


DISEASES  OF  THE  BHAJN 


II.  Disorders  of  eluff  hraiirlics. 

(a)  Anteriiir  cvrebral  syndromes,  erural  palsies. 

(b)  Middle  (rrcliral  syiidrumes. 

1.  Palsies:   hetnorrliuge.  cmljolism,  throuibuiiiM, 
apoplexies. 

(1)  MunopiepEiA :  facial,  bmchiul. 

(2}  Combincil  palsies.    A[>oplexics  in  general. 

(3)  C'omplpte  [Mtlsifs:  rapsulararid  siipracapsular. 

(4)  Thalamic  syndromes. 

2.  .\phaHiim. 

3.  Hernia nnpsias. 
(e)  Posterior  <*t'r('l)ral  syndromes. 
<fl)  Iiitrrinr,  Mi|HTiiir,  p(_»stcrior,  wreW'llar  syndromes. 

III.  l>is()r<]prs  (if  large  triuiks  from  obliterating  lesioii:^. 
1.  Uasilar  sMidromes. 


CEREBRAL  APOPLEXIES. 

A  tabular  summary  of  all  these  is  to  be  foimd  at  the  close  c»f  the 

chapttT  on  Midliniin  Disorders  ff/.  r.l. 

Cerebral  Apoplexies.-  Hemorrhage,  Thrombosis,  EmboUam. — <  'lean- 
flit  examples  <if  these  syndromes  are  rare.  The  patients  presetit  mixcfl 
eondilions  save  in  the  feft-  instances  of  emlwlism  due  to  the  dnsure  of  a 
main  trunk.  For  this  reason  the  general  rather  tlian  the  sperini  t>*pe 
of  apoplectic  attack  will  be  described.  Special  indications  a-*  to  tlir 
loi'ikli'/ation  of  the  region  involvwl  will  l>e  noted  later.  Pontine  and 
midbrain  localizations  have  already  been  discussed,  as  have  also 
disorders  of  tJie  cerebellum. 

I>ifiiribution.  Causation. — Men  are  more  often  affected  (seven  to  Rve) 
than  women,  and  four-fifths  of  tlie  ca.ses  occur  after  forty  years  of  affr. 
Artcriosclcrrais.  as  indicated,  plaj-s  the  more  ini]hirtant  role  in  heninr- 
rhage  fiTnl  in  thrombosis,  and  the  smaller,  rather  than  the  basal  vi-saeb 
are  responsible,  f'ardiac  hj'pertrophy  with  increased  MocMl-jiressure 
(ISO  to  225  mm.)  is  the  chief  accompany iiig  factor,  and  is  closely  as.soci* 
ated  with  the  arteriosclerotic  prtM-ess.  (hnmic  kidney  disease  is  also 
a  frctiucrit  cniiconiitaMt  factor  {'.Id  per  cent.).  Kxi-iting  causes,  such  as 
great  physical  exertion,  lifting  heavy  weights,  coitus,  vomiting,  n)ugh- 
ing.  sneeziaig,  etc.,  were  fnmierly  given  a  protninent  place.  It  is  rlnubt- 
ful  if  they  have  nmch  unportance.  In  a  large  scries  of  cases  studied  by 
Jonc^,  in  a  considerable  number  the  stroke  otrurred  within  a  ft*w 
minutes  after  getting  out  of  bed,  so  that  tlu!  sudden  clumge  in  blood- 
pressure  on  awakening  and  getting  about  was  chiefly  responsible. 
Many  patients  develop  apoplexy  during  sleep,  although,  other  thinjpi 
being  equal,  sleep  is  a  protection.  Psydiogenic  facton;  play  a  much 
lar:ger  role  tlian  is  at  present  comprehended. 


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CKREBRAL  APOPLEXIES— ATTACK 


577 


The  localization  of  the  hemorrhage  (thromlnis)  varies  greatly, 
night  aiifl  left  sifles  arc  ahoiit  fquully  iiivolvt"*).  MorgaKi^i's  eurly 
riictum  ttmceminp  tlie  greater  prevalence  cjf  right-sitletl  hcinorrliages 
has  little  support  from  extensive  statisties.' 

The  <'hicf  syndromes  arc  of  the  ii)i<hlle  cerebral  tyjie.  The  bniiiches 
of  the  lenticulnstriate  arteries  supplj'inp  the  intenial  capsule,  caudate 
nucleus,  lenticular  nucleus,  ami  optic  thahtmus  are  most  fr«(ucntly 
iiuolveiE.  Thus  the  must  frequent  syiiilronie^  arethe<tjmhii3P<l  palsit-s. 
arm  and  leg;  ann,  leg,  and  face;  arm,  leg,  fac-e,  with  sensory  symptoms 
tind  Hphusic  {^amplications. 

("nrtlca!  hemorrhages  are  prohubly  much  more  frt^uent  than  is 
usually  supposed  since  many  (iccur  without  the  death  of  tlie  jiaticnt. 
Tlu'se  result  in  more  limited  syndroujes,  such  as  aprnxias.  arm  utnni)- 
plegias  (anterior  cerehral  sjiulronie). 

^Iollopk-gias  of  the  leg.  isolated  aphasias,  lower  quadrant  hcnilaiiup- 
sias,  and  the  thalamic  syndrome  Mong  more  especially  to  the  mi<hlle 
cerehral  syiicirome.  while  mind-blindness,  and  homonymous  heini- 
anopsixLS  are  the  chief  features  of  the  isolate<l  piwterior  cerebral 
syndromes. 

Midbrain,  pontine,  medullary,  and  eerehellar  hemorrhages  are 
comparatively  infpequeut,  and  have  a  special  s^Tidromy  deserihetl 
elsewhere.    iSee  Chapter  VIII,  Diseases  of  the  Midbrain.) 

The  Apoplectic  Attack.— Nausea  and  vomiting  arc  the  most  frtHpient 
precursors  of  the  apoplectic  attack.  In  tluxMnbosis  or  embolic  occluil- 
ing  lesions  twitchings  or  even  convulsions  are  more  frequent  as  precur- 
sor* of  tlie  attack  tluin  in  hemorrhagic  ca.s(y.  In  hemorrhagic  ca.ses 
with  convulsioiw  the  bleeding  is  more  liable  to  have  extended  to  the 
ventricles,  an<l  can  frequently  l:>o  demonstrated  by  lumbar  ]tuucture. 
This  is  not  invariable,  however. 

The  attack  is  usually  abrupt.  Dizziness,  heaviness,  anxiety,  head- 
ache, parestiiesia-  may  be  dcscrihcfl  by  thow  who  do  not  at  first  br<'ome 
suddenly  unctinseious,  ani)  \et  in  wlimn  a  gradually  developing  state 
of  unsciousness  occurs  with  jwraphasia  and  gnulual  weakness  of  one 
side  of  the  body.  Many  patients  are  able  to  descriW  the  begiimuig 
symptoms  with  accuracy  after  recovery  from  even  a  profound  coma 
lasting  a  week  or  uiore.  Loss  of  const-iousness  Is  usual,  however, 
especially  in  hemorrhagic  cases,  less  often  present  in  thrombosis  or 
cinbolism,  especially  in  the  beginning.  Iii  Jones'  scrie.>i,  47.7  [)er  cent, 
of  cases  of  embolism  showed  loss  of  consciousness,  impaiiment  in 
tiO  per  cent.  Thromboses  show  a  similar  percentage,  while  hemor- 
rhage is  accompanied  by  loss  of  con-sciousness  in  T.!  [ter  cent,  of  the 
cases. 

Coma  Is  then  apt  to  develop  and  is  accompanied  by  stertorous 
breathing,  and  by  a  slow,  full,  anil  n-gular  pulse.  The  patient  is  [jale, 
or  the  face  may  be  c<>nge:«te<l,  Uie  extremities  are  cold.     Tlie  limbs 


>  Sc«  W)fi  cnnee  i<»lli.t;t«d  by  Joiiw.  Btnti),  IIHKt. 


;J7 


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DISEASES  OF  THE  Bfi.4/Ar 


are  usunlly  completely  relaxei].  Irritative  phenomena  arc  usuaUy 
more  intlicativt;  of  rortieal,  basal,  or  ventricubir  liMnorrhages.  Minute 
variatuHis  in  the  excursion  of  the  twn  sides  of  the  chest,  irrcpiilarity 
of  the  iisualK'  diluted  and  light-inactive  pupils,  minor  signs  of  inn'm- 
bihty  (Marie-Foix)  uiay  enable  one  to  locate  the  side  of  the  heniorrhage 
even  in  this  comatose  state.  Other  signs  are  loss  of  corneal  reflexes, 
no  reaction  to  painful  stimuli,  loss  of  rcHexcs  in  general,  occasiouaiiy 
involuntary  urination  and  defecation.  Itetention  is  more  apt  to 
occur. 

In  severe  states  of  coma  with  marked  rise  in  temperature,  ItKJ*  F. 
to  105*  F.,  with  twitching  or  eunvulsive  jerks,  ver>'  slow  hcurt  action, 
later  developing  sjTnptoms  of  irregular  heart  and  brealhiiig,  the 
hemorrhage  is  probably  very  extensive,  teuds  to  How  into  tiie  vcntrides,, 
and  rleath  ensues  in  a  few  hours  or  ;>  few  dav-^. 


h'lf..   ;il-i.      ( 'iiri'liriil  lH-iuiirrli;>Ki'  nillilii  lt;i.-  vi.-titrnlc. 


Thalamic  cases  are  frequently  attended  with  marked  eoma,  whirl 
may  be  very  protracted,  three  or  four  weeks,  without  definite  hetni- 
plcgic  signs. 

Jaeksonian  con\'ulsive  attacks  usually  indicate  meningeal  bleedinp. 
Some  patients  show  a  tendency  to  clouding  of  conscionsaess  vlIiicIi 
comes  and  goes. 

lleioven  from  the  iinmeiliate  attack  may  take  place  in  a  few  hours 
or  after  weeks  or  more.  The  residuals  found  will  vary  according  to 
tlie  loi-atiou  and  extent  of  the  lesion.  It  b  in  tlus  stage  that  a  diagnosis 
of  the  localization  and  extent  of  the  lesion  can  be  made. 


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579 


Atifrrior  Carrhnil  St/ii(friniir. — In  emboli,  thrombi,  mul  lienmrrhage 
of  tlie  aiit>ertor  wrehral  arteries  tlie  lesion  may  he  limited  or  he  very 
extensive. 

Mikl  ur  sevcpi!  aiul  acutp  (■xjiifusions  with  variausly  rulored  mental 
defet-t  states  are  freiniently  the  result  of  initiiite  or  more  extensive 
ehanges  iti  the  vascular  supply  of  the  fruntal  lobes,  supplieii  by  the 
anterior  cerebrals.  These  patients  not  infrequently  present  lacunar 
s.NTnptoms  when  the  medullar\'  vessels  are  involved.'  The  clinical 
picture  is  pnrtean,  depending  on  the  severity  of  the  hemorrhage,  or 
softening  (from  embftlus  or  thrombus)  and  the  distribution  of  these 


>  'j'^ 


t.Z 


V  » -«>^- 


r  '' 


T"^ 


Fki.  314. — £xteiunve  VfFntritruSur  liem'>rriisiff>>  itoin  rui>iiiro  of  ftnamnloiis  (dupliftflud) 
nnUTii^r  cniikinuuicuLiuK  ariery. 

fwal  softeninp*.  The  course-  is  more  halting:  epileptiform  or  apo- 
plectifurm  attacks  with  acute  confusions  occur  from  which  the  patient 
is  apt  to  make  a  diniad,  n<it  anatomicii],  reccfvery.  The  patient 
is  usually  in  the  fourth,  fifth  or  sixth  decade.  There  is  increa.stng 
sense  of  incompetency.  Vertiginous  attacks  oc-cur,  with  headaclies, 
often  mi^^minous  in  rharacter.  Speech  and  thought  associations  are 
interfered  with  an<l  minor  monoplegias  devel<)p.  Apmxia  miiy  Ik*  an 
isnlatnd  symptom,  or  there  may  be  cnmbintil  apraxiii  ami  crumi 
monoplegia. 

In  more  extensive  lesions,  softenings  occur  (lacunar),  the  patients 
seem  to  drop  large  portions  of  llieir  mental  life  quite  suddenly.    These 

<  LMmhert:  Stale  Hai^.  Bull..  IIKIO,  ii,  45<J. 


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DISEASES  OF  THE  BRAIN 


s(rfteiiiiipi  usiittlly  sliuw  themselves  at  first  n.s  acute  exritetl  confu-sioM, 
stmiftimes  even  manic-like  in  thoir  pencrii]  trend:  others  slww  no- 
called  hysterical  coloring;  while  in  tlie  later  and  more  advanced  cuses 
aprasias,  haUucinoses.  and  more  global  defects  appear. 

General  progression  results  in  marked  mental  enfeeblenient — urteruH 
sclerotic  deterion»tioii~or  a  sudden  new  and  more  extensive  lesion  may 
cause  sudden  death. 

Irnlatire  atviple^es  from  cortical  vast-ular  disease  develop  not 
infre<|ueiitly,  even  In  younger  individuals  following  various  iiifeetiotis 
(thrombi,  emlK>]i  of  cortical  vessels),  alcoholism,  syphilis,  lead.  Mere 
transitory  mikl  shock  may  usher  in  the  disorder  witli  twitching,  jerky, 
choreiform  accompaniments,  or  these  motor  disturbances  may  Infer 
develop  as  residuals,  with  or  without  epileptiform  attacks.  Pares- 
thesisp,  astereognosis^  weakness  of  an  arm  or  leg,  or  mild  paresis  of  the 
facial  musculature  may  develop.  True  epileptic  residuaJs  may  be 
IHTmanent  sjTnptoms  of  certain  i>f  these  cortical  arteriosclerotie  focnl 
lesions. 

The  m'lAdlr  cerebral  9ffnilrojne.i  are  the  most  frequent.  Here  hcmi- 
{Jeijin  is  the  most  striking  rwidual  symptom.  In  total  lieniiplegia, 
usually  ca[»sular,  aupracajisuliir,  the  face,  arm,  and  leg  of  the  same  aide 
are  involved.  The  uppi-r  brunches  of  the  facial,  wrinkling  of  forehemi, 
closure  of  eye  are  mn.  usually  inipHcated.  Nor  are  tJie  eye  nioveinent.i 
modified  unless  the  lesion  is  located  lower  down,  crura  or  in  tJie  mid- 
bniin,  when  another  syndrome  is  present.'  The  face  is  drawn  to  the 
healthy  side,  the  tongue  pnijeots  to  the  paralyznl  side  on  pnitnihiun. 
Dysphagia,  from  hemiparesis  of  the  jMilate  develops.  The  si»ft 
l»alate  hangs  lower  on  the  paralyzed  side.  The  neck  may  l>e  iiivolveil, 
init  15  less  a])t  to  be,  wherea.H  the  paralysis  of  the  arm  and  leg  are 
characteristic.     (See  Plate  VIII.) 

The  arm  is  flaccid.  6abby,  apt  to  be  edematous,  blue,  cold,  and  bt^gj'. 
The  ri'flexes  whidi  during  ntum  arc  lost,  gnuhially  return  and  shortly 
become  exagg(?rate<l.  (-"haddock's  wrist  phcn<imeaon  develops.  There 
is  little  or  no  atrophy,  and  the  electrical  reactions  are  normal.  Later 
contractions  may  develop,  or  these  may  wcur  closely  following  t!»e 
attack  if  the  lesion  involves  only  a  portion  of  the  arm  fibers  or  en- 
crofiches  upon  the  tluilamus.  The  abdominal  reflexes  are  diminished 
or  lost  on  the  paralyzdl  side. 

The  leg  is  flaccid,  i.s  thrown  about  the  hip  like  a  flnil,  may  be  edema- 
tous and  flabby,  and  also  shows  later  the  signs  of  pyramidal  tract, 
upix'r  motor  neuron  disonler,  i.  r..  imreased  knee-jerks,  ankle-clonus, 
Babinski  and  Chaddix-k  reflexes,  wiUi  increase*!  muscle  tone  and  norinal 
electrical  responses. 

The  grade  of  the  paralysis  varies  greatly.  Witli  some  it  is  a  transi- 
tory weakness  which  passes  in  a  iev,-  weeks  or  a  few  months,  in  others 
it  is  a  complete,  pennancnt  aiul  markctl  pandysL*.  with  later  deveiop- 


>  Mill&ni-Clutilrr,  IW>nt«ti<-i,  rU- ,  q.  t. 


CEREBRAL  APOPLKXfES— THALAMIC  SYNnitOMES 


5fil 


itig  coiitrBC'tures  and  ti>tal  utiilattfral  tlisahility.  Any  intermediary 
urade  may  hr  cxiM'i'tivl.  In  the  milder  forms  of  lieiiiiplci;ia  the  little 
signs-  see  Kxamiiiatioii  McIIukIs  are  ui  great  value  in  elearing  up 
the  situation,  siiiee  some  mild  hemiplegias  may  be  t^onfiijted  with 
psychoKeiiic  iNil^^ies,  especially  in  thalamic  eases. 

Ifem'tane.ithtfitt  may  accompany  the  hemiplegia,  or  the  patient  may 
have  II  hemiiinesthcsiK  \vith<jut  any.  (ir  with  minimal  hemiplegia. 
ITii-s  argues  fur  the  implicjitiuij  tif  a  pc»rtion  nf  Tin*  thalamic 
fil>ers. 

The  patients  complain  of  numlmess,  eoldnesSj  and,  depending  on  the 
liK'atiitri  af  the  lesi^m,  may  lose  their  stercugnostic  sense,  may  not  he 
able  til  distinguish  beat,  nor  eold,  or  may  have  subjective  sensations, 
haptic  halluciiiatiuns  of  the  limb  area. 

Scnsorj'  disturhiuures  from  cerebral  lesions  are  extrejiiely  diverse 
and  of  great  importance  \x\  the  diagnosis  of  brain  disorder,  particularly 
in  arterial  disease  and  in  brain  tumors.  They  are  best  discussed  as 
piirts  of  till'  tliHlainii'  or  sui)r;ith;ilamie  syn*lruTnes. 

The  Th&lamic  Syndrome.'-  If  the  chief  U>dy  of  the  thalamus  Ls 
involved  or  with  itartinl  iniplicjttinn  of  related  extrapyriimiclal  tracts, 
a  eliaraeterlslio  iieuniiogicid  ctunplex  results,  teniied  by  Hejerine  and 
his  |iiipil  Uonssy  tlie  thalamic  syndrome.  It  is  one  of  the  middle 
cercbrid  artery  coiubiiiatious. 

The  chief  features  sliuw  usmdly  after  an  apoplectic  attack  with 
the  ordinary  Mgns  of  a  severe  hemorrliage.  thrombosis,  or  emlwlism. 
In  certain  syphilitic  cases  the  attack  may  be  com pii rati vely  slight, 
nr  the  syndrome  may  develop  with  no  signs  of  an  attack. 

I'racticaily  the  entire  mass  of  sensory  fibers  carrying  impulses  of 
all  kinds — the  tests  for  most  of  which  have  already  been  outlined — 
have  their  synaptic  junctions  witlun  tlie  optic  thalamus.  These 
cellular  junctions  are  the  thalamus.  Only  the  most  Itmitrti  attention 
can  be  given  here  to  the  numerous  fibers  iteming  from  the  chemical 
rewplore  of  the  respiratory,  gastn>-intestinal,  or  genito-urinary  trad, 
nor  tliose  from  the  urgjins  of  iutcrual  secretion.  Some  of  these  un- 
doubtedly made  their  synaptic  junction  in  other  than  thalamic  struo 
tures— globus  pallidus,  putauieu,  etc..  for  example.  The  tlialaiuic  (or 
related)  synapses  of  these  pathways  have  not  yet  been  sufficiently 
worked  out  for  teaching  purfwses. 

The  chief  features  of  the  thalamic  .syndrome  are: 

I.  A  persistent  kiss  of  superficia]  sensation  of  one-half  of  the  body 
Uld  face.  This  loss  to  touch,  pain,  anil  to  temperature  is  more  or 
less  definite,  subject  to  ctinsiderahle  variation  and  to  partial  recovery, 
but  the  loss  of  deep  sensibility,  deep  pr«?s3Ure,  postural  seiLse,  etc., 
is  much  mure  pronounced,  ami  is  more  apt  to  persist.  This  latter 
is  usually  more  marked  dujtally  and  in  many  instances  dtminisheii 
pmxiinally. 

'  Jclliffe:  Thtt  Tluliinuc  Synilronw,  MmUcd  Record,  Fotiruory  1,  IBIO,  for  nfanmm. 


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DrKKASKS  OF  TfTK  BRAlft 


2.  TlifPt-  is  sliglit  lifiniataxin  ami  more  or  less  complete  ast* 

3.  There  arc,  in  the  contplctc  s>ni(innnc,  atnite  pains  on  the  atfectwl! 
side,  which  are  ver.'  persistent,  (liming  on  in  pamxysms.  They  an? 
frequently  extremely  severe  and  rarely  respond  to  the  ordinary  anal- 


MrtJ  e-  -  - 


—F.  earileo' 
tliaiam 


\o  \  **  1  HI 


Meitiilla 


Flo,  31d^^To  sliow  itio  uoitiljoii  mill  relaiiaiin  uf  tLv  ui>tic  thnlaitiiu  ta  llie  central 
MLDWi^-  patli,  Twu  dUciiti-(  |>ii1h)>  I'nift  in  (Jk-  "pitial  curd:  a  croi^m)  M't-niHlno'  pnlh  in 
lh«  ventmlaMnil  column  whirli  cnnvpyB  tni|)rc«donM  of  pain.  t*nii.i?rnture.  and  Uturh. 
ftnd  a soeoiid  immMsod  patb  in  tlir  tlunnl  cnlumD  which  alto  mrriFK  uiuih. and  in  whirh 
run  impillBw  ihnt  imd(>rtlo  the  sense  of  pcudlion,  tlif  nppr«nniion  o(  ninri>ment,  tho  di»- 
criminativn  i>f  l.nt>  ifuiiiti,  niid  the  rm'MRDitiDii  of  viltralMiit.  »ue,  (tUu|)v.  lurm.  M'eiofal, 
mid  Min-iinUntv.  Thutm^'^iiid  |t&ihd<>c-iiiwHt«jiiu  the  luw^r  jHirt  of  thv  tnodttllii oblimititia, 
but  T\>Dt  scpiirato  from  the  fimt  path,  at  least  as  liiith  an  the  pons.  All  tltoac  HX-ondary 
•enitory  fibers,  nnw  rrtULirvl.  trrminntf  in  Ihn  vRntmlnfrrnl  tvs>on  nf  Iho  optic  liialiUDiv. 
The  tinproMone  they  vtirry  ure  ivktouj^  berv  and,  thrvujth  iat«rciU(it(>d  ut-uroiie,  nrv 
rtliitrllnit«l  alnnK  two  diilint-t  piilHn;  thn  nn^  rftxrioc  Jnipraseinmi  ta  ihi-  rorcliml  rorlcx, 
th«  other  toward  Ihn  tuore  incaiai  parU  of  the  op)ir  thaliuiiua.  Thr  i-iirtit-othatamic 
Hbcrs,  whirh  tomiiualc  in  thi'  latvnd  nurlpus  of  the  itplir  thalumus,  are  alsu  ohown. 
CHimkI  and  BolmM.}     (Comraro  Piute  X.] 

geairs.  These  pains  may  involve  a  single  memher,  may  he  limited 
to  tlie  side  of  tlie  face,  eonstituting  a  thalamic  trigeminal  ueurolgia,  or 
they  may  invoK-e  one  whole  side  of  the  iKxIy. 

4.  Iliere  is  usually  a  more  or  le^  distinct,  though  slight,  hcmiplcgift 
which,  in  the  unmixed  syndromes,  rapidly  clears  up.  ("uiitraclures 
rarely  <levelop  in  the  pure  s>Tidrorae.    In  the  mixed  sjTidrome — with 


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CEREBRAL  APOPLEXIES— THALAMIC  SYXDHOMES        TiSS 

exteiisiun  of  t!»u  Icsioti  to  tlio  Inteniiit  fapsuk— fuiitrat*tiires  rnay  be 
present. 

').  (.Iioreif.  sillietuid,  or  paralysM  a>;itaas-likv  inuv('ment.s  may  be 
present  on  tht*  iiffectetl  side. 

These  are  the  chief  symptoms  of  optic  ttialamiis  disease,  but  in 
adilitioii  tn  these,  Head  and  Holmes  have  pointed  out  an  extremely 
suKRestive  series  of  affective  reactions  which  are  due  to  lesions  which 
cut  the  optic  thalamus  from  its  cortical  connections.  They  liavc 
opened  up  an  attack  upon  the  analysis  of  the  sensorj'  content  of 
emotional  reactioiLs.  They  show  tliat  in  this  tj-pe  of  lesion  there  ia 
a  tetideiicy  to  react  excessively  to  unpleasant  stimuli.  The  prick  of 
a  pin.  painful  pressure,  excessive  lieat  or  cold,  all  produce  more  tlJs- 
tress  than  on  the  nonnal  lialf  of  the  body.  Thus,  in  one  of  Head  and 
Holmes's  patients,  if  a  pin  was  dragged  lightly  across  the  face,  or  trunk, 
from  the  sound  to  the  affected  side,  there  was  felt  an  excessive  dis<om- 
fort  as  it  passc<i  the  middle  line.  The  patient  not  only  complained 
that  it  hurt,  but  the  face  wa.s  contorted  with  pain,  and  all  this  notwith- 
standing the  fact  that  there  was  less  ability  to  distinguish  head  from 
point,  yet  the  prick  was  more  disagreeable.  This  anomalous  state  of 
afTairs  is  characteristic  of  a  thalannc  involvement. 

This  excessive  affective  reactivity  Is  present  not  only  to  pin-prick, 
but  also  to  deep  pressure,  to  extremes  of  heat  anci  i-olil,  tn  visceral 
stiinulatioH,  to  scrapiuf;,  rouglniess,  vibration,  tickling,  to  pleasurable 
stimuli,  and  to  ideational  emotional  states.  Not  all  patients  show  all 
of  these  reat-tions,  hut  in  practically  90  per  cent,  of  the  thalamic  cases 
examined  by  Head  and  Holmes,  excessive  affective  rc.spon.sc  to  one  or 
more  measured  stimuli  were  found.  For  heat  and  cold,  and  other 
forms  of  sensibility  a.s  well  as  for  pain,  the  extawsive  response  may  be 
present,  and  yet  the  patients  are  unable  to  detect — r.  e.,  are  anesthetic 
to — the  stimulus  itself.  So  far  as  the  ideational  affective  reaction  is 
eoucenu'd,  these  patients  express  themselve-s  as  follows:  On  Iiearing 
nfliecting  music.  "A  horrid  feeling  came  on  in  tlie  atfccted  side,  and  the 
leg  screwed  up  and  startwl  to  shake."  The  singing  of  a  (."oniic  song  left 
ooe  patient  absolutely  cold,  but  a  tragic  song  produced  a  very  distinct 
unpleasant  effect.  One  patient  said,  "My  right  hand  seems  to  crave 
sympathy,  niy  right  side  seems  more  artistic."  In  prat-tically  all  of 
the  cases  the  increased  affective  reaction  was  ac(x>mpanicd  by  actual 
seasory  loss. 

A  more  detailed  study  of  tlie  loss  of  seatibility  in  thalamic  disorders 
made  by  Head  and  Holmes  reveAl«f  the  following:  No  sensory  func- 
tions are  so  frequently  affected  as  the  appreciation  of  posture  and  the 
recognition  of  |>assive  movement.  The  amount  of  this  loss  varies 
greatly  from  a  scarcely  measureable  defect  to  complete  want  of 
recognition  of  the  posture  of  the  limbs  of  the  ultnonnal  half  of  the 
body. 

Tactile  sensibility  is  frequently  diminished,  but,  excepting  In  a  few 
cases,  where  all  appreciation  of  contact  was  destroyed,  a  threshold 


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DISEASES  OF  THE   BRAIN 


mulii  Ik'  ulttainoil.  It  wa.s  iiIwh.vs  [Hissililr  tn  slio^v  llmt  incnti-:!! 
thf  sin-iigth  of  the  stinmluH  imimiv^l  ilip  prii|«irtion  (»f  rifiht  aiu-iwci 
unless  the  nbsen'Htions  M*erc  t^onfiistvt  by  the  <lii<aprt'«»blc'  tiii)>Iin);  0 
other  awtssdry  sensation:*. 

I^x-alization  of  the  spot  toueJietl  was  defeftive  in  h»If  the  fH.ses  whei 
sensjitioii  was  sufficiently  preserve<l  tu  carry  out  atx-urate  trsls.  Thi 
inability  ti>  recognize  the  site  of  simulation  was  efjtiallv  grtat.  whctha 
the  patient  was  pricked  or  touched.  In  cases  where  localisatiou  wi 
(travely  afTected,  the  disajcreeable  sensation,  so  easily  evoked,  tcnda 
tn  spread  widely  on  the  abnormal  lialf  of  the  body.  A  prick  on  tb 
hiind  may  cause  an  extremely  painful  sensation  in  the  cheek  or  side 
and  sometimes  the  patient  simply  recoKiiizcd  the  stimulus  as  a  rhang 
within  himself,  and  did  not  refer  the  discomfort  from  which  he  siifTerw 
to  the  action  of  any  extental  ajfent. 

Sensibility  to  ijeat  and  cold  may  show  all  degrees  of  change  fi 
total  loss  to  a  slight  increase  of  the  neutral  zone.  Meat  and  culd  a 
not  diss(H'iate<l ;  and  if  one  fonn  of  sertsation  is  lost,  tlie  other  wi 
l»e  gravely  disturbed.  The  apjtarent  exceptions  ari.se  froni  a  nusij 
terpretation  of  the  sensation  evoked  by  Mgh  or  low  temperatures  oi 
tlie  affected  half  of  the  bmly. 

Not  infreiiuently  the  compass  test  cannot  In-  carrie<l  out  I)ecau.'i 
of  the  gross  loss  of  sensation  and  imibiiity  to  recognize  contact;  huti 
whenever  tliis  method  can  be  applied  a  threshold  can  be  worked  out, 
and  widening  the  distance  Iwtween  the  points  increases  tlie  accuraoy 
of  tlie  answers. 

The  ]iower  of  estimating  the  relation  between  two  weights  is  fre 
quently  disturbed  on  the  abnormal  lialf  of  the  [wKly.  If  llie  appnn'ia- 
tion  of  i>o5ture  and  movement  is  alTectctl,  the  patient  can  no  longer 
rtvugnize  the  identity  or  tlie  difTen-nce  of  two  weights  plai-ed  on  the 
unsupported  hands.  Hut  so  long  as  tjictile  sensibility  is  not  Hiuiin- 
ishcd,  tlie  patient  cau  still  estimate  tlie  relation  betwi-en  weights 
applied  one  after  the  other  on  tlic  same  spot,  and  can  rci'ognize  the 
increase  or  diminution  in  weight  of  an  obje<'t  already  noting  on  the 
hund. 

The  appreciation  of  relative  size  is  often  disturbed  in  tliese  ca»es. 
With  care  it  is  usually  easy  to  demonstrate  a  difference  in  the  thrcMhoIfl. 
Slwix'  and  fonn  in  three  dimensions  are  frequently  not  recognizaI»|e 
on  the  Bfl'eeted  hand.  But,  if  tactile  sensibility  is  not  grossly  alTe(-te<j. 
the  patient  usually  retains  an  idea  that  the  object  possesses  a  fomj, 
and  may  give  a  considerable  percentage  of  right  answers. 

Vibration  of  tlie  tuning-fork  is  felt,  in  almost  all  thalamic  cases^ 
but  the  length  of  lime  during  which  it  h  appreciated  is  usually  shorter, 
and  sometimes  tlie  rate  of  vibration  is  tliought  to  be  slower  ou  the 
afTectet!  lialf  of  the  body. 

Houghness.  as  tested  with  Gruliam  Bnmn's  estbesiometer  is  usually 
recognized,  except  in  those  cases  in  which  the  loss  of  all  forms  of  sensa- 
tion is  unusually  severe. 


SUPRATIIAIAMTC  SYNDROMES 


5S5 


Partial  syndnmies  are  more  fn*<|tient  tban  the  classiral  symlrimif 
(liwrilipil.  To  summarize;  the  iimiii  siymptiiiiis  i>f  ihf  cdinpli'te 
syriilri-mn'  are: 

1.  IVrsistt'iii  lii'niiiiufstlu'sia,  more  cir  less  nmrkcil  for  siipcrfiriul 
sensibility,  tHrtual  puiu,  ttuiperature,  most  inurki-d  for  Jeep  seu- 
sihility.  aiwl  luMicf  loss  or  diminution  of  postural  sense  and  atstereog- 

2.  Wild  hemiplegia,  usually  rcffresaive. 

3.  Mild  hemiata.xia,  with  chorea-athetoid  movements  either  spon- 
taneous or  on  an  attempteii  movement.    Adiadokokinesia  at  times. 

4.  Paroxysmal,  shooting,  neuralEic  pains,  often  very  persistent  and 
severe  and  not  helped  by  the  usual  analpesirs. 

5.  Overrespoiise  to  alFet'live  stiuuili,  jMtrtieuhirly  on  afre(.*teil  side, 
with  emotional  hypenietivity  to  varied  sensory  impressions. 

Sensory  Changes  in  Cortical  Lesions,  Suprathalamic  Pathways.— 
The  analysis  (»f  >en.sory  stimuH  in  fcrehrul  and  thalamic  disonlers  is 
of  the  greatest  importaiK-e  in  cerebral  localization,  licnce  an  e.xteniletl 
presentation  of  contemi)orary  work  is  lU-sirahle.  In  tlie  chapter  on 
Peripheral  Xerv'es  the  chief  sensorj'  syndromes  of  the  first  sensory 
neurons  were  discusseii.  Those  of  the  cord  are  presented  elsewhere. 
Hedistributions  take  place  in  the  medulla  and  midbrain.  Those 
disturbances  due  to  lesions  within  the  thalamus  have  just  been  pre^ 
sented.  l-'inally  the  thalainocortiea!  jiathways  make  a  fui'tlier  regroup- 
ing of  sensory  qualities  in  the  entire  course  of  tlie  sensor}'  pathways. 
(See  Plates  IX  and  X.) 

The  analysis  of  these  phenomena  introduces  complex  factors,  and 
it  is  necessary  to  abandon  all  generalisations,  even,  for  instance,  lifcht 
toucii,  cutaneous  sensation.  The  results  of  the  test  must  be  stated 
in  terms  of  the  tests  employed.    (See  Sensory  Examination  Methods.) 

TJaing  graduated  tactile  stimuli,  such  as  von  Frey's  hairs  and  the 
pressure  esthesioraetcr,  the  chief  results  have  been  tliat  a  cortical 
lesion  may  reiiuco  the  accuracy  of  response  from  the  affected  part 
to  graduated  tactile  stinnili.  The  form  assumed  by  tliia  defective 
sensibiUty  differs  from  that  prwlucei!  by  lesions  at  other  levels  of  the 
nervous  system.  The  affected  part  may  respond  to  the  same  graduated 
hair  as  the  normal  |)art;  but  this  ri'sponse  is  irregular  ami  uncertain. 
Increasing  the  stimulus  may  lead  to  no  corresponding  improveuient. 
and  even  tlic  strongest  tact'lc  hair  may  occosioiuilly  evoke  less  certain 
answen  than  a  liair  of  much  smaller  bending  strain.  Moreover,  u 
touch  witJa  the  unweighted  csthcsiometer  may  be  as  effective  at  one 
moment  as  the  same  instrument  weighted  with  'M)  grams  at  anotlier. 
In  such  cases  no  tactile  threshold  can  be  definitely  ohtjiined.  This 
irregularity  of  response  is  associated  with  persistence  of  the  tactile' 
sensation  and  a  tendency  to  hallucinations  of  touch.  Where  the  sensory 
defect  Ls  not  sufficiently  grnss  to  abolish  the  threshold,  jjer^iistence, 
irregularity  of  res|K)nse  and  a  tendency  to  liallucinate  may  still  disturb 
the  records. 


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mSEASES  OF  TUB  BRAW 


ill  nil  citsfs  whcrt*  tai-tile  !st;nsil)ility  is  atfi't-ttnl,  wlictluT  ii  tiin*sl)i>]i| 
mil  ill'  olitaiiieil  nr  lutt,  fHti);iii'  is  Iniliictit  wltli  uiiiiMial  fm-tlity. 
Althniiyh  till-  patit-iit  may  cease  tt»  n-spoiid  to  tiit-tilr  stiiituli  over  tlic 
affecttNi  jmrt  in  ('tms^xjuencc  of  fntigm',  his  answers  may  remain  as 
KOoU  as  bffow  from  ihi-  nonuiil  parts.  Tlif  fatimit*  r.s  Nm-jiI  ami  nnt 
general. 

With  stationan'  (f)rtical  k'sions,  micdniplirottHl  by  stiites  uf  sht>ck 
or' by  "diasohisis,"  sensibility  t(»  timrh  with  ti»ttim-wo(iI  is  rarely 
lost  over  bair-cluil  parts.  Over  hairless  parts,  stimuhition  with  tiilton- 
w(H)l  may  prfwiuce  a  sensation  whieh  swrns  "less  plain"  tn  the  patient^ 
and  liis  answers  may  show  the  same  incoustuncy  so  evident  when 
he  is  tested  with  graduated  ta<-tile  stimuli. 

A  pure  cortical  lesion  lead.s  to  no  ehanjre  in  the  threshold  to  measur- 
able painful  or  uncomfortable  stimuli.  Nor  does  the  patient  express 
greater  disHke  to  these  stimuli  on  one  side  than  on  the  other.  A 
prick  may  he  said  to  be  "plainer"  or  "shar|w*r"  on  the  nnnnal  than 
on  the  afTei-ti'd  side;  but  this  is  due  to  a  defective  appreciation  of  the 
pointed  nature  4>f  the  stimulus  am]  bears  no  dirert  rchitiun  to  the 
paiitfuhie^s  of  the  sensation  evoked. 

Temperature  tests  show  that  (.«)  the  neutral  zone,  within  the  stimu- 
lus, wa.s  said  to  be  neitlier  hot  nor  cohl,  was  <onsiderably  enlarge<l  in 
comparison  with  thiit  ob.sen'eH  on  similar  normal  parts  of  the  same 
patient,  ih)  The  patient  complainetl  that,  although  he  remgniiied 
correctly  the  nature  of  the  stimulus,  it  seemed  "less  plain"  than  over 
nonnal  parts.  His  answers  were  less  eanstant,  and  less  certain;  a 
lemjx'niturc  rectiRnized  without  ilifficully  at  one  time  seemi-d  doubt- 
ful at  another,  (r)  Tlic  power  of  discriminatijig  tJie  relative  coolness 
of  two  stimuli  or  the  relative  warmth  of  two  liot  tubes  may  be  dimin- 
ished. Thus  'H)°  C.  may  be  said  to  be  tJie  .^arae  a.s  ice,  although  both 
are  uniformly  calle<l  cold,  and  40^  ('.  may  seem  a.s  warm  as  or  even 
warmer  than  4S'*  ('.  The  faculty  of  appreciating  the  ivlation  tn  one 
another  of  two  tem|>eratures  on  the  same  side  of  the  scale  is  dis- 
turbed. 

Tests  for  /)o*(«re  and  for  po-wrw'  nmmiiifntjt  show  that  (a)  cortical 
le»ion.s  most  frequently  disturb  the  recopiition  <»f  po.'fture  and  of  pa^ 
sive  movements.  Whenever  sensation  is  in  any  way  affected  in  con- 
sequence of  a  corticjil  lesi<m  these  two  fuintions  .suffer.  (6)  In  nil 
their  cases  the  disturbance  in  the  faculty  of  recognizing  posture  and 
passive  movements  was  greater  toward  the  periplierat  part.s  of  tJie 
affecte<l  limb,  (c)  When  a  patient  with  unilateral  disturbance  of  these 
faculties  attempts  to  point  to  some  part  of  hi.'*  WMy,  defective  knowl- 
edge of  its  position  cause;*  greater  error  thiiii  want  of  recognitiou  of 
posture  and  movement  in  tlie  Iiand  with  wliich  he  (mint'^.  {(f)  When 
testing  tJie  patient's  power  of  appreciating  passive  m<)vemcnt,  tlie 
answers  are  frequently  uncertain  and  lialhainations  of  movement 
may  occur.  Ami  yet  the  patient  may  be  remarkably  consistent  and 
accurate  when  nonnai  parts  arc  test*-*!. 


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SVPBATIlALAMtC  SYKDBOXtES 


587 


LdCttUziiticrrt  frsh  show  that  («)  thf  |M)WiT  of  Incjiliziii^  the  ^tiI^u]ate(t 
spot  is  not  infrwiiu'ntly  prtyerveil.  iilthmiKh  sensation  ma>'  be  other- 
wise ili.sturl«il  a.s  a  itniseqiiemt*  of  i-itrtiral  lesions.  (/;)  This  faeiilly 
is  iiuip]H*[i(lent  of  the  p^iwer  of  ri'fojtiiizlng  the  [xisition  of  the  affected 
limb;  apprwiatiori  of  jMwtiire  may  he  htst,  nlthimgh  loealization  is 
not  in  any  way  diiniiiishw!.  [r)  If  the  pikwer  of  localization  is  lost,  the 
patient  will  l>e  utuihk'  to  recognize  not  only  the  p^isition  of  a  spot 
tnuehe*!  but  also  the  position  of  a  prick,  (r/)  When  localization  ia 
defective  in  consequence  of  cerebral  lesions,  the  patient  does  not 
habitually  loi'alize  in  any  particular  (direction,  but  ceases  to  be  certain 
where  he  ha.s  been  touched  or  pricked. 

The  romjm^.t  tfjtl  shows  that  («)  a  cortical  lesion  may  destroy  the 
power  of  (liscriniinatiiig  two  compass  points,  both  when  applied  simul> 
tanetmsly  anil  eonsocutively.  If  thi-t  is  the  case,  ni>  thre,»^hold  can  be 
obtained  for  either  fonn  of  the  test;  increasing  the  distance  between 
the  points  does  not  ctmstantly  improve  the  acruracy  of  tiie  answers. 
C^)  This  disturbance  is  not  caused  by  changes  in  tactile  appreciation; 
f<ir  it  can  be  demonstrated  equally  well  with  two  painful  as  with  two 
tactile  stiniuJi.  (e)  The  cuuditioti  of  tactile  sensibility  and  the  accu- 
racy of  the  simultaneous  compass  test  arc  closely  associated;  a  dis- 
turbance of  the  Tjictile  threshold  is  usuall\'  accom|Minied  by  a  raised 
threshold  for  the  appreciation  of  two  (mints  applied  simultaneously. 
(rf)  Should  the  p^mer  l>e  prt*ser\'ed  of  recupnizing  two  points  when  the 
compasses  are  applie^l  consecutively,  localisation  will  be  found  to  be 
intact.  'Hie  patient's  a[tpri*ciation  of  the  two  |Kiinls  when  they  are 
sejMirated  by  im  interval  of  time  Isrlue  to  the  recognition  of  the  separate 
locality  of  the  two  spots  tonchecl. 

Appreciation  of  weights  shows  that  (tt)  the  jM>wer  of  estimating  the 
relation  of  two  nbjw-ts  of  the  same  size  and  s)ia|H'  is  readily  disturbed 
by  eiirtii'ul  lesions,  ih)  Thoujjh  the  patient  may  retain  sensjitiotis  of 
contact  when  the  weight  is  placed  in  his  hand,  all  power  of  recognizing 
the  relative  heavmess  of  the  object  hjis  disappeared,  (c)  This  faculty 
is  equally'  (lisUirl>ed  in  most  cases  whether  the  weights  are  placed  on 
the  supported  or  the  unsupporteil   han<l. 

I'rom  these  and  related  studios,  Head  and  Holmes  maintain  that 
sensory  iinpulst-s  pass  fn.)m  the  thalamus  to  the  cortex  in  five  groups: 

1.  Thuse  eoncemetl  with  the  recognition  of  posture  and  passive 
movement.  If  these  impulses  are  affectwl  the  power  of  dtscriminatuig 
weights  on  the  niisupportitl  hand  ma\    be  als4t  diminished. 

2.  ("ertain  tactile  elements;  integrity  of  this  group  is  ncix'ssary 
for  the  discrimination  of  weights  placed  on  the  fully  supported  hand. 

3.  Tho»e  impulses  which  underlie  the  appreciation  of  two  points 
applied  simultaneously  (the  compass  te.it);  on  this  group  also  depends 
the  recognition  of  slice  and  shape. 

4.  Those  which  underlie  the  ]K»wer  of  Incali/jng  the  situation  of  a 
stimulateij  spot.  Recognition  of  the  double  nature  of  two  points 
appHetl  consecutively  also  depends  on  tliis  group  of  impulses. 


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DIfiBASSfl  OF  THE  RRA1S 


Ty.  All  rittrumi  irn|mlscs  firi-  Knai|n'<l  toftt'tlier  In  umicHir  u  sculc  ctf 
si'iisiitifins  wiTh  licHt  jit  otic  fiid  mill  imU  at  tlit-  utlicr.  At  tlir  tt*vel 
witli  wlikli  uc  arc  now  dfuliup  these  iinpiilst-s  liavc  alrpuily  cxcitcil 
the  atrtrtivc  ci'utor  and  are  passing  away  to  the  eortex. 

The  fuuctiiinal  integrity  <>f  the  eitrtex  enables  attention  to  be 
coiicentTated  upon  those  chanf^es  which  are  pnKJiiced  by  the  arrival 
of  afferent  impulses  (Head  and  Holmes).  When  this  is  disturbed, 
some  impulses  evoke  a  sensation,  but  otliers,  from  laefc  of  attention, 
do  not  affect  eoiLseiousness.  Attention  no  lunger  moves  freely  over 
the  sensory  field  to  he  focuased  successively  ou  fresh  groups  of  seiisory 
impressions.  Sensationi*.  once  evoked,  are  not  cut  s}iort  by  the  moving 
away  of  the  focus  of  attention  as  when  cortical  activity  is  perfect. 
Henee  arise  persistent  sensation.^  and  halluc-inations  whirh  are  so 
prominent  a  feature  of  lesions  of  the  cortex. 

The  cereliral  cortex  is  the  organ  by  which  attention  may  be  fmnisserl 
upon  the  changes  evoke<l  by  seiis*)ry  impulses.  Such  attention  is  to 
furtjier  tlie  niseful  work  in  band.  A  pure  cortical  lesion,  wliieh  is  noi 
advancing  or  causing  peritxlic  discharges,  wilt  change  the  seusibility 
of  tlie  affected  parts  in  such  n  way  that  the  patient's  answers  Appear 
to  be  untrustworthy.  Such  diminished  power  makes  the  estimation 
of  a  threshold  in  many  cases  impossible.  I'ncertainty  of  response 
destroys  all  power  of  comparing  one  set  of  impressions  with  anotlier 
and  so  prevents  iliseriminiition.     'l"his  interferes  with  function. 

In  addition  to  Its  function  aa  an  organ  of  local  attention  the  sensor>' 
cortex  is  also  the  storehouse  of  past  impressions.  'ITiesc  may  rise  into 
consciousness  as  images,  but  more  often,  as  in  the  case  of  spatial 
inipressioiis,  remain  outside  central  <-onsriousiicss.  Here  they  form 
organized  models  which  may  be  termed  "schemata."  Such  patterm 
modify  the  impressions  produced  by  incoming  sen:4or>'  impulses  in 
such  a  way  that  the  final  sensations  of  piisition,  or  of  Incality,  rise  into 
consetoiisness  chargi'd  with  a  relation  to  something  that  has  ha])pened 
before.  Destruction  of  such  "Hcheniata"  by  a  lesion  of  the  wjrtex 
renders  hnposaiblc  all  recognition  of  posture  or  of  the  locaUty  of  a 
stimulated  spot  on  the  affected  part  of  liie  body. 

In  daily  life  all  stimuli  excite  more  or  less  both  thalamic  and  cor- 
tical ii-nter^,  for  most  unselected  sensations  omtain  both  affective 
and  discritni native  elements.  Mut  among  the  tests  employed  in  sen- 
sory analysis,  some  appeal  almost  entirely  to  the  one  or  the  uther 
center.  The  test  for  recognition  of  posture,  as  earritii  out  by  Head 
and  Holmes,  is  purely  discriminative;  while  the  ]jain  prtKlueetl  by 
.squeezing  the  testicle,  or  to  a  less  <lcga*c  by  the  pressure  nlg«)nK*lcr, 
appeals  almost  exclusively  to  the  more  affective  center. 

Sen.sory  impulses  arri\ing  at  the  optic  tlialainus  are  regroupetl  in 
such  u  way  that  they  can  act  upon  both  what  Head  calls  its  essential 
center  and  the  sensorj'  cortex.  Tile  essentia!  organ  of  the  thalamus 
is  excited  to  affective  activity  by  certain  impulses,  and  refuses  to  react 
to  those  which  underlie  the  purely  discriminative  aspects  of  seusaliou. 


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These  pass  on  to  inHucnn:  the  cortical  centers  where  they  are  readily 
nccepteri.  In  a  similar  way,  tlie  priinarj*  irenters  of  the  cortex  cannot 
ffceive  those  ct>in|>onents  which  underlie  feelinR  tone;  In  this  <lirection 
thpy  are  cnmplcTely  blocked. 

It  has  Itrny  bwii  recognised  that  sensations  accumulate  feeling 
tone  to  difTerent  degrees.  In  those  which  underlie  postural  apprecia- 
tion this  tpiality  is  entirely  absent,  wliile  visceral  sensations  are, 
in  some  instances,  little  more  than  ii  cliungi'  In  n  general  feeling  tone; 
the  former  set  of  impulses  appeals  almost  exclusively  to  the  cortical 
center,  the  latter  to  that  of  the  optic  thalamu:^.  All  ihemial  stimuli, 
however,  make  a  double  appeal.  Kver>-  sensation  of  heat  or  cold  is 
either  comfortable  or  uncomfortable;  the  only  entirely  indifferent 
temperature  h  one  that  is  neither  hot  nor  col<l. 

In  tlie  same  way,  some  unselected  tactile  stimuli  appeal  botli  to 
the  sensory  ciirtex  and  to  the  ojitic  thalamus.  For  not  only  is  a  ti»nch 
always  related  to,  and  dLstiii|;mshed  from,  something  that  has  gone 
bcfoTe  it.  but  we  hjive  shown  tJiat  contact,  esjiecially  of  an  object 
ninving  (iviT  hwir-elad  parts,  ts  capalile  of  exciting  thalamic  arti\'ity. 
Vibration  of  the  tuning-fork  also  makes  a  double  npjieal,  fcir  when 
the  cortical  parts  are  cut  tlie  amplitude  of  the  vibration  must  ha 
greater  in  order  that  it  may  be  appreciated;  on  the  otiier  liaiid,  the 
vibratory  efTcct  may  be  stronger  on  the  abnormal  side  in  those  thalamic 
cases  where  tlie  affectix'e  n-spon-se  is  excessive. 

But  these  two  centers  of  con.sciousness  are  not  coequal  and  inde- 
pendent. I'nder  normal  conditions  the  activity  of  the  thalamic 
ewiter.  though  of  a  difTerent  nature,  is  dominated  by  that  of  the  cortex. 
When  the  sensation  normally  produced  by  a  prick  is  examined  it  is 
recognized  that  the  pain  develops  slowly  anil  lasts  a  considerable  time 
after  the  stimulus  luis  censed.  Moreover,  the  sanie  InleiLsity  of  stimu- 
lation will  produce  a  different  effect  on  the  same  spot  on  different 
occasions.  A  long  latent  period,  persisteiiee  and  want  of  uniformity 
are  chnracteristic  of  all  painful  sensations.  This  is  seen  in  an  exag- 
giTatc<l  form  in  cases  where  tlic  tluilamic  center  has  Ijcen  freed  from 
control.  The  response  to  prick  is  slow,  but  persists  tong  after  the 
stinuilus  has  ceased.  Moreover,  the  reaction,  when  it  occurs,  tend.-* 
to  be  explf>sive;  it  Is  a.s  if  a  spark  hail  firetl  a  magazine  and  the  coiLse- 
(jueiices  are  not  commensurate  with  the  cause. 

()n  the  t«)ntrary,  the  si*n,sutlons  nonniilly  pnxiueed  by  moderate 
tactile  stimuli  are  eharaeterizitl  by  a  short  latent  period,  and  disap[K'ar 
nhnost  iinnie<lintely  on  tlxe  cessation  of  tlic  stimulus.  A  lesiim  i>f  the 
sensory  cortex  ilisturl>s  both  these  characteri.sties.  Tai*tile  setLsatioiis 
becomes  uncertain  and  incalculable,  and  no  threshold  can  l>e  obtaiuetl; 
pcrsbtcncc  and  hallueiiiHtioiLs  mar  the  uniformity  of  the  records. 

The  work  of  Head  and  Holmes  (ends  to  show  lliat  ihe  sensory  cortex 
is  the  organ  by  which  attcntiiMi  can  l>e  concentrated  on  any  part  of 
the  body  that  is  stimulated.  'Hie  f<icus  of  attention  Is  arrested  at  any 
one  spot  by  the  cluuiges  prodiiceil  by  cortical  activity.    These  are 


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DISEASES  OF  THE  BKAtN 


sorted  out  aad  brought  into  relation  with  other  9ensor>'  proeesses, 
past  and  present.  Then  the  focus  of  attention  sweeps  on.  attracted  by 
some  other  stimulus. 

All  stimuli  which  reach  as  high  up  as  the  thalamic?  center  have  a  high 
thresliold.  They  must  reach  a  high  intensity  before  they  can  enter 
conseiousiics.s,  hut  mice  they  have  risen  ahcivc  the  threshold  they  tend 
to  produce  a  change  of  excessive  amount  and  duration,  and  this  it  is 
the  buHiness  of  the  cortical  mcclianian  to  control.    The  low  intensitj* 


'^ 


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Flo.  3in  Fk).  .117  I*Ki.  318 

'FtUA.  SIR,  'MT  mid  illH. — ToixiKniphy  cf  Itic  feaMOy  dirt url>a tin-,  in  a  raiw 
tliiUmie  ByndmnK-,  riiihl  »ndp.  ut  nil  yenn'  diirathin  in  »  wotOBD.  aoMl  t)fty-Av«  y«n.n, 
Tberv  is  mild  hvniipleaiii  o(  the  rinhl  nkIi-  with  iTilcnM*  rhoivy-Hthc-tnid  muvi>inei)bi 
(>r  thi^  hAiiil  und  foot.  Thorv  is  a  TnarkcJ  ntniiA  in  nil  vnUuitiiO'  iiiAvMiienta  of  liw 
name  eide.     KxaKBoi^l i"!!  <'f  (tic  tviidiiii  rpfles^n  of  llip  riiilil  eidi*.     No  Httbinski  reflvx. 

Tlirri?  an-  v«r>*  nctivn  mid  »(■%■*«•  MjHuitanecmM  putiFi  uvn  ihc  ciitirc  rigJil  n6c.  tA4-tite. 
pain,  and  themml  scDBibillly  is  dimiiiishcKl,  but  not  aboli«ti«d,  i>a  ili«  eutiiv  tiuhl  wle. 
(Vitnpnw  dinrriminfttion  mnrkivlly  ufTrcied,  Coinpl*^)^  nstcffHiKniina.  Tiut»,  ■mell,  mad 
bratiiiti  urv  diniitiiahed  on  iho  riKhl  nde.  ViBiuD  is  uuimpuitud  niid  llinrc  i*  iiu  bmni- 
annpiiiH.  tN>pp  urDMihility  i»  tnnrc  nllurrd  llijin  iniperfirinl.  The  wnse  of  porition  U 
nllcmi,  iKniy  Hctixibility  in  cnucb  diauui»fa«d.     (Thoiiiait  and  (^liiny.) 

of  the  stimuli  that  can  arouse  the  sensory  cortex,  and  its  quick  reaction 
|>eriod,  enable  it  to  control  tlie  acti\"ity  of  the  cumbersome  mechanism 
of  the  thalamic  center. 

This  view  of  the  sensory  mechanism  explains  many  of  the  facts 
recognized  by  stu<ients  of  disorders  t>f  the  nervous  s>*stem.  It  enables 
one  to  umlerstand  how  integrations  can  (►rr-nr  at  all  afferent  levels  of 
the  ner\ous  system,  ami  make  development  possible  even  in  the 
individual.    Tlie  aim  of  human  evolution  is  the  i*ontn>l  nf  fet-ling  and 


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instinct  hy  disirimi native  mental  actinties.  This  stniRKlr  on  the 
highest  plane  of  mentjil  life  \n  begun  at  the  lowest  afferent  level,  and 
tJie  issue  beenmes  mtire  elcarly  ilefined  the  neawr  semiory  impulses 
apimmeh  the  field  of  consciousness.  Finally,  in  tenns  of  Uergjioii, 
"tin'  cerehral  tnt-chiinism  is  arran^nl  just  s<i  as  to  thrust  back  into 
the  unconscious  almost  tlie  whitle  of  our  past  and  to  allow  beyom)  the 
thrc^jhold  onlv  tlmt  which  will  furtltcr  the  work  in  hand,  to  do  useful 
work." 

Apraxia. — TliIs  terra  was  first  used  by  (loftol  in  1873,  in  a  Breslau 
thesis  on  Aphasia.      His  patient  ate  his  soap,  urinatetl  in  hi:^  water 


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Fm,  319. — Lwttliisliou  of  B[>rux!a.  PnMti%'«  maon  frum  IcaEau  Eu  xht  left  •iipni- 
niiu-|[iiml  nyrud  nnil  (<i,  It.  e,  d)  Bnutil  m(>lai)(aUc  lumora  from  ona  c«se  of  tola]  bilaloral 
nitrnxia.     hi  IMk  nur  fon  wrrp  nlnr>  fniinil  in  hoth  optir  thalatnL     (vnn  Mnn&kdw.) 

pitcher,  am]  was  desoribed  Jis  having  lost  his  understanding  for  objects. 
Such  defects  had  been  noted  before,  and  it  is  worthy  of  note  that 
Ilufililinjpi  Jackson,  in  )SiM\,  called  attention  to  a  similar  tx-pe  of 
phenomenon,  au<l  attac]ie<i  much  importance  tu  it.  Quagtino.  in 
lS(i7,  described  a  casts  Kinkclnburg,  in  1.S70,  another,  in  which  recog- 
nition of  things  and  people  was  lost,  and  createtl  the  term  asj-mbolia. 
Wernicke,  in  1X74,  expan<lefl  the  term  Jisymbolia,  while  Kreiid  finally 
Mtili'/A-^l  the  term  annnsiu,  to  cover  all  types  of  loss  of  sensory  or  motor 
object  innigcs,  apni\ia  then  iM'in^  arrangci)  as  a  form  nf  loss  of  knowl- 
c<]gc  of  objcits.  really  a  fonn  of  visual  agnosia.  The  superficial 
observer  ealU  these  jwtients  "dementi'd." 


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DISEASHS  OF  TUB  BHAIS 


From  this  early  use  of  tl»e  term  aproxia,  there  lia.s  been  a  di-Ntinct 
vRflflticji),  bruuglit  prominently  into  the  furegroimi)  hy  I.icpmatin 
in  1900.  He  defined  the  disturbance  as  a  lack  of  knowledge  of  Uw 
use  of  objects,  althougli  there  was  no  true  agnosia,  or  loss  of  recoji;- 
nition  of  what  they  were.  Out  of  the  later  studies  of  Liepmann, 
I'ick,  von  Monakow,  (I'llollander  and  others  has  come  the  following 
gi-neral  definition  of  apraxia. 

It  c'onsist,s  in  an  inability  to  perfonii  certain  subjectively  purposeful 
movements,  or  movement  cximbiiiiitiuns,  the  motor  power,  sensation, 
and  Cfjordinalion  being  intact.  Such  an  iimbilit\  will  naturally  depend 
upon  at  least  three  factors;  one  may  be  unable  to  recognize  the  object 
which  is  to  be  use*i,  in  which  case  there  is  a  sensory  apraxiu,  in  the 
same  sense  as  one  speaks  of  a  sensory  aphasia,  or  a  visual  apnoMa. 
Should  the 'patient  recognize  the  object,  call  it  perhaps  by  name, 
state  its  use,  and  yet  in  atteniptiiig  to  use  it  totally  fail  in  pro|M'r 
motor  act,  it  is  temieit  a  motor  apntxia.  It  bcitin  underst<KH)  here 
that  there  is  nn  necessary  change  in  the  motor  arc,  r-ither  on  the  incom- 
ing seiLsory  or  outgoing  motor  aide.  Tlius  one  can  speak,  as  Wilson 
has  done,  of  a  motor  uphasic,  as  having  an  apraxia  of  his  speech  mus- 
culature. In  grave  intracerebral  ehanges  tlie  knowledge  of  the  proper 
kinetic  images  to  carry  out  purposeful  actions  in  the  arms  aiul  Icjp 
may  be  complexly  involved.  This  is  termcil  an  intraiisychie  apraxia. 
Clinically  it  is  usually  overlaid  in  the  general  psychir  loss,  and  is 
often  hiehided  in  the  loose  and  unprecise  term  dementia. 

Apraxia  may  he  then  either  sensory  or  motor;  it  may  l»e  unilateral 
or  bilateral,  it  may  be  exteiwi%'e.  involving  many  muscular  gronpit 
or  may  be  limited  to  a  few,  such  as  an  inability  to  ])rotrude  the  tongue 
on  (ieinand  or  close  the  eyelids,  etc.  with  perfet-t  [Hiwer  in  other 
movement.^. 

Liepmann's  celebrated  case  was  able  to  do  things  with  hi»  left  hand, 
but  failed  entirely  with  his  right.  When  told  to  brush  the  examiner's 
c<»at,  he  picked  up  a  c»nier  of  it  carefully  In  IiLs  left  band,  then  piekeil 
up  the  brush  in  his  right  Imnd,  with  which  he  made  movcmcnJs  as  if 
to  brush  his  hair.  Askal  to  pour  water  into  a  glass  frtmi  a  carafe, 
he  grasped  the  carafe  with  his  left  hand,  to  pour  water  into  the  glass 
held  in  the  right  hand,  after  which  the  glass  was  brought  to  the  mouth 
without  any  water  in  it.  The^c  patients  fail  to  <-arry  out  the  simple 
conimamls  to  blow  a  kiss,  make  a  thn'atenlnp  Hst,  soldier's  salute,  etc. 

In  ideomutor  apnivia  llic  situation  is  more  complicatetl.  One 
patient  given  a  tooth-brush  recognizetl  it,  then  began  to  brush  his 
beard  with  it  clumsily;  another  In-ing  given  a  pistol,  which  he  nameii 
correctly,  on  being  tohl  to  sh(M>t  it.  grasped  the  Iwrrel,  blinked  and 
put  the  muzzle  into  his  left  eye.  Another  patient,  being  given  a  cigar 
and  a  match-box  opened  the  latter,  stuck  the  cigar  in  it.  and  tried  to 
shut  the  box  as  tlmugli  it  were  a  cigar  cutter.  Then  taking  the  cigar 
out  rublMfl  it  on  the  side  of  the  box  as  though  It  were  a  nntti-h.  The 
entire  nnler  of  procedure  was  badly  devised. 


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DISEASES  OF  THE  BRAIN 


(Jiuschisis,  «f  the  left  frontal  urea  from  the  right  fmntul   area  wifl 
s^ein  to  I>riiifi  ahnut  an  H|)rHxia. 

Ihvi'muopsia  is  an  infrequent  sign  occurring  as  a  result  of 
apoplexy.  As  a  symptom  of  middle  ct'R'hral  disease  it  may  n-sult 
from  tlialainic  lesions  (pulvinnr,  genieulatcs)  and  is  usually  a  per- 
manent residual.  It  is  rarely  a  teniiwrary  condition  but  may  show 
marked  improvement.  The  type  is  a  bilateral  lionionymous  hemian- 
opsia. Quadrant  hemianopsias  more  often  Iwlonj?  tu  the  mirhlle 
cerebral  !»yndr(>mes,  altlionph  limited  lesions  of  the  cuneu»  may  cause 
quadrant  hemianopsias.' 

The  visual  fields  will  var\-  greatly  according  to  the  tract  invoU-^ 
ment.  In  posterior  rerehral  s^Tidromes  occipitJil  eortioal  typos  of 
heniiamipsia  are  present.  Tliese  show  ver>'  irregular  visual  iicltls. 
PsycliienI  Minrhiess  (loss  of  visual  memories)  may  also  result  from 
posterior  cen-bral  involvements.  Here  the  portions  of  the  occipital 
cortex  about  the  calcnrine  fissure  and  cuncus  arc  implicated.  It  is 
usually  an  ateorapanying  symptom  of  the  apoplectic  attack  hut 
may  be  isolated  and  often  combined  with  a. hemianopsia. 

Apha»}a  is  a  fretpient  result  of  the  hemiplej;ic  attack  (right  hfnii- 
plegia  in  right-luinde<l  i)ersons:  left-sided  in  Ieft-hande<l  i>ersoiis). 

The  type  of  aphasia  depends  entirely  upon  the  location  of  the 
lesion  and  the  areas  servetl.  Transitorj'  aplasias  are  extremely* 
common,  occurring  in  at  least  one-half  of  the  attacks.  Permanent 
aphasias  are  rarer,  about  one-half  of  the  patients  recovering.  "Yhe 
different  forms  of  apliasia  and  the  lix-alizatioii  significance  arc  discussed 
under  Disorders  of  Speech.    (See  page  31 1.)* 

Papillary  edema,  even  choked  disk,  may  be  a  sjTnptom  of  apoplexy, 
and  is  found  on  the  side  affected.  It  is  most  frequent  with  large 
lesions," 

Diaenoaia. — In  the  matter  of  the  middle  cerebral  sjTidromes  rfiiefly, 
B  differentiation  of  the  apoplectic  attack  in  terms  of  causation — hemor- 
rhage, thn)mhosis.  or  endxdisin — is  highly  desirable,  although  it  ia 
not  iiKva>s  possible.  The  eiid-resnlts  may  Ix-  Identical,  but  the  ante- 
cedent coiiirHtioiis  vary.  Cerebral  hemorrliage  is  comparatively  rare 
in  the  young,  but  it  may  be  seen  at  all  dwadcs,  and  even  ui  intra- 
uterine life.  \N'hen  occurring  in  early  youth  it  b  usually  a  result  of 
parental  sypliilis  or  of  some  acute  illness.  In  cases  of  cerebral  hcmoi^ 
rhagc  the  imlient  is  usually  over  forty,  shows  signs  of  arterial  disease, 
frecpiently  with  hypertrophied  heart,  and  often  has  nephritis.  The 
attack  is  usually  sudden,  often  prccedeil  by  emotional  disturham« 
or  sudden  change  in  position  that  modifies  tlie  blood-pressure.  The 
attack  is  more  likely  to  be  accompanied  by  unconsciousness  (75  per 

'  (^'iimimrp  WilUiniml  unil  Sncnp-r:  Dip  Nmtmlusjr  dot  Aukm  Ii>r  cumplete  dueu»- 
nun  kikI  bitiliuiEinpliyi  lilno,  Ilcnachea.  in  LewuiJonky '•  Unttdlnicti  dcr  Npun>kiKie. 

*  Comp.  V.  Moiiaknw'*  Dfa;  LtjluUmatiua  im  GruHtiirD.  1914,  for  most  recent  diaciukloa 
qI  tl)0  eoniplicnted  &phauft  qUMliou. 

*  UhtboO:  NeiuoL  CwtralbUtt,  lIKlO. 


CERKHHAL  Al'Ofi.EXIES—DIAOXOSlS 


505 


cent.}.  Severe  vpntririitar  honirtTrhages  show  Ii!(m>iI  cm  Ininlwr  puiii> 
ture,  but  this  pnK'ediire  is  rarely  calleil  for  save  in  supposed  triuimntic 
cases. 

ThninilMisls  occurs  also  in  older  iiidividuuls,  ami  in  svpliilitics  par- 
ticularly, rneonscinusness  is  less  apt  t"  occur,  nr  ilevt'Inps  in  pro- 
(Crcssivc  staRCs  as  it  were.  Tlie  prmlannata  alrca'iy  mentioned  jire 
mere  ttpt  to  have  heen  present.  Markedly  ather<tmat()us  arteries 
speak  fur  thronibo.sis,  and  mild  sipn^  of  deteriuratiau— lacunar  syn- 
cbomes — speak  for  thrombotic  types  of  disease. 

Knibolism  is  almost  invariably  associated  with  .wime  acute  disease — 
tyf)h(iid,  acute  septic  infections  (artituhir  rlienmatisni,  Ko'i'Trlu'tt, 
s<-arlet  fever,  malaria,  ete.l.  Acute  endcM-i'rditis  is  often  jtrt-sent  and 
the  individuals  are  apt  to  be  young.  I'ncunseiousne.is  is  less  apt  to 
occur;  when  occurring  it  is  likely  t*)  develop  very  suddenly,  ajid  is 
more  f)fteu  present  in  basilar  and  carotid  occlusions  than  when  other 
arteries  are  biwked. 

Hfnnirrha;;es.  especially  wliea  small,  frequently  show  the  nuixinuim 
symptoms  early,  with  ftradiial  betterment,  while  thromboses  usually 
show  the  re\-crse,  the  symptoms  having  a  tendency  to  spread  or  to 
deepen. 

Ophthalmoscopic  examuiation  is  always  iiiii»erative.  Dilatation  of 
the  pupil,  usually  presiMit,  can  be  obtainiHl  by  enrfiiu  in  u  few  irnruites. 
DilFuse  retinitis,  sit-ejdled  retrobulbar  neuritis,  is  highly  indicative  of 
hasal  syphilis  or  syphilitic  endarteritis.  In  hemurrhage  (he  vessels 
of  the  disk  nrv  apt  to  be  engtirged.  This  is  not  so  in  embolism  nor  in 
thmudiosis.    Choked  disk  points  to  a  neoplasm. 

The  blood- pressure  attonis  diagrn>stic  criteria.  It  is  apt  to  Ik*  hiph 
in  hemorriuigc  aiul  in  embolism,  biit  low  in  thrombosis,  also  in 
neoplasms,  syphilitic  endarteritis,  and  cerebral  abscess. 

Other  disease  processes  to  he  distinguished  are  hvslerical  hemiple- 
gias, sync»)pe,  epileptic  attacks,  general  paresis,  uremic,  alcoliolie,  or 
encephalitie  conni. 

Ihji^tf-rirui  hcmi]»legius  are  rarely  acci»ui))!inied  In'  nncunsciousness. 
Hysterica!  delirium  may  complicate  the  pirture.  Later  the  signs  of 
pymmidal  tract  invohement,  such  as  inerca-se*!  reflexes,  Babinski, 
('hadd(*ck,  biss  of  abdominal  rellexes,  (irasset  and  Hoover  phenomena 
arc  not  present  in  hysterical  hemiplegia.  In  certain  mild  tlialamic 
cases  the  sensory  diangi'^i  may  be  thought  of  as  of  psychogenie  origin, 
but  careful  summing  up  of  the  residt*  outlined  on  pages  7ti-7S  will 
show  the  somatic  signs  of  tlialamic  involvement.  Personal  consultation 
experince  has  .shown  tliat  many  tbalaniic  cii.ses  are  diagnoswl  as 
jjsychogenic. 

rertain  Ifteunar  syndromes,  especially  in  the  anterior  cerebral 
distribution,  which  are  mild  and  which  present  momentary  confusion 
(worse  at  night),  cmot tonal  instability,  irritabilily,  tendency  (o 
weeping,  etc.,  are  frequently  mistaken  for  hysteria.  Suggestive  treat- 
ment of  such  a  case,  as  by  u  metronome  as  personally  observed,  is  not 
likely  to  succeed. 


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DfSBASES  OF  THE  BRAIS 


Lacunar  symlromea  with  sofu-nings  in  the  frontal  areas  are  also 
mistuken  for  irmnir  attacks.  Ihrre  i>  c-Diifusion.  some  disorientation, 
excitewent,  and  after  a  sliort  time  the  whole  thinjj  may  clear  np, 
Icnvinji  only  slljjht  defect,  easily  overlooked,  unless  careful  intelligence 
testa  are  applied  (presbyophrenic  excitements,  presenile  excitements 
— see  Senile  and   I'resenile  Psychoses.) 

I'remic  mma  is  usually  of  more  gradual  onset.  There  are  prt-cetJinp 
signs  of  heavirierw  un(3  to.xemia;  convulsive  movements  arc  not  infre- 
quent, witli  signs  of  Inequality  of  respirntion  of  the  two  si<lcs  of  the 
chest,  possible  pupilliiry  iucqualilies.  possible  variations  in  response 
to  sensory  stimuli  on  the  two  sides.  Involuntary  reflex  motor  responses 
to  joint  squeezing  and  finger  squeezing  (Marie-roix)  are  itsiially  absent 
in  ureniir  coma.  'Hie  generiil  odor  of  the  patient  is  often  characteristiel 
in  uremia.    Some  uremic  |>atients  develop  apoplectic  attacks  as  well. 

Diabt'tic  covm  shows  similar  <ItfTicttlties.  .Acetone  (kIot,  large 
amounts  of  sugar-containing  urine,  usually  slow  onset,  ntid  the  previous 
hibtory  nuist  he  relied  upon. 

Jlrohnlic  anna  is  frivi|ucutly  diagnosed  by  the  police  as  apoplex>% 
since  many  alcoholics  do  have  apoplectic  attacks.  Some  severe 
intoxicatioTts  resemble  apoplectic  coma  very  clo.sely,  but,  as  a  rule, 
the  eoma  is  less  profinmd  in  alcoholism;  the  reflexes  are  often  pre- 
ser%'ed,  in  a  measure,  and  the  uniformity  in  the  hilateraliiy  of  the 
relaxiitinii  is  evident  (alisenie  of  Marle-I-'oix  signs).  One  should  be  on 
one's  guard,  however,  and  look  for  all  of  the  little  signs  of  hemiplegia.' 

Epileptic  and  .tijjirnpaf  uiUickfi  mrely  present  great  difRcultics.  The 
bistort"  of  a  previous  attack,  the  sr-anx-d  boily  or  head  and  tongue  of 
the  epileptic  i.s  uhcn  eviilent,  while  in  synco^K'  the  coma  is  u.su:dly 
.shallow  and  the  fecbk-  respirations  and  superficial  heart  action  point 
to  the  difficulty. 

An  aixiplectiform  attack  may  he  the  first  sign  of  pare»ig.  i^uch 
attacks  are  iisnully  due  to  cerebrul  e<lema,  and  may  he  at  first  incli»- 
tinguisliitiik'  fniui  an  ajKiplexy  (non-paretic).  The  Inter  history  and 
examiualiou  will  a-jually  establish  a  diagnosis,  although  the  jjscudo- 
[taresis  of  arteriosclerotic  softening  is  often  oidy  distinguishable  from 
paresis  by  the  cytobiolugical  reactions.  (See  chapter  on  Syphilitic 
I>isea.ses  of  the  Nervous  System.) 

Prognosis,  —  liecovpry  from  the  attack  and  amelioration  of  the 
residual  symptoms  are  separate  problems. 

Cerebral  hemorrhage  is  u.sually  more  immediately  fatal  than  either 
thrombosis  or  embolism.  Deepening  etnna,  ( 'he.nie-.*^tokes"  respira- 
tion, irritative  phenomciui,  jerking,  convulsions,  blood-pressure  (vcr>' 
higli.  over  2liO  mui,  or  very  low,  under  00  mm.),  murked  rise  in 
temiwrature  arc  the  u.sual  lethal  signs.  General  eouvuUions,  retinal 
hemorrluige,  bhxid  on  puncture,  bilateral  paralysis  are  unfavorable 

■  Dcj>rirM>:  SemtnlftKiA,  1914,  2H«<1.    .lelUffe:  Utile Hikim of  HrmiptrciM.  I*<MtfTwluAto, 

1S12. 


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signs.  After  reeovor.v  fnjtii  rntna,  wmtimii'd  tfUipiTaturv,  udvuiiciiig 
symptoms,  restlessness,  delirimn,  loss  »if  sphimtcr  eontrol,  tmphie 
disturbarurs,  indie-ate  a  ^rave  prugnosis  iiml  probable  death  in  from 
two  to  three  weeks. 

Karly  attacks  of  lacunar  softening  are  rarely  fatal,  but  indicate 
thfit  a  fatal  tenninatlon  fnim  a  more  severe  type  of  attaek  will  be 
pr(»bable  in  fnini  one  tu  three  years.  Inasmiieb  Jis  this  is  ii  form  wliieli 
is  fri'tiiientiy  mistakenly  diiignosed  jus  Insteriial  In  the  early  mild 
attacks,  w>metinics  as  a  nijld  nmiiie  attack  lexeiterneiit  ami  confusion), 
one  should  Ihe  on  one's  giinnl  \n  this  not  infretjiient  syndrome. 

The  recovery  from  the  residual  sxTnptoms  will  vary  greatly  upon 
the  nature,  UK'ulization,  and  extent  of  the  lesion.  A  careful  plotting: 
of  the  entire  symptomatnlogy  will  determine  the  area  involve*!  in  tlie 
destructive  prwess,  and  the  eH'eets  of  diaschisis  must  first  be  separateii 
out  from  those  of  actual  tissue  destniction,  since  tlie  former  ure  more 
apt  to  disappear. 

Aphasias  are  usually  recovered  from,  almost  invariably  in  left- 
sifled  hemiplegias  in  the  rijjlit-lmiiditl.  In  rii^ht-lmnileil  lieniipleKias 
aphasias  are  recovered  fr<mi  in  about  one-half  of  the  patients, 
especially  in  the  intelligent  who  will  make  an  ctTurt  to  nnkiurate 
themselves.  If  the  lesion  lies  directly  within  the  aphusic  area  the 
chances  f(»r  recovery  are  less. 

Hemianopsias  are  not  infrequently  diasclutic.  When  so  tlicy  pass 
within  ft  few  weeks.  In  thalamic  lesions  they  are  apt  to  be  [x*rmanent, 
as  are  cortical  hemianopsias  persisting  over  a  few  weeks. 

i  lemiplegia.  if  total,  is  apt  to  persist  in  some  degree  at  least,  although 
most  patients  are  able  to  get  about  in  three  montlis  or  more.  Help- 
lessness persisting  over  six  months  or  a  yenr  has  been  partially  recovered 
from.  l'"ueiul  jMilsie-s  usually  recover.  Leg  jMilsy  is  rarely  as  persistent 
as  arm  palsy,  but  both  react  favorably  to  appropriate  tn'atment. 
Karly  i-ontraeturc  usually  means  bad  therapy. 

Thalamic  Involvement  is  a  bud  prognostic  feature— tlie  pain  and 
irregular  mitvemeiits  (choreo-athetoirl).  henna n est hesia,  etc.,  usually 
persist. 

Mental  defects  may  clear  up  almost  entirely,  cspceially  when  slight, 
but  careful  intelligence  tests  (see  chapter  on  Mental  Examination) 
should  be  utilized  in  all  cases,  es]>ecially  to  decide  me<lic<»legal  prob- 
lems which  may  arise — testamentary  or  contract  capacity,  respon- 
sibilitj',  etc.  A  sensory  or  motr>r  aphasia  alone  is  not  necessarily  a 
sign  of  an  mteliigence  defect;  many  aphasics  are  very  intelligent. 
They  sunply  cannot  utilize,  in  speech,  the  kin)\\ledge  they  have. 
(See  chapter  on  Senile  and  Presenile  Mental  States.)  A  motor  aphasie 
who  cannot  get  hb  symbols  over,  as  it  were,  may  not  be  any  more  of 
a  dement  tJian  an  Knglisiunaii  traiiig  to  make  a  Chinaman  understand 
what  be  is  saying. 

Treatmeat. — Prophylaxis  applies  particularly  to  those  over  fifty 
years  witli  arteriosclerosi.s,  and  sustained  high  blood-pressure.    The 


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leiMlpiiry  to  heitmrrlmnc  lurr  is  ^nvit.  Sudi  patii'iits  slniulil  slow  duuil 
smiiewhat  in  their  work,  if  strenuous  and  falling  for  intense  und  sus- 
tained I'H'iirt,  nnd  e-sptriftUy  if  emotional  rails  Hreferquotil.  A  nuMlenite 
amount  of  work  and  freedom  is  desirable.  Invaliding  a  prospective 
licmorrliagif  case  is  ina<lvisable.  A  partial  psychoanalysis  to  shnw 
faulty  handling  of  the  emotional  reactions  Is  highly  benefirial,  esi>eci- 
ally  in  hypertenRive  states. 

I  )iptjiry  fadilism  is  to  he  avoided.  Excessive  eating;  is  to  lie  avoideii 
and  :di  idrolml  ^should  be  restricleil.  IVoiein-frec  diet — vegetable 
proteiiLs  are  the  same  us  animal — keeps  down  the  bkxHi-pressurc  ui 
many  eases.  Some  seareh  should  be  umde  to  see  if  spetifie  protein 
sensitization  exists. 

Caitful  n-iiulation  of  the  gastro-intestJiial  tract  is  called  for,  the 
kidney  finirtitms  should  be  scrutinized,  and  the  liver  metabolism 
regulated. 

It  is  doubtful  if  drug  therapy  is  of  any  service  in  prophylaxis.  Tl»e 
iodides  have  beeii  usetl  widely,  but  their  utility  is  still  undeciiie*!. 

Treiitment  of  the  attack,  even  if  there  is  no  uiiconseiousness,  requires 
LiiinietUate  rest  in  Ix'd  if  possible.  If  striken  away  from  home  tlic 
patient  should  he  moved  as  little  as  possible.  With  high  tension,  hot 
font-packs  will  help  to  reduce  it  (not  hot  enough  to  hum  the  uncon- 
.scious  iwtient).  In  cases  in  which  the  liliHMl-jiressurc  rises  steadily, 
ke*'ps  alnive  2ofl  mm.  anil  with  very  deep  cDUia,  bloml-lelting  (10  to 
12  oz.)  is  advisable. 

1  Ij-ptwlennic  nialication  by  bhiod-pressitre  rcilucing  drugs  in  hemor- 
rhage is  alone  advisable  in  coma,  and  only  vcrj'  small  quantities  of 
water  should  be  used,  as  water  raises  blood-pressure.  Hydrochlorate 
of  gelseniine  in  doses  of  y^  grain  is  fairly  active  and  reliable.  The 
nitrites  are  not  available. 

IF  the  patient  can  swallow,  tincture  of  aconite  in  X([v  ilases  may  be 
given,  watching  the  blood -pressure.  Tlie  dose  may  l»e  repeated  in  an 
hour.  Pressure  should  be  kept  below  '2<M_t  inm.  if  |jossible.  Tincture 
of  vcratruui  viride  in  lHv-w,  evtTV  two  hours,  or  the  fl.  ext.  of  g*-lsem- 
iuin  in  same  doses  at  same  intervals. 

Pre^-ssu re-reducing  drugs  should  Ih*  used  with  cauliou.  ITic  Ixigh 
pressure  folknving  hcmorrhiige  is  usually  «>mpensalory  and  for  the 
purjMisc  of  keeping  up  an  elTective  vascular  irrigation  of  the  medullary 
nuclei  following  a  rujjture  in  the  arterial  pijK'  line.  These  drugs  should 
be  used  only  when  it  Is  known  tliat  a  high  pressure  preceded  the  attack. 

Early  purgation  is  desirable;  'J  gtt.  of  croton  oil  is  useful  in  states 
of  deep  coma.  This  may  Ik;  placeil  with  butter  on  tlie  back  of  the 
tongue. 

It  there  is  marked  excitement,  chloral,  gr.  v  xv,  or  paraldehyde, 
3j-ij,  may  be  pven  by  mouth  or  by  rectum.  Tepid  sponge  l>aths 
help  restlessness.  Veronal  and  trional  are  useful  in  the  restlessness 
of  lacunar  softenings. 


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599 


Care  of  the  muuth.  drooliu^,  uioviiiK  the  pHtk-nt,  rcmovnl  of  all 
ohstruetiuiis  tu  breathing,  sliould  be  attended  to  at  onee. 

N'tnirislunent  may  he  omitted  in  the  early  stftjffs.  A  purin-free  diet, 
mostly  milk  and  gruels,  to  which  sugar  and  eggs  may  be  added  later, 
siiimUl  ronstitiite  the  standard  diet.  In  the  presence  of  ditiiciilty  in 
swallowing,  milk  enemas  are  tu  be  given. 

In  rardiac  ntnnir  rases,  with  low  blcxid-pressiirf — rhletly  throml>oses 
— va-smlilators,  eamphor,  and  adrenalin  may  be  ni-cessary. 

Surgiciil  treiitment  may  he  ailvisuble  fi)r  meningoa!  vr  siihcDrticnl 
hcniurrhuges.  Tertain  nephritic  enttes  are  helped  by  lumbar  puneture. 
and  the  withdrawal  of  20  to  5()  e.c.  of  fluid.  The  patients  should  be 
kept  quiet  several  weeks,  attention  being  paid  to  giving  ease  and 
comfort  by  cuHhifnis,  ]>rop,s>  siipport.s,  and  freciuenl  ehanges  of 
po,iition. 

L&te  Treatment  of  Hemiplaiia. — 'I'he  reeent  itivestigatinns  nn  the 
functioiLS  of  the  pyramidal  tnicts  {von  Monakow,  Sherrington,  Franz) 
make  the  outlook  for  the  rceduontional  treatment  of  hemiplegia,  much 
more  hopeful.  It  woiUd  seeui,  as  a  result  of  this  wurk,  tluit  the  pyram- 
idal tracts  are  not  the  excliLsive  earners  of  volitional  motor  control. 
Destruction  of  tlie  motor  cortex  of  the  eat,  dog,  or  monkey  causes 
only  about  two-thirds  of  the  pyramidal  tract  to  degenerate.  The 
iiidicalious  are  that  there  is  a  large  extrarolaiulic  motor  area,  probably 
in  tlie  frontal  and  parietal  lobes,  particularly  for  the  face  and  upper 
extremities.  In  addition  to  these  faet^  arc  the  further  facts  brought 
out  by  stimulation  of  the  motor  cortex,  viz.,  the  so-called  motor  centers 
do  not  correspond  in  extent  in  different  animals  of  the  same  species; 
they  are  not  of  the  same  extent  on  the  two  sides  in  the  same  animal; 
repeated  stimulation  does  not  always  produce  the  same  movements, 
sometimes  there  are  a*lded  movements  and  sometimes  the  movements 
arc  the  exact  opposite  as  extension  where  there  was  fonnerly  flexion. 
All  this  indicates  that  the  motor  cortex  is  by  no  means  as  fixeil  in  the 
relation  of  its  cells  to  a  definite  muscular  function  as  has  heretofore 
been  supposed.  On  tlie  contrary,  it  would  seem  tluit  it  had  retaiiiwl  a 
considerable  fluiditj',  a  large  capacity  for  axljuatment  so  that  the 
movement  resulting  from  stimulation  of  any  particidur  part  was 
dependent  upon  the  functional  set  of  tlie  assm-iated  neun)ns  at  tJie 
moment  of  stimulation.  If  this  is  true  It  can  be  seen  how  systematic 
motor  reeducation  may  serve  to  facilitate  discharge  through  paths 
not  heretofore  consciously  usevf  both  hy  bringing  into  use  associated 
cortical  motor  cells  and  pathways  nearby  and  also  by  drawing  upon 
the  extrarolandie  regions. 

The  application  of  the  principles  elucidated  have  in  fact  been  pro- 
ductive of  most  excellent  results  in  the  treatment  of  hemiplegias.  A 
most  detailed  scheme  of  movements  calculated  to  overcome  the  motor 
defccis  should  be  mappal  out  ami  persisted  in  daily.  This  plan  should 
be  l>egun  a  few  <lays  after  the  injury,  practically  as  soon  as  the  patient's 
mental  state  wilt  permit  of  cooperation.    It  should,  at  first,  he  limited 


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600  DISEASES  OF   THE  BRAIN 

tn  11  few  iniiiiitc's  ami  Inter  |in)loiij.'f<l  with  i-an*  to  avoid  cxrt^ssivc 
Futiguf.  Tlu*  iiursc  can  (inally  k'ani  wliat  Is  to  Ih"  June  and  cxciriae 
the  patient  perlmps  an  liour  cinily,  addin);  diversions  to  the  daily 
routine  thai  include  a  utilizatiuii  uf  tJie  ncwl>'  acquired  inoliuiLs. 

Such  exercises  must  jjct  away  from  die  hackneyed  and  stupid  calis- 
thcnii'!*.  etc.,  which  have  prevailed  In  the  past.  Tlic  p.syche  of  the 
patient  must  he  put  into  his  work  and  the  exercises  worked  out 
alnng  pmper  kinetic  lines  (Mensendieck  exercises  and  the  like) 
employed. 

Klectricity  is  nf  douhtru!  service.  (lalvanism  aids  srime  of  the  pains, 
the  aiMxle  sh<uild  he  over  the  painful  urea. 

The  general  care  (if  the  invalid  will  dejiend  largely  upon  hiy  ccunomic 
status.  Travel  Is  helpful  iti  supplying  a  mental  stimulus  and  llie 
warmer  climates  and  nitire  interesting  foreign  resorts  are  ciijoyahle, 
mid  thus  of  direct  ihcrapeutjc  value.  Varied  occupations  suited  to 
the  iuJividual's  temperament  and  habits  should  be  sought  for,  wherein 
resourcefulness  is  a  n,Tcat  asset. 

Specf'h  training;  for  aphasia  may  a(x>omplLsh  much.     It»  detail*;, 
as  well  as  many  others,  cannot  be  entered  into  here.' 


SINUS  THROMBOSIS. 

There  are  three  varieties  of  sinus  thrombosis,  the  so-called  marasmic 
variety,  occurring  in  debilitate<I  individuals,  and  as  a  result  of  eanliac 
weakness,  cachexia,  rhlorosls,  etc.  Thrombosis  of  a  sinus  may  als4>  he 
de|H-ncleut  tm  injury  as  a  result  of  fractun-  of  the  skull  or  Injury  to  lj»e 
skull  during  difficult  labor.  The  most  iinp<irtant  form  of  sinus  tJirom- 
bnsis,  however,  is  that  deiK-ndent  uptiii  infection,  and  its  most  frequent 
variety  is  the  throndiosis  of  the  lateral  sinus  due  to  the  spread  of 
infection  from   niiddleH'ar  disease. 

Symptoms. — The  general  symptoms  of  sinus  thrombosis  are,  in 
accordance  with  the  above,  those  of  infection,  namely,  chills  and  fc%'er, 
and  with  the  breaking  down  and  liqueficatiun  of  the  thmnibus  and  its 
distribution  in  the  general  circulation  there  may  Ih?  pyemia,  with 
abscess  f(tnriati(m.  These  abscesses  may  occur  in  the  brain,  cerebrum 
and  ccrcl»ellum,  or  the  infection  may  extend  directly  from  the  sinus 
and  produce  a  local  or  a  general  meningitis. 

The  Imal  s,\7nptoms  vary  with  tlie  sinus  involved,  hi  thrombosis 
of  the  liilrrni  tdmiji,  depcndcEit  upon  middle-ear  disease,  there  is  usually 
u  venous  congestion  and  edema  over  the  mastoid  process,  and  the 
thnimbiis  may  extend  into  tJic  jugular  vein  and  be  palpable.  Carrrnutis 
sinux  (lirumbosis.  owing  to  the  druuiage  of  tlie  ophthalmic  vein  back- 
ward iuto  this  sinus,  produces  quite  charactcnsticall>'  marked  exoph- 

1  CoDiult  White  Kiid  JcUiffc:  Modern  Treilnieul  of  N'vn-oiif  ii»d  MoutAl  DiMWse, 
%'ol.  if,  rordetAUMtduirumtanflf&ll  of  the  tMktum  uf  trestmeiil  in  chaplvn  by  K.  Tflucy 
A)m1  8.  A.  K.  WilaoQ. 


I 


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Ptu.  321. — Scbona  ehotrioE  v«DOUa  aiDUses  of  iho  head.     (After  Mnvuweii.j 

in  its  area  of  di<4tribution.  Invdlveini'iit  of  tliis  sinus  rarely  remains 
unilatnml  but  soon  becomes  bilateral  by  spreiid  of  the  alFeetion  by 
way  of  the  eireiilar  sinu.s. 


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«02  blS^AS^S  Of-  THE  BRAin 

In  longitudinal  sinus  thrumbosis  in  distended  fontanelles  (in  children) , 
nosebleed,  caput  medusee,  and  swelling  of  the  frontal  and  parietal 
veins  are  the  chief  local  symptoms. 

Treatment. — The  treatment  of  these  conditions  is  essentially  surreal. 
Septic  involvement  of  the  cavernous  sinus  is  generally  fatal.  The 
condition  is  usually  inaccessible  to  surgical  interference. 

Thrombosis  of  the  lateral  sinus  is  not  an  infrequent  complication 
of  a  middle-ear  disease,  and  if  seen  early,  is  susceptible  of  successful 
operation.    The  sinus  may  be  opened  and  the  clot  cleared  out. 

The  other  sinuses  of  the  dura  may  of  course  become  inv^olved,  but 
generally  secondarily,  and  do  not  present  such  characteristic  clinical 
pictures. 


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chaf;teh  XIII 

TnilORS  OF  THK  BUAIN. 

TiiMORS  of  the  brain  are  relatively  infrequent.  They  occur  at  all 
BRcs,  are  found  in  every  conreivahle  location  within  the  craiiial  cavity, 
and  are  of  a  (jreatly  variefl  pathnlopy.  Extensive  niunographa  have 
be<'n  published,  and  no  feature  of  disease  nf  the  ner\'ous  system  has 
attrac-teej  nitirf  uttention,  not  only  by  rea-Hiiii  f>r  it,s  prartieal  importance, 
hnt  nlsn  because  of  the  t-ontributions  tii  t-erebral  local i /.at ion  and 
funftion.  The  t-liief  literature  to  1917  may  be  found  in  Starr,^  von 
Monakow.*  Oppenlieiin,'  Tootli,*  and  Hwllifh.* 

Ii]  18,0<K>  i-aseH  of  nervous  disease  wTurriuj^  in  ten  years  at  the 
Viiti<lerbilt  ("linic  there  were  48  bram  tumors.  Tliis  Ls  a  rainimutn 
computation.*  Bruus  st^ites  it  as  high  as  2  per  cent..  Cusbiii^;  as 
U.75  per  cent.,  Kedlich,  from  4000  cases  of  nervous  disease,  the  same. 

Etiolojy.— The  causes  for  certain  tmnors,  such  as  tuberculoma, 
sypliilDtiiii,  iietinoniyeoses,  are  well  known.  P'nr  both  syphilitic  anti 
ttibercuknis  tumors,  and  possibly  other  tumors,  traumatism  may  l» 
an  additional  *'lement  for  their  speeial  looftlization.  Metastatic  tumors 
follow  from  their  primary  sources.  Certain  teratumat«,  demuitds, 
aiiKJ"UUita  are  congenital  conditioas,  while  chtilesteab>mu1a,  chnrdoma, 
(■lunuln.imji,  liiiunia,  and  inyxouia  are  also  developmental  iinonudics. 

The  traunuitie  genesis  of  tumors  in  general,  or  of  any  out*  type  in 
particular,  apart  from  aneurisms,  is  hijfhly  problematical,  yet  if  tlic 
trauma  aud  symptom  development  are  related  in  specific  and  vcr>' 
definite  ways  the  causative  nile  may  be  debated.  Thus  if  the  injury  is 
suHicicntly  intense  to  definitely  injure  the  skull,  the  time  interval 
iHJtween  the  accident  and  the  development  of  the  symptoms  not  too 
^reat,  and  tJie  localization  of  the  probable  tumor  near  to  the  site  of  the 
injury',  the  relationship  may  justifiably  l>en|>en  to  serious  consideration. 

Vari«ties. — The  chief  forms  met  with  mny  Ix-  classitieil  as:  (I)  true 
tuniiirs,  (2)  infectious  tumors,  (^)  piiriLsilic  cysts,  (■!)  iiiienrisms,  (5) 
vascMhir  cyst-s. 

1.  True  Tumors. -^f  these. ^^'uwia/a  are  the  most  frequent.  They 
preponderate  over  auy  other  claas  in  adults.  In  Tooth's  summary  of 
500  cases,  4U  per  cent.,  were  Rliomata.     Children  rarely  come  to 

'  Text-book  of  Nurvoua  DiMa*«),  4Ui  ed.,  Brain  Surwry. 

'  Geihirapnthahii^,  2(1  <^.,  Die  l4)kAliiinHnn  ini  CiniMhim,  1014. 

■  Pie  0«tirhwuUU>  im  Obinis.  'id  «d,  •  ilraiii.  vnl.  S6.  [>.  61,  1912. 

*  HiuuUiuch  tier  NL-itnilriAJc,  I<«wuQ(loivBky.  1012.  vol.  Ui. 

•  S<N>  Hoport  of  CJinic  of  Prof.  M.  Allan  Simt.  1900  ItHW. 


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tht*  Nittitinal  Hospital  in  l^iiiilnii.  heme  TimjIIi's  low  iMTcentape 
tulierculous  tumoR.  (iliomata  occur  lliroiighout  the  hraiii  as  drcuw- 
scribed  or  as  diff'use  tumors,  and  are  extra-  as  well  as  intracerebral.  The 
general  tendenry  is  toward  difTuseiiess  jiiid  depeneration  wit  h  biTimrrhaRe 
and  fatty  and  cystic  fonuatioiis  takes  place  priiiuii>ally  in  intracerebral 
prouths.  Thus  the  symptoms  arc  apt  to  tlevclnj)  slim'ly  and  inter- 
mittently in  ctirtex  or  basal  ganglia,  wcasioually  from  the  epcndjiua. 
They  may  invade  an  entire  hemii>phere. 

Sarctimatti  arc  less  frequent,  restricting  the  term  sarcoma  mmr 
strictly  than  is  usvial.  and  rejecting  the  itimpromise  >;lii>sarcoina. 
Nearly  all  gliomata  sliow  elements  indistinguishable  from  sarcoma. 
They  u.sually  develop  slowly  in  the  brain. 

Chloromata  are  leukemic  in  origin  and  are  rare.  They  invi>lve  the 
periosteum  or  the  ba.se  and  thus  cau.se  compression  plienomena  which 
often  persist  for  sMnif  time. 


J'm,  .332— IiihUrntitiE  Rlimttii  of  hiual  gitnglia. 


Fibmrnatn  (neurofibromata)  are  comparatively  common  bratn 
tumors  (10  jut  cent,  in  Tooth's  ciillcction,  inciuilmg  fibroglii>ma). 
They  develop  diicHy  about  the  cerelK'llo|iontine  angle  (acoustic)  but 
may  develop  along  nthiT  cranial  nerves.  OccjLsionally  they  npc 
mtiltii}|e.    They  develup  slowly. 

Endotheliomota  art'  comparatively  fnxpicnt  (14  per  cent,  in  TtKtth'g 
collection).  Tliey  seem  to  confine  themselves  chiefly  to  the  anterior 
fossce.  They  are  usually  small  and  nmltipte,  develop  slowly  and 
chiefly  in  the  falx  region. 

Choriiwruita  arc  infrc<|uent,  and  only  rarely  reach  a  considerable  size,' 

CarcinomaUi  (5.8  per  cent. — Tooth),  clcisely  relutwl  to  the  endothelio- 
mata  are  usually  secondary  (metastatic),  rarely  primar)'. 


'  Jt>llill«  uid  Lktkin:  Journal  at  Nervous  md  Mcaml  Dtaoom.  January,  1B12. 


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605 


Psnmmoinnta,  rliorduniata,  lipomata,  enchondromata.  anginnmta, 
ostcomutft,  ailciitiiiiHly,  clmlesti'ouiHta,  tcratoraata  (pineal).'  ami 
demumis  are  aiiiuug  the  raritit'.H. 

2.  Infectious  Tnmora. — These  are  tuberculous,  syphilitir.  actinu> 
mycotic. 

Tultfrcuiovmia  are  possibly  the  commune-st  cf  all  tiiniont,  tx-rtainly 
ill  children  (Starr,  VX\  In  <MKI  tumors  recordwf).  They  are  extremely 
rare  after  forty  years.  TheN  are  fretiueiitly  ecmglonu'nile  ur  miilti])le 
in  tyjx",  hence  givinjEi  rise  to  mixed  Nyndniines.  'Ilu-rc  may  lie  a  few 
very  »mall  miliary  tubercles  ur  a  larj^e  lirokea-dowii  tubercle  ma.ss,  with 
every  conceivable  intennediary  stage.    They  ilevelop  chiefly  in  the 


Pio.  32S. — Chordonu  ol  biMP.     i  JvlbRv  uud  Larkiu.} 

cereMIuni,  pwluncle,  basal  Kan^ilia,  poiis.  and  cortex.  In  Zapjjert's 
Rfoup  of  89,  37  were  in  the  cerelH'llum,  20  in  the  cerebral  i-nrtex,  13 
in  the  basal  gnnglia,  .">  in  the  pons.    They  liave  a  i>a<l  ])ro}jnosis. 

Stfphilontata. — Ciunimata  are  not  infrequent.  They  are  practically 
limited  to  adults,  and  are  not  rcrorded  from  conj^enital  syphilis.  They 
may  appear  from  unc  year  to  thirty  yearb  after  infection.  They  occur 
chiefly  as  flat,  inliltratinj;;,  irrepidar  masses — ie,ss  often  a.s  definite 
nodular  masses,  chiefly  at  the  base  of  ihe  brain.  Tht^y  are  discussed 
more  fully  in  the  chapter  on  Syphilis  of  the  Nervous  .Sy.stera  (q.  v.). 

Aetwotnt/cosiit  of  the  brain  is  a  niritx. 

)  Bailey  oud  J«lliffe;  Tumon  ol  tb«  Vrnval  Uody.  Arch.  Int.  Med..  Decembrr.  IDI3. 


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3.  Paraaidc  Cystic  Tumors. — ('tjsiictrcus  of  the  brain  is  a  ranty  ai 
is  seootidary. 

4.  Aneurismal  Tumors. — Annirisms  nre  verj'  frequent  in  cervbraj 
vessels.  They  are  iinwtly  siniill,  hut  lurge  aneurisms  wcur  at  times 
and  give  s.Ntnptoms  of  pressure.  They  octur  in  patients  usually  from 
forty  to  seventy  years  nUi,  iind  art-  mostly  of  tlie  basilar.  They  cause 
pressure  sjinptonis  at  times,  with  ohatructive  symptoms— basilar  syn- 
drome— or  lliey  rupture  and  produce  s.NTnptoros  of  cerebral  hemor- 
rliafip.' 

Symptoms.— Brain  tumors,  even  of  a  large  size,  may  be  found  at 
juitiipsy,  liiid  yrt  not  Imve  given  rise  to  any  rer-ognizeil  sjinptunis. 
Tubert'uluuuita  are  thus  frequently  found  in  ehildren.  With  more 
precise  investigation  such  latent  tumors  ore  becoming  rarer,  espcdally 
fiim*'  tlif  importanrc  uf  mental  symptoms— jKychoMes,  so-called  hys- 


Flo.  ;W4, — OuiiiiiKi  i.f  hriiin. 


t 


terias.  etc. — unaecoinpanicd  by  sensorimotor  syndromes,  is  becoming 
recognize<l.    Many  small  tumors,  especially  ostcomata,  i)Kammnma, 

slowly  ilevelopliig  and  circumscrilied  gliomata,  chulesteati>mata  cause 
very  few  sjinptoms.  Occasionally  a  tumor  will  show  moriosymp- 
tomatirally,  as  by  epileptic  convulsions,  mild  speech  disturl>ances,  mild 
sensory  defects,  optic,  olfactory,  auditory  hallucinations  or  hemian- 
o]>sia,  without  being  recognized. 

Tlie  symplflms  arc  best  considered  as  CO  general  and  (2)  local  or 
focal. 

The  gciiernf  irijmpiDms  are  indicntivc  of  the  effects  of  the  tumor 
as  a  whole,  irrespective  of  its  special  nature  or  localization.  They  are 
due  in  general  to  the  effects  of  increased  intracranial  pressure,  which 

'  Borullua:  Brain,  l(Hi7,  p.  285;  IteinbarUt:  t'ebvr  UiraactcrieDsaeur^-BineD  und  ikra 
FdIkau,  Mitt.  a.  d.  Cr«iL«^  d.  M«<1.  a.  Ch.,  19IH,  sxvi. 


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in  certain  tumors,  mitably  of  the  posterior  foiwa  and  cerelx-llum,  appears 
early  ami  is  usually  marked  even  with  i^mall  tumors,  whereas  tumors 
elsewhere  often  may  show  little  itf  such  pressure  s^-mptTims.  Suinetimes 
the  focal  syiiiptotus  iippt*ar  liefore  the  general  nnes.  ( reueral  symptoms 
rarely  have  any  lot-alizinj;  diapnostir  value.  Some  uf  the  f^eueral  s\Tiip- 
tonis  of  jin-ssurt'.  iTariia!  nerw  psilsies  for  example,  may  even  teiiil  tci 
niisleiul  one  as  to  a  loealizing  eliagnosis.  Kurtlienuore.  in  cerebral 
tumors.  Hi'ute  swflMnp*,  iint  ideiitieal  with  but  relate*!  to  nlenias, 
often  jiive  rise  to  vvts  anumalous  symptoms  and  tend  to  obscure  the 
diagiuwis  and  render  it  unfcrtain.' 


t'lo,  S25.— Aneurism  of  baailararlciy.     CLjirkin.) 

The  eJiief  s.Ninptoms  nf  peneral  value  are  headaehe,  imasea,  vomiting, 
di«ziiie,ts,  respiratory  anrl  eardiae  disturbances,  metabolic  chanses, 
mentn]  sij^ns  of  sleeplessness,  sometimes  drowsiness,  optic  nerve 
changes,  and  convulsive  phenomena.  These  general  i>ympt«ras  have 
a  tendency  to  be  progressive,  but  may  var>'  coiLsiderably  in  their 
intensity  from  time  to  time,  especially  tn  syphilomata,  tulx*rcuhnuata, 
and  Kliomala.  At  times  they  remain  stationary,  again  they  may 
regress  nnti  disappear. 

Ilriiilftchr.  This  is  frequent.  Most  patients  will  iiavc  headache, 
especially  if  the  tumor  is  of  protracted  growth.    Headache  is  an  airiy 

•  dtJiUei:    Jour.  N«rv.  aoii  Menu  Dig..  1911,  xU,  ISi. 


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TUMORS  OF  THE  BRAIN 


sipi.  Practirally  every  patient  with  jt  hcadarhe  shoultl  he  questioned 
ami  examined  fur  the  ptis-sibility  nf  its  being  cnnsed  bv  a  cerebral 
tunmr.  The  headfiehe  usually  starts  mort-  or  U-ss  irrcK"Iftrfy.  ^-"^  ^^^ 
queiitly  iiitpnnittfnt  in  tlic  early  stagt^  and  tben  U-iiinies  i>ersistent. 
being  (hill  or  seven-;  if  ilitll,  with  pj'ritids  tif  excnieiHtinn  exnit-rlmtion. 
Diiiniul  variatiiULs  may  be  noted,  unil  einulioual  excitement  or  geiienil 
causes  ior  increasing  intraenuiial  pressure  increase  it,  often  with  addi- 
tional symptoms,  such  as  verti)t<i,  vomiting  or  even  agitated  or  coma- 
tose cotifiisions.  Nut  infrequently  aneurisnial  tumors  will  reveal 
pulsiition  by  anseultatiim.  Aligraine-like  iieudadies  are  ver>"  frequent 
ill  early  states,  partieiiiurly  in  basal  casi-s,  hyixipliysis,  Imsal  giinimata, 
neii  re  fibromata,  or  there  may  be  niigraine-Hke  exaeerlmtions  on  a 
dull,  he'avy,  jjjay  bitckjfn^nnd  of  pain.  Children  usually  respond  to 
suclt  variatiutu  by  attac'ks  of  screaming,  pulling  the  hair,  or  beating 
the  head. 

Later,  sctmewlmt  mentally  diiUe<l  patients  may  even  deny  any 
headache,  or  even  forpet  having  had  a  period  of  great  distress. 

The  headache  of  cerebral  tumor  is  mostly  diffuse,  but  it  may  be 
hx'ali'/ed,  in  which  ease  it  may  «erve  tn  iTidieatr  the  general  site  of  the 
tumor.  Such  is  rendereil  more  probal>]e  if  further  substantiated  by 
percussion  tenderness,  a  highly  Important  proet'duri',  jicreiission  dul- 
uess,  and  .r-ray  shadow.  The  site  of  a  lieadaclie  is  a  \'er>'  uncertain 
guide  for  localization  purposes,  however.  Frontal  tumors  often  give 
rise  to  occipital  headaches  and  vice  rer.ta;  right-sided  tumors  to  left- 
sided  pains  and  vice  rfr.t(i.  The  gf.mrnl  drift  for  localize*!  pain  is,  how- 
ever, in  favor  of  a  .similarly  located  tumor.  Among  head  s>Tnptoms 
may  1k'  mentioned  the  iiceasionally  found  auseultnlioii  notes  of  uneu- 
rismal  tmuors;  tlie  presence  uf  enlarged  head  (hydrocephalus),  and  tlie 
overfilling  and  increased  tortuosity  of  the  veins  on  the  forehead,  face, 
conjunctiva,   etc.,   of  the  aflecte*!  side. 

Trigeminal  neuralgic  attacks  may  be  general  or  at  times  a  focal 
(cerebellopontine  angle)  sign. 

.Yfiwf-n,  wmifhig,  and  dizzinejtir  are  frequent  in  late  stages  of  n  cere- 
bral tumor,  and  more  <iften  found  in  children  and  In  those  [mtients 
with  rapidly  increasing  signs  of  ijitracranial  pressure — posterior  fossa 
tumors  particularly.  Such  vomiting  may  occur  spontaneously — pro- 
jectile in  type  or  as  an  accompaniment  of  the  hcadwhe  mses, 
especially  when  migrainous  in  type.  Vomiting  often  Ls  absent  entirely 
even  with  large  tumors,  \\1icn  present  it  more  often  tx?curs  in  the 
morning,  and  at  times  it  is  so  persistent  as  to  lead  to  inanition, 
exhaustion,  and  death. 

In  cerebellar,  peduncle,  pontine,  and  medulla  tumors,  and  those 
causing  prcssun'  uri  the  superior  cereltfllar  peduncle,  or  its  inonning 
pathways,  the  nausea  and  vomiting  may  be  accompanie<l  by  unilateral 
vertigoes  or  with  tendencies  to  turn  or  to  fail  in  one  direction.  Here 
general  and  ftx-al  s>Tnptoras  coincide.  Frontal  tumors  may  occasion- 
ally cause  such  onc-sid«l  vertigoes  from  implication  of  the  frontal 


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extensions  of  the  ccrcliellar  pathways.  Vertigoes  from  m-ular  palsies 
are  lix-aliKing  sj-mptoms  (quarlrifEeminal  syndromes — occasionally 
oortirnif. 

Cnrdmc  and  liex}uminnj  Sigitg. — SIowiwss  of  tin*  pulse,  at  timtrs 
markeil — 30  to  40 — is  a  general  si^  of  intracranial  pressure,  am)  more 
esiK-ciatly  in  inarkal  grades.  HentT  it  is  apt  to  hr  a  latf  rather  than 
an  enrly  sjtnptoni,  unless  one  of  direct  irritation  of  the  vagus  (iiiechillary 
pressure).  Tlie  hradycaniia,  at  tiuK-^  arrhythmia,  may  appear  period- 
ically during  hea<lache  exacerbations,  or  at  times  independent  of  the 
same  (acute  swelling  reaction). 

Medullary  tumors  cimse  respiratiiry  changes,  at  times  slowness, 
again  irregiihinty,  and  ('he\Tie-Sti>kcs — with  acute  pressure  symptoms 
(hydrorepjiahis  intenius).  Hiccough,  yawning,  and  relate*!  respiratory 
signs  iiR-  weasioually  present- 

Mrtnlmlic  DisiuThancen. — These  are  irregular  in  their  development 
and  evolution.  Fever  is  infretiuent  save  as  n  complication  of  the 
late  stages. 

Cachexia  and  marasmus  are  present  with  certain  carcinomata.  and 
marked  adiposity.  Ovarian,  and  in  partieuLir  testicular  aplasias,  are 
frequent  in  certain  h.vpophyseal  (pituitary)  tumors  or  tlio.se  causing 
internal  hydrocephalus  by  possible  implication  of  the  infundibular 
regifjn  through  general  pressure  (pineal  and  corpora  quadrigemina 
tunuirs).  Acromegaly  is  a  special  case,  a*  are  also  the  rly.slrophia 
adiposogenitalis  s>'ndromes  which  are  discussed  in  the  chapter  on  the 
Disorders  of   flic   Endiicrimius  (Hands. 

Meninl  Sigrix. — These  are  of  great  value,  both  general  and  localising, 
in  friHii  ftn  to  So  per  cent,  of  the  cases.'  They  vary  cojisiderahly, 
and  are  particularly  pniminent  late  in  the  disease,  although  here 
masked  under  the  genenil  s^-mptoms  of  apathy,  confusion  t>r  cuma. 
Tumors  of  any  region,  large  and  small,  and  independently  of  their 
pathological  nature,  may  cause  psyelueal  ehmiges.  <'ertain  IiH'alititw 
cause  siwcial  psychical  alterations  to  be  discussed  under  focal  and 
localizing  spnploms. 

In  the  early  stages,  slight  impairment  of  attention,  with  slowness 
and  difficulty  in  grasp,  retardation  in  motor  response,  and  a  i-onfusion 
or  hewildemtent  may  he  present.  Heady  forgetting,  slight  esthetic 
lapses,  and  moral  breaks — with  the  telling  of  .shady  stories,  sliowing 
of  bad  taste,  exhibitionistic  fancies,  even  gross  lapses — such  as  oiwn 
nia.sturbation,  etc. — occur.  The-se  are  the  precursors  of  a  more  marked 
grade  of  retardation  of  mental  function.  leading  To  apathx'.  ILstlcssness, 
lack  of  initiative,  at  times  with  i-nnfusioual  e[jis4Hles — getting  h>st — 
fugues,  fussincss,  emolionulism.  etc.  In  marked  states  of  confusion 
and  dis4}ncntation  a  typlwU  KoRiakow's  syufirome  (f/.  r.),  without 
polyneuritis,  may  be  present, 

>  CianpllI,  SrhuMtcr.  and  iitlwn:  Hue  BibUnKrapfay  in   ilvdiich.  Himtuntor,  LeWHn- 
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Later  stages  show  t.vpical  pictures,  not  di^tiiiRiiishable  from 
of  arteriosclerotic  deterioration,  or  paresis — i'.  e.,  so  Tar  as  the  purt?!.^ 
mental  picture  is  conccriuHl. 

Certain  less  K*'i"'''al  syiiiptuins  ufteii  present  tlieinselves  and  are 
of  a  certain  localizing  value.  Hallucinations  of  snaell  speak  for  ulfuc- 
torj'  lo^e  or  olfactory  tract  involvement.  Tliose  of  sight  for  occipital 
cortex  localization,  those  of  sound  for  temporal  lolie  trouble. 

The  tendency  to  joke,  be  facetious,  show  manic  idea  associations, I 
even  flight  of  iileas  with  eviphoria,  is  at  times  present.  This  is  morel 
often  found  in  prefrontfll  tumors,  especially  left -sided,  but  may  occur  ini 
tumors  iif  other  regions,  usually,  however,  all  reaching  to  and  involving! 
the  cnrtex.  These  syinplntns  are  possibly  tlialaniic  overresponscs 
from  thalamocortical  interference  at  cortical  levels. 

Certaui  patients  show  definite  depressed  states — with  hypochon- 
dria.sis  or  even  melancholic  suicidal  ideas.  Others  show  manic  pictures 
with  wild  flight  or  marked  maniacal  deliriimi.  Tertain  patients 
develop  delirium  rfurinp  certain  of  their  headache  paroxysms.  Para- 
noid trends  also  manifest  themselves  in  a  few  instances.  So-called 
hj'sterieal  symptoms  arc  frequently  encountered.  Careful  analysis 
shows,  however,  nojisychii-Hl  cuiiversituis.  Kmotionalism  ami  delirium 
arc  incorrectly  termed  hysterical  because  of  a  lo*)se  application  of  the 
term  lij'stcria. 

Optic  Nerve  CAoMj/f*.— Tliese  are  of  the  greatest  importance  in  diag- 
nosis of  brain  tumor.  The  general  features  arc  discussed  in  the  chapter  ■ 
on  Cranial  NervTS.  From  (10  to  NO  per  cent,  of  all  pattent.s  show  optic  " 
nen-e  changes,  which  vary  largely,  depending  upon  the  grade  of  intra- 
cranial pressure  ami  the  size  and  UH-atitm  of  the  tumor.  Those  tumors 
causing  great  ititmcranial  jirf-ssmre  (posterior  fossa  jMirticuIarly) 
naturally  cause  choked  disk  and  optic  neuritis  earlier  and  in  more 
marked  degree.  Optic  nerve  changes  may  be  absent  even  witli  large 
tumors,  ami  small  tumors  of  the  pons,  medulla,  motor  area,  basid 
ganglia,  c<irpus  eallosum,  and  hyjKiphy.sis  may  give  rise  to  ih>  optic 
nerve  <'hanf;es.  The  optic  nerve  changes  develop  gradually.  Thej'  are 
unilateral,  later  bilateral  or  develop  bilaterally  synchronously.  As  a 
rule  tumors  of  one  side  show  beginning  nerve  <^nges  on  the  same 
side  earlier  and  mort-  niarketlly  than  on  the  opjKisite  side.  The  ruverse 
can  also  be  true  and  the  localizing  value  must  not  be  overestimated. 
The  general  trend,  however,  is  as  stated  ((iuiui). 

The  visual  power  may  not  be  h>st  even  with  marked  grade  of  swelling 
or  of  atrophy,  but  there  is  later  a  gradual  loss  of  vi.-yioii — often  seen 
in  early  signs  by  the  irregularity  of  the  color  field  loss  (interlacing 
phenomena,  scotomata,  etc.).  The  hemianopic  changes  which  are  not 
infreciuent  in  cliiasm,  p<]sterior  tract,  pulvinar,  and  parts  of  tlie  path- 
ways are  discussed  in  Chapter  V. 

Motor  PhenmjjfTta.—The^e  are  local  or  general.  Epileptiform  attacks 
arc  frequent— particularly  in  chihlren.  When  limited  JacLstmian 
attacks  are  present,  the  localizing  value  in  the  motor  cortex  h  evident. 


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(ill 


save  for  the  few  exceptions  of  pontine,  cerebellar,  and  peilunnilap 
Jacksoniaii  tittaoks.  I'etit  ninl  attacks  are  also  not  ilifrequent.  Some 
patients  Hie  in  the  cnnviilsive  seizures. 

Foca!  or  Local  Symptoms. — Tliese  omy  hv  unioEi}:  the  first  »)f  the 
symptoms  enrountercd,  especially  in  cin-umscribe'l  cortical  tumors, 
but,  as  a  rule,  die  focal  symptoms  develop  after  the  general  ones;  again 
they  advance  tflpether.  Tliey  are  best  considered  with  reference  to 
the  areas  involved,  such  us  the  s.Mnptoms  of  the  frontal  localizations, 
central  convolutions,  parietal  lobes,  temporal,  etc. 

Frontal  l/ihe  Itnnorjt  are  those  located  ahead  of  the  prt'ceiitrul  sulci. 
Those  of  the  frontal  poles,  foot  of  tliird  fmntals,  are  frequently  tennetl 
prefrontal  tuniurs-  The  functi<ins  of  llie  fnmtal  urt-as  are  chiefly 
those  of  coordination  of  psychical,  chiefly  iittellectuid  processes.'    They 


Fio.  328.- 


iti':il  I'iIm'  tiiiiiur,      ( I^irkiri 


contain  motor  areas  (or  the  innervation  of  the  muscles  of  the  neck, 
throat  and  alMiominal  muscles  and  the  thin!  fmntal  convolution — 
Brocas'  convolution — Ls  a  motor  apha.sia  area,  Marie  and  Ids  pupils 
notwitltstandinfj.  On  the  base  the  olfactory  and  optic  piuhways  may 
be  inviilviil  by  direct  or  indlrtn-t  iiijtir,v,  luid  pres.vure  posteriorly  causes 
pyramidal  tniet  symptoms.  CerelH-llar  iMtthway  pnijections  also  lie 
in  the  frontal  poles. 

Tints  the  symptoms  of  tumors  lying  within  the  frontal  lobes  may 
show  considerable  variation  actx>rdinjc  to  their  size  and  site.  Many 
smalt  tumors  hwatcil  «ieep  in  the  cortex  are  HppHn-ntl.N'  syniptoudess 
from  tJie  neun illogical  point  of  view.  I'aranoid  states,  octiisionally 
restiltinff  fn>m  such  tumors,  are  readily  overlookefl,  al.s*i  mild  tlepreswerl 

*  Fniu:  FuticiJoiu  o(  the  i'mntal  Luboa,  ArvbivM  of  l^yrliology.  IW)7. 


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TUMORS  OF  TUB  BHAIX 


States  which  are  ralleil  neurnsthenia.  One  sMtiptom  of  special  inipfw- 
tance  is  a  tendency  to  make  jokes  (Witzelzucht),  or  a  tcndencj'  to 
talk  or  answw  besiHe  the  point — at  times  an  apparently  intenti<tti«l 
effort  tu  mislead.  Oni-  ikws  not  necessarily  locate  a  tiinrif »r  in  the  frontil 
lobes  by  reason  of  this  tendency  to  jnkitig  alone.  At  times  thf  iR-lui^'iiir 
is  infftntile  ami  cliildish,  and  diajriiosetl  hy.stepia.  A|;;aiii  patients  ait 
irritable,  excitable,  churlish,  even  luive  furious  outbreaks  of  WTath  ud 
arc  violent,  capricious,  or  the  picture  of  gradually  advancing^  stupidity, 
with  inability  to  grasp,  loss  of  initiative,  slowness  of  power  of  applica- 
tion, is  seen.  In  riftbt-hiuided  tumors,  the  psydiical  disturbanct^  arr 
more  frequent — Schuster'  <S0  per  cent.).  PfeilTcr,*  Miilier.* 

Orientation  for  the  external  world,  time  and  space,  is  apt  to  be 
involved  more  than  personal  orientation.  Complete  disorientation, 
as  in  Korsakows  sjTidrome,  is  cKcasionally  fninMi. 


Fto.  •127. — Fr»rilnl  lulu-  iiinmr  rKiu'ivrd.  1'hi.4  patk-iit  Ituil  Una  ul  anirJI  rta  tb* 
tamnr  side.  WiiicUuclit.  atoiuKrius  uait.  aii<l  luw  ol  n>aUrol  of  feoea-st  tim««i.  with 
olherwiM- iiiiimpHiinl  intclliticnrp.     Nntiirnl  mws. 

At  times  halludnations  of  smell  appear  from  pressure  on  the  olfao 
tor>'  pathways,  or  hallucinations  of  sight,  photumata,  fmm  similar 
pressure  on  opti(-al  pathways  at  the  ba.se. 

Vertigo,  with  a  drunken  gait,  may  Iw  a.scribed  probably  to  the  higher 
association  of  space  perceptions  and  indicates  frontal  involvement 
of  rerebellar  eoniponeuts,  the  gait  Iteing  closely  related  to  that  of 
cerebellar  syndromes — the  patient  staggers  to  the  tumor  side;  adia- 
dokitkiiiesia  and  asynergia  arc  nsually  absent  here,  however.  (See 
Cereheilar  Syndromes.) 

Invnhintary  rlcfccatiori  or  uriiiatinn  rxrurs  at  times;  most  fretjuently 
with  somnolent  patients,  The  patient  whose  tumor  is  here  figured 
had  a  marked  cerebellar  gait,  was  keen  and  active,  jocular  and  Imppy, 


'  Th**ii».  Stultaurt,  1902. 


'  IVtiisch.  ZoiW-^Urih  f.  Nvneiihvilkutidv,  voU.  x»,  xnit,  xdii. 


*  An:h.r.Fk]rdi.,i]vu. 


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613 


with  occaiiiuiml  I<Kvs  of  l)lu4]rli'r  tiii«l  r*.'<'tiil  riiiK-tion  \\\\\\  hull udnut ions 
of  smell.    Tlic  luinor  m-^'iipicd  the  U*ft  fnmUil  pole  (KiR.  327). 

Apractic  disturbfincw  are  occasional ly  met  with  in  frontal  tumors, 
and  those  involving  nr  pressing  upon  IJrnciis"  fonvoliitiori,  left  side, 
cause  tniKI  {pftrapliasia).  <ir  severe  motor  aphasias  in  right-hatuletl 
indiviiluuls,  usually  of  grudtiul  onset  ami  often  remittent  in  eharaoter. 

Other  motor  si^tis  are  stiffness  in  the  neck  with  forward  and  hjiek- 
wurd  fixatiuHH  of  the  liaud  and  tenilencies  lo  treinor  of  the  luind  on 
the  side  of  the  tinnor.  tn  a  tliird  of  the  euse^.  cpiU-ptifonn  attacks, 
often  Jac'ksoiiian.  nceur.Jroiu  pressure  uu  the  uiotur  arva. 


'^. 


.<. 


v.: 


Ttn.  326.— DvoivaMoa  in  braiit  eA\vt  rrni'ival  ot  «  (rvnlol  tumor.     (Goodluitt.) 

Central  Conrolutioiu^. — The  functions  chiefly  involved  are  those 
of  llic  V(>Iuntary  niuscidar  activity,  hen(x*  paresis,  paralysis,  spasms. 
Tumors  of  this  refjion  are  never  latent.  Irritative  phenomena,  spasms, 
convulsions,  s]x>Bk  for  cortical  locations;  paralysis  for  tleeper-seated 
lesions  involving  the  pyramidal  paths  from  the  motor  areas.  Small 
tumors,  eorticfllly  located,  cause  isolated  Jacksoniau  attacks;  the 
more  extended  the  tumor  the  more  widespread  the  miisrular  involve- 
ment; even  small  tumors,  httwever,  may  cans*'  wide-spnad  Jat-ksonian 
or  grand  mal  symptoms.  Often  the  first  olftervwl  motion  arcumpanted 
by  tingling  affords  a  cJue  as  to  the  more  definite  localization  of  the 
tumor;  again  an  orderly  and  uniform  progression  in  tiie  development 
of  a  Jacksonian  attack  is  vnliiahle  in  localization. 


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8>iuptoms  may  also  appear.  Senjiory  phenomena  are  frec)uent  in 
postcentral  convolution  tumors.  'ITie  phenomena  have  been  exten- 
sively (Ie«cril)eil  in  the  chapter  ilejilinx  with  sensnry  L-hanges  due  to 
ii»rtieul  iiiiH  suht'nrtieal  lesions. 

(  Vnlral  cdtivulutiun  tumors  are  among  those  mope  readily  localizuhle, 
aiul   usually  more  a^-cessible  to  operative  relief. 

T'nnrUii  /.fiW.— ^AVlieii  tlie  tumor*  press  forward  towunl  the  [kis- 
terior  eentral  loin's  sensory  si>;us  are  pn>due«i  like  thost*  already 
mentioned.  Lcft-sidcd  tumors,  m  right-handed  persons,  especially  of 
the  inferior  parietid  lobes,  cause  cortical  sensory  aphasia  of  Wernicke 
of  various  grades.  .Alexia  and  ajjraphia  may  also  be  found  in  left-sided 
lesions. 

Kpileptic  attacks  witli  hidlucinatory  uuras  of  taste  occur;  also  a 
general  Korsakow  syndrnme  may  develop.  Other  pathways  from  the 
sensory  arejis  ma.\'  Iw  cut  off  by  tumors  in  tliis  refjion;  hence  eitlier 
hemianopitJas,  optic  a^osias  or  optical  aphasias  (f;yrus  nngularia). 
Apractic  disturbances  are  of  value  in  localizing  left-side<l  tumors. 
Katatonic  syndn)mes,  confnsi(tn,  apathy,  or  p-neral  loss  of  orientation 
may  be  encountered  but  are  equally  present  in  right-sided  and  left- 
sided  cases. 

Occasionally  parietal  tumors-  give  rise  to  ptosis,  paresis  of  the 
lateral  movements  of  the  head  and  the  conjugate  motion  of  the  eyes 
to  the  opposite  side.  (Ceplialorutarv  ami  wulorotarv  paralvsis,  ijee 
I'late  VII.) 

Deep-seated  lesions  may  impinge  upon  or  involve  tlie  motor  path- 
ways. 

TcmpoTal  Lohea. — The  cortical  end-stalioiLS  of  the  auditory  path- 
ways whicJi  art;  Ixitli  (■ri>sstHJ  and  uni-russcd  arc  chieHy  eontaincil  in 
the  first  and  second  teni|)itral  lobes,  ('ortical  deafness  is  practically 
impossible  in  unilateral  lesions  but  has  resulted  from  bilateral  involve- 
ment. 

Word-deafness  is  the  most  striking  result  in  left-sided  lesions.  This 
is  a  progressive  atTair,  often  Ix'ginning  with  dithculty  in  finding  words, 
parapluisia,  and  resulting  in  more  severe  forms  in  alexia,  agraphia, 
logorrhea,  and  total  word-deafness.  Ijirge  tumors  also  cause  indirect 
symptoms  and  may  lead,  by  pressure  on  motor  arcAs^Hroca  -to 
total  aphasia,  and  epileptiform  convulsions. 

Auditon  hallucinations  are  not  uifrequent,  showing  as  aura.'  in 
[•JleneratiKed  grand  mal  attacks.  Gitstatory  and  olfactory  phenomena 
ttf  similar  nature  result  from  hippocampal  or  closely  related  lesioits — 
uncinate  tits. 

Tumors  of  tlie  under  surface  may  cause  hemianopsia,  through  pres-s- 
ure  on  the  optic  tracts,  and  by  pressure  on  the  pjTamidal  or  fillet 
tracts  cause  liemiparesis  or  hemianesthesia. 

In  cotain  cases,  as  Knapp'  has  shown,  there  may  be  an  orderly 

I  Dio  GwrbwCtUt^  il.  rt^litoi)  u.  liiikcD  ScliUfeulappciuf.  IdOa:  Muuctioo.  mod. 
Wcluucbr.,  IWJK. 


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FOCAL  OR  LOCAL  SYMPTOMS 

OccipiUil  A<Jw'.-  The  nuI-pr()jcctioiis  of  the  oplii-  truc't<  ore  |iK-iit<ii 
licrir  partHiihirlv  in  ami  al«Hit  the  colcnriiic-  fisstirf.  ('nniplrti* 
lioinonytiioiis  ht'iniaiiopsiii  is  the  i-hit-f  sviiiptoin  of  tumors  of  this 
area.  This  hemianopsia  usually  spares  the  papilloniaeiilar  huiHlles 
and  ia  often  unperfeivwl  hy  the  |>atieiit.  CJuailnirit  lieiniunopsia  is  aUo 
found.  Tumors  may  exist  and  heruianopsia  be  absent.  It  is  most 
often  present  with  tnmors  of  the  meriian  aspect  of  the  oceipital.  also 
with  tliose  lying  i»n  the  convex  surface,  ant!  hence  the  more  readily 


;<»■'  ^ 


Fi<i.  332. — ^Tunor  ariajimt  from  die  mcningM  and  lut'JMiu)^  down  lo  Utr  ri>rpii.i  i-ul|i>fctitTi. 

(Baldiviu.') 

removable.  \'Hrious  stages  of  bHndncss  may  also  result,  and  there 
may  exist  h  mind-blintluess  from  left-sid(vl  lumnrs,  also  alexin,  nf^^phia 
and  aeiLwry  aphakia. 

CXiier  optie  sipis,  siteh  as  phoneineK,  vari»ms  scintillating  scntoraata, 
optical  liallucinations  aiul  i]hHion.s  occasionally  result  from  oeeipitiil 
tumors,  and  these  may  exist  as  auras  prece«iing  general  epileptic 
convulsions. 

Tumors  on  tlie  inferior  surface,  by  compression  of  t!ie  cerebellum, 
will  eniise  cerebellar  signs,  and  occasionnlly  palsies  result  from  tumors 
lying  on  tlie  external  surface  of  the  occipitkl  lube. 

<  iouraiil  Mf  NcrvtiuK  mtd  MotiUl  l>iKpui>p.  IWi], 


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TUMORS  OF  THE  BRAIN 


Cifriitia  Vuihmim}  — Isuliitdl  atllosal  lesiims  art'  cxtix-nifly  rjif. 
.Sflitister  gatlien*  HT;  Williams  ;i,S.  ronRciutnl  ahsentt'  is  known  with 
no  definite  svinptoms.  Apraxia  (dj-spraxia)  of  the  Ie(t  hand  is  an 
occasional  s\rnptoin  due  to  interrupt  inn  of  forward-lying  eAllosal 
fibers,  especially  those  between  the  sensorimotor  areas,  from  left  to 
right,  and  is  nf  speeinl  signifieanee  in  dia^fnnsis.  Possilily  iniiid-blind- 
ness  resiilt.s  from  lesions  of  those  eallosa!  fibers  uniting  tlie  two  optic 
fields  (Bnwlmunn  IS,  ID),  also  termed  the  visual  psyehie  area.  This 
is  rittt  vet  established  definitely.' 


Kiu.  SSiJ.^Tunior  wilb  Jttraphjf  uf  the  eorelieUijJtt. 

I'aretic  syndrt>raes  of  the  extremities  occur  with  callosul  tumors. 
Duprf  loeate-s  tlieni  in  the  anterior  eallosal  region  if  the  paretic  sj-mp- 
toms  are  in  the  muscles  of  tlie  face  anH  toiigiie;  pareses  and  ataxias 
of  the  upper  extremities  from  niidcalUfsat  fibers;  paresis,  ataxia  and 
hemianopsia  from  posterior  caltosal  fibers.  \"nn  V'alkeiiberg's  exten- 
sive studies  of  the  callosum  do  not  at  all  corrolwrate  Dupre'sdeiluotions. 

Tumors  tif  the  eollosum  arc  mare  apt  to  show  i-oniplex  syndromes 
due  to  involvement  of  the  neighboring  parts;  if  lying  forwartl,  frontal 
signs  are  adde*!;  midetilU>sal  region,  p>Taniidal  tracts,  epilepsies,  etc 
General  psychical  sjinploms  are  usually  present,  and  appear  early, 

■  Aysln:  lUv.  d,  [Mtol.  X«rv.  and  M«at..  1015,  p.  449. 
*  Vbu  Valkeabcfg:  Brun,  Novamber,  1013. 


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PROCNOSrS 

They  approach  the  ty\K  due  to  ^ncral  pressim*.  Kor*nk(>w  unH 
puretic  syiirlnnnc8  tlevehip.  There  is  little  of  diaKiiustic  sigiiitiiaiRC 
in  the  mental  sijins. 

Tumtim  of  tht  i)i>tic  Thalmmm.—  The  sxTnptonis  are  iliseussed  under 
the  section  im  tl»e  ThaJamie  Sjndrome  (g.  c).  Involvement  of  the 
lenticular  nucleus  (see  Wilson's  disease),  tumors  of  tlie  midbrain, 
pons  uiid  metltilla  have  heen  dlscnssefl.  Those  of  the  cTrel>e!lum  aiiil 
ceri'lifll  upon  tine  angle  will  be  found  under  rerehcllar  Syndrurnes, 

Diagnosis. — ^fultiplc  sclerosis,  paresis,  arteriosclerotic  disease,  all 
forms  uf  headadie,  tuben-ulous  meningitis,  chronic  hydrocephalus, 
and  hysteria  are  the  chief  conditions  causing  difficulty. 

Multiple  sclerosis,  if  the  patches  are  solely  cerebral,  may  cause 
confusion,  especially  in  the  acute  cases,  as  described  by  Marburg  and 
others.  Tlie  bitemporal  pallor  of  the  disks  in  this  disorder  ditfers 
from  the  usual  pressure  clmnges  in  the  disk.  Nystagmus  is  not  a 
fRt[uent  brain-tuintir  sign.  Other  signs  of  pyramidal  tract  implica- 
tion may  be  identical.  Heailaches  are  usually  alisent,  also  nausea  awl 
vomit  big. 

Pseudoparetic  and  artcrio^^clcrotic  jwychical  syndromes  (Korsakow's 
psychosis)  are  frc<piently  ct>nfu.scd  witli  cerebral  tumor,  i.  e.,  the  cause 
nf  the  mental  picture  is  overlooked.  Thus  a  tumor,  which  might  have 
been  remiivwl,  has  l»eeii  misseti  imder  the  psychotic  disguise.  Kye- 
gnmnd  changes  are  usually  jHisiti^-e  in  these  eases,  yet  may  l>e  absent. 

Headache  should  always  l>e  scrutinizwi  cari'fully.  A  [MistinHuenzal 
occipital  headuche  which  ia  very  frequent  lUid  extremely  severe  and 
per^stent.  is  frequently  highly  suggestive  of  brain  tumor.  The  head- 
adics  from  lead  poisoning,  anenua,  and  nephritis  are  also  to  be  exclude*!. 

Brain  abscess  and  tuberculous  meningitis  must  be  excluded  on  the 
ground  of  their  difTcrcncc  in  development  of  symptoms.  Symptomati- 
cally  speakinp,  they  may  be  considered  as  tumors.  This  is  also  true 
of  chronic  hydrocephalus. 

Cerebral  pmu-ture,  withdrawing  a  small  plug  of  brain  tissue  through 
a  trephine  u[K-niiig  and  cannula,  is  often  of  grntt  aitt  iti  iliugiiosing  very 
jjuzzling  cases. 

PiOKDoais. — No  definite  prognosis  can  be  laid  down.  Everytlilng 
depends  on  the  site  of  tlie  tumor.  In  general,  apart  from  surgical  relief 
and  from  medicinal  trt'atment  of  syi)hilomata.  the  outlnok  is  pessi- 
mistic. Sudden  death  Is  not  infrequent  and  lumbar  puncture  U  an 
extremely  dangerous  procedure  witli  brain  tumor,  often  leading  to 
sudden  collapse  and  death,  especially  with  tmnors  of  the  posterior  fassa. 

Sypliilomata  and  gumnmta  of  tlte  brain  have  a  fair  pn)gn«tsis.  Better 
residt.s  are  i)btainwl  with  mercury  by  inunction  and  by  icMHdes  tjian 
by  salvarsan  in  the  beginning  treatment.  .Salvarsan  may  be  used 
later  to  attempt  to  kill  ofT  all  the  spirochetes,  but  with  well-advanced 
8yphJh>mata,  salvarsan  is  apt  to  set  up  a  dangerous  reaction.  Hound, 
hard  gummata  do  not  at^orb,  as  a  rule,  and  are  best  considered 
surgically. 


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.620  TUMORS  OF  THE  BRAIN 

Treatment. — Medicinal  treiitmeiit,  cxt-eptiiiK  for  syphilomata,  is 
useless,  and  involves  a  waste  of  valuable  time.  The  chief  objecta  to  be 
attained  are  early  diagrumji,  immediate  exclusion  of  syphilis  by  sero- 
logical tests,  eye-ground  examination  with  particular  study  of  the 
color  fields,  ej-ad  localization  as  soon  as  possible,  and  surgical  remoral 
or  jHiUiation  (decompression)  to  save  the  eyesight  or  to  gain  time  for 
a  more  exact  localization. 

The  details  for  applying  these  principles  have  already  been  noted. 
The  results  to  be  expected  in  any  particular  case  are  problematical, 
yet  from  10  to  20  per  cent,  of  all  brain  tumors  (seen  in  the  large) 
ha\'e  been  removable,  with  at  least  in  10  per  cent,  practical  recovery. 
Kven  with  such  chances  against  him  the  patient  should  have  the 
benefit  of  the  doubt  if  a:  competent  surgeon  is  a%'ailable.  Sui^cal 
skill  is  a  very  large  factor  in  the  results;  a  good  abdominal  sui^^n 
is  not  necessarily  a  good  brain  surgeon.  The  brain  is  semifluid  and  an 
intricate  switch-boanl  of  highly  important  structures;  there  are  no 
unimporiant  areas  in  the  brain;  many  surgeons  have  treated  it  in  the 
past  as  though  it  were  an  abdominal  viscus.  The  results  have  been 
disastrous. 

Most  brain  operations  are  best  done  in  two  stages.  Decompression, 
usually  subtemporal,  alone  is  often  the  only  possible  procedure.  It 
often  relieves  a  recently  acquired  blindness. 

.  The  situation  referable  to  brain  3urger\'  for  cerebral  tumors  is 
rapidly  advancing,  and  better  and  better  results  are  being  obtained 
and  regions  hitherto  impossible  to  reach  (hypophysis,  etc.)  have  been 
approached  with  results  which  a  decade  ago  would  have  been  impos- 
sible.' Notwithstanding  all  this,  the  general  attitude  should  be  one 
of  extreme  caution. 

'  See  Starr:  Brain  SiirRery;  Halsted:  Treatment  of  Btnin  Tumors;  \\'hit«  and  Jdliffc: 
Modem  Treatment  of  Nervous  and  Ment:il  Disease. 


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CHAPTKR    XIV. 
S\Pini.I.S  OF  TIIK  NKUVOUS  SYSTEM. 

SypuiLis  of  tlif  nervous  syHtcin  is  so  protean  m  its  cliaical  forms, 
that  the  sigiuiic-ant'e  of  syphilis  as  an  etiolo[?icaI  factor  in  uervous 
diseases  is  frequently  overloipke<l.  The  ithysictaii  with  his  eye  rivetwl 
upon  a  diniral  pirTiiie,  be  it  an  amyotiophir  lateral  wlerosts.  a  failing 
nieuiwry.  a  (xrsistent  nervous  weakiK-s.N.  an  isohited  criinial  nerve 
palsy,  a  progressive  nubiciilar  ntmpliy  of  the  ann  muscles,  or  a  pro- 
Iractet!  seiatica,  may  rea'lily  overliH)k  the  fact  that  syphilis  is  the 
unique  eaiise  for  these  syn<!r*pnies. 

Tlier**  is  no  lield  in  uie<lt<-ine  wheivin  similar  dLsease  pictures  may 
arise  from  as  ninny  ditTerin^  causes  as  in  the  domain  of  tlie  nervous 
system.  Nor,  on  the  other  hand,  where  a  single  etiolof^ical  factor  may 
give  rise  to  so  many  dissimilar  clinical  pictures.  Ilrnee  the  com- 
plexity of  the  whole  suhject,  and  the  lu-ol  fur  iterating  and  rcitcratitiK 
the  advice  that  in  nearly  all  nf  (he  elinieal  pictures  wlneli  have  (ir  have 
not  l>oeii  ^veii  descriptive  terms  in  nervous  or  nu-nta]  disease,  the 
[HissihiJity  of  syphilis  as  a  dirwt  etiological  factor  or  as  a  complica- 
tion, or  as  causing  confusion,  should  l»e  home  in  mind.  Hence  the 
necessity  for  detailed  and  minute  inquiries  into  all  of  the  possible 
s.vmptomatology  of  hereilitary  or  ac(|uireil  syphilis,  which  in  all 
questionable  cases  should  bf  sui)]3lemented  by  complete  senilopical 
and  cytological  exanutiations. 

The  fonnerly  ver\-  distiiut  dividing  lines  Iwftween  the  lesimiLs  of 
hereditary  sypliihs.  acquire)!  syphilis,  and  nictasypliilis  are  slowly 
being  obliterated,  and  in  time  it  may  probable  seem  strange  that  it 
could  have  l>een  thought  tluit  spina!  luiil  cerebral  syphilis  on  the  <mc 
hand  should  ever  have  been  considered!  different,  let  us  auy,  fnnn  tabes 
and  general  paresis  on  the  other. 

Since  it  has  eume  to  be  believed  that  both  talies  and  general  paresis 
rtrst  up<Hi  a  syphilitic  basis,  the  variety  nf  sypliilitie  di^on^l•r^  showing 
fairly  dear  clinicjil  entities  has  been  eidarged.  Knrrher,  with  the 
recognition  of  many  acute  and  subacute  psychnscs  due  to  syphilis 
the  i»sycliiatric  Impders  have  l)een  further  extended. 

In  the  presetit  cluipter,  then,  the  discussion  will  oincern  itself  chiefly 
with  i'linical  fonns,  without  any  extended  ultempt  l)eing  made  to 
dilferentiato  types,  whieh  in  reaUtj'  are  .so  kaleidoscopii*  that  they 
defy  description. 

At  the  sanir  time  it  neetls  to  Ite  emphnsi^ied  that  .such'intemie<liary 
forms  are  ever-present  realities.    Clossical  pictures  of  a  disease  are 


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SYPHILIS  OF  THE  NKHVtWS  SYSTEM 


largely  literary  efforts.  They  are  the  product  mainly  of  the  desmptivc 
urt.  The  netiuil  priM-esse-s  going  on  in  nature  in  the  cnnfliet  i>f  man 
Hguiiist  the  splrothete  do  not  show  (-iassical  types,  but  rather  a 
mnltiplieity  of  variations,  with  here  ami  there  tlie  stutistieal  prominence 
of  this  or  tliat  trend  in  tlie  reaction,  whidi  is  called  the  disease. 

History. — I.et)ncino  as  early  as  1497  dejicribe<l  paralysis  as  a  con- 
scquente  of  s>Tihilitic  infection.  He  here  referred  to  what  is  kntinn 
as  hemiplegia,  which  may  result,  as  is  well  known,  within  a  few  ^"ears^ 
even  a  few  month.s,  after  infection. 

Joseph  r.rtinU'ck  (\rm),  Kniser  (1511).  Tlrich  von  Hutten  (1519), 
all  lay  writeTN.  mention  pamlyses  of  the  limbs  as  due  to  the  disease. 
Kmser  speaks  of  his  patient,  a  syphilitic  paralytic,  and  with  a  psychosis, 
aw  having  made  a  remarkable  recovery,  under  treatment  by  Bruno, 
by  niaking  a  vow.  Paracckus  (1530),  although  still  confusing  gon- 
orrhea with  syphilis,  a.s  had  been  and  is  still  being  done,  left-  indiea- 
tioTis  (tf  a  description  of  sypbilitic  nienitjgitis,  ami  in  speaking  of  the 
sypliilltic  virus  sjiid  that  it  affected  all  of  the  organs  of  the  JmhIv. 
Nowhere  in  Fracjistoriuy  Clo21).  who  gave  the  natiie  syphilis,  are  direct 
references  t»  the  nerviiu.-*  H>"i*tem  to  be  found.  Nicolaus  Massa  (1536) 
gave  an  early  description  of  sypliilitic  neuralgias.  Borgarutius  (l-ViT) 
also  described  neuralgic  pains  due  to  s.vphilitic  disease  of  the  meninges. 
Amatus  Lu«itanus  (l.'jfJl)  des(Tibe<l  headaches  due  to  intracranial 
osteitis  of  s)*philitic  origin.  Bntalli  (IfiCiH)  made  an  obsen'ation  that 
blindness  might  be  Hue  to  syphilitic  di.se-ase  of  the  brain.  Femis  (I*i7) 
M(»rgagni  (l(i(HI)  noted  the  arthropathiejt. 

Ihiring  the  fullowiiig  century  many  rt^erenees  liave  l»een  found 
showing  the  recognition  of  the  relationship  of  syphilis  to  nervous 
disease.  Only  a  few  can  be  mentioned  here.  Thus.  Guarinoni  (HUO) 
descrilied  epileptic  attacks  from  syphilis  of  the  brain.  Vldus  \'idiiis 
(1611)  descriVied  epilepsies  as  <hie  to  syphilitic  cranial  caries.  Thiery 
de  Herj-  (l(i;i4)  and  Zechius  (IlioO)  also  calle<l  attention  to  d^-philitic 
spasms  as  well  as  epilepsie.s,  ZacutiLs  Lusitamis  (1(544)  described 
cases  of  blindness  due  to  gumma  of  the  brain,  quoting  Holalli  a  centurj' 
ahead  of  him.  In  IfiOfi  a  special  treatise  on  syphilitic  pains  was  written 
by  Blagny. 

Attention  might  be  called  to  the  works  of  SchuHzius  (1610)  and 
Willis  (1672)  a  propttji  of  the  aubject  of  general  paresis.  To  Willis 
has  alwaj's  been  a.scril>ed  the  honor  of  the  first  description  in  which 
one  could  definitely  recognize  general  paresis. 

By  the  end  of  tins  (seventeenth)  century  a  fairly  broa<l  view  of 
sypliilitic  nervous  disease  Imd  been  obtained.  Syphilitic  headaches 
were  described  by  l-'elix  Plater  (IfUl).  Hhodius  (1657)  descril)eil 
gummata  of  the  dura  and  syphiUtic  hemiplegias;  Ballen  (1663),  spinal 
8yphiliti<-  disease  and  spasms  in  the  facial  region;  Cummius  (1084), 
diplopias  and  eye  palsies.  Aatruc  has  revici*'«l  tlie»e  writings 
completely. 

During   the   eighteenth   century   the   picture   expanded   rapidly. 


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HISTORY 


623 


TntrrcoKtal  neiiralgio-s  (I7G2),  deafness,  loss  of  fiinell.cAries  of  ba.se  of 
skull  (17ft2),  sfiatk-a  (1715),  psyrlioses.  .Sypliilitic  munia  waa  descrilH.'*] 
by  Sanchf  In  1777,  amaurosis  (1748),  facial  palsy  (175S),  leptomcniu- 
gitis  (!7(J6),  syphilitic  arterial  disease  (I7i.>(i),  paraplegias  (myelitis) 
(1771).  and  a  number  of  other  conditions  were  des<Til>ed.  and  may 
be  oonsiiltrd  In  Lagneau's  interesting  monograph  in  wliicii  'J'M  case 
hist<)ries  are  cxillected.  Astruc,  Bonet,  and  Morpigni  otTer  the  richest 
Utemry  sources. 

It  may  be  recalled  in  thia  place  thai  John  Hunter,  in  1787,  stated 
tliat  he  never  observed  syphilis  in  tlie  internal  organs,  including  the 
brain.  The  weight  of  his  authority  retarded  progress  for  many  years, 
especially  in  England.  Indccii,  it  was  nut  until  Riconrs  sound 
obser\-ations  were  publi^ed  that  liunter's  enormous  blunder  was 
fully  remedied. 

V'in-how's  studies  fl847)  on  phlebitis  and  arteritis  had  laid  tlie 
fmmdatiaii  for  the  modem  knowledge  of  bloodvessel  syphilis,  although 
it  may  he  recalled  that  Morgagni  (1700)  anrl  Ilnrne  (17S2)  both  math' 
extremely  important  studies  on  vascular  s\philis.  These  Imvc  Iktii 
fully  developed  by  lluebncr  [1874)  and  Alzheimer  (19tW). 

Tlie  studies  of  Virchow  on  the  fonnation  of  gnmmatiiu.s  granulo- 
mata  and  related  syphilitic  phenomena,  practically  establisliwl  the 
modem  era  of  study  of  the  piitholog>'  of  this  tlLsejise. 

Tht^  succecfting  years  have  filled  in  the  picture  with  a  number  of 
details,  the  chief  additions  having  l>een  those  of  Nissl  and  Alzheimer, 
who  have  establislieii  the  highest  criteria  for  the  pathology  of  this 
disease  so  far  as  the  nervous  system  Ls  concenie<l. 

The  latest  chapter  in  this  interesting  history  is  that  dealing  with 
the  iiiscovery  of  the  exciting  agent,  and  the  final  clearing  up  o!f  the 
entire  subject  of  etiology  and  moilcs  of  infection.  Schaudinn  (IllOo) 
demonstrated  the  parasite  whi<'h  he  called  Spirwheta  pallida.  Its 
(*ynon\iny  has  varied  to  arcorri  with  principles  of  botanical  anvl  zoo- 
logical nomenclature.  Treponema  pallidum  has  the  bcj^t  sanction. 
which  in  xocjloxieal  iicmiendatnre  is  not  gnvern«l  by  usage  but  by 
definite  principles.  Doele  (1892)  is  thought  to  have  first  seen  the 
parasite,  but  Schaudinn,  then  Kpaschen,  I'ischer,  MetchiiikolT.  and 
Koux  established  its  identity  and  its  alliliations  with  the  pnitozoa.' 

It  is  found  in  congenital  syphilis  of  the  ner\*oua  system,  in  syphilitic 
gumma  of  the  brain  and  spinal  conl,  in  syphilitic  meningitis,  even  in 
the  cerebrtfspinal  fluid,  both  of  congenital  and  acquired  syphilitics. 
Mcjore  (IfilH),  Nnguchi,  Nichols,  and  Hough  found  it  in  the  pan*tic 
brain,  an<l  it  luis  been  reported  to  have  l>een  found  in  the  spinal 
meninges  of  tabetics. 

The  final  studies  of  Ncisser,  Metchnikoif,  Uoux,  and  others  have 
laid  bare  the  entire  story  of  the  inoculability  of  the  disease  and  its 


■  Sec  NoRuebi:  "S|iirocl)u«l<M"  Juunial  ui  Ltaboraioiy  utd  Oiuical  Mediviu*.  March, 
IS17. 


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SYPHIUS  OF  THE  NRRVOUS  srSTE}t 


tran.smissinn  from  animal  tn  anininl,  while,  utilizing  the  knowlnlge 
gained  hv  BnnU't  ami  (»eng(m,  Wiisseniiaiui  and  liLs  pupils  have 
elaborated  a  st'n>l>iiilnjiu'al  tcchiut.'  whk'h  hu:s  made  (me  imle|K'ndent 
of  climcal  or  anamncstc  data  relative  to  a  knowledge  on  the  pan  of 
the  patient  nf  the  infection. 

Thus,  in  the  pa.st  deeade,  a  flood  of  light  ha.H  been  tlirown  upon  the 
disease  and  its  relation  tci  other  protn7x>fl,n-eausod  diseases,  nntnbly 
tryijaiinstnninsis,  which  Ims  illnininatf.'d  and  n)a<le,clear  the  entire  path 
whiel)  has  been  so  busily  travelled  sinee  Columbus  brought  this  most 
pnrtentious  e^otil.•  tn  tlie  old  work!. 

Diagnosis.— The  <)iagnosis  of  syphilis  of  the  ner\*ou.s  3>-stein  pre.%nts 
eertaiti  diffiniUies  which  rapiclly  incTcasing  pcrfcetitnis  in  laborator>- 
te<'lmic  are  res4>]ving  with  eoitsiderable  sntx-e-ss.  These  laboratory 
bindings,  (■ond)ined  with  th<>se  of  the  neiirt^Iogical  examination,  permit 
an  almii-st  eertjiin  diagnusis  of  this  disease  in  the  nervous  system,  either 
lis  i-ougi'uitiil,  ariinireil,  or  as  »>-callt'd  para-  or  nietasyphilis. 

The  chief  fentures  in  such  diagnosis  are:  (1>  seareh  for  the  organ- 
isnts;  (2)  serological  investigation  of  the  blotxl  and  cerebrospinal 
fluid;  (3)  e>"t<>logieul  examination  of  the  cerebrospinal  fluid;  (4) 
eheniical  examination  of  the  cerebrnspitml  fluid;  (5)  clini<'al  examinft- 
tiim  of  the  pupillary  reflexes. 

I.  Smrrh  fur  Orgiinitins.-  The  parasite  has  heen  found  in  tlie 
cerebrospinal  Hniil,  but  as  yet  in  but  few  instances.  It  ha.^  l»eeji 
cultivatwl  fniui  the  cen-bnisptnal  MuitI  (N'ichols  atul  Ilougli).  More 
i-eeeiit  work  by  injecting  the  fluid  into  the  teMide  of  rabbits  has  added 
eniisidcnibic  iiifoi-niation.'  IMte  results  thus  obtained  ailded  tn  those 
previcmsly  on  record  show  positive  findings  in  primary  and  seeondar>- 
syphilis,  without  nervous  manifestations,  in  a  toiid  uf  2  cases  (iiunv 
Wfore  the  eighth  weel;);  in  seatndury  syphilis,  fn>ni  the  thini  to  the 
twelfth  mouth,  in  7  cases:  never  in  tertiarj*  sj^ihiliH.  In  the  cases  with 
ivbje«tive  nervoiLs  symptoms:  in  early  syphilitic  meningitis,  once; 
nenrorfxiirrenee  (eight  months),  once;  ft|>i»plexy  ami  lit*iniplegia 
(seven  months),  once;  (one  year),  once;  syphilitic  meninptis,  once; 
spinal  syphilis  (ten  years),  onee;  tabes,  2  eases,  am!  profcressive  pai^ 
alysis.  .'>cjL>»es.  In  iiJierited  syphilis,  soon  after  liirtli,  2  cases;  syphilitic 
leptomeningitis  later  in  life,  once,  and  juvenile  paralysis,  onee.  This 
compilation  includes  Friihwahl  and  Zaloziecki's  2'A  syphilitic  [latients 
tested  in  this  way.  Spirochetes  were  found  in  only  4  of  the  total  23; 
onee  in  recent  seef)ndary  s,\'phili.s,  once  in  older  seeondarj"  s^'philts 
(without  nervous  symptoms),  onee  in  early  meningitis,  and  once  in 
progressive  paralysis.  They  add  that  large  numbers  of  others  with 
tftlx-s,  paralysis  and  brain  syphilis  were  also  ti-ste<l,  with  constantly 
negative  i-esnlts.  The  inoculation  lesion  in  t}te  rabbit  testicle  was  so 
slight  that  only  the  mici'oseope  discloseil  its  positive  nature.  The  data 
presented  show  that  the  c-erehrospinal  fluid  is  only  rarely  infcrtiou.H. 

'  FrQhwivlti,  Z«lfui4>rkl:  Beri.  klia.  W<?l)uiwhj-.,  ,riuiuiu>-  3,  lOIOi. 


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DIAGNOSIS  ^  fi25 

iThe  flviid  otherwi&e  may  or  may  not  be  nornml.  and  there  muy  or  may 
nut  111'  a  positive  sen»r< Hctioii  aik!  sympt/mis  on  the  part  of  the  ner\'ous 
system.    There  is  thus  no  rt'^iilarity  in  tJic  iindinjrs. 

2.  liiological  or  Syerohn/tail  TfxU  vf  lih»ni  and  CfrrhrtKtitiiial  Fivid. — 
(«)  lihtiil. — Priifticaily  all  furuis  of  early  syphilis  of  the  nervous 
system  should  show  a  positive  Wassermann  reaction  in  the  blood. 
Then-  are  exceptions,  but  syphilis  nf  the  nervous  system,  like  s>-philis 
elsewht-re,  y;ivp.s  a  positive  rtwtioii  in  early  cases. 

Whereas,  the  number  of  |xjsitive  findings  should  be  as  hifjh  as 
1(K)  per  ci'iit.  in  ca.si's  of  early  syphilis  of  the  nervous  system,  in  its 
seeoiulitry  and  tertiary  stages  the  number  of  positive  results  may 
fail  to  even  TO  |>er  eent.,  and  in  the  latent  period  may  sink  to  .Vt  per 
cent.  AVhctlier  tliese  retltuiHl  percentafti's  speak  for  the  (joihI  results 
of  tr<'atment  or  are  deijetideiit  upcHi  otlier  as  yet  uncertain  factors 
is  yQi  to  Ix'  dccitie<l.  The  aleuhols  interfere  with  the  reaction.  Henee 
the  results  of  a  Wasscnnanii  test  are  apt  to  be  unreliable  if  the  patient 
has  taken  aleohol  within  forty-eight  hours  of  the  time  of  making  the 
test. 

(/>)  Cfrrhriisphinf.  Fluiit. — Tlie  hehavior  of  the  rerebrospinal  fluid 
to  the  Wii-ssermaan  reacti<in  is  of  special  significance  In  the  diagnosis 
and  treatment  of  syphilis  of  the  nervous  system.  It  is  almost  unifonnly 
positive  in  general  pare.sis,  even  when  small  quantities  (0.(12  e.e.)  of 
tile  serum  arc  employed.  !ty  the  use  of  such  small  quantities  it  woohl 
appear,  from  llie  work  of  Ilauptinaiui  and  Mossli.  that  pjiresis  alone 
will  cause  a  positive  result,  but  with  larger  quantities  of  cerebrospinal 
fluid  (0.4  to  0.8  e.c),  practically  all  forms  of  cerebrospinal  syphilis  will 
give  a  positive  reaction:  tabes,  cerebral  sypliilis,  meiiingorayeUtis,  etc. 
(.fbiuptmanii,  tl(»ltzmanu,  Swift  and  Kills.)' 

Syphilis  without  ner\'ous  involvement  usually  give.s  a  negati\e 
reaction,  even  when  large  <|nantities  of  the  HuiH  are  usecl. 

It  must  constantly  be  b<»rne  in  mind  in  the  diagnosis  of  syphilis  of 
the  nervous  sy.stem  that  the  reaction  of  the  cerehrnspinal  Huifl  in  the 
Wasseniiaim  test  is  purely  monos.\niptonmtic.  The  jiositive  or  nega- 
tive results  must  always  be  iuter{>reted  in  iissfM-iation  with  other  fl 
iaiHjralory  and  clinical  te.sl.s.  .^s  Nonne  has  well  said,  the  Wasser-  , 
jnann  reaction  Is  only  u  symptom.  Like  other  symptoms  in  a  syndrome 
it  may  or  may  not  be  present  without  afTceting  the  validity  of  the 
syndrome  from  its  diagnostic  aspects. 

3.  Cytological  Examinntimi  of  the  Cerebrospinal  Fluid. — The  teehnic 
of  puncture  camiot  be  entered  into  here,  but  one  point-should  l>e 
b<)rnc  in  mind:  the  procedure  is  not  always  without  danger.  It 
should  be  done  with  care,  the  fluid  being  withdrawn  very  slowly,  drop- 
wise  in  some  cases,  and  the  patient  shonlil  rest  In  b«I  several  hours, 
preferably  both  before  and  after  the  operation.  One  of  iJie  functions 
of  the  een'bnispinni  fluid  Is  to  maintain  an  ecpmllty  In  the  intracerebral 

■  Sve  KniiLiui:  Sorolos>-  in  Ncrv-oiw  S>|tbili«,  fhiUdclphia,  Ifla. 
40 


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020 


SYf'HIUS  OF  THE  SBRVOUS  SYSTEM 


prc:*.->ure,  ami  any  siuMt'n  alteration,  surh  as  is  produced  hy  the  witii- 
drawalof  5,  10,  or  15c.c.  of  the  Huid,  i.s  apt  to  disturb  such  eciuilibriiun. 
Headache,  nausea,  vnmitinf;,  dizziness,  arc  among  tlie  unplrasant 
effects  in  those  wlm  react  hadly.  Such  are  few,  but  they  exist,  am) 
care  is  imperative.  Some  are  IwljK'd  hy  lyinjt  <jiiiet,  with  foot  of  1h.'«I 
elevateil  and  wltli  aspirin,  10  grains,  repeated  if  necessary.  In  patients 
in  wiwm  bruin  tumor  is  suspcetc*!  special  core  should  be  taken,  as 
here  A  few  cases  of  stKlden  death  have  been  reported  following;  hunhar 
puncture  willi  withdrawal  of  lliiid. 


Fio.  334. — LympIuHiyUB  In  normal  (left)  awl  {iiircUo  (Hght)  ccrchronttlDol  fluid. 

(Krnepelin.} 

lu  pathoIi>i;ifat  cen^bmspiMal  fluid  an  incmisc  in  lymphocytes  is 
the  most  striking  feature.  tK-er  7  to  10  lymphocytes  to  the  cubic 
millimeter  indicates  pathological  fluid.  Otlier  cells  may  also  Iw  foutul. 
such  83  jjolymorphnnuclcar  leukocytes,  plasma  cells,  and  occasionally 
eosinophile  and  endothelial  cells.  Ucd  blood  cells  u.-^iially  aime  from 
the  wound  of  the  puncture. 

The  iluid  is  hest  fixed  and  imbedded,  and  then  stained  by  the 
Alzheimer  method.  This  is  the  most  complete  and  satisfactory 
method  tlius  far  devised,  as  it  pennits  of  the  countin):  and  study  of  all 
tlie  cells,  llie  Knc-ks- Rosenthal  eountiuK  chamber,  however,  is  that 
used  in  llie  grejiter  number  of  instances.  Us  pesult.**  are  nion*  quickly 
obtained,  althougii  they  lack  the  tinatity  of  tlie  AlKheimer  method. 

A  normal  cerebrospinal  fluid  is  a  clear  liquid.  It  has  a  specific 
gravity  of  1000,  a  slightly  alkaline  reaction,  and  is  almost  free  from 


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cellular  constituents— I  to  5  IjTnphocj-tes  per  cubic  millimeter,  as 
estimatwl  by  the  Fuths-Uoseiithal  method,  may  be  cnnsiderwl  normiil.' 

Changes  in  ('erel/rospinal  /VntW.^ln  rerebrospitml  syphilis,  in  tubes, 
iiiit)  ill  Ki'iifral  jmresis  there  is  usually  an  increase  in  the  nnmber  of 
lynijihocytes.  They  mny  run  up  into  the  huiwlrerls.  (rsjH'ciuUy  iii 
some  eases  of  acute  lueiungtiniyelitis;  also  in  some  fulminating  cu^es 
of  paresis.  Tn  fact,  most  metiin(jttie  pri.K'esscs  are  aecompanie^l  by 
increase  in  cellular  content.  l*olymiclpur  i-ells  are  fretiuent  in  the 
acute  types,  sometimes  tuberculous  meninKitiM  excepted,  and  as  the 
pr*x*ss  tenily  to  chronicity  there  is  a  ten<lency  to  lynipIuH-ytosis  and 
loss  of  other  cell  tyjtes.  'Hw  pleirt-ytosis  of  syphilis  lias  usually  Ix-eii 
attribute*!  tn  a  nieninptic  pmci'ss.  It  has  lieen  suggested  as  due  to  a 
|)eriarteritis  n>.  v%'ell  (Szeesi). 

Certaiii  ^'uenil  variations  may  be  reconled.  The  earlier  :ttu(lcnts 
were  more  didactic  in  their  stntemciit.s  conceniiiiir  specific  differences 
in  the  mnnber  of  cells  as  ilistinguishing  cerebnKspinal  syphilis,  tubes, 
aiui  [larcsis.  Kiirtlicr  extension  of  the  studies  shows  rhem  to  have 
been  ill  part  unwarranted.  'I'hus  it  has  been  saivt  that  the  lower 
nnml>ers  point  to  rerebrosphwl  s>i>bili8,  the  lugher  number  to  tabes, 
mill  the  liighest  to  jwresis.  Tills  is  perhaps  so,  but  it  is  not  an  absolute 
rule.  The  niimlKT  of  cells  seems  to  bear  a  mor*-  definite  relatimi  to 
the  activity  of  the  underlying  irritation  or  iiiflanimattiry  process  than 
to  its  kitid.  Thus  a  .stationa^.^■  tjibes  may  shitw  few  cells,  also  a  paresis 
in  remission,  whereas  an  acute  cerebnispinal  syphilis  nr  an  acute 
menirgomyelitis  may  show  many  cells. 

A  tluid  rich  in  iMflyniorplions  cells  is  indicative  of  a  ver>*  active 
procP:NS,  s\philitir  or  otherwise. 

In  cerebrospinal  s,\^ihilis,  tal>es,  and  particularly  in  paresis,  it  is  of 
great  importance  to  note  tliat  a  pleoc-vlosis,  oftentimes  (»f  very  marked 
grade.  ina>'  antedate  idl  neurological  symptoms  of  the  after-coming 
disorder.  Thi.s  has  been  shown  repeatedly  by  Sicard,  by  Itavaut  and 
others.  This  preparelic  perio4l  has  been  dijignostintted  as  long  as 
two  years  before  the  onset  of  the  disease.  Thi.s  point  is  well  to  bear 
in  mind  when  one's  advice  is  a.ske<l  as  to  the  advisability  of  marriage 
of  sj-philitics  in  the  forties.  It  is  not  at  all  an  infreqiient  ex|}erience 
to  find  the  outbreak  of  paresis  occurring  in  men  of  from  forty  to 
forty-five,  who  have  lM:'en  from  one  to  three  years  married,  and  many 
have  waited  tJus  long,  feeling  that  liecause  of  an  early  i^typliilis  it  were 
wiser  to  defer  marriage  until  a  safe  pcriwl.  A  return  will  be  made  to 
the  prophylactic  features  later  in  the  more  detailed  discussitm  of  the 
therapy. 

How  soon  after  infection  by  .\vphilis  may  IjinphiK-ytosis  appear  in 
the  cerebrospinal  fiuidV  Varying  answers  are  available,  but  liavaut 
has  reportetl  its  presen**  at  least  two  nionths  after  infection.  The 
presence  of  lymphocytes  almost  invariably  speaks  for  nervous  syphilis. 

*  Set!  TbuiDMa.  Hill.  tLtlLiburtoo^  Proc.  Koy.  Soc.,  vut.  Ixiv,  for  nurnuil  fluiil. 


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SYPIlllia  OF  TUB  NERVOVa  SYSTEM 


In  patients  who  have  tlius  far  been  followed,  the  development  of 
nervous  acrideiits,  hemiplegia,  paraplegia,  meningomyelitk,  etc.,  hu 
taken  place. 

Witii  active  tlierapy  tlie  pleocytosis  Is  apt  In  disappear.  Are  those 
patients  who  retain  their  l\Tiiph(ir\"t(wis  on  the  way  to  tabes  or  paresis? 
This  is  ail  iuiportaut  problem  which  lias  been  answered  yes  and  no. 
Its  definite  answer  is  yet  to  come,  as  the  necessary  time  for  deter- 
niininij;  tJie  full  sigmficance  of  the  results  of  c-ytological  study  of  the 
fluid  has  not  yet  elapsed. 

Vnnn  the  therapeutic  point  of  view  tlien  the  whole  subject  of  pleo- 
cytosis of  the  cerebrospiimf  fluid  is  full  of  slj^iufieaiipc.  and  in  need 
of  eortstjuit  attention.  In  this  connection  it  should  again  be  cmpha- 
sizeil  that  lymphocytosis  alone  does  not  mean  syphilis  ulono.  It  can 
be  said  that  absence  of  l.vmphwj'tes  at  lea»t  negatives  tal^es  and 
paresis^to  this  gcnerulization  there  arc  but  few  recorded  negative 
observations.' 

Lyniphoc\tosis  is  not  limited  to  sj-philis  of  the  ner\-ous  sii'stem, 
hmvcver.  It  is  marked  in  sleeping  sickness,  an  allied  disease  (Spiel- 
uieyer,  Molt).  It  la  often  also  high  in  tul>erculous  meningitis,  but 
is  here  usually  complicated  b>  the  presence  of  pol>TnorplionucIcar 
leukocytes.  In  u  few  cases  »if  nuihiplc  sclerosis  lymphcM'\te^  have 
IjGcn  foiuid.  In  the  ai-ute  stages  of  poliomyelitis  lymplioejtes  may 
be  found,  also  in  epidemic  cerebrospinal  meiiiugitts  aud  in  herpes 
zoster. 

4,  Chemicai  Erfinunfition.—Her^  the  presence  of  a  reducing  agent 
(Fehling's)  iuul  of  gUdiulin  is  to  be  cstimatcil.  Most  fluids  contain 
the  fiinner.  When  present  in  large  quantities  it  may  point  to  a  tuber- 
culous meningitic  process. 

Incrcast-d  globulin  content  is  a  dm ract eristic  feature  of  parciiis. 
hi  tabes  iiicifase*!  globulin  is  the  rule,  as  is  idsci  the  case  in  cerebro- 
spinal sypliilis.  but  to  a  less  extent.  Markedly  increased  globulin 
content  is  not  infrequent  in  spinal  cord  tumors,  giumnattius  or  nnn- 
syphilltic.  Increased  globulin  is  also  a  feature  of  the  acute  stage  of 
throiidiotie  softening  of  arteriosclerosis  when  the  softened  area  touches 
the  meningeal  sac.  The  gllobulln  reaction  is  apt  to  nin  along  with  the 
lymphocj'tosis.  It  Iws  no  ajiparent  alliances  with  the  lindings  of  the 
VVassernmmi  ti^st. 

Sumtnary  nf  JLoioratory  Findings.— Four  y?f(ic(M/7iJ.— Before  jiassing 
the  diagnostic  significance  of  the  clinical  examination  ol  the  eye 
reflexes  a  word  should  l>e  said  n*lative  to  the  value  of  these  "four 
reactions,"  as  Noimc  has  calletl  them.  It  has  been  said  that  taken 
alone  they  may  mean  nothing  positive,  s()  far  as  a  differential  of  the 
difFerent  types  of  syphilis  of  the  nervous  system  is  concerned,  but 
when  read  together  they  aiford  important  guides  to  iliugnosis  and  to 
treatment. 

>  KUetwIwiger:  AroUv  f.  PByfiliiBlrlc.   lUll;  FosIvt,  LrK-aiulowaky.  Hnwlliucb  dor 
Neuroloftc. 


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629 


Noniw's  (Niiu-hiMiniis  iirp  jjerliaps  tlic  nm«t  cxteasivc  timt  Wf  possess 
on  (Itis  point.  Tlicy  are  fmimU-il  ii|K)n  his  own  fXiwriciuT  witli  Ifi? 
patients  witli  tubes,  17!*  with  pjiri^.sis,  !I7  witli  cerebri )spiiud  sypluliit 
(arterial  tvTWs).  tW  patients  with  multiple  scicrosia,  3S  with  brain 
tumor,  ami  14  witii  spinal  eonl  tinncir. 

Expressed  schematically,  which  schemes,  as  he  well  remarks,  are 
not  profhicts  of  nature  hut  nf  man.  the  followinp  results  of  the  four 
reactions  are  to  Ik*  expected,      (I)  blood  ami  (11)  flwid. 

I.  Blood  examination. 
Wasseroiann  re*ctiou. 

(a)  Positive.  Is  characteristic  of  .s>-philis  witli  few  exceptions 
(already  noted).  A  po.sitive  Wasserraann  of  tlic  bIr>od 
serum  says  nothing  further  than  that  the  individual  luts 
come  in  some  manner  in  contact  with  syphilis,  either 
thmnph  hen-dtty  or  by  infei'tiim.  It  diMW  not  say  that 
the  disease  from  wliieh  he  suffers  is  due  to  s\-philis. 

(b)  Negative.       Is  differentially   dJugnustic   aKiun.st   paresis, 

since  it  is  only  very  rarely  tlmt  the  blood  in  paresis 
gives  a  negative  reaction. 
II.  Study  of  cerebrospinal  fluid. 

(a)  Normal  fluid.     I'ressure  90  to  130  mm.  water,    filobulin 

reaction  negative — not  over  5  or  6  cells  to  e.mm.  (Fuchs- 
lioscnthal). 

(b)  Pathological  fluids. 

1.  Increased  prcasupc^ — over  15  coun.  water. 

2.  Positive  piuLse  I.     Globul'm  reaction. 

3.  Increase*!  cell  count.  (These  three  symptoms,  in 
coordination  or  alone  indicate  the  presence  of  an 
organic  nervous  disorfler,  syphilitic  or  non-syphilitic.) 

(c)  If  the  disease  of  tlie  nervous  system  is  syphilitic,  then  the 
WtLsscnnaun  test  of  the  fhiid  will  show.  If  (he  Wusser- 
mann  reaction  (original  method — 0.2  c.c.  of  the  fluid)  is 
positive,  there  is  great  probability  that  the  patient  is  a 
paretic,  or  a  taboparetic,  much  less  often  a  cerebntspinal 
syTihilitie,  or  a  pure  tal)etic.  In  nearly  all  cases  of  cerebro- 
spinal syphilis  and  of  tabes  the  Wassermann  reaction 
becomes  positive  by  using  0.4  to  1  cc.  of  fluid. 

Nonne's  t>'{ncAl  findings  are  as  follows: 
I,  Paresis  or  taboparesis. 

1.  Waasermann  reaction  in  blood  positive  (1(X)  per  cent.). 
Pressure  increased. 

2.  Phase  I,  globulin  reaction  positive  (OS  to  liX)  per  cent.). 

3.  Lymphocytosis  (95  per  cent.). 

4.  Wa,s8ermann  in  fluid. 
(a)  Positive — ulmut  85  to  90  per  cent,  with  original 

method  and  0.2  c.c.  fluid. 
(6)  Positive  ui  1(X1  per  cent.,  witii  larger  quantities  of 
fluid. 


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SYPiriLIS  OP  TItB  KSRVOUB  SYfiTPM 


II.  TuIh-s  without  purtsis. 

1.  VViissernjiuiri  reartinii  in  MchhI  ptwitive  (GO  to  70  perccjit.^ 
Pressure  usually  iui-reasod. 

2.  Phase  I.  reaction  globulm  and  positive  (90  per  cent.)- 

3.  Lympliotytusis  iKwitive  (iK)  per  cent.). 

4.  Wassemiann  in  HuiH. 
(fl)  OriKinul  iiietluMl,  [).2  CO.  p<witive  (5  to  10  per  eent.TT 
(A)  Larpcr  ejuantities  (KH)  per  cent.). 

III.  rerebruspiiial  syphilis. 

1 .  Wft-ssermnnn  rcariJoii  in  Iilotxl  [Misitive  (80  ta  flO  per  wnl.)- 
Pressurf  frequently  increase<i. 

2.  Phase  I,  reaction  usually  [Mtsitive.  exceptionally  nepativc. 

3.  Lyuii)lnK'yt()si.s  nearly  always  jKwitive. 

4.  Wa.ssermann  in  (hiid. 
(o)  Original  methods  (0.2  e.o.)  positive  in  almut  10  per 

cent. 
(fc)  Larger  cpmntitie^  nearly  alwaj"?  positive  (of  value 

in   iliapMisis   of  imihiple  selenisis,  eerehrnl   ai>d 

spinal  tuiU4>r). 

These  results  of  Noiuie'a  summarize  fairly  accurately  the  present-day 
attitude  i>ii  the  value  of  the  four  reactions.  Tiie  full  sipniJicanee 
of  the  findinRs  ran  lie  gained  only  by  reference  to  the  originals.  This 
field  iif  work  is  rajiiilly  expanding,  and  that  which  now  appears  on  the 
frontiers  of  our  kntuvletlge  will  undouhletlly  be  niueli  cruKtifieil  by  the 
rapidly  uclvaiu-ing  anny  of  invej^tigators. 

AoniTiiiNAi.  Tksts. — These  additional  tests  are  valuable  1>eciiuse 
sypliilis  may  be  present  with  u  negative  \VHs:*ennann.  These'  ease>i 
of  so-callctd  latent  syphilis  with  negative  Wassertnaim  occur  in  al>out 
35  per  cent,  of  ca.sea  with  no  active  aign.s  of  the  disease  hut  with  a  clear 
history  of  infection. 

Thi  Luetiu  Test. — Tliis  Ls  a  cutaneous  test  with  a  siLspensioii  of 
killed  njiiriiclu'tf  eolturcs  as  prepared  by  Nngiiehi.  kimwri  us  luetin.  A 
positive  reaction  appears  in  the  form  of  a  red  papule  with  indurated 
areola  in  five  or  six  days.  This  test  is  especially  valuable  in  tertiar>' 
and  latent  syphiliSi,  conditions  in  which  the  Wassertnaim  reaction  is 
sometimes  negative.  It  Is  valimble  also  in  diHVrentiating  from  other 
conditions  wlii<h  might  give  a  positive  Wassermnnn.  fiir  tJiis  test 
appears  to  be  a  specific  for  sj'philis. 

Primjcaiiw  Wrurxennajin. — 'ITiis  test,  like  the  luetin  test,  is  valuable 
where  syphilis  is  susiKt-ted.  but  the  AVas^scrinami  is  negative.  It  is 
dependent  upon  the  fact  that  a  negative  Wassemiaun  nia\  W  changed 
to  positive  after  an  injection  of  satvarsaiL  Tliis  change  may  occur 
quite  promptly  or  only  after  several  days.  Nicliols  recoromonds 
making  the  VVassermann  twenty-four  and  forty-eight  hours  after  an 
injection  lO.-t  gram  salvarsan  or  0.0  gram  neosalvanuin)  and  again 
after  seven  antl  fourteen  days. 


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himif'g  ColUmlai  (laid  Tent. — 'ITiis  test  is  <iepeiiilaiit  !ip*m  a  color 
roirtioii  whirh  makes  it  ver\'  (Icliciite.  It  has  nn  arlrlotl  value  because 
u  single  test,  depemliuK  ujkhi  llie  degree  of  fliseuNmitioii,  temls  ti» 
show  whether  we  arc  ilenliiig  with  a  frank  hietie  or  a  metaluetie  pro- 
cess. For  tills  reason  it  is  to  some  extent  replaeiiig  tlie  Wiis^^miann 
teat.  For  n  description  of  the  tedmic  the  student  is  referred  to 
special  works.  A  number  of  other  tests  have  recently  appeared,  but 
those  mentioned  arc  the  mo?t  important. 

5.  The  Eye  Hefiexe^. — In  the  diagnosis  of  s.v'phiiis  of  the  ncr\-ous 
sj'sttin  the  neun>Iogieal  examination  of  the  eye  reflexes  is  of  para- 
mount value.  ITere  irregul;irity  In  the  size  of  the  pupils,  irreRularity 
in  tile  pupillary  margins,  the  imiHiirment  of  the  etuisensual  light 
reflex,  the  slowing  in  reaction  to  light,  fatigjibility  of  the  light  retlex, 
alteration-s  in  response  to  accommodation  eKorts,  the  full  develop- 
ment of  the  Argyll- Robertson  s\-ndrome,  are  all  to  be  considered. 
These,  one  or  all,  constitute  extremely  delicate  and  valuable  criteria 
for  the  clinical  appraisement  of  syphilLs  of  the  central  nervous  system. 

.■\  fully  developeil  Arg\ll-ltiil)ertson  synilrnme — loss  of  (lirt*t 
pupillary  light  reflex,  with  fn-e  and  atopic  response  to  aceonnniidation 
reflexes  in  one  or  both  eyes — represents  for  the  most  part  a  fairly  posi- 
tive criterion  of  sypliilis  of  tlie  nervous  system. 

There  are  many  who  believe  that  this  syndrome  affords  positive 
proof  of  nervous  .syphilis.  This  we  do  not  believe  to  be  true,  not 
only  upon  clinical,  but  also  upon  anatomical  promids.  Clinically  the 
Arg^'Il-Uobertson  syndrwne  luis  been  ohservcil  following  <iirect  injury 
of  t!ie  riiidliraiii  structures  (pistol  shot — (iuillaiti),  it  has  been  observeil 
in  poisonings  otlier  than  tltose  of  syphilis,  alcohol  (in  Kor^ikow, 
Wernicke's  poHoenLvphalitis  superior),  it  may  result  from  pressures 
(tumors  of  tliirrl  ventricle,  pineal),  from  poliomyelitis,  from  trypano- 
somiasis, from  orbital  trauma  (Velter,  Ohm),  and  from  otlier  rare 
anomahnis  disorders,  .\nalomically  the  syndntme  represents  implica- 
tion of  cenain  reflex  paths  in  certain  peculiar  combinations,  and  such 
implications  and  combinations  arc  purely  fortultttus  and  accidental, 
j'.  *•.,  so  far  as  nosology  is  concerned. 

As  u  matter  of  fact,  however,  these  coinbimitions  rarely  take  place 
except  as  a  result  of  Uie  widespread  changes  inducctl  by  one  particular 
t>*pc  of  poisoning-  the  syphilitic  virus  so  that  for  elinicjil  purposes 
the  presence  of  a  permanent,  bilateral,  ArgyJl-Uobertson  syndrome  is 
nearly  enough  positive  for  syphilis  to  permit  one  to  assume  its  presence, 
and  to  therapeutically  guide  iHie's  self  acconlirigly  (Rose.)' 

Testing  f<)r  the  Argyll-Uobertson  syudrome.  Iwnvever,  is  not  as  simple 
as  it  Is  usually  supi»os<;d.  The  ortlinar>'  ilevi(vs  of  having  a  patient 
face  the  window,  and  then  cover  ami  uni-<iver  the  <ipened  eyes  witJ» 
tlic  hand:  focussing  the  eye  upon  a  distant  object,  and  then  upon  the 
finger  in  close  proximity  to  the  nose;  these  tests  for  the  most  jNirt 

1  Mayar:  Jour.  f.  PsyiJi.  ti.  Nnr.,  lOlfi,  »ti,XfI. 


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syvnitis  OP  the  uervovs  system 

HIV  I'litia'Iy  t<M»  tnuk'  to  |KTnut  one  to  jiidpe  witli  <vrtainTy  ttint-emintf 
the  Ai-j;yll-K(ilHTtsi>n  syiidnmif.  Such  iiielhnds  may  suffice  fur  the 
miijority  of  iastaiices,  but  in  no  fielil  of  nruniliiKy  is  it  nmrv  ilt-sinihlr 
to  utilise  the  mast  iirciirate  uK'thocis  than  in  dealing  with  the  vexed 
question  of  sypliilis  nf  the  iienons  system. 

Few  diniei»ns  t-an  follow  out  the  Intricaeies  of  Weiler'.s  c-omplicated 
methiKis,  but  tht*y  may  be  necessary  in  rertain  doubtful  cases. 

Uepeatol  exaininatioiLH,  under  carefully  regulatetl  sui>ervi.sion.  in 
the  daylight,  and  in  the  dark-roora.  are  therefore  desirable  when  test- 
ing for  anomalies  in  the  pupillary  reHexe,s.  f'arefiil  eheekinj;  of  the 
results  obtainerl  by  the  small  pocket  electric  lamps  is  iiniH'rative,  as 
occasionally  they  give  annnmlous  results  and  may  lead  to  serious  errors 
(Oppenheim)-  The  prfsence  of  a  fully  develoiK'd  Argyll-Uobertsnti 
s>iHln»nTe  may  be  said  to  be  a  liiglily  probable  positive  pnKjf  of  s\'phUi9 
of  tlie  centra]  nervous  system,  particularly  of  the  cerebral  and  mid- 
brain neurons.  Its  absence,  however,  by  no  means  negatives  syphilis 
of  the  iien'ous  system,  since  cerebral  gummas,  cerebral  s\7»hilis. 
paresis,  tabes.  s\'philitic  meningitis,  meiungomye litis,  conl  gummas, 
syphilitic  radiculitis.  s.\-philitic  neuritis,  all  may  be  present  without 
any  anunialies  in  (he  pupillary'  reflexes.  It  has  already  been  pointed 
out  that  the  lnhoniTciry  findings  of  paresis  and  of  tabes  have  anteilnteil 
the  develnpmenl  ot  neurological  sigiw  by  at  least  a  couple  of  years, 
and,  moreover,  it  has  been  emphasized  that  pathological  alterations 
in  these  pupillar>'  reflexes  are  after  all  only  chance  happeniugs,  when 
certain  reflex  arcs  in  certain  combinations  arc  caught  in  the  mesh  nf 
the  infiltrative,  syphilitic  ulteratiinis.  The  chance  is  a  large  one,  it 
is  true,  buf  still  it  Is  purely  u  statistical  matter  of  what  has  happened. 
One  woni  may  be  added:  in  many  eases  [if  cerebrospinal  syphilis 
one  can  gauiife  tJie  progressive  amelioration  of  the  patient's  conijition 
by  tlie  gradual  return  of  tlie  anomalous  pupillary  reflexes  to  a  more 
normal  condition.  Thus,  an  absolute  Argyll-Uobertson  8yn<lroinc 
may  liecome  a  rt'lative  one.  A  miilatera!  Argyll-Uobertson  may  be 
Inst;  stowly  reacting  pupils  may  show  prompt  reactions;  irregularities 
in  size  may  disajipear;  rapid  fatigability  may  let  up;  a  consensual 
light  hiss,  often  the  first  anomaly  to  ap[>ear  in  i-ercbnispinal  s\7ihilts, 
will  clear  up;  irregularities  in  the  pupillary  outlines  will  make  way  to 
regular  outlines,  etc. 

An  inability  to  modify  pathological  pupillary  rcaetiuns  by  ample 
sypliilitic  therapy  argues  in  part  for  the  chronicity  of  the  process,  or 
the  inefficaey  of  treatment.  This  is  not  an  absolute  rule,  however. 
It  may  be  possible  for  a  syphilitic  process  to  permanently  destroy  por- 
tions of  the  pupillary  reflex  paths,  and  then  be  completely  niwi  iwrnia* 
nently  arresteil.    The  pupillary  reflexes,  however,  remain  impaired. 

In  rehition  to  this  question  of  the  pupillary  reflexes  and  anti- 
syphilitic  treatment  the  problem  arises,  What  is  the  pn»lmble  outctmic 
of  a  sypliilitic  p^K-ess  which  comparatively  early  in  its  course  has 
destroyed  the  pupillary  reflex  paths?   Can  it  be  decided,  say  after  two, 


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ifivf,  iir  U'li  years,  iliirinu  uliHi  litiic  tlitr*'  lias  exisltd  an  Ar^yll- 

^ItolHTtMHi  >!ynilr(iiiu'  iinr]  littk*  dsf.  that  tlir  di^caso  has  U't-ti  coiii- 

plutdy  and   |M'rniiiii*'nll>    iirrrslwly       Sincr   the   rapiti   rxtfTision   iif 

knowlediio  uonceming  the  cerebrospinal  fluid  this  question  can  be 

an.swered  better  at  the  pmscnt  time  than  ever  before. 

If  the  si^iis  of  a  iiu-niiiKitis— aculr,  snhariite,  or  chmnie,  /.  r., 
incrt'ase  In  t-elliilar  elements,  iiicreiise  hi  globulin,  atul  positive  fluid 
Wikssermaiin,  renitiiii  al»sciit,  thi*n  it  eati  he  f:iken  a-i  hijjlily  prubahit' 
that  the  disease  pnu'ess  has  been  arrestcil.  Judi^ing  by  clinical  nietliods 
alone  a  Iniig-standinj:  and  urichangcabk-  A rg\"l I- Robertson  pupil  may 
be  the  only  le-sion  in  a  praclieally  cured  syphilis  of  tlie  nervous  system. 
It  is.  however,  to  be  realiz*'*!  that  sueh  a  pupillary  anomaly  may 
exist  as  hmn  us  from  twelve  to  sixteen  years  (alone  ^  and  then  the 
patient  may  develop  a  pan^is  or  tabes.  Of  eleven  personal  oWrva- 
tiona.  now  extendinjt  over  twenty  years,  only  two  patients  with  l*»nR- 
standinR  Arg>'ll-l{nbert.son  pupil  have  not  developed  further  sijiiis 
of  brain  syphilis.  ('ert«iii  ilee[j-M-ated,  climnie,  .syptiililic  arteriid 
processes,  which  may  lead  to  t'ocali/.e<l  lesions,  hemiplegia,  apliusia, 
et*'..  may,  however,  gti  nn  for  some  time  uithuut  distinct  signs  of 
[iieniii);eal  irritation  with  the  eharaeteristie  cellular  reactions. 

Clinical  Fonns.  — It  has  already  been  siatwl  that  the  so-i-alled  classical 
forms  ihf  syphilis  of  the  ner\ous  system  are  largely  abslractictus.  The 
patliologicai  processes  are  predominantly  either  meningeal,  arterial, 
infiUrative,  i  e..  guminaloas  in  character,  or  ]>aperich>inatoui*  alone 
or  in  ct>mbinations,  and  the  clinical  manifestations  are  extremely 
variable,  ctimplex,  and  eoiifiising,  depending  upon  the  interactions  of 
the  pathological  trends  and  the  v^iatioiLs  in  anatomical  (latbs  Inter- 
fered with.  ^', 

Fortunately  for  the  therapy,  t&  clinical  type  is  of  ser-ondary  con- 
sideration, yet  then-  are  certain  therapeutic  variables  that  render  it 
ilesirable  that  a  fuller  analysis  of  clinical  forms  should  be  nuide  than 
would  at  first  sight  seem  advaiilageoiis.  Vor  instani'C,  it  may  he 
recalled  that  certain  patients  witli  memngeui  infiltrations  of  tlie  liaae, 
with  or  without  gummatous  nodules,  either  of  the  base  or  of  the 
finnexity,  at  times  may  be  indistinguishable  clinically  fn>m  a  paren- 
chjTnatous  type.  A  nihilistic  theraiH'utic  attitu^le  relative  to  the 
latter  priK-ess  would  therefore  work  greatly  to  the  disadvantage  of  a 
patient  with  the  former.  Primary  sjT>hilitie  vascular  disease  U  often 
ver>"  amenable  to  treatment.  Often  its  clinical  picture  is  that  of  a 
paresis. 

The  following  clinical  forma  are  to  lie  distlnguishefl: 

1.  Syphilis  of  cranial   Ixmes. 

2.  S\-philis  of  the  basal  meninges. 

3.  Syphilis  of  the  convexity;  epilepsies. 

4.  Cerebral  sj'pbilis— jtrterial  types. 

5.  Terehnd  syphilis— parenchymatous  ty|)es  {general  paresis,  tabo- 
paresis). 


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sYptnus  Off  fns  HEnvoits  sVstEAt 

6.  Sj-jiliilitio  psycliosw,  ncntte  ami  sulMirtite. 

7.  Tal>es. 

8.  Syphilitic  »piiial  iufniiif;i(ls:  menliigduiyetitisi   myelitis;    sypliiJ- 
itic  radi  rule  neurit  is,  tind  related  syphilitic  syndromes. 

9.  Hereditary  syphilis  of  nervous  5>"stem. 

For  a  fuller  efnisideration  of  the  protean  variations  the  moiioji^raplLs 
of  Uilmpf,  Nonne,  Mott,  Plaut,  Oppenheiin,  Fnrster,  Schaffer,  and 
Foiynier  should  Iw  consulted. 

I.  Syphilis  of  th«  Cranial  Bones  Causing  Nervous  Syroptoms.^ 
These  were  ix'*-o(([ii/i-(l  as  riirl>  as  the  end  t>f  the  .sixteenth  ceiiturj'. 
Sypliilis  of  the  erunial  lMiiie:<  shows  itself  praetit-ally  in  the  form  of 


FK).  335. — QuminfL  of  brain. 

gummata.  Caries  of  the  cranial  l>iuies  aloue,  while  knowii.  rarely 
gives  rise  to  nervous  s\Tnptoms,  headache  exeepte<l.  These  guinumta 
may  Im*  circumscribe<l,  iu  which  case,  if  large  enough,  ihey  (^i\e  rise 
to  the  s.vmptoms  of  a  tumor  of  the  brain,  which  sijrii.'*  are  larpily  deter- 
mined by  the  precise  locatinn  of  the  f:;ummata.  These  circum9cril)ed 
gumniatH  may  attain  enonnnus  proportions.  A  p<'rsnnul  oljservation 
(J.)  recalls  a  nunima  of  the  left  frontal  region  (tlte  size  of  a  tennis  Iwll) 
wluch  originaled  in  the  Iwrne  dura  and  protruded  into  the  right  frontal 
lobe.    Similar  jtummata  are  not  infrequent. 

Cranial  bone  gmnmata— usually  involvinR  the  dura  as  well  -are 
more  frequently  flattcncfl  and  spreadinR.  Here  the  symptoms  of  brain 
tumor  are  usually  present.     Headache,  nausea,  vomiting,  sleepless- 


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SYPHILITIC  MEMSGinS  OF  THE  BASS 


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iiess,  are  aiimiif;  tlie  getieral  symptoms,  while  Intnilizin^  sijciis  in  Riwit 
variety,  depcnHinj;  iiprin  the  sitnatinn  of  the  jitimmatoiw  masses 
are  present.  Kpileptiforiii  etvnviilsions.  lasting  for  years,  may  be 
the  sole  signs  of  sueh  gummatous  formations,  occ^upjing  or  due  to 
pressure  upon  the  motor  areas.  Sueh  patients  are  often  mistakenly 
treated  as  epileptie^,  ami  the  monographs  of  Mott.  Oppeiiheim,  lUimpf, 
Nniuii',  ill  rrcciit  yearn,  hpi*  repleto  with  miiopsy  reeonls  of  sueh  eases. 
Monoplegia.^  of  \  iirtoas  sorts  result  from  such,  as  also  aphasias,  word- 
blindncss,  and  various  cranial  nen'e  palsies. 

In  athiition  varioiLs  fonns  of  periostitis  and  of  osteitis  occur.  Tliis 
latter  may  lead  tu  exostoses  or  to  osteoporosis.  In  connection  with 
syphilis  of  the  vertebra'  it  should  Im-  rememliered  that  the  pr(iifs.ses 
are  more  often  involved  in  distinction  from  tuberculosis  which  more 
frequently  involves  tlie  bod>".  Sj-philis,  too,  more  often  afTeets  the 
cerviciil,  whlh*  ttibei-CMhtsls  mon*  often  the  dorsal  vertebne. 

Itarer  caries  i>f  cranijil  bnnc  caries  of  the  liase  (sphenoid)  Ci'iinpli- 
cated  often  by  caries  of  the  upjx'r  vertebra',  an-  also  known.  .  I'etren 
has  studied  these  in  detail,  and  has  shown  the  value  of  ./-ray  fxaiuiiia- 
titais  hi  their  diagnosis. 

'2.  Syphilitic  Meningitis  of  the  Base.  -Hi! s  Is  the  most  eummon 
fonn  of  eerebral  syphilis.  Its  most  frctpa-nt  site,  in  the  beginning,  is 
in  and  about  the  interjiediineular  s|>ace,  thus  almost  invariably 
involving  the  optic  chia.'on.  From  here  it  tends  to  spread  in  all  direc- 
tions, pressing  into  the  sulci,  thickening  the  meninges,  by  infiltration, 
hy  arterial  disease,  or  by  giimnuitons  growth.  Tsnally  all  t>pe.s  of 
pathological  alteration  are  fiumd.  Tlie  gunnnatous  iiuusscs  not  infre- 
quently invade  the  brain  irtnictures  as  well,  grow  about  the  emerg- 
ing ur  entering  craiUHJ  nerves,  and  even  involve  the  l)ones  c»f  the  skull, 
and  the  upper  cervical  vertebree.  Thus,  spinal  meningeal  infiltra- 
tions almost  iiivariably  accompany  this  ba.sal  syphilitic  meningitis. 
M'heix-as,  the  dilfuse,  ttniglouierate  types  are  mure  fn^quent.  isolated 
vascular  disease,  eircutnscribed  gummata.  or  other  simpler  manifes- 
tations i>i  the  disease  may  occur,  In  which  latter  case  the  syndromes 
are  apt  to  be  simple. 

'I'he  clinical  course  of  the  nn)re  frequent  t\|»es  of  basal  syphilitic 
meningitis  often  resembles  genend  pare.srs,  t^pecialty  in  the  iH-ginning, 
but  the  grachiiil  extension  of  the  Inliltniting  or  gminnatous  develop- 
ments intn>duet's  variants  which  often  permit  a  differential  diagnosis. 

Headache  is  a  fretpieiil  atid  cariy  sign,  often  preee*ling  other  symp- 
t4ims  by  weeks,  months,  or  even  years.  It  has  the  fnxiuent  nof'turnal 
exacerbations  so  frequently  pictured  as  ciukract eristic  of  sxpbililic 
hea<lache.  It  is  described  variously  as  boring,  stabbing,  and  percus- 
sion at  the  base  may  show  teiHleniess,  tliough  less  frequently  than  in 
convexity  meningitis.  The  cenical  complication-s  spoken  of  often 
result  in  stiffness  of  the  neck. 

An  early  implication  of  the  optic  nerve  is  to  be  expected.  It  shows 
itself  (20  per  rent,  to  40  per  cent,  of  the  cases)  either  as  a  pressure 


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SYPHILIS  0^   THE  NERVOUS  HYSTEM 


neuritis  (neuritii-  atrophy)  of  the  nerve  in  one  disk,  then  in  the  other. 
later,  if  heaHarhc  and  vomiting  or  other  signs  of  intracranial  preiwiirt* 
are  proniinent.  (■lioke<l  lijsk  in  hoth  eyes  is  apt  to  he  present.  Atn>pluf 
(legenpratioii  hiiH  o|>tir  iiriiritis  »rf  les.-i  oftrii  fooml.  Markwl  ditninii- 
tioii  ill  visual  jitiiity  may  be  present  without  any  ilisk  evidences  of 
disease. 

The  third  nerve  is  fretjueiitiy  and  usually  irrefjiilariy  involved.  It 
is  ehanuteristic  of  bu.sal  syphilitic  meningitis  that  suct-essive  hranches 
arc  implicated.  First  one  eye  may  show  a  ptosis,  then  perliaps  an 
iTitertial  rectus  palsy,  then  tlie  other  eye  may  show  a  dilated  pupil, 
slow  in  its  rea<'tions  to  light,  then  ptosis  develofw  here.    Occasionally 


iiu,  3ao.  — Ceri;l>ral  syptiilu  punsii. 
Third  iiorve  pnloy. 


Flu,  aa7. — CcTi;l>riil  ?yi,IJl-;  ■■\nh  iliit-.i 
and  fourth  nerve  piijcii«a.     (StHnp.) 


the  ftccommiwlation  reflex  is  lost.  A  sctics  of  cases  will  show  a  great 
variety  tjf  oculomotor  palsies.  A  true  ArgjU-Hobertson  syndrome  is 
not  )nfri'»i.uently  ohtatne<l. 

Other  t  nniial  nerves  are  often  includetl.  Variations  in  the  cornea] 
reflex,  in  the  sen-sibility,  pain,  anesthesia"  of  the  face,  point  to  a  tri- 
geminal eon  I  plication.  A  |)eriplieral  facial  palsy  may  l>e  ppi-si-iited. 
In  some  in(ii\  idutils  the  deeper-lying  cranial  nerves  ( IXih.  Xth,  Xlth, 
XHth)  are  caught  in  tile  .syphilitic  extension,  with  tlieir  cluiracterislic 
sf.'mptoms.  'i'he  eighth  ner\*e  is  probably  frequently  involved,  but 
often  too  slightly  to  elicit  complaint. 

The  mental  picture  is  usually  very  striking.  It  is  frequently  that  of 
a  slowly  developing  apathy,  or  heaviness  advancing  to  coma,  or  unewi- 


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SYPHJUTIC  HrESlXGITIS  OF  THE  CONVEXITY 


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sfioiisness,  with  periods  of  acute  confusion,  possibly  violent  delirium. 
Tlicri'  is  a  marked  variability  in  these  patients  from  tiay  to  day  and 
also  considerable  (Hfferenres  in  different  patients.  Some  patient.s 
develop  a  sort  of  drunken  delinuni;  others  are  heavy  and  stupid  and 
ft[>athetie;  others  are  furiously  violent. 

One  special  featun-  is  fa-quciilly  met  with.  This  is  a  rapid  altera- 
tion in  tlie  mental  picture,  when,  after  a  period  of  acute  confusion  or 
deep  coma,  the  patient  Ix-comcs  ahnost  practically  clear  within  a  few 
hours.  This  occurrence  may  even  follow  a  period  of  con\*uIsive 
.H'izures.  Careful  tests  reveal  an  underlying  series  of  <lefects  it  is  true, 
but  from  a  lay  view-point  the  patient  may  appear  to  have  made  a 
complete  recovery  so  far  as  his  [jsyrhosis  is  concerned.  Without 
treatment,  however,  the  patient  ajjain  develops  his  apathy,  confusion, 
<Ii'lirium,  or  coma  and  not  infrequently  dies  in  this  state.  Sometimes 
death  results  by  suicide  as  tlie  patient  develops,  slowly  or  rapidly, 
a  distinct  depression  witli  possibly  persecutory  ideas. 

Tluis,  mentally,  tlie  patients  may  show  the  nid-time  nibrics  of  acute 
cunfu-sioii,  dementia,  mania,  melancholia,  paranoia,  etc.  This  alone 
hidicates  the  futility  of  retjarding  the  sj-mptom  pictures  which  have 
gone  by  these  names  as  diseases,  some  for  humlreils  of  yeans.  Happily 
present-day  [>syclnatry,  largely  under  the  iuHncnce  of  Kraepelln's 
Iwichinjr.  rccti(iiiizcs  than  as  only  the  protean  and  kaleidoscopic  pic- 
ture-formation of  not  only  sypliilis,  but  other  disease  processes  as  well. 

Biological  and  c>'tological  inetluKls  have  iKrniitted  this  definite 
change  in  attitude,  and  have  show^l  the  essential  and  close  relationship 
of  many  diverse  neurological  and  fwyohotic  sipTidronies. 

3.  Syphilitic  Meningitis  of  the  Convexl^.— This  differs  from  the 
former  uniy  in  llie  trend  of  its  symptoms.  The  pathological  processes 
are  practically  identical.  Many  iitdividunis  show  that  the  process  is 
general,  invi.blng  both  the  base  and  the  convexity;  in  some  instances 
the  i)athok»giciiI  changes  being  more  marked  on  the  convexity  than  on 
the  biLsc. 

Convexity  syphilis,  like  the  basal  variety,  may  be  a  fairly  localized 
affair,  or  it  may  be  difTuse.  It  may  be  limited  to  the  meninges,  or 
involve  the  bones,  or  the  hrain,  or,  as  is  most  usual,  all  three. 

Here,  headache  is  a  prominent  sign.  It  Is  paroxysmal,  and  often 
shows  a  n<K-turnnl  inrreas*'  in  severity.  iVrcnssion  affords  valuable 
evidence,  as  localized  tenderness  is  ver.\'  coumion. 

Here  the  general  syndrome  of  brain  pressure  is  usually  less  cnipha- 
sizwl.  Nausea,  vomiting,  giddiness,  may  be  present,  but  are  iBuaJly 
Ute  in  devriopmcnt.  or  more  traasitory.  Optic  nerve  changes  are 
less  frequent.  Isolated  s\-mptoms  are  more  prominent.  Kpileptiform 
oonviilsions  indicate  that  the  process  is  in  or  alMtiit  the  motor  areas. 
Not  infrequently  the  attacks  are  of  the  Jacksonian  tyi»e.  Involve- 
mi'iit  of  HriKii'.s  coiivohnions  p^hIuits  temporary  ur  mure  enduring 
inotur  apiiasic  attacks.  Siiinelimes  these  aphakic  attaeka  clear  up  in 
u  few  minutes,  an  hour  or  so,  or  a  few  days.    Minor  speech  difficulties 


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1139 


lay  ont.v  indicate  the  pussihility  that  an  aphakia  might  devekip. 
Complete  motor  nphasia  devi-Itips  only,  a>  u  riiK*.  with  hi'niiplejjic  nr 
iniiio|)U'Kii'  atronijjaiilnifiits.  lVu<h>bulbiir  piilsy  altutks  jiulicale  h 
hilateral  iiivnlvfiiient,  pn»bably  both  ttirticHl.  less  frequently  cortical 

,  on  one  side,  und  sulx^irtical  ou  llie  oppthiite  siile. 

I    Monoplegias  uf  van-ing  tx-pes  are  not  infrequent.     HeiT^niark'  lias 
devoted  a  large  iiionngraph  to  tlieir  sliHly.     Sei\s«ry  distiirbnnces, 
Itcniiam-.stJiesijp,  astereognnsis.  haptir  halhifiiiaTiors  are  met  with. 
W'ith  (htfiLse  nieningoi'iieephiditic  changes  the  jjii-ture  of   general 

^paresis  13  assinned,  and  it  is  particularly  difTicnIt  to  difVerentiate  this 

[riisiirder.    The  clinical  pictures  may  be  iis  various  as  tliose  of  paa-sis. 
I'ossibly  tlie  only  means  to  distinguish  them  is  that  claimed  by  Plaut, 


Vu 


.il<i 


KyphOitic  vascular  (Uma«>. 


i-^ni^  lui'i 


and  apparently  suljstantiatetl  by  Nonne  and  several  others,  that  in 
paresis  the  four  rcat^'tions  are  all  positive;  the  i-ercbrospuial  fluid 
showing  a  positive  \Vas.sernianii  witli  ().(l5  c.c.  of  Huid.  With  meniugo- 
sncephalitis  Haiipttnann  and  Nonne  liavc  shown  that  the  ihiid  is 
legative  when  small  quantities  are  used,  but  positive  when  0.4  cm. 
are  employed. 

Tliis  geiicntlization  seems  to  hold  true  not  only  for  convexity  menin- 
gitis, but  also  for  those  fomis  in  which  the  hixsc  i.s  more  especially 
involve<l,  altbuugli  ils  will  lie  later  jwinled  out  in  the  dtscussir»n  of 
)aresis,  variability  in  the  Wasserinarm  reiwtion  is  not  tnmsual. 

■Brwo.  1911, 


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SYPUILrS  OP  THE  NERVOUS  SYSTRyf 


4.  Cerebral  Syphilis.  -Vascular  Types. — In  coiiHidering  the  s.imp- 
tomato!c)g>-  of  patients  who  are  thought  to  have  ren'liral  yypliiliii. 
altentiun  may  iigain  be  callwi  tn  the  fact  tluit  tlie  dividing  line 
Ijetwf^n  cfn-bral  syphilis,  hasjil  metiingeal  sj'phllia,  convexity  s^'phihs. 
etc..  are  iiidcfinite.  llarely  does  one  find  a  pure  basal  or  convexitj- 
meninttiti^  without  some  involvement  of  the  cerebral  substance  on  the 
one  Iiand,  wliile  ttuivcrscly  it  is  as  rare  to  find  sjiihiUtic  pmces-^s 
strictly  liiiiitcd  to  the  cerebral  suKstanre.  and  not  invtilving  the 
meninges.  One  can  postulate  pure  typt^s  fur  purposes  of  description, 
but  disoAse  is  rarely  a  respeetor  of  one  cenrbnd  ti.ssue  more  than 
anotlwr. 

Stoptiims.—  It  is  for  this  reikstm  that  fme  Is  (•<ins1aiitly  reminded 
of  t!ie  multiplicity  of  symptoms  found  in  cerebral  syj)hilLs,  In  this 
connection  it  would  not  be  without  profit  to  glance  for  a  moment  at 
the  diagnoses  of  certain  csmesf  reported  by  Nonne  in  his  monograph 
several  times  alluded  to.  The  patients  were  illustrations  of  i»asal. 
or  convexity,  or  encephalie  brain  syphilis,  usually  c<Mnbined  forms. 
The  short  descriptive  diagmwes  run  as  follows:  SiH-cific  hcafJaclu"  a 
year  after  infcetion,  with  seconilnrics  in  skin  and  mucous  uiembrancs: 
headache  atal  pupillary  anomalies;  headache  and  obstinate  vomiting, 
with  tertiary  testicle  signs;  progressive  simple  dementia  cunil  by 
treatment;  pntpressivc  dementia  with  defect;  ci)mbination  of  c*hi- 
vcxitj*  meningitis  ami  paresis:  gummatous  meningoencephalitis  of 
convexity  with  gimeral  symptoms,  choked  disk  and  anti.s}'pliilitic 
ti-eatmcnt  unavailing;  siirgical  treatment  of  gunnniLs  with  cure; 
Jacksonian  epilepsy;  cortical  epilepsy,  choketl  liisk,  pariNis  of  left 
leg;  cortical  epilepsy,  iiptic  neuritis,  arterial  liciniplcf;ia;  cortical 
heniiepilcpsy  and  geiiend  cortical  symptoms;  arterial  hcmiapoplcxy 
with  hemicpileptie  conx'uUions;  generalized  epileptic  seizures;  liemi- 
anesthctic  attacks  with  cortical  general  signs;  uremia,  etc.  Such 
illu.<$trations  might  be  almost  indefinitely  contiime^i.  They  are  not 
the  exceptions,  they  arc  tiic  rule.  One  is  tempted  to  indulge  in  the 
generalization  that  one  hundrwl  consecutive  patients  with  the  t\'pes 
of  cerebral  s>'philis  under  consideration  would  show  one  hundred  dif- 
ferent clinical  syndrtmies.  Practically  all  of  those  Just  enumerated 
belong  to  the  convexity  typen  of  cerebral  syphilis.  Their  enumeration 
may  prove  of  service  in  Iwalizing  the  process. 

A  similar  series  for  the  basal  types  may  Ix*  e<|iially  of  sen'ice: 
Gumma  of  right  frontal  lobe;  pressure  neuritis  of  optic  nerve;  ehoked 
di.sk  with  ^neral  cerebral  .symptoms;  bilateral  neuritic  optic  atrophy; 
re^'urretit  optic  atn>phy;  hemianop.'^ia;  bitcmponil  lieniianop-Vm; 
homonynuius  Icft-.sldcd  hemianopsia  with  righl-sidc<l  abtluccns  palsy: 
temporal  Jienminopsia;  cranial  nerve  and  epile|wy;  hcmiunop.sia; 
hcmianopie  pupillary  reaction,  in-ulomotor  palsy;  epilepsy,  oculomotor 
palsy;  ptosis;  internal  rictus  palsy;  optic  atn^phy;  partial  oculo- 
motor palsy,  fifth,  seventh  i>alsy;  second,  third,  foiirth.  Hfth.  sixth 
ner\'e  involvement;  fifth,  sixth,  seventh,  eighth  nerve,  right  arm  and 


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icg  palsy;  seventh,  eighth,  psychosis  (paranoia  acuta)  with  tnanic 
nuMHls;  third,  fourth,  sixth,  tenth,  eleventli  nerve  palsies;  second. 
ihiril.  fourth,  sixth,  seventh  with  epilepsy;  tbinJ,  fuiirtli,  s<-\'enth, 
polyuria;  iso]ate<t  intcnml  ophthalmopjcgia — to  mention  any  more 
would  be  to  needlessly  extend  this  chapter.  The  lesHon  such  findings 
indicate  is  obvious.  These  are  commonplaces  of  neurology  but 
frcc]ueiitly  overlooked. 

lint  eliminating,  as  far  as  possible,  the  \iiried  syndromes  of  cortical 
or  basal  syphilitic  meningitis,  and  limiting  the  discussion  of  the  present 
section  to  these  forms  of  cerebral  s\'plulis  due  more  piirtic'ularly  to 
arteritd  disease,  what  is  its  more  frequent  s>TDptomutol()gy? 


Km.  341. — S>TluliU(^  mcnineiUit.     Eodanerilin  o(  iMutilur  &rter>'- 

Tu  the  first  place  it  may  be  mentioned  that  arterial  tN-pes  of  brain 
ayphilts  may  be  found  very  shortly  after  infection — as  short  a  time 
&s  two  or  three  nioiitlis.  Naunyn  in  a  thorouRh  study  found  that  48 
ptfr  <Tnt.  of  '.iXi  cases  reported  on  by  him  developetl  signs  of  cerebral 
syphilis  within  three  years.  On  the  other  hand,  forty  years  have  been 
known  to  elapse  between  infection  and  the  development  of  a  cerebral 
sj-phills. 

ffcre  the  prodromal  symptoms  arc  usually  headache,  dizziness, 
sleeptessnes?,  irritability',  inability  to  apply  one's  self  continuously 
41 


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SYPHILIS  OF  THE  NERVOUS  SYSTEM 

to  one's  work,  lack  of  mterest  in  work,  etc.;  in  genera),  the  socalled 
iiPuriLsthenic  sj-nHrome.    These  are  naturally  not  absolute. 

//crtWrrc/ic— The  heatliu-he  is  iisuii)ly  ver\'  disagreeable;  it  usually 
has  a  raifcmtory  rhiirarter — here,  thca-e  ami  els<'where.  usually  dull, 
it  is  at  limes  Ijoring.  It  is  Inconstant,  intermittent,  often,  not  by  any 
means  nlways,  worse  at  night  than  in  the  daytiine.  It  may  disappear 
for  weeks  or  iiiontJis,  and  then  suddenly  reap[)ear.  It  may  also  be 
the  niily  sipii  nf  t'erebral  syphilis  for  months  or  even  \eara. 

DizzittesJi. — l>izzincsa,  in  shorter  or  longer  attacks,  Is  very  siicnifi- 
cant  of  arterial  rlisease.  It  is  usually  associated  with  ^c  headadie 
but  may  appear  as  the  single  s>*mptom  of  brain  s,\-philis.  Like  the 
headaehe  it  is  apt  to  h*'  increased  by  mental  or  physical  work. 

limmnnn. —  Insomnia  is  frequent,  often  iilisthiate,  quite  variable 
anrl  not  infrwpicntly  sleep  is  made  irregular  anrl  non-restful  by  the 
sense  of  heaviness  iii  the  head  or  uetual  headache. 

r.rifchicat  J>i.ilurbancf9. — Psychical  disturbances  are  the  rule  in 
these  patients  with  arterial  disease  of  the  cerebrum.  They  l>er«»roe 
more  or  less  apathetic,  lose  interest  in  their  work;  art^  nnahle  to  work 
be<rause  of  forgelfutne-ss  or  inefficieriey.  With  this  there  is  increasing 
irritaibility,  an  inability  to  size  u])  the  situation.  Such  severe  distnrb- 
ftjice  is  arrived  at  oidy  after  some  time  as  a  rule. 

Ahiiurnial  •SVeepmiv.f. — Abnonnal  sleepiness,  chiming  on  in  attacks, 
is  not  infreqiiciit — such  [jeriods  of  torpor  or  apathy  often  intermitting 
witli  peritwls  of  anxiety  or  of  acute  restlessness  or  excitement.  Periods 
of  stupor  or  semicomatose  states  may  occur.  They  often  presage  more 
distinct  neurological  signs,  being  hased  a.s  they  frequently  are,  np4in 
sudden  extnivftsation.  infiltration  or  thrombotic  plugging  off  of  the 
blood  from  small  area.s  of  brain  tissue. 

Many  patients  with  cerebral  syphilis  <if  this  general  chararter 
remain  in  this  condition,  it  may  be  for  some  time;  they  show  a  picture 
])reeisely  similar  to  <Trlain  patients  with  general  paresis.  It  is  in  this 
general  group  tliat  the  greatest  diffieulties  in  diagnosis  occur.  As 
lias  been  previoiLsly  state«l,  a  positive  "four  reactions"  is  the  sole 
criterion  for  (iifTerentiating  the  two  in  the  present  state  of  our 
knowledge,  and  even  this  is  not  certain. 

Brain  tumor  is  also  tn  be  thought  <if  in  diagiuMis.  Paresis,  braiti 
tumor,  possibly  giuiima,  cen-liral  s^'|)hilis,  at  times  cannot  lie  dLs- 
tinguished  one  from  another  elinieally.  With  bmiu  tmnor,  non- 
eotupUcated  by  syphilis,  the  absence  of  the  four  reactions  affords  t 
positive  criterion. 

Local  Sifmptoms. — As  a  rule,  however,  the  greater  number  of  indi- 
viduals with  cerebral  syphilis  <|pvelop  local  symptoms,  ami  neun)I)^ical 
rather  than  psychiatrical  syndromes  come  uito  relief,  or  tlie  latter  are 
intenitingleti  with  the  former.  Palsies  develop.  These  are  transi- 
tory, partial,  not  wiilespread,  or  may  be  severe,  complete,  and  per- 
manent, showing  \arious  hcmiplegic  syndromes,  according  to  the 
anatomical  site  of  the  major  disturbance— usually  thrombotic — cortical, 


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capsular,  midbrain,  peduncles,  pons,  or  medulla— the  s>TnptomatoloRy 
of  the  different  forms  of  whirl)  are  dealt  with  elsewhere. 

Sucre-tsive  attarks  of  nilM  and  transitory  palsies  are  very  sif^tuficaiit 
of  cerebral  syphilis.  Monoplegias  are  not  infrequent,  nne  arm,  one  leg, 
one  side  of  the  fare,  possibly  the  cortical  speech  areas  with,  in  case  of 
double  lesiuu,  pseudobulbnr  palsy.  Minor  spcet-h  disturbances  are 
extremely  frwuicnt.  t reniors  of  the  facial  muscles  usually  nccompanying 
the  stumbling,  stuttering  or  ilrawling  speech. 

A  list  of  the  usual  clinical  diagnases  similar  to  those  already  outlined 
for  basal  or  convexity  meningitis  would  show  a  multiplicity  of  phe- 
nomena  no   le^^s  complex    in    the   neurological    fielil    and    certninly 
inlinitcly  more  vurieil  In  the  mental 
sympttun   pictures.      As  these  latter 
will  lie  dist'ussed  more  in  detail  in  the 
section  on  the  psychoses  no  furtiier 
mention  will  be  made  of  them  here. 

Parenchymatotis  Typ«s.  —  Qdneral 
Paresis.-- It  Is  uinal  to  separate  pan- 
sis  a.s  well  as  tabe.s  from  ol-her  syphi- 
litic <lisordeni  of  the  nervous  system. 
under  the  general  caption  of  piira-  or 
tiictasyphilitic  disurtlers.  Fournier  is 
largely  responsible  for  this,  and  lu 
paresis  and  talies  he  lia.^)  ixMeil  a 
numWr  of  other  disorders,  in  other 
parts  of  the  lH)dy,  to  which  he  applies 
the  term  pnra-  or  nu-ta^syphilitic. 

.lust  why  para-  or  nietasyphilLs  is 
not  known,  es|X'ciaI!y  s<i  far  a.s  the 
nervous  system  Is  concrrned.  Many 
ingenious  hypotheses  have  been  foniiu- 
latcd  with  the  ])ur|Mise  <if  explaining 
the  differences  between  jjaresis  and  tJibes,  on  the  one  hand,  ami  other 
forms  of  nervous  sj-philis,  secondary  or  tertiar\',  on  the  other.  It 
would  serve  little  puqiose  to  eiuunerate  them  in  detail,  since  none 
has  as  yet  compelled  conviction. 

To  return  to  the  syphilitic  etiology  of  paresis.  It  is  praclifally 
conceded  "  no  syphilis,  no  paresis."  One  is  not  speaking  now  of  those 
few  individuals  who,  either  because  of  the  presence  of  brain  tumor, 
or  the  existence  of  arteriosc-lenwls,  or  of  other  cerebral  disorder,  show 
a  close  clinical  resemblance  to  paresis. 

I'inally  the  fiialings  by  Moore  and  Noguchi  of  TrfpnnrDta  [Hilt'ulum 
in  twelve  of  seventy  paretic  brains  serve  to  render  more  certain  the 
relationship  of  the  organism  to  the  disease. 

But  syphilis  does  not  hy  any  means  necessarily  lead  to  iMirt-sis,  for- 
tumitely.  The  most  recent  studies  of  Mettlcr  show  tliat  about  2  per 
cent,  of  those  infected  with  sypliills  develop  jMircsls.    A  considerably 


Flu.  'M2. — P»ruiLiil.-ull>ur  inaXty  (njui 
-lyphilitir  riispaae.     (TUiH-'j.) 


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SYPniUS  OF  THE  SSRVOVS  SYSTEM 


larger  pen-enlage  develop  cerebrospinal  syphilis — how  large,  can  only 
Im"  RtirmLscd. 

The  quretion  then  nrises,  How  is  it  timl  m  certain  cases  a  disorder 
arises,  usually  more  tlmn  five,  more  frequently  about  ten  yeare  after 
infection  wlueh,  wliile  eloscly  rcseiubliiig  many  forms  of  cerebral 
syphilis,  yet  differs  from  it  in  certain  vcrj*  noteworthy  particulars, 
and  what  underlies  these  differences?  In  otlier  words,  Why  para- 
or  metasyphilis? 


Klo.  343. — cerebral  nyiihilia  (urt'  n  ,i  (.[..■(  wiili  «oft«runff.    Aphimia,  licini|tl«itlA, 
MdviUtniii:  ik'iio'iiliii.     (LftfomJ 

Naturally  there  are  those  who  say  there  is  no  difference,-  either 
anatomically,  biologically,  or  therapeutically.  They  are  in  the  minority 
.with  certain  well-developed  argimienis,  some  of  which  are  as  yet 
unanswerabte.  The  present-<lay  attitude  is  to  maintain  a  distinction 
lietween  the  strictly  vascular  syphilitic  disonlers  and  genend  paresis, 
L-hieKy  because  the  histological  |>atholog>'  is  unique,  the  biological 


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teats  are  slijtlitly  tlifTcreiit,  himI  tlu'  result:*  i)r  therapy  iliverse.    The 
ilifTcn-nces  an*  pn)bitbly  niorr  itt  clejjrei'  tliari  of  kiiuj.  huwever. 

Alzlieimcr  and  N'i.ssl  have  laid  ilowii  fiindainentul  disiiurtUMis  in 
the  patholofiiral  picture.  Thr  chief  jxiints  art-  (|tiaiititative,  and  tn 
a  less  extent  qualitative.       In  paresis  the  pureiuh>Tnatou.s  charijifes 


Ftu.  344. — Trapanenin  paUiidiiin  ia  Um  brain  of  a  pureLio.     (Mourv.; 

are  predominant;  in  cerebral  syphilis  the  vascular.    Their  re,searohcs 
have  remained  uucontrovcrte*!,  although  modified. 

SraiTOMK. — 'I'lie  syndrome  w  channterizi-d  liy  a  liewildering  mul- 
tiplicity of  forms,  which,  .sliifting  in  the  indiviilual  patient  frttni  mouth 
to  month,  at  times  even  from  day  to  day,  prevent  any  clean-cut  deacrip- 


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PA  RBaia— SYMPTOMS 

1.  Simple  jlementing  types. 

2.  Simple  depresses]  types. 

3.  TIk-  expiiiisive  nr  socrIIc*!  clasHiml  tj-pe. 

4.  'i'lie  iipiuited  types. 

5.  The  irregular  types  with  localized  sxinptrtins,  Lissaucr,  tabo- 
paretic  fonn. 

(i.  Juvenile  paresis. 

Before  even  attempting  a  description  nf  these  purely  nrti6ciul 
creatioiiH,  pictures  which  iin.>  ituistuntly  shiftiii;^  and  showing  eoni- 
binations  of  detaib,  u  brief  glunre  at  tlie  chief  symptom  compoueats 
is  advisable. 

These  have  frequently  been  divided  Into  the  mental  and  physieal, 
but  as  this  is  a  purely  arhitrary  di-stinction  it  will  not  hi-  empfiasized 
here.  As  has  been  notetl,  a  diagnosis  of  an  im|>ftiiliiig  paresis  may  be 
made,  at  times  some  years  iwfore  its  onset,  by  the  findings  in  the 
cerebrospinal  fluid,  but  attention  is  here  first  frtciwsefi  uixin  the 
iiieiitid  picture.  \  peculiar  psychical  weakness  is  one  of  the  early 
pheiumiena.  Tins  Ims  been  badly  tenned  neurasthenic  by  some.  A 
difficulty  in  perceiving  external  impressions  shows  this  uitellectual 
loss.  In  the  early  stages  it  may  require  special  study  of  reaction  times, 
which  are  usually  lengthennl.  but  soon  absent-mindedni^s,  inattention, 
loss  nf  details,  forgetfnhiess  nf  important  fnets,  heccjrne  apparent. 
There  is  a  gradually  developing  loss  of  ability  for  prolongeil  mental 
efTiirt;  in  c<tn\'ersation  finer  shades  of  meaning  ar<*  lost,  the  patient 
\H  no  longer  alert  and  keen,  as  perhaps  has  been  his  nonnal  luibit. 
The  mental  deterir>rat5i)ii  going  on  leads  to  many  changes  in  his  usual 
cotiduct,  until  the  jmtient  nuiy  be  no  longer  quite  sure  of  himself  in 
his  customary  surround  bigs. 

Certain  patients  develop  a  state  of  dreamy  coasciousness,  as  though 
in  a  mildly  intoxicate*!  state. 

Increased  fatigability  is  another  early  symptom.  Much  has  l>een 
written  (if  the  preneurasthenic  stages  of  part^sls.  This  c.^cessive 
fatigue  ina\  jirevcnt  him  from  stiirting  anything  new— sometimes 
he  even  falls  asleep  wliile  at  work  or  in  conversation. 

D^ectv  of  lidcnlion  and  Memory. — Retention  and  memorj'  soon 
commence  to  show  defects.  Careful  studies  in  tJie  early  stages  have 
shown  difficulties  in  asscKriation.  Icsscnwi  capacity  for  learning,  di.s- 
turbance  in  attention,  often  with  guoci  retention.  The  j>aticnl.s  forget 
recent  happenings  more  readily,  not  knowing  what  has  transpired 
a  week  ago,  yesterday,  sometimes  a  half-hour  ago.  Thest?  gnis>er 
defects  U'long  to  the  later  stages  as  a  rule.  The  nietnciry  of  lime  rela- 
tions gradually  slips  away,  the  patient  being  unable  \o  arrange  suc- 
cessive phases  in  an  orderly  series.  Thus,  many  of  these  patients 
sliow  tlie  greatest  defects  in  their  appreciation  of  time  differences, 
when  marriefl.  age  of  oldest  child,  and  related  striking  faet^  of  life. 
In  later  stages  all  sense  of  time  may  become  effaced. 


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64& 


LtHiii  lif  JwIffmnti.—'lAKia  iif  jitd^iiiciit  iiiitiirgilEy  gnes  iiii  intri  jntMtu 
willi  tin*  KfiKTal  [(svcliioil  ilisinti'^nitiiu].  In  the  i.'Hrly  stajci^  even 
Tftiiutl  iiit'tluHls  of  ti'stiiij:.  sudi  as  ihuse  <if  (rrfgor,  sliow  tiiut  uihti^ 
taintic^'.  toinni<lifti<>iis,  logical  lapses  arc  not  infit'quent.  The  patients 
ari!  eaaily  di-slrac-ted  by  sounil  ajwiH'latioiis,  Si  x9  =  iW.  elc.  As  this 
loss  of  judgment  noes  on  the  patients  may  make  ihe  most  al>surd 
plans.  Thf'y  do  the  most  \niusnal  things,  often  involving  their  entire 
fortiiiies  and  pliiyinp  havix-  with  nil  of  their  carefully  \v((veii  sucIhI 
fabric.  IVeam  world  and  real  world  become  bopeleasly  confused  in 
lliis  fumlamentnl  psychic  crumblinj;. 

Hallucinations,  illusions,  and  eliaiiges  iu  simple  sensor>'  perception 
are  found,  hut  they  are  not.  as  a  rule,  prominent  features  in  paresis. 
I)ehi.sion  forinatioii  is  naturally  pre.senC  in  many  instjmces,  although 
certain  patients  may  go  through  the  disorder  with  but  few  delusional 
developments. 

DrIuxUmx. — The  delusional  ideas  vary  immensely — they  are  usually 
5en>e]ess  and  fimtasiif  imd  when  combine<l  with  ai-tive  creative  phan-^ 
tasies.  as  they  frcfpiently  are,  es|)ecially  in  agitatol  or  excited  pcritxJs,; 
pasit  all  bounds.  These  patients  think  in  niilliuiLs,  billiotLs,  quadrillion.^, 
etc.  They  are  princes,  kings,  enipertirs,  potentates,  priests.  Christ, 
Got!,  supergoils.  They  have  rubies,  pearls,  dianunuls.  emeralds;  two 
wives,  a  dozen,  a  harem,  thou^ands  of  beautiful  women,  etc. 

T'hese  delusional  ideas,  simple  or  phantastie,  are  also  liable  to  great 
lability.  They  are  always  chaiiging;  njntradictorT.'  its  well  as  uneon- 
scions.  New  ones  come,  old  ones  go.  revivals  take  phut*.  I'rogres- 
sions  may  go  backwani:  Xow  they  have  millions,  next  moment  liave 
thousands;  now  a  king,  in  ten  minutes  u  fine  soldier.  One  can  at 
times,  by  talking  with  thes«'  jwitients,  expand  or  contradict  their 
delusional  exuberaiR'e  almost  at  will. 

T'he  same  characteristics  may  Iir  noted  in  regard  to  delusions  of  a 
depressive  or  hypochondriacal  nature.  Xihilustic  delu.^ions  stu'li  as 
bi-lievijig  they  have  no  stomach,  no  bnirt.  or  are  dead  are  not  infre- 
quent in  these  tj'pi's. 

Atteratioti  of  Ktnotuntal  Aviivity. — The  disposition  or  emotional 
reactivity  Ls  involved,  as  Is  the  intelligence.  As  a  rule  the  patients 
in  the  early  stages  are  hyiH'rexcitable — others,  however,  arc  markedly 
depressed.  T  hey  are  apt  to  be  touchy,  surly,  cross,  even  luiving  violent 
outbursts  for  the  most  trivial  events.  'I'here  is  often  a  distinct  damper 
in  tlieir  higher  ethical  feeling,  so  iliat  the  stimulus  of  conversation, 
the  jny  of  music  or  art,  of  variotLs  social  relations  gives  way  to  a 
i-areless  iinliiTercnee,  often  at  grt-at  variance  with  the  psyclmmotor 
activity  of  the  patient. 

As  tlie  disorder  progreisses  the  miHxl  is  apt  to  be  colored  by  the 
delusional  Interpretations.  Anger  and  laughter  may  follow  one  another 
in  quick  sue»rssion,  and  a  great  \'ariety  of  ficetuig,  changeable,  often 
contradictor)',  emotional  states  are  passed  through. 


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sYpnrus  OF  the  nehwus  ststkat 


Churacler  Alterations.  -The  cliaracter  altt-ratitms  are  prpdoniiimnt. 
I>ecision  u  projjn^ssively  lost;  instability  ami  fmjUmriiincss  alttr- 
natiii^  with  ubhtiriancy  and  iierverseiiess.  Initiative  is  ntluceJ,  und 
the  putipTtt  may  herome  as  day  in  tlir  potter's  Imnd;  such  periods 
cififii  alltTiiate  irrcKiilarly  with  impulsive  hcctilessucs-s.  Krat>|>elin 
relates  the  case  of  a  jjatifnt  who  steppcil  out  of  a  secoml-story  window 
to  jjick  u]i  H  I'igar  that  he  liappeiied  to  nntii-e  on  the  walk  beneath  him. 
Criminal  uetioiLs  may  be  a>nimitted  in  just  the  same  manner  as  llie 
case  ol"  tlic  piirctif  who  shot  at  Mayor  (laynnr,  of  New  York.  Suicide 
may  occasional ly  take  place  in  tlie  same  manner.  Stealing  is  hy  no 
means  infrequent,  and  sexual  misdemeanors  and  crimes  are  extremely 
prevalent.  This  blunting  of  the  repressions  Inculc-ateil  by  the  force 
of  civilization  is  particularly  noticeable,  and  predominantly  in  the 
sexual  sphere.  Hence  results  the  frequent  telling  of  lewd  stories, 
consorting  witii  people  of  quite  inferior  social  status,  exhibitionism, 
shameful  and  open  masturbation,  and  even  genital  aasaiiltt. 

}>furof(jgica{  Sign.''. — Here  one  finds  not  infrequently  in  the  hcgiu- 
ning  phases  a  dull,  heavy  headache.  Hyperesthesia  often  precwU-s  the 
blunting  of  any  special  sense,  and  various  localizetl  disturbauces,  such 
as  wonl-liliiidness,  wonl-ileafuess,  auditory  hallucinations,  apraxia, 
asymltolin,  astereoRnosis.  indicate  a  special  localization  for  tlie  time 
bciiin  in  more  or  less  definite  ti)rtical  areas.  Oi}tic  nerve  atrophy 
occurs,  at  times  early,  in  from  r>  to  10  per  cent,  of  the  cases.  Special 
changes  in  the  optic  disk  arc  recognizable  in  from  12  to  50  per  cent- 
of  the  eases. 

Changeg  in  Cutanenus  t^enmbHity. — Vep>'  frequently  cutaneiius  sen- 
sibility is  modified— simrp  pains,  numbness,  itching,  etc..  occur,  and 
in  those  forms  reeognizcd  as  taboparetic  these  often  show  the  s|>ccial 
localizations  of  the  tabetic.  Out  of  these  changed  sensations  delu- 
sional interpretations  frequently  arise.  A  general  insensibility  to 
peripheral  stimuli  devcloiw  later,  and  the  patient  may  then  pay  little 
attention  to  any  kimi  of  irritant,  heat  or  cold,  full  bladder,  distended 
rectum,  etc.  Occa.sionally  such  i>atient'*  mutilate  themselves,  cutting 
off  a  finger,  or  the  tongue,  or  the  testes  in  order  to  get  rid  of  what 
seems  to  them  a  foreign  body. 

Mutiir  Incifiirti'fmiiiimJt. — Motor  incoordinatiuiis,  from  initial  trem- 
bling to  more  high-gnide  ataxias,  apraxias.  adiadokokinesias.  Rom- 
berg, asynergius,  are  common.  Intention  tremor  is  not  infrequent 
and  perseveration  is  almost  never  missed  in  the  later  stages. 

Pitforderg  of  Speech. — In  speech  the  motor  <lifficulties  have  been 
specially  studied  since  Esquirol  first  laid  stress  upon  such  chaiigcb  in 
mental  wises.  Frequently  beginning  with  slight  stumbling,  a  slurring 
over  certain  letters  or  s^illahles,  r,  /,  etc.,  the  paretic  develops  verj' 
cliaracteristic  speech  anomalies.  These  come  out  with  marked  prniai- 
neacc  in  the  use  of  test  phrases^lectricity.  Methodist  Episcopal, 
organization,  truly  rural,  third  cavalry  brigade,  etc.-  when  certain 
letters  are  rcpeate<l.  stumbled  over,  or  elided.      Paraphasia,  aphasia, 


I 
I 


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PA  ItBSISSTMPTOMS 

ataxia  uf  sp«*ei-li,  jjerseveralion  are  Dmon^  the  frequent  later  develop- 
ineiits  until  only  a  mumbling  may  be  possible  in  the  last  stages.^ 
Similiir  cliaiigcs  take'  pliifT  in  writing. 

iy  SympUmis.-  In  the  (xnilar  inovernent-s,  antilogiius  <liflicultifs 
are  observed  and  m  the  pupils  uiie  observes  a  variety  of  clianges. 
Statistical  studies  show  these  pupillary  anomalies  to  be  extremely 
freqnent.  Uilferenee-s  in  size  from  50  t«)  SO  per  cent.  (Kaehe);  dis- 
tortion of  the  pupillary  outlines,  "4  per  eent.  (Jnffroy);  Ar^vll-Hobert- 
soii  pupil,  oO  in  70  ]>er  eent.  (Wc^tphal,  .Itiiiins.  Arndt,  etc.}.  .Many 
of  these  pupillar>'  anomalies  undergo  considerable  variation,  elianging 
from  time  to  time  even  without  treatment.  Iii>ss  of  consensiml  light 
FfHex,  as  already  noted,  is  often  one  of  the  eHrliest,  and  at  the  same 
time  one  of  the  most  persbtent  of  the  pupillary  anomalies. 

CoTivuhirc  Pheuomnui. — Convulsive  plienonietia,  epileptiform  or 
apoplectiform  in  character,  are  rarely  mls.sed  in  paresis.  They  are 
usually  of  the  t-ortieal  epileptic  t>-i>e.    They  often  occur  early  in  the 


Fuj.  MS. — Sotol  pivtunM  of  purvtiu  MinvuUiuu.     ( KtM-iwUn.) 

disease  or  may  punctuate  any  period  in  its  development.  At  times 
litnitec),  they  more  often  arc  generalized,  and  fn-quently  have  prn- 
droroata,  such  a.s  dreamy  .states,  motor  ineofirdi nation,  thickness  uf 
speech,  twitchings,  ete.,  as  a  rule  occurring  early.  As  isolated  phe- 
nomena, t>-pieal  statiLs  attaok.s  may  be  observed,  with  as  many  as  KX) 
or  more  epileptiforin  crises  in  twenty-four  hours.  .-\ti  jtltack  tn  the 
very  early  stages  may  last  only  a  few  secomU:  the  jHitient  suddecily 
sinks  back  on  his  chair,  and  is  all  right  in  a  few  nHtmcnt-s — while,  on 
the  other  liand,  status  attacks  may  persist  a  week  or  even  more, 
i'nconsciousness  is  u.Kual.  though  it  may  l)e  \'ery  slight  or  Heating. 
A  vast  variety  of  focal  residuals  ha\e  ]»een  describeti. 

Similar  changes  may  be  observed  on  the  sensory  side  of  the  nervous 
sjTitcm,  and  so-adlwl  |)siichie  equivalents,  as  in  the  more  classical 
epilepsies,  are  frequent. 

Stati:4ticid  studies  show  the  very  great  frequency  of  these  attacks, 
OlwrHleiner  reconling  them  as  often  as  iu  IW)  per  cent,  of  his  patients; 
while  Junius  and  Amdt  in  their  recent  extensive  study  give  them  as 


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652 


SYPHJUS  Of  THE  NERVOXTS  SYSTEM 


fKxnirring  ui  53  per  cetil.  A  perscmal  study  (.1.)  wf  two  him<Jrt*<I  i-a^«^ 
showed  them  iti  7S  jter  ifiit.  of  the  patient.s.  Kniej>eliii  JielievK* 
that  treatiiH'iit  in  hed  limits  (he  number  and  frcffucncy  of  tin;  atlHck^s; 
his  Munich  statistii-s  show  nn  Ineidenee  (»f  nhoiit  (Vi  per  t-ent. 

Alkmtions  in  liejlfxeji. — The  tericU>ii  ri'Hexes — triceps,  radius, 
luiee-jerks  and  Achilles — are  usually  positively  involved,  cither 
excessive,  in  the  fireater  number  of  oases,  or  dimiiiisheil,  esi>wially  in 
those  patients  with  posterior  cord  involvement,  which  Is  frequent. 

When  tlie  deep  reflexes  are  found  to  be  InereiLsed  other  sjToptoniji  of 
involvement  of  the  pyramidal  tracts  are  n<»t  infre(|uent.  Babin^iki 
reflex,  very  frequently  Chaddock's  external  nmlle«)lur  sign,  at  times 
the  paradoxical  reflex  of  ()<»rdon  occurs.  I\»ssibly  there  is  an  nnkle- 
clonus,  and  spasticity  in  gait  is  present.  If,  on  the  other  Imnd,  the 
deep  rcHeses  are  diminished,  other  signs  of  involvement  of  the  posi- 
tion den.se  and  deep  sensibility  fibers,  travelling;  the  posterior  colunm 
pathways,  are  usually  found.  Ataxia,  Romberg,  girdle  sensatioiLS. 
anesthesitc,  etc.,  pain*  of  the  radicular  type,  are  also  often  eucounteretj 
in  these  taboparetlcs. 

In  most  of  the  patients  there  is  great  variability  in  tlic  two  sides. 
Occasionally  one  finds  spactidty  of  one  and  hypotonia  and  ataxia  of 
the  other,  and  combined  sjinptonis  are  to  be  exjiected  in  the  later 
stages,  especially  in  those  patients  with  prominent  cord  localixations. 

In  the  final  stage  c(jntractures  occur  in  the  bed-ritlden  patient. 
They  are  unable  to  do  anj-thing  and  muscular  twitches,  spasms, 
localized  ntrophies,  and  a  veritable  museum  of  anumulics  is  to  be 
lof>ki*tl  fnr. 

t'intlings  in  Cerebrospinal  Fluid. — The  findings  ui  the  cerebroBpiiial 
fluid  have  already  been  discussed.  Suffice  it  to  say  here  that  they  are 
of  paramount  importance  and  a  diagnmis  of  paresis  without  the  signs 
obtainable  in  the  cerebrospinal  fluid  must  always  be  regarded  as 
lacking  in  a  most  important  element. 

Fnnugh  has  been  said  to  show  that  the  clinical  picture  of  paresis 
may  he  closely  counterfeited  by  a  number  of  otJicr  jmthological  states 
— notably  brain  tumor,  oerehrosplnal  sj'philis,  arteriosclerosis,  clironic 
alcoholism,  sleeping  sickness,  etc. 

The  findings  In  the  fluid  are  very  deBnite.  A  positi%^  four  reactions, 
the  fluid  useti  in  small  quantities— O.Uo  to  0.2  c.c— is  almost  certainly 
diagnostic  of  paresLs,  yet  at  times  it  would  appear  tliat  positive  four 
reactions  are  found  in  other  syphilitic  processes  which  do  not  behave 
like  paresis.  The  earlier  didactic  attitude  of  Plant  seems  to  \)c  in 
need  of  some  revkion,  but  ut  the  present  time  there  is  not  Muflicieut 
autopsy-con tn)l led   nmtcrial    to   permit   absolute   dicta. 

Vasomotor  and  Trophic  Disturbances. — Vasomotor  and  trophic  dis- 
turbances may  appear  early  and  come  and  go;  among  tliem  skin 
eruptions,  such  a.s  herpes,  and  pemphigus  are  the  commoner  t>pcs 
met  with.  The  ready  appearance  of  bed-sorra  and  abscesses  indicate 
the  lowered  resistance  of  the  skin  and  subcutaneous  structures. 


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PARESIS- FORMS 


653 


The  bodily  temperature  may  show  considerable  variation,  even  on 
opp<>site  sides  of  the  body;  it  is  usually  subnomial  in  the  later  staRes. 
save  following  cuii^ulsive  seizure.  Sltfp  Is  irreRuliir,  esjieoially  in 
the  excited  stages,  when  the  paretie  may  nut  sleep  for  days^wlierca.'; 
in  torjiid  stages  or  in  those  quiet,  dementing  forms  the  patient  sleeps 
or  h  ill  H  do7e  mueh  of  the  time. 

The  appetite  is  faprici(tns,  and  the  btnlily  weiplit  is  apt  to  fall  ufT 
in  the  early  stages  and  during  excitement,  to  iH-eomc  uiudi  increased 
in  the  tor|>id,  quiet  states. 

Disorders  of  the  bladder,  and  incontinence  of  urtnc  and  feces,  all 
sooner  or  later  come  within  the  outlines  of  the  picture. 

Ilettn'gsiojfji.—  One  eiitiical  feature  whieh  i-i  very  striking  is  the 
temlency  of  thb  disorder  to  show  marked  remissions.  In  certain 
respects  this  is  a  general  law  in  dbease  processes,  but  in  paresis  it 
appears  most  striking  because  of  the  almost  miraculous  change  that 
takes  place  in  the  patient.  Such  patients  one  would  say  were  al>out 
to  (lie;  they  liecome  absolutely  helpless,  eonvulsinu  follows  convulsion; 
in  the  interim  they  know  notlting,  are  be<l-ridrleu.  have  to  be  fed,  soil 
themselves,  and  are  reduced  simply  to  breatliitig,  heart- beating 
automata.  They  may  remain  In  this  condition  for  weeks  Hud  months, 
and  then  pick  up  a  little,  and  then  more  and  more,  and  \\ithiii  a  space 
of  six  weeks  to  thn-e  months  many  such  p;itients  appear  to  be  almost 
well  and  like  themselves.  They  have  risen  from  the  dead,  and  strange 
to  say,  although  the  relatives,  friends,  and  business  associates  have 
been  told  over  ami  over  again  perhaps,  for  they  should  he,  tliat  this 
Is  not  a  cure,  that  it  Ls  only  a  remission  of  .s\'mptonis,  the  patient  is 
frequently  ivstorcd  to  all  liis  vW'i\  rights  and  given  full  ttintnil  of  liLs 
aiTairs.  In  the  majority  of  cases  this  is  disastrcnts:  he  may  buineh 
out  into  new  lines,  involve  his  fortune,  marrj-  unwisely,  and  then 
after  a  few  month.s,  perhaps  a  year — the  longer  remLsaioas  on  reconl 
have  been  five  *>r  six  years — the  average  in  about  six  months—^tbe 
symptoms  return,  often  in  rapid  i>rogre-ssion,  and  usually  lead  to 
death  after  variable  intervals  of  from  six  montlis  to  a  few  years. 

Tonoa. — To  return  now  to  the  subject  of  tlie  Uvms — those  more 
or  Icsa  artificial  groups  which  for  the  purposes  of  description  psychia- 
trists agrtT  iiixiii. 

The  symptomatology  of  paresis  varies  within  such  wide  limits 
because  of  the  extent  and  distribution  of  the  pathological  changes; 
because  of  the  individual  make-up  of  the  patients,  and  because  the 
dis(«Ke  pnx-ess  not  only  affects  the  highest  psycholugiciil  levels  hut 
strikes  deep  into  the  ph^-sit-ochenin-al  and  s,\Tn pathetic  fmiTiilalions 
HiK)n  whieh  these  higher  levels  are  built.  The  ilisease  presents, 
tlierefore,  a  combination  of  pttychologieal  symptoms  more  or  less 
explainable  at  that  level  coupled  with  disintegrations  of  a  much  more 
material  cliaracter  and  stable  orgaiii/jition. 

I.  Oententintt  Form. — That  whieh  characterizes  this  general  group 
is  tlie  progressive  mental  deterioration  with  motor  |)are.sis.     Excite- 


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SYPIilUS  OF  THE  HEtiVOVS  SYSTEM 

ments,  convulsions,  extravagant  Hvluston  format  tons  are  m»t  prominent 
and  when  present  are  tmiisitury.  In  these  iniiividnals  there  is  the 
earlv  pniiKJ  of  nervtms  irritable  weaknt-ss.  with  loss  uf  mental  alert- 
ness. nitKKllness,  inahilily  t"  work,  fnrget fulness,  and  steadily  increasing 
poverty  of  thought.  Naturally,  tlie  picture  beginning  in  this  way 
may  suddenly  change.  This  is  sufficient  to  throw  the  patient  into 
another  Kn)Uj> — hut  if  tlie  development  is  of  the  sKm*,  progressive 
nature,  gradually  advanring  mental  weakness,  fleeting  deliwional 
ideas,  often  with  cliililish,  weak-iiuntled  features,  these  are  the  general 
svTTiptoins   [if   the   dementing   type   nf    paresis. 


iji. 


I'll),  it*li).- — Siitiidt!  illume h I iiig  Juriii  of 
puttain. 


of  fMi-ini. 


2.  l>e}m\f)frff  fi;rmj».^Here  anxiitus  depression  is  in  the  foreground 
of  the  mental  ])ictuix'.  Hypochondriacal,  delusional  states  are  pn>mi- 
nent.  The  patients  continually  complain  ahtmt  Inxlily  discomfort; 
have  lost  their  intestines,  or  have  destroyed  their  manhood  hy  ma»- 
turUation  or  sexual  excesses.  Tliesc  delu.sifinal  ideas  l>econie  more 
and  more  nonsensical.  In  nmny  instances  the  hypochomlriacnl  ideas 
are  dcijcndent  upon  fancied  sinful  actions  or  wnmg-doing.  They  are 
great  sinners,  they  nuist  he  prnteeted  from  the  jx^ice,  they  fear  tliey 
will  he  siTit  UM-ay.  Such  patients  often  have  (x-rsi'cutor.'  iileas,  and 
when  such  arc  prominent  early  in  the  di.spase,  hefon;  there  is  nmrked 
deterioration,  they  are  frequently  regarde<l  as  "paranoiacs"  especially 
hy  those  schools  which  regard  names  a.s  disease  entitie-s  and  seek  for 
diagnoses  fntin  a  "jNithogiiomonic"  symptom.  These  part'lics  with 
persecutory  ideas  often  have  pronounced  hallucinations  of  heanng. 


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PAltBSIS—l-VnMS 


656 


Notwithstanding  these  hj-pochondriaral  or  perseoutorj',  delusional 
intrrpretationa.  these  patients  are  markedly  indifferent;  they  are 
apathetic,  talk  and  move  in  a  monot(ini>us,  dull  inatini'r,  and  take 
little  interest  in  their  aurroiin<linKs. 

Thus  the  Itjss  uf  energ>\  the  libido  in  Jung*s  sense,  not  being  able  to 
go  forward  in  the  nfTairs  of  life,  a  marked  pathological  introvcr»ion 
takes  plat-e.  and  the  regression  takes  hold  of  all  sorts  of  noii.sensical, 
childish,  infantile,  and  anhaie  phantasies.  Pathological  projection 
also  is  common,  ami  one  lias  a  regular  chaos  of  pathological  mental 
meahanisms.  The  sense  of  reality  is  so  markedly  impaired,  and  the 
affective  relativity  so  cut  off,  that  the  noiLsensical  Iwliefs  have  no 
(■orres[M»tKliiip  nr  adei|uati-  enmtlonal  relationships.  Tlie  jwrsonality 
is  fragmenting  and  disintegrating. 

Childish  rcgressi<iiis  of  hen>  forinatiun  appear.  The  patient  is  a 
god.  a  king,  an  emperor;  like  Jack  and  the  beanstalk,  he  is  miles 
high;  as  in  (Julliver,  he  ia  a  great  giant;  as  in  Midas'  touch,  or 
Aladdin's  lamp,  he  breaks  the  hank  at  Monte  Carlo,  or  is  the  owner 
of  immense  gold  mines,  fabulously  valuable  jewels,  ete. 

( 'ontrasting  states  i»f  great  inferiority,  weakness,  poverty,  cause  them 
to  be  wry  fejirrul,  easily  coiifiLsed,  easily  h>st;  they  iH-g  for  pnrteetitm, 
hiile  fn)m  anger,  or  ask  piteously  for  food,  preserve  scraps,  etc. 

They  become  unnumageablc  in  bed,  and  finally  in  many  the  agita- 
tioTi  and  fear  develop  great  resistance  and  violence.  Self-dcstmetion 
may  hv  attempted,  mutilation  occasionally  occurs.  Most  of  these 
attempts,  however,  arc  fragmentary,  non-sustained  and  bungling. 

Stupomus  states  show  a  contrast  to  this  marked  violence.  They 
mny  persist  for  weeks,  months,  or  even  years.  The  patients  lie  stupitily, 
"depressed,*'  nr  anxious  in  bed,  iniclcaii  and  uritnaiiageable.  Special 
rigi(lities,  catatonic-like  ui  their  nature,  may  develop. 

The  special  statistics  show  that  from  15  i>er  cent,  to  iC*  per  irnt. 
of  the  material  in  some  of  the  larger  European  hospitals  and  clinics 
may  l>e  in  general  tlu-own  into  this  depressed  category. 

:i.  hUiHtnitivr  TyjH-.-^. — This  gctjcral  tjix'  has  been  for  years  con- 
sidereti  "classical,"  yet  they  are  not  a,s  fretjuent  as  the  demonte<l  types. 
Tims,  Kraepelin  gives  30  per  cent.  In  his  ITeideUrcrg  series,  .hinius 
ami  Arndt  27  [kt  cent,  in  their  Berlin  material.  It  is  to  In*  regretted 
that  the  spcciali.>4t  Ims  failed  to  emphasize  this  feature,  which  is  of  so 
much  value  to  the  general  practitioner,  and  has  confused  the  issues  by 
speaking  of  a  "change  in  t>*pe."  It  is  of  more  value  to  insist  upon  the 
cuinparative  rarity  of  the  megalomanic  features  of  paresis,  since,  as  the 
aventgi'  ineilical  man  has  lieen  taught  to  recognixt*  pan^is  by  this  sign, 
it  is  not  to  be  wondered  at  tliat  so  much  delay  has  occurred  before 
the  rect^nition  of  paresis.  The  cmpliasis  should  not  be  laid  upon 
the  comparatively  rare  cxpaasive  cases. 

in  this  megalomanic  t>'jK  the  boastful  ego  rises  to  superior  heights. 
Everything  i-s  seen  fn)m  the  stand-point  of  a  feeling  of  abundant 
energj'.    At  first  the  ideas  are  those  of  great  exaltation,  nithiu  the 


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SYPHILIS  OF  THE  NERVOUS  SYSTEM 


hoiuuis  of  iiuniml  human  experience,  but  soon  the  patient  loses  his 
earthly  bonds  and  soars  to  siij>erhuman  unrealities.  His  strenpth  is 
appalling;  his  education  superior  to  any  others  in  the  world;  h**  s]x-3iks 
ten,  nay,  all  lanR1laK^•^;  has  all  wealtb;  all  i»wpr;  figures  mount 
from  thousamls  to  miJIioiLs,  to  pages  of  ciphers.  .\nd  in  kaleidosoopie 
clianges,  and  great  individual  variation  one  learns  of  many  amrvrls 
of  superior  excellence  only  dreamed  of  in  childish  pluntasy,  or  seea  in 
the  boasts  of  inferior  i>coplcs. 

One  feature  of  tliis  frightful  niegalumania,  which  Iws  its  very  great 
ups  and  downs,  should  never  be  overlooke*!;  namely,  the  tendency 
for  such   |iatienLs  to  commit  genital  in<liscreiions,  even  atrucities; 

or  to  engage  in  the  most  foolhardy 
enterprises,  thus  je<i[Mirdizing  life  and 
pntperty. 

lliis  feature  in  paresis  is  of  so  miu4) 
importance  that  sjietial  attention  shuuld 
Im- devoted  to  the  legal  measiirt^  which 
should  be  jnvoketl  to  prevent  the  wijrst 
consetpiontrs  of  this  mental  weakness. 
That  megalomania  lias  a  distinct 
deterioration  background  is  seen  in  the 
frequent  combination  of  ti  p*>«ir  rlrrk. 
in  a  state  institution,  who  s|x?-ak.s  of 
the  nDillinn-dollar  novel  he  is  writing. 
It  consists  of  a  few  mi.serahle  .trraw|» 
on  toilet  paper,  or  on  the  edges  of  a 
daily  riewspaiKT.  This  is  only  a  type. 
Such  inconsistences  may  he  rejul  nf  in 
the  classics  of  |>sychintry.  from  the  work 
of  .\rnold.  in  ITIH).  ti»  tlie  present  time. 
Tliese  phantastic,  exultwl.  euphoric 
states  very  frp<iuently  el»lK<rate  on 
sexual  themes.  Thus  the  patients  have  hundmls,  niilliuiLs  of 
wives  or  eoncubines — "  Solomon  was  a  piker  in  this  matter,"  boosted 
a  Helle^nie  patient.  The  rhildren  are  more  numerous  and  R>nrr 
beautiful  than  any  promised  to  the  ancient  Hebrew  heroes. 

One  patit-nt,  mentionetl  by  Kraepelin,  coulil  lift  ten  eU-pliant^,  wns 
two  hunilri'd  years  old,  ft  feet  tail,  was  a  beautiful  Adonis,  wetglnxl 
four  hundred  poumls.  had  an  iron  chest,  an  arm  of  silver,  u  head  of 
gold.  KM)  wives,  KXN)  million  boys  and  girls,  his  urine  was  Uhine  wine, 
and  Ills  feces  were  gold. 

The  illustrations  might  W  rc]x'ated  n't  ififinitiim.  They  arc  to  be 
found  in  riciier  or  p4M)rer  elaboration.  In  shorter  or  huiger  intenals  of 
excitement,  in  this  exalted  euphoric  type,  but  one  may  see  a  hun<lre«l 
paretics,  as  a  general  practitioner  may  see  them,  in  the  early  stages, 
ami  never  get  a  ghost  of  an  idea  of  such  experieiui's.  Of  this  HKI 
some  time,  scuiner  or  later,  2.>  to  30  of  tliem  nill  be  liable  to  extubit 


yju.  3fil. — I'arcw.  i>howinK   iraii 
diose  l)'|»p. 


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the  exalted,   euphoric,    ineKH-kmrnnic  picture  here  indicated   rather 
than  dcscriheri. 

Coiwcion.sne-ss  is  usually  much  clouded  In  t\m  form,  especially  while 
the  delusiuiial  prujectioiis  are  in  their  full  jcn'^'th.  Time,  place,  the 
lereat  workl,  i:^  a  dreamy,  far-off  plac-e  t»f  little  moment  to  the  mind 
eiigtipcd  in  its  arniliitious  proprain.  rontiniiity  of  thought  is  practi- 
cally impi»s:iil>l^,  atid  chaos  and  anarchy  exist.  In  such  minds  Imllu- 
einalions  are  frequent. 


Kli.,    ;{nJ,  —  Ks''i1<vi  [.iirrLic,      i  Knifiiclui.; 


The  mood  is  happy,  overHowinR  with  schemes  for  gi>od  detnls  and 
jlcncrosity,  mid  ull-cnihmciu^  in  its  lm>thcrly  love.  Hut  ii)hcrfiice 
is  nut  til  he  expcftcil.  Ily|nic!if»idriiH-al  ideas,  such  as  delusions  tiiat 
there  an'  worms  in  the  linid  may  n*st  in  hizarrc  eimneetioii  with  the 
dt'lusiiiri  of  K'iiig  a  great  philos<ipher,  a  Shakespeare,  etc.,  ami  changes 
ia  iiiikk]  are  of  frequi-iit  occurrence.    Weeping  follows  ecstaay,  aiid  is 


42 


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SYPHfUS  OF  THB  NERVOUS  SYSTEM 

►replaced  by  beatific,  sublime  happiness.  Sudden,  passionate  excite- 
ment leaps  up  under  restraint,  to  subside,  or  to  be  diverted  by  su(^ 
a  trifle  tis  a  ttiHiiig:  leaf,  ur  a  ring  at  t)ic  dcM>r  IkOI. 

llie  great  psydiomotor  excitement  is  a  striking  feature,  and  (tne 
difficult  to  manage.  These  patients  n-alk  miles,  are  on  the  go,  meeting 
people,  busily  engaged  lu  everybody's  business,  making  plans  for  self 
and  others,  and,  when  eonfined,  the  limits  of  a  paretic's  violence 
knuws  MO  bounds,    lie  is  transfunned  iiitu  a  raviiij;  animal. 

Throughout  all  of  the  excitement,  (iiverTibility,  constant  changing 
of  plans,  mixture  of  silly  pleasure  and  sujjerficial  sadness,  there  is  the 
note  of  great  deterioration  of  critique  and  emotional  degradation  and 
degeneration  which  shows  particularly  in  the  conventions  relative  to 
one's  jiersoii.  Carelessness  in  dress,  unclean  11  ness,  grnssness  in  eating, 
loss  of  finer  susceptibilities,  coarse  expressions,  frank  immoralities — 
these  arc  but  a  few  of  the  possibilities  in  sueli  lax  conduct. 

In  watching  such  patients  from  day  to  day,  one  b  struck  by  the 
immense  variability  in  the  picture.  The  ideas  of  gramleur  may  all 
vanish,  the  patient  denies  he  ever  said  any  such  thing,  he  may  get 
angry  in  a  dispute  over  the  matter,  and  then  launch  into  a  magnificent 
grand iln^pient  invective  of  colus-sal  outlines. 

As  the  dementia  increases,  the*  large  ideas  may  entirely  disappear. 
or  be  preserved,  and  npi>ear  on  the  surface  only  as  a  few  words,  or 
niunnurs,  "ginKl  to  cat,"  "fine  women, "  "millions,"  etc. 

Finally,  in  the  later  stages,  the  patients  all  sink  to  a  more  or  less 
common  level — "sans  evcr%tbing." 

Among  the  expansive  forms  may  Iw  found  the  quick,  galloping  ca.ses 
who  die  within  a  short  time.  Increasing  experience  seems  to  show, 
however,  tbnt  thest*  excited  ty|jes  inilieate  a  very  severe  reactive  pro- 
cess, and  hence,  if  they  do  not  die  in  the  height  of  the  reaction  (gidlop- 
iiig  cases),  they  provide  the  greater  nnmlxT  of  the  more  stationary 
and  protracted  fnrm.s— those  who  make  a  iMirtial  recovery-  with  defect, 
and  who  later  <lisintegrute.  Uemissions  seem  to  be  common  in  this 
type  as  well. 

4.  Agitatetl  Forms.-  Those  patients  who  show  a  predominant  motor 
activity  in  the  lieginning  may  be  said  to  be  grciuped  here.  Great 
H'stlc.ssiics.s  nnw  through  the  entire  picrt:urc.  The  mental  c<intent  is 
ver>'  variable — eiipimric,  depressed,  hypochondriacal,  moofl  colora- 
tions fiit  in  and  out.  Galloping  cases  are  usually  groupeil  here,  in 
wliicb  an  extremely  rupi<]  and  fatal  course  is  present. 

This  is  really  only  a  subgrouj)  of  the  preceding  type,  only  artificiiUly 
separated  off  by  reason  of  the  more  consistently  persistent  psychomotor 
restlessness.      I{enii.s.sions  are  frequent,  as  are  also  the  a]>opleciiformi 
and  epileptiform  attacks.    The  pathological  process  simply  hm  a  wider* 
extension  in  the  motor  areas. 

The  acute  delirious  cases,  somewhat  resembling  delirium  tremctis 
of  alcobulism,  and  independent  af  it,  are  ornut^d  by  Kriic[)eUi<  ia  the 
agitated  group. 


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TABOPARESIS 


659 


5.  Irreguliir  Types. — lA$*<nur,  etc.  These  patients,  showing  irregu- 
Inr  fonns  of  (U'volnpinetit;  neiimsymptnumtic  proiipings.  hemiplegias, 
etc..  arc  hfre  hniught  lugethcr.  Tin-  Iirinipifgic  and  tahojxiretic 
groups  arc  the  more  frequent. 

TalHtiHiresin.-  Taboparesis  is  the  more  striking  of  these  irregular 
forms  uml  <leservts  a  further  outlining. 

It  has  been  assumed  hy  many,  esiMM-iaHy  by  neurologists  (SehafTer, 
for  snummry.  IfU'J)  that  talws  may  \n-  reganied  as  a  .spinal  paresis,  and 
paresis  a  cerebral  tabes;  that  is,  the  dtsea.'**  vju-ies  only  by  reiLSon  of 
the  greater  severity  of  the  proeirss  In  the  one  or  the  other  locali- 
zatioti. 

Kniepelin,  on  the  other  hand,  aeeentuates  tlie  )ip|M)sing  psychiatric 
view,  that  whereiia  the  two  disorders  are  undoubtedly  fuiidanjeulally 


i^^" 

^ 

l^^^\ 

^P.    ^~- 

'  1 

wL 

^H^^^    '^H 

^^^V                         ^^^H 

m'-  ' 

^^H 

^^K.      ^^^^^^H 

mk 

w 

wn 

^ 

Flo.  <163. — Pareniit  witli  tittwtic  rbansvM  tn  spinaJ  cord. 

sj-phililic,  j-et  they  are  two  different  kinds  of  processes,  and  that  wlien 
the  s>'niptoins  of  tal>es  are  added  to  paresis  the  changes  in  the  eord  are 
not  e.xaetly  similar  to  those  found  in  tabes  limited  to  the  cord.  The 
di(Ter(.-nt  findings  in  the  cerebrospinal  fluid  in  the  two  disoniers  would 
point  to  some  .sort  of  a  ilifferem-e  as  well.  The  whole  discussion  still 
rcst.H  in  the  lap  of  the  gods. 

CiinieAJly,  taboparesis  shows  tn  a  rondiiimtion  of  the  symptoms 
observed  in  the  two  fonus.  Uayitiond  and  N'agentte  would  have  it 
that  every  paretic  wouhl  show  talx'tie  signs.  If  lie  live*)  long  enough. 
In  those  patients  with  pronounced  tabetic  onset  one  fimls  the  frequent 
pupillary  anomalies,  the  tliminution  or  loss  of  the  patellar  redexes, 
Itombcrg  sign,  ataxia  of  lower  or  upper  extremities,  ur  both,  hypo- 


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SYPHILIS  OF  THE  NERVOUS  SYSTEAf 

Umia,  lancinating  pain.s,  crises,  and  artlirtipatiiH^.  These  ore  fouod 
ill  the  more  definite  taboparetics  closely  associated  with  tho  \tiyych'u-a!i 
disturbtiiioe^  already  nutlined.  Tn  the  more  cliissicral  tabetic  paticnU 
tlie  mental  disturliances,  to  wliieh  Cassiivr  and  O.  Meyer  have  devoted 
their  attention,  are  very  distinct  from  those  of  paresis. 

0.  Juvenile  I^aresis. — This  form  is  quite  distinct.  It  was  appareutty 
first  recopnize<I  as  late  as  1877  by  (Houston.  It  appears  at  the  present 
time  not  infrL-quently.  since  the  Wassemiann-I'laui  fin<liiip.s  otfiT  surh 


J'lu,  rfii.- — Jiivi'iiilc  [■;ir'~ 


'iii;ir|ji(>(l  iXago. 


certain  criteria  for  its  determination.  Sucli  tests  seem  nc<Tssaiy, 
since  the  clinical  picture  may  he  so  extremely  variable — henue  it  was 
overlooked — many  patients  dying  diuK'iosed  as  "indieeilps." 

Here  tlio  patient  nmy  innkv  a  coinimratively  nonnal  de\'eliipineiit 
to  five  nr  ten  years  nf  afje-  (rrtain  non-dcvclupmeiitui  forms  prubnhly 
heloni?  here,  but  an-  now  disregarded.  Then  the  child's  mrntalitj* 
seems  to  tlrop.  In  ohicr  ^-hildren,  ten  to  sixteen,  this  dn>p  is  more 
apparent.    I'lKir  memory,  bad  motor  adaptation  and  tP'adual  dementia 


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SYPHILITIC  PSYCHOSES 


m 


upjK'nr.      ('hilclislirwss.    fabrication.    i-xnU'iiients,    and    depressions, 

fears,  and  auxicties,  are  frequent.  Epilepliforni  convulsions  appear 
—many  juvenile  jjaretics  are  Katlu-rwl  into  tlic  uinishuuses  and  epileptic 
culonies  as  "epileptics  with  feeble-iniudednesa" — and  after  a  fourae  of 
three  (ir  Four  ytjirs,  with  frradiiallv  deepcninR  mental  disintegration. 
(he  patient  dies.  Tlie  hislopjUli<)l(>i;ieal  eharifies  an*  identical  with 
those  of  the  adult  form. 

It  is  noteworthy  tliat  the  ajje  of  oaset.  from  seven  to  tweK-e  years, 
is  the  same  length  of  time  that  in  the  adult  form  elapses  bt^ween 
infeetion  and  the  outcrop  of  the  metasyphilitie  disease. 


^  •- 


Ftu.  355.— LSraiii  o(  a  iJiititiil  uitli  a  ayjiiiiiiii','  psji.Ii'mIj  "i  amtv  inuiii:i'.\»I  tviJi;. 
KnlArgMl  itnd  i-nicurgcvl  vcasnU.    Syijlitlitir  niviiiiiKiIiR. 

5.  Syphilitic  Psychoses.— lu  this  section  are  inelmJed  the  psychoses 
wliieh  are  assoeiated  with  cerebral  sj-philis  and  with  tabes.  In  the 
present  rftate  of  knowledge  a  clear  (H^tinetiou  cannot  be  made  either 
on  patholouieal,  elinieal.  or  psycliolnKieal  j:ronnds  betwtrn  the  siwmlled 
metasyphilitie  and  the  more  clearly  syphilitic  conditions,  and  there 
arc  undoubtedly  all  sorts  of  gradations  between,  these  two  practical 
divi.sions. 

Forma.— AVj/rn.iMt'HiVi. — Kraepelin  speaks  of  a  s^-philitic  neuras- 
thenia- a  form  of  mental  tlistnrbanire  inucli  written  upon  by  earlier 
anlliors.  The  jireneurasthenie  phase  of  a  cerebral  syphilis  or  of  a 
paresis  is  not  now  under  revipft'.  It  is  apt  to  appear  shortly  after 
infeetion  and  manifest  itself  m  a  nervous  discomfort,  difficulty  in 


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SYPHILIS  OP  TUB  SERVOVS  SYSTB.yf 


Flu.  3&Q.— Uruiii  nf  a  pntipDl  nith  a  diromc  syjihililic  ps)'cbu»i&  ul  n>iuimi-aj  tyi>t'. 
Sypbiliiic  Ict^tuineiiUisiiU,  i^achymcDuigilu. 


Fio.  3A7. — Briiin  ot  juvenile  paretic  sbawinc  marked  ntniphjr. 


SYPHILITIC  PSYCHOSES 


663 


thiiikinf?.  irritability,  distiirhanre  of  sleep,  pressure  in  the  head, 
variable  uiiil  chftiigfahitt  (liwninfiiit  hmiI  pnili.  To  tliesft  may  I"»e 
ailiWl  slight  (lepri-ssioii,  dizzinfss,  t-onfusion,  anxiety,  slight  (liHlfiilty 
in  finding  words,  temperature  variations,  paresthesiie,  and  nausea. 

IMiiny  students  prefer  to  interpret  tliese  symptoms  as  a  direct  result 
of  the  infection,  and  not  as  a  circumscribed  syndrome;  but  slight  vascu- 
lar cliaiifjes,  minute  pupilliiry  alterations,  and  particularly  evidence  of 
meniiLgeal  irritation  as  shown  by  the  spinal  fluid  l\Tnphoc\to»is,  point 
in  the  direction  of  its  being  something  more  than  a  simple,  infectious 
reaction. 

Plant  has  described  the  pgyckoses  which  are  associate  with  cerebral 
8>'philis  and  with  tuljes  in  ten  groups.    The  groups  are  a-s  follows: 

1.  Simplt'  Lurtif  U'ealairsM  ttf  }(iiul.  This  is  the  weakness  of  mind 
which  usually  goes  with  gross  lesion  of  the  braiu,  marked  by  hemiplegia 
or  nuuioplegia.  It  is  generally  the  residt  of  the  blocking  of  u  consider- 
able vessel  by  a  thrombotic  process  and  usually  occurs  in  relatively 
youug  people.  There  is  no  well-<lefine<i  type  of  mental  defect  resulting, 
as  this  is  deijendcnt,  of  course,  upon  the  location  of  the  lesion  and  uiwn 
the  make-up  of  the  individual.  There  may  be  depreaion  or  euphoria 
or  a  simple  forgetfulnesA  and  indifference.  f>ociusional  cases  of 
arterioscleroMS  occurring  early  in  lift;  ^^iniuEute  this  condition  very 
closely. 

2.  SypkilUi^  PxeiuSoparesiK.^HvK  we  have  a  group  of  cases  which 
seem  to  occupy  all  jjortions  of  the  territory  between  the  true  s>'philitic 
psychoses  and  paresis.  On  the  mental  side  the  distinction  between 
pseudoparesis  an<i  paresis  is  practically  impossible  to  make.  Persistent 
auditor.'  hallucinations,  however,  seem  in  exp-'riencc  to  have  pointed 
quite  strongly  to  pseudujHuvsis.  The  most  reliable  diagnostic  criterion 
is  the  beha\nor  of  the  cerebrospinal  flui<i  touTtrd  tlie  VVaasermaim 
reaction,  it  being  often  negative  in  vascular  s\'philis  and  positive  in 
paresi-s.  Wliile  this  ii,  not  an  absolute  difTcn-ntltttion.nnd  largLT  doses 
of  the  serum  may  produce  the  jiositive  reaction,  it  is  still,  however, 
one  of  the  most  important  differentials.  It  has  to  be  remembered,  too, 
that  some  eases  of  paresis  are  found  with  negatively  reacting  fluid, 
and  rarely  cases  of  lues  with  positively  reacting  fluid. 

3.  ParantAd  formjt  Conihhied  with  Tabes. — In  this  group  are  found 
patients  who  dt>  not  show  any  considerable  deterioration,  but  present 
ideas  of  iKTsecution  with  numerous  auditory  hallucinations  over  a 
considerable  period  of  time.  'I'Ticre  is  no  self-reproach,  they  remain 
lively  and  affable,  and  what  seems  to  be  |>ei'uliar,  present  marked 
hallucinations  of  common  seusibility  Hccom|»auie>d  by  pimntastic 
ideas. 

i.  Paniiiiiiil  Forma  w-itkmit  Tabriic  Symptoms. — In  this  group  arc 
found  partinoid  ideas  combined  with  auditory  hallucinations,  rather 
resembling  the  alcoholic  hallucinoses.  A  prouounewl  delusion  of  jeal- 
ously was  present  in  one  case  described  by  Plaut.  Tbey  have  to  be 
seiMrated    from   manic-depressive   psychosis  and   particularly  from 


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SYHIIUS  OF  THE  NERVOUS  SYSTEM 


*"*■ 


Flu,  36S. — DovBstntinn  nf  eurt«x  io  pjimris.     {Knu.'|wlin.) 

(Icnieiitia  precox.  The  separation  from  the  latter  is  nmdc  from  the 
aUsencc  of  catatonic  signs  and  failure  to  develop  marked  evidences  of 
defect. 


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TABES 


665 


5.  Certain  ICpilejjfip  Fortiuf. — Tliese  appear  tn  be  <lm-  to  tlu*  t'tidur- 
ttTitic;  L'han^s  in  the  Hiiia'l  ftirtU-al  vessekiiiKl  nmy  be  cMinUnu'il  with 
piiiiilj'tie  phetiomi'iiH  which  tk'vi-lop  as  a  result  »f  tho  parlicipatiuu  of 
tlic-  hirgcr  vessels  in  the  disense  process.  'I'he  cases  rt-semble  very 
chisely  Keniiine  epilepsy  and  must  he  d liferent iatw!  by  the  iieurolnnical 
and  serolopciil  fiiiitliiips.  A  case  descrlbeil  by  I'lnut  showeil  transitory 
tlream  states. 

li.  Short  Utilhicinatiiry  Confuted  Staten. — ^Thesc  resemble  tlie  con- 
fusions associated  with  the  epileptic  furms,  and  the  Fretieh  have 
considered  them  in  the  same  doss  with  the  crltes. 

7.  P-it/fhiitir  DiihirhiiufTs  Aumciatt'd  with  Si/phHiiir  CariHue  lyitmae. 
—This  eundition  proImbJy  develops  most  frequently  in  connection 
with  syphihtic  aortitis. 

8.  PityvkoJtes  Hrjfembiing  Manic-depreaxise  Py^hosisi. — Here  con- 
ditions arc  grouped  which  superfieially  very  closely  resemble  the  manio 
deprt-ssive  psytihoaia.  As  a  rute,  however,  there  is  something  to  attract 
attention  as  indieating  at  least  an  aberrant  ftirui.  On  the  tin-ntal  side 
the  delusions  are  more  grotesque,  mure  out  of  harmony  witli  the 
personality  of  the  patient,  or  show  an  mireasunabteness  which  is  not 
comineasurate  with  tlie  degree  nf  excitement.  On  the  ph\Tiieal  side, 
of  wHirse,  inar-tive  pupils  sluiuld  lead  to  a  siTulugiail  exainination. 
Oeeasiunally  such  episodes  occur  a  long  time  before  the  outcrop  of 
frank  symptoms  of  metasyphtlitic  disease. 

9.  Merttal  />urorrf(rr  Due  to  SifphiiiK  as  a  Psychic  Trauma. — Here 
a  ps3"chogenic  psychosis  which  is  more  apt  to  take  a  depressive  form 
is  included. 

10.  iifTrdiiary  l.netic  Mrntal  DiMurbanrcs. — This  envisagi's  psyeho- 
pathically  defective  subjet^t**  and  weak-minded  ehildren  with  luetic 
etiology.  The  exact  relation  between  lues  and  viirioua  forms  of  wejik- 
mindness  h  not  accurately  known,  but  it  is  known  thut  a  large  luunljer 
of  the  feeble-minded  gro^up  arc  luetic.  Syphilitic  brain  iliscasc  may 
occur  in  early  infancy  and  proceed  for  some  time,  producing  only 
transient  symptoms,  perhaps  an  occasional  convulsion,  and  ultinmtely 
lead  to  serious  defect- 

T).  Tabes.— History. —  In  any  historical  presentation  a  sharp  distinc- 
tion must  l>e  nuule  lietween  the  name  tain's  dnrsalis,  and  the  disease  as 
now  nntlcrstiHid.  So  far  as  is  known,  the  fumier  had  its  wrigin  with 
llippficrates,  the  latter,  if  one  ac<x'pt-s  the  post-Columbian  origin  of 
syphilis,  coulil  only  have  i-omc  into  existence  among  Europeans  and 
tlieir  descendants  after  the  sixteenth  century. 

The  various  interpretations  given  to  the  Hippoeratic  term  through- 
out the  ages  is  a  chapter  of  surprises.  Spermatorrhea,  g<(norrhca. 
leucorrhca,  gleet  were  its  initial  meanings,  with  or  without  signs  of 
organic  iHsease  of  the  cord;  when  combined  with  ct>rd  signs — myelitic 
processes.  usualK'  tuberculosis — I'ott's,  etc. — it  was  called  tabes 
nervosa  or  mvehjphthi?.ts.  Out  of  this  mass  the  dist*«se  of  the  pnrseut 
dny  was  separateil.    It  was  natural  that  excessive  venery  shcmhl  have 


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SRVOVS  SYSTSld 

the  luwer  abdomen,  aud  secretitiiis  from  the  genittHunnary  or| 
was  held  to  be  h  close  one. 

As  to  tlw  earliest  observations  of  modem  tubes,  the  traces  are  very 
indistinct.   To  the  elinicians  of  the  sixteenth  am!  seventeenth  centuries, 

the  confused  niaiis  of  pantplcKias  wi 
practically  insoluble,  and  it  would  &p\ 
that  it  was  only  in  the  iM'jjinninn  of  the 
nineteenth  centur>'  that  tlie  process  of 
difriTentiiitiuu   took    place.      E.    Horn 
(ISl(i)  called  attention  to  a  number  of 
the  iinixjrtant  featuivs  including  blind- 
ness; Weidenbach  (1817)  attempted  to, 
make  a  separate  disease  of  it^hc  coii-' 
tested  the  intlammatory  origin— said  it 
had  nothing  to  ilo  with  consumption, 
altlioug:h   still    nnable  to  break   away 
from  the  Ix'lief  in  the  excessive  venery^ 
etiology  then  rampant.  Sehcsmer  (.Ihli»)i 
described  the  peculiar  ^it  in  an  unmi»-] 
tukable  manner,  while  \V.  Horn  (1827) 
emphasized  the  real  alntence  of  a  true 
paralysis, and  spoke  of  an  ataxia  whereby 
this  affection  was  different  from  ntlier 
forms  of  myelitis.    l>ecker  (1838)  called 
attention  to  the  sn*a>'iiig  and  unsteadi- 
ness with  closed  eyes,  which  was  t;ikcn 
up  by  Homberd  three  years  later  and 
reehristencd  Ilomberg's  iign. 

Patholofcically  the  characteristic  cord] 
sipns  were  nut  unobserved.  Hutin  (1S2S) 
ilescriU's  tliem,  OUivier  of  .'\ngiers(  1S37) 
gave  the  picture  reproduced  here  in 
part,  while  Cruvcilhicr  (lba2-lS4o),  in 
his  Atlas,  (i^ves  masterly  clinical  and 
pathological  descriptions. 

Rr>inl>erg  in  the  first  edition  of  his 
Lehrbueh  gave  greater  precision  to  the 
ilesoription.  and  Steinthal  t!S47)  threw 
together  the   incomplete  paralysis  (or 
ataxia),  the  Romberg  sign,  and  the  char- 
acteristic gait,   but   without  any  real 
grasp  of  the  situation  clinieally^orjpatho- 
logically.       l-ater  Romberg,  in  the  second  edition  of  his  text-book 
(IST)])  gave  greater  precision  to  the  concept,  and  gave  a  classical 
«lescription.    Finally.  Duciiienne,  in  the  years  1S52  to  !S."jS,  eluliDruli^d 
the  general  idea,  and  gave  the  first  complete  and  adequate  deseriptiuii 
of  the  ilisorder.    It  may  be  said  that  Horn  and  Romberg  had  practiailly 


Fia.  3ft3."IUufltratioii  of  fht 
c«rd  of  m  tabotic  ipvon  by  Oili\iM' 
of  Ansien  In  1837. 


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made  out  of  the  genera!  tabes  dorsalis  eollection  a  special  tabes  doraalia 
ctjIU'ction  in  the  sense  of  present-day  eimeeptioiLs  in  the  physinln^ical 
and  patholnfjical  fashionlnp  of  which  Todd  ( t.H47),  whu  seemed  to  ^rasp 
the  fact  that  incikirdiimtion  and  imstcrinr  mlumns  were  rpliit«'<i, 
Uokitimsky  (1H54).  Viraliow  {iH'u)),  Tiirck  U><.'>1>).  Landry  (1.S.J8), 
and  Gull  (IS'jM)  made  lusting  eontrihntions.  The  reirent  histury  ^ives 
us  tlie  iijuni-s  of  <"hiir<-<it  (]S*i.H).  X'ulpian.  and  Tupiaard,  and  in  ISfi,'? 
three  niouographs  appi-ar  by  Eisenmann,  I^eyden,  and  Friedreich, 
while  the  later  ctmtrihiitions  of  VVestplial  (1875),  ArjiyH-Rubertson 
(lStJ9).  Marie.  RedUch  and  Obersteiner,  Nairentte,  Oppenlieiin, 
Dejeriric.  Goldsscheider.  Erb.  Nissl,  Schaffer,  and  Alzheimer  record 
the  detailed  studies  in  etic)h)gy.  symptoniatolo^',  pathogenesis  and 
spinal  cftrd  conditions  of  the  last  two  decades.'  I'lnally,  the  even 
more  ret*nt  work  of  the  serolof^jsts,  particularly  Wassermaiin,  Titrun 
and  Plant.'  and  No^nchi  has  ^iven  the  final  word  rtT^arding  the  etio- 
loflieii!  factor,  syphilis 

Etiology  and  Occunence. — Syphilis  is  the  oidy  cause  of  talx-s.  The 
statistical  metln>d  had  idtnost  proved  the  syphilitic  etiology  of  tabes, 
but  with  the  advent  of  the  objective  methods  of  Wasijcrauinn  and  his 
students  all  doubts  havo  vanished.  In  the  nion*  recent  work  of  the 
most  a>miM.'teiit  serok)gists  syphilitic  substan«;s  are  found  in  the 
blood  serum  of  practically  cvery^  rase  (I'laut,  Inc.  cit.).  Furthermi)re. 
the  cytological  examination  of  the  cerebrospinal  fluid  shows  the 
presence  of  cellular  exudates  characteristic  chiefly  of  the  sjphilitio 
processes,  and  as  will  be  seen  in  the  consideration  of  the  palholoKieal 
features,  the  syphilitic  nature  of  muny  of  the  findings  is  beyond 
controversy.  Finally,  Trefjimema  pnliiilutn  has  been  fouud  iti  tlie 
spinal  aird  areas  in  talx'tii-s. 

Pscudotabctic  synilromes  are  known  to  occur  in  multiple  sclero.sis, 
ill  tumor,  in  caries,  in  poisoning  by  alcohol,  pellagra,  diabetes, 
ergot,  etc. 

What  seeondor>'  factors  are  necessary  to  determine  why  this  or 
that  patient  infected  with  syphilis  shouki  develop  tabes  rannot  yet  be 
answered.  I^ess  than  one-half  of  1  per  cent,  of  the  infected  develop 
the  <lisen«e,  so  that  other  factors  are  demanded  on  n  priori  grourifls  to 
explain  why  one  syphilitic  individual  develops  it  and  idnety-nine  syphi- 
litics  do  not;  and  this  is  true  only  for  certain  races.  The  many  cases 
of  congenital  tidies  followirg  a  syphilis  from  the  same  source,  suggest 
variations  in  the  \tr\is.  Similarly  the  large  nnnilMT  of  talwties  who 
are  known  to  have  followed  the  wake  of  certain  syphilitic  j)n)stitutes 
(Morel  Lavallee.  Erb,  Brosius — glass-blower  cases).  The  other  factor 
must  be  due  to  variations  In  resistance. 

'  .li>lliErE-:  On  Snmo  of  tho  More  Uewrnt  LiiPTiilure  of  Tulici  ndmnli-*.  Ptiiluilci^'  nnd 
EtiuliifO'.  Inli»rrintinniJ  f 'liiiicif.  1{H>7.  ii,  257.  Later  liU-nitiiT*.  bw;  Snhaffer:  lyewanilniv- 
eky  Huiidliiii'lt  mtil  work  liy  NfaHtniry.  KtOO.  For  ei^rly  liMiiiry  iruri.tiill  E.  Mi<)'«r. 
Krili.■•^h-Hislo^i.t^^M>  BrohiirhlimKon,  RlrnwtburK  Disf.,  lS>iO. 

■  Tilt.'  Son.>(ltajciiuHi]i  v(  Syijhitui  in  pBycbiaUy  iNvrvuiu  Niul  Mental  DutoiUB  Uoou- 
KTUph  (^Hm,  101 1). 


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SYPUfUS  OF  THE  NERV0U6  SYSTEM 

Both  of  these  factors  are  impossible  to  measure,  but  it  is  highly 
douhtful  if  any  of  the  many  causes  usually  mentionet),  such  as  ex[NtMire 
to  coKI  iiiid  wet,  tmiima,  excessive  venery,  etc.,  have  a!i.\tlnii||;  tucio 
with  the  aftcr-develdjiiiu'iit  of  a  taWs.  The  inultiplioity  of  assigned 
causes  makes  it  mure  than  probable  that  none  are  concerucd.  F<»rcl 
Robertson's  specific  l>aoilhis  is  certainly  not  a  proven  seciHwIary 
factor.  Trauma  Is  hinlily  (ioubtful.  It  may  cause  a  pseudotabes, 
or  may  hasten  the  fuller  flc\  eloinncnt  of  the  s>*mptoms.  Of  hereiliiy 
little  is  kriowii.  Charcot,  Horgherini,  Krb,  and  Gowers  have  laid  much 
stress  upon  it. 

Ovfiirrrnce. — Tlie  majority  of  cases  occur  in  tl»c  fourth  deewde,  but 
this  is  largely  due  to  tlie  fact  that  the  disorder  comes  on  ten  to  twenty 
years  after  infection,  arul  syi>hi]itic  infection  usually  iKX-urs  In'tween 
the  twentieth  and  thirtieth  years.  The  disease  may  appear  at  almost 
any  periixl  after  infection  (fifteen  to  seventy  years  of  age).  The 
avcnige  runs  from  tliirty-five  to  forty,  the  a\'erage  interval  aft«r 
infection  a}«>nt  fifteen  years,  with  extremes  at  four  to  thirty-five. 
Drjerine  ami  Uaynumd  re|>nrt  cases  forty-five  and  fifty  years  after 
iiifcHion.  In  crertain  races  with  a  tiigh  syphilis  percentage  (Algiers) 
tabes  is  practically  unknown,  and  there  is  every  reason  to  belie^'c  that 
the  syphilis  has  Iteen  there  present  since  the  sixteenth  wntury.  In 
other  races  from  three  to  five  of  every  one  hundred  s\^lhili^ics  develop 
the  disease.  In  i-ertain  cimntries  the  nitio  of  men  to  women  is  4  to  I, 
in  others  10  to  1. 

Occiipfition  seems  In  play  only  that  role  that  speaks  for  increased 
oppttrtuiiities  for  syphilitie  infection. 

Symptoms.  The  symptomatology  of  taln-s  is  umrke<lly  diverse, 
and  whereas  it  seemed  at  one  time  that  it  prcs<-ntcd  a  more  regiUar 
picture  than  other  nervous  disonlers,  accumulating  ex|>erience  shows 
that  l.N'pical  pictures,  so-called,  are  the  exception  rather  than  the  rule. 
In  other  Wiirds,  there  is  no  o3ie  symptom  that  may  not  l>e  al»sent,  and 
very  few  symptoms  that  may  not  be  present  in  disorders  other  than 
tabes. 

Nevertheless  one  can  rely  fairly  well  upon  tlie  following  grouping 
of  s.vniptnms:  Lancumting  neuralgic  pains,  mostly  in  the  lower 
extremities,  usually  prcccfling  all  of  the  other  .symptoms;  paresthcsiie 
and  rclatetl  sensory  disturlwinces,  analgesias.  h\"poesthesias,  loss  nf 
the  tendon  reflexes  {patellar.  Achilles).  incom])lete  or  complete  Arg.vll- 
Ruliertsoii  pupil,  unilaterul  or  hiliUeral  ataxia  in  both  extremities, 
HomlHTg's  sign,  bhuhier  df;«tnrbHri(rs,  hyijotonia.  oeiiliir  palsies,  posi- 
tive WassiTiiiaruL  in  the  bkntd  and  lym|»hc»cyt(>sis  in  the  spinal  lluid. 

A  host  of  other  symptom:*  may  In-  [n-cscnt  in  individual  cases,  cither 
early  or  late,  but  those  ju.st  mcntione^l  belong  mon'  [wrticularly  to 
tlic  majority  of  the  eiuses,  and  arc  usually  sufficient  to  make  an  early 
diagno!«is.  A  description  of  the  indi\'idnal  symptoms  will  show  some- 
what of  the  pro[Kjrtionate  occurrence,  both  in  point  of  lime  and 
frequency. 


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Paim.— Severe  lancinating  pains  occur  in  about  iKJ  per  cent,  of  the 
cases,  ami  usually  as  an  initial  sij»n  ((V)  per  cent.).  'Hie  |>atientSj 
complain  in  an  almost  stfn*<»ty|)^ti  manner  of  ha^nng  had  sharp, 
severe,  fugacious  imins  usually  in  tlie  sciatic  ami  crural  distributions, 
which  the>'  speak  of,  and  unfortiinaticly  arc  re>c«rdcd  e\'eii  by  physi- 
cians, as  rheumatic.  Tliesc  paiud  ct>me  on  in  attacks,  last  a  few  niinntes 
or  more,  several  hours,  a  few  days  and  then  disappear  to  again  recur. 
They  may  precede  the  development  of  other  .sraiptoms  by  a  few 
months  or  even  many  years  (twenty-two  years — Krb).  The  average 
varies  widely.  They  are  an  indication  of  the  leptomeningitis  or 
radiculitis  which  is  one  of  the  fuinlaincntal  resnlts  of  the  syphilitic 
virus  or  pro<Iucts  induced  by  it.  Maloney  contends  they  arc  mainly 
due  to  implication  of  the  vegetative  nervous  system  and  gronps  pain 
with  gastric  and  other  crises.  The  pains  are  usually  of  extreme 
severity  and  are  much  dreaded  by  the  patient. 

Whereas  the  distribution  is  predominantly  sciatic  or  cnmd  and 
radicular  at  first,  the  pjiins  may  be  widely  <listributed.  and  may  in  fact 
8Uirt  in  any  sensory  n>cit,  cranial  or  spinal.  Thus  trigeminul  neuralgia 
may  be  an  initial  sign,  or  the  pains  may  affect  the  larjnx,  or  the 
stomach,  or  tlic  heart,  the  bladder,  the  testicles,  the  intestines,  and 
give  rise  to  various  forms  of  crises,  so  characteristic  and  so  much 
feareii.    The  pains  may  be  felt  in  the  skin,  or  deejwr  lying  structures. 

Deep,  boring  pains  are  also  present,  usually  later.  Not  infrequently 
the  larger  ner\'e  trunks  are  somewhat  painful  t«i  pressure.  This  fact 
may  lead  to  ct.>nfusion  in  separating  an  aleoholic  or  other  neuritic 
pseudotabes. 

Crises. — ^Tliese  Iiave  some  relation  to  the  pains  of  tabes,  and  are 
probably  due  to  similar  pathological  altenitious,  but  locate*!  in  other 
sensorj'  and  sjTnpathetic  root  areas.  The  best  known  are  the  gastric 
crl-ws,  noted  as  early  as  lK5(i  by  (Inll  and  recYigni-A-d  by  Charcot 
(ISfiS)  as  In-longing  to  the  general  picture  of  tal>es.  The  jwtients  have 
sudden,  Niolent  gastrie  poin.  rarlijiting  in  all  directions,  and  in  the  severe 
attacks  accompanied  by  imusea,  vomiting  and  great  prostration.  Like 
the  pain  attacks,  these  crises  may  last  for  hours,  or  a  few  liuy^  and 
then  disappear  for  weeks  or  months  to  recur  at  irregular  intervals. 
They  disiippear  a.s  rapidly  as  they  come,  and  (luile  aniilng(tus  to  the 
lancinating  pains,  may  lie  early  or  late  s>-mptoms.  Certain  ca.ies  of 
tabes  l>egiii  with  such  i'ri.ses.  Such  a  beginning  is  frequently  not 
rtHvgnizod  and  ha.s  oftei»  led  to  laparotomy. 

Sitnihir  cris<'s  affeciing  other  internal  organs  have  the  sami*  etiulngy 
and  course.  Thus  there  are  intestinal  colics  with  diarrhea,  rectal 
pains  with  tenesmus  ami  diarrhea,  vesical  mscs  with  strangury, 
urethral  crises,  renal  colic-like  attacks,  testicular  crises,  vulvovaginal 
crises.  lar>niReal  and  tliapliragmatic  <'rise-s  with  cyanosis  and  dyspnea, 
phiiryugeal  rriscs  H-ith  tibstiaate  hiccough,  bromhial  crises  with  iinigh, 
i-ardifti.-  with  angina-like  altu(ia.  Sneezing  attacks  have  Ueen  d«aeobed 
OS  an  initial  tabetic  »gn. 


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SYPHILIS  OF  THE  NERVOUS  SYSTEM 


Sftijtorif  Involcemrnt. — As  &  result  of  the  implication  of  the  meninges 
of  the  sensorj'  roots,  ultpnitioiis  in  the  seasorj"  funrtions  take  f^aoe. 
Tlie  |HilI»jI<igk-al  priM'i'S!*  in  svnw  is  so  gradual  or  mild  as  not  to  Rive 
rise  to  pain,  and  in  many,  initial  i»prestlicsias  may  precede  the  pains, 
but  more  often  the  same  puthologieal  process  gives  rise  to  both. 
Tinpliiifi.  nuinbniiss,  crawlinj;  sensations.  Hashes  of  hot  and  oild. 
shpht  benumbing  of  the  taetilc  .sensibility,  lansing  the  sensation  t>f 
wearing  a  glove,  or  walking  upon  a  textile  are  the  usual  forms.    'tUcy 


^^^ 


Y 


y 


Piit.  80<t. — Tnlxv  itivulviiiK  ll'v  i.-au(la  ).x|iutia.  nbowiiiit  tliit  nitlii'ular  (li-*IriHili''ii  "( 
the  vctMor}'  dUturbahciM.  Tarlile  pain  iiimI  llicminj  4o-n>LJhllily  wi>ro  involv^il.  Tlii' 
patiniit  Imt  hnd  v<>*'Lt>  ami  fphiiirtcr  diitiirlniinNn.  T}il>  ftori^ud  dorsal  rwl  Mnn  »I  •> 
BUghtly  [nvrtlvwl,  Iwiirc-  tho  setimory  changca  in  iht*  arms.     [IVjwim'O 

may  be  expeeted  almost  anywhere  fnvm  tlic  region  of  the  trigeminus 
llirongli  liny  seuwry  eerviral  nerve  braneli  to  the  tijis  of  the  toes, 
altlmu^dt  l!u' ulnar  region  seems  a  site  of  special  pre<lJlei-tion.  ()e^•a^ioll- 
ally  they  cause  tlie  iMx-uHar  girdle-Iwind  si'nsation.  at  one  time  i'>in- 
si<lered  so  eharacteri«tlc  of  tidH-H.  A  whole  limb  may  I.m'  invttlveii, 
hnt  umler  any  *-oridition  the  tendency  for  the  sensory  disturbances  is 
to  show  a  ra<lieular  di?tribulion  (Dejerine)  (.Figs.  .■iG4-3r)N). 

hicreasing  ^ensitiveness  is  also  frequent,  so  that  the  patient  dreu<]s 
the  cold,  or  draughts,  or  sudden  shocks,  or  the  clothing,  not  on!/' on 


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account  uf  tlie  abnormal  sensitiveiic^,  but  because  the-se  nmy  bring 
[>ii  t!ic  sevtrriT  pains.  Tactile  anesthesia  folltms  this  am!  is  a  direct 
resullant  uf  the  dt't^'iicralive  prtK-css  hi  tUe  rtxd  area.  Tlifst*  arc  alsti 
irregularly  distributed. 

Other  sensory  fuiictioiui  also  bt-comc  involved.  The  jMiiii  feuse 
may  become  lost  in  irregular  areas.  Uetardution  in  the  carrying!  of 
pnin  impulses  is  present  at  times.  Complete  loss  is  a  sign  of  a  c<)m- 
jik'te  lesiiui.  Malorey  gives  three  signs  of  a  partial  lesion:  I,  a  nii-sed 
sensor^'  threshold;  2,  delayotl  ijerception;  and  '.\,  a  sensation  of  im- 
j»eri"ect  contact.  Thciv  may  also  be  numbing  ttr  luss  of  hfat  and  cold 
sensibility.  Uony  sensibility  as  tested  by  the  tiuiing-furk  also  may 
be  absent  and  shows  irregular  distribution.    In  general,  deep  sensibility 


-*' 


Flu.  365  Vta.  300  Pi».  307  Fio.  3(H 

FlOfl.  3G6.  3f>6.  3C7  nrul  308.— Radicular  dislHhuUun  oi  ■mtsory  diaturlMptw  iii 

tnhiw^  Pica,  ittto  and  '.UW  nipratM-nt  the  ilutritiuUtin  t>f  tartilp  Bii(!stheaiii;  Fi)^.  .167  and 

30H  tli«l  of  lowa  r>4  pain  and  t«o)|>eru|iirv  twnnv.     {Dejortuv.) 

is  more  profoundly  affected  than  epicritic  sensibility.  Maloney  states 
that  this  is  due  to  the  fact  that  the  vegetative  nervous  system  is 
largely  concerned  in  deep  sensibility  an<l  is  the  sensory  syst*'m  mainly 
atfectrd  in  tabe.s.' 

Since,  as  has  Ixtn  (Hiinted  out,  Ranson*  identifies  the  cutaneous 
J'prfitopatliic"  system  of  Head  witli  wrtain  unmyelinateil  filxTi  of 
the  posterior  spinal  roots,  tins  conception,  as  nmintainwl  hy  Maloney, 
is  probably  the  «>rrwt  one.  In  1!)I2  Ran.son  published  his  discovery 
of  unmyelinated  fibers  in  the  tlor.sal  roots.  These  are  mostly  cutaneous 
nerves,  and  they  practiciilly  all  enter  the  corti  in  bundles  whicli  lie 
laterally  to  the  myelinati'd  fil>ers  of  the  same  root.    The  former  are 


4'i 


'  Mulnucy:  Tnb*^  I>nr»iili»,  Ntw  York.  I0I7  (nd^-MlflO  »(bcet»). 
•  Am.  J.UU.  Iliyf..  IPIll.  xl.  571, 


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SYPUILIS  OF  TUE  NERVOUS  HYSTEM 


called  by  Hanson  the  "lateral  division"  of  the  dorsal  root.  A  much 
smaller  numl)er  of  n)yelinatt<l  fibers  is  found  also  in  this  lateral  divi- 
sion. AW  the  neurone  of  the  lateral  tlivision  nm  up  or  dowii.  in 
Lissauer's  traet,  a  very  short  distance — ^ustially  less  than  a  sej^ment. 
That  is  to  say,  tliese  fibers  nin  into  the  gray  matter  at  or  near  the 
level  at  whidi  they  enter  the  eord.  Their  intraspinal  course  suggests 
at  onee  that  they  arc  the  tWtcrs  of  pain  and  tempcrutwre  sensations, 
since  it  is  kiiowii  that  the  afferent  impulses  underlying  these  sensations 
pass  through  the  gray  matter  as  soon  as  they  reach  the  eord. 

Ataxin. — 'Mw  most  prominent  sign  of  the  sensory  invnlvement  just 
noted  is  seen  in  the  gradually  (sunielbm-s  siidde?ily)  devetopinp  ataxia. 
The  fibers  conducting  the  impulses  from  the  joints  and  the  museU-s 
to  the  chief  organ  for  their  cotirdi nation,  the  ccrelxrlUmi,  are  degener- 
ating, and  there  results  an  imperfect  knowledge  of  the  position  of  the 
joints  and  of  the  states  of  muscular  tension  necessary  to  the  proper 
performance  of  motor  fimctions.  There  results  a  h>^)<iTonas  and  sway- 
ing of  the  arms  in  the  tinger-nose  test  and  finger-finger  test,  and  of 
the  legs  in  the  knee-heel  test,  and  in  walking.  The  patient-s  are  |»ar- 
tially  or  completely  unaware  <»f  where  their  limbs  may  Ih',  ami  are 
unable  to  control  the  same,  save  to  a  certain  degree  through  other 
avenues,  namely,  the  eyes.  AtTording  to  Maloney  this  uuawareness 
is  due  to  the  suppression  by  the  psyche  of  the  feeble,  imperfect  and 
delayed  postural  images  which  arise  from  the  musculature  in  the  area 
of  tlie  afTeeted  nerve  roots  and  which  owing  to  the  misleading  nature 
of  their  infnrmatinn  are  suppressed  in  favor  of  vision.  Hence  with 
eloscil  eyes  all  (if  these  signs  of  ataxia  are  marketlly  increas<'d.  \Vitl> 
this  great  uncertainty  of  niovenieut  there  is  nn  musctdar  jMindysis,  and 
little  loss  of  muscular  strength,  save  as  the  patient  generally  becomes 
weaker. 

6'«[Ydisturl)ancesareaccompaniments  of  the  ataxia,  and  are  extremely 
characteristic.  They  were  described  by  Schermer  as  early  as  ISllt. 
In  the  early  stages  the  patient  notes  a  dillieulty  in  going  up  and  dnwii 
stairs,  or  finds  himself  insecure  on  uneven  surfaces.  He  stunibles 
and  at  times  falls,  .\t  night  he  finds  it  mon*  diflicult  to  get  about,  and 
he  siKUi  notitx's  that  lie  must  keep  his  eyes  glued  to  his  legs  ur  the 
surface  on  which  he  is  walking  if  he  is  to  be  able  to  control  them. 
Ijiter  he  must  walk  with  a  cane,  and  his  legs  are  thrust  somewliat 
wider  apart,  are  tlm>wn  somewliat  irregularly  forward,  and  arc  then 
brought  to  the  ground  with  a  sharp  stamp,  the  knee  l>cing  stiffened 
or  even  Ix'ut  slightly  liackwanl — overextendi'd — at  times  so  much  so 
as  to  cause  him  to  full. 

His  step  becomes  quicker  and  more  stamping,  until  he  rcaebes  a 
point  where,  unless  he  has  trained  himself  to  walk  anew,  he  beeoines 
bed-ridden.  Maloney  has  demonstrate*!  that  the  preataxic,  ata.xie, 
and  bed-ridflen  stages  are  not  an  much  stages  of  structural  demolition 
as  stages  of  mental  deterioration,  stages  of  loss  of  cerebral  eontrol  over 


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voluntan'  movement.  The  manner  of  rising  from  a  chair  or  sitting 
down  soon  becomes  very  olmracteri-stlc.  T!ie  ataxia  in  tlu-  upiKT  ex- 
tremities, which  is  usually  le>s  tlmn  thnt  in  the  lower,  affct-ti  the  patient's 
writing,  the  huttotiiug  of  the  clothes,  his  dressing,  etc.  His  haml^  are 
constantly  moving— one  finger  and  then  another  is  rai.scd  or  lowered, 
or  the  lATist  turned.  Oppenlteim  ha.s  calle<!  ]jartitrular  attention  to 
these  Rpontanenus  nrnvementH,  wlilch  closely  resemble  a  static  ata>ia, 
ami  Hre  found  throughuut  the  IwMly. 

Other  muscles  natiimlly  may  Ik*  involveil  in  the  ataxia,  particularly 
those  of  the  face,  uiuuth,  tongue,  larynx,  pharynx  In  which  case 
speech,  singing,  swallowing,  etc..  arc  affected.  Many  patients  die  of 
aspiration  pneumonia  tliruttgh  ataxia  in  the  swallowing  apjwratus. 

Romberg's  sign  is  another  result  of  the  loas  of  position  sense.  It 
may  be  an  early  sign,  but  is  more  apt  to  develop  later  in  the  disease. 
Many  patients  without  well-developed  Romberg  nr^  imable  to 
balance  themselves  on  one  foot,  and  further,  a  mild  Ilomberg  may 
he  more  readily  dwnonstrated  by  having  the  patient  hend  slightly 
forward. 

Tendon  Heflf^es. — Westphal  firsj  emphasized  the  importance  of  the 
diiuinutiiin  or  loss  of  the  tendon  reflexes — notably  of  tlic  kuee-]erk 
ami  the  Achilles  reflex.  These  belong  among  the  initial  sj-mptoms  in 
the  larger  niunlier  of  cases.  The  knee-jerk  may  ht'.  first  diminislicd 
on  one  side,  best  dcmon.strable  by  the  .lendrassik  method,  or  lost,  and 
this  for  years,  perhaps,  before  the  development  of  a  fwinplete  Wcstphal 
phenomenon.  The  Achilles-jerk  is  h"st  in  a  similar  manner  and 
not  infretjuently  even  before  the  loss  of  the  knee-jerk  (Babinski 
method). 

These  tendon-reflex  changes  are  all  referable  to  the  degenerations 
in  the  root  zones  and  sensiory  columns. 

CniTiia!  AVrw  InwfTrrrutit. — ;\ny  one  or  all  nf  the  cranial  nerves  may 
be  implicated.    Ixjss  of  smell  is  rare. 

I'ujiiUnnj  Hvflexex.  —  Here  a  striking  phenomenon  is  obser\'ed. 
I'utients  with  tabes — as  with  many  other  sj-philitic  affections  of  the 
medullary  or  midbrain  region— ^how  a  diminution  or  loss  of  the  pupil- 
lary light  reflexeji,  without  any  loss  of  the  r*'flex  of  nmvergence  or  of 
accommodation.  This  is  the  Argyll- Rohcrt^irn  i)henomenon.  It  is 
present  \n  uver  lid  per  cent,  of  tlie  ca.ses,  anti  may  be  present  for  many 
years  without  other  s>inpt«ms.  Tlie  pupils  are  apt  to  Ije  at  first 
irregular  in  si/*,  and  also  not  infrequently  in  shape.  The  light  reaction 
is  at  first  less  pnwnpt — iL^ually  in  one  eye  Iwforc  the  other  later 
both  eyes  are  involved.  Myosis  in  uuirke<l  degree  is  then  apt  to 
develop.  I-.<tss  of  the  i*onsensiial  light  reflex  is  one  of  the  earliest 
signs  of  this  pupillary  cliange  (Weiler).  The  .sympatiictic  dilatation  of 
the  pupils  is  alio  soon  diminished  or  lost. 

Ojiiu-  nerrf  changes  are  frequent  and  may  occur  early.  There  is  an 
iiTvgulnr  gray  atrophy,  with  narrowing  of  the  macular  vessels  and 


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sti|MUion  is  alM>  frtKiueiit,  hut  fecal  incontinence  nut  cumniuii.  Ixtsa 
or  incn^se  of  soxiial  licsirp  is  nn  early  sign;  imiNrtence  la  comntoa; 
njiittimf>iis|)rin|Msiii  unusual.  _ 

TrupUic  Symiittiinjt. — TIutsc  may  involve  any  of  the  tissues  of  tlie 
body,  but  purticidRrly  skin  aiul  hones.'  .trtkrointthu:i  are  very  frequent, 
usually  oecurring  after  the  disonier  is  well  advaneetl,  not  infrequently 

ns  an  early  symptom.  Tlie  knee- 
joint  i.stlie  jrtini  of  sjH-eial  jireclilec- 
tion.  The  arthropathies  usually 
develop  with  surprising  rapitlity — 
w\t]^  edema  and  swellln)^  but   none 


Fl«.  J7U. — iiilA'4.      ihinj  nerve  ^nldy. 


itip  rib. 


of  the  usual  signs  of  a  rheumatic  joint;  then  neve  bone  formations 
take  place,  with  or  without  subluxation.  Almost  any  joint  may  be 
affected,  even  tlie  jaw. 

I'Vagility  of  the  bones  Is  a  further  eomplieutioii.  IVrfnrating  ulcers 
of  the  feet  constitute  another  tr>pbieclist)nler.  The:^^  Intpliie  clianj^es 
constitute  further  evidence  to  tlie  fact  of  the  implication  of  the  vege- 
tative (pn>topatliic)  fibers  in  tal>etic  patliolojry. 

Mtucuhr  .Urvphifs. — An  initial  neuritis  may  give  rise  to  an  early 
muscular  atrophy,  but  atrophies  are  not  common.' 

liloofl  Serum  and  Cerchroapmal  Fluid. — ^The  Wassermann  rt'aetion 
of  the  bloiMl  serum  is  positive  in  most  of  the  eases  of  tabes.  The  cere- 
brospinal fluid  is  positive  in  from  fiO  to  80  |>er  rent.,  and  I'laut  iy  of 
the  opinion  that  it  will  be  found  to  be  more  often  so  with  improved 
tccbnie.  Nomie  and  Ilauptmann,  by  using  larger  quantities  of  scrum, 
have  established  this.    It  seems  to  be  less  often  positive  than  in  paresis 

>  Flufm.    Dip  (ni|ibU<ilu>  8t6ninBcD  bci  d^  Tnlie*  Oonalis,  Brriin  TMeu,  1888. 
■Sm  topliuliy:  Arch.  (.  Peyi;h..  4<M1'. 


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SYPHIUS  OF  TIIK  NERVOUS  SYSTEM 


imnilHT  iif  t-a-SfS  it  runs  im  acnitf  couri**,  uuiisuig  tlenth  witliin  a  few 
years.    In  others  it  is  stntiinmry  ami  in  this  sense  sots  well. 

Duchemie  (ISoS  1N5U).  in  liis  inemcrable  description,  made  a  tlivi- 
sion  into  three  stap's,  which  have  heen  !«unewhat  mrKlifieil,  Tl»c 
periods  usually  c:onsi<kTe<l  at  tlie  i)i-c!«*nl  tinu-  an-  as  follows:  (1) 
I'rodmmal  or  pn-ataxie  stage;  (2)  ataxic  iieriiMH;  |:l)  puralv'tie  peritxi. 

Such  a  division  is  of  arhitniry  value  only;  lui  two  cases  are  exactly 
alike.  The  ppeataxic  sta(^>  may  last  many  years,  or  there  may  he  none, 
ataxia  ami  iwiralysis  developing  with  extreme  nipidity.  The  ssyniplnnis 
are  »n  many,  and  the  times  of  their  appeaniiKt;  ^»  variahle.  tlmt  a 
so-eallcd  t.Niiical  course  is  tlie  exreption  rather  than  the  rule,  yet  a 
not  unUHiial  course  is  one  extending  over  aUmt  ten  years,  with  two 
nr  tlitt^e  years  (tf  pains,  with  or  withnnt  eris<rs,  then  the  gradual  de\eloi>- 
inent  of  the  loss  of  knee-jcrkh,  Argyll-Uoliertson  pupils,  >rradually 
inercasiny  difficulty  in  walking,  w^irsc  in  the  dark,  Homberti: — ^then 
the  paticnt.4  are  confined  to  bed,  and  then  the  stage  of  paralysis  and 
atrophies.  Maloney  denies  the  existence  of  the  paralytic  stage  an<l 
rijjhtjy  calls  it  the  surrender  stage,  the  stage  in  which  the  ataxic  will 
not  puy  the  lax  in  effort  which  niovrinent  demands. 

Dentil  results  from  the  disease  itself,  or  fmni  complicating  disorder 
— bulbar  accidents  causing  pneumonia,  laryngcftl  choking,  canliac 
syncopes,  kidney  complicutions,  very  often;  intercurrent  disease  such 
as  tubercijosis,  in  large  part,  pneumouia,  typhoid,  and  eriisipclas  iu 
smaller  percentages. 

Prognosis  is  always  most  sinister.  Stati<niary  cases  are  knuwn,  hut 
a  question  eoncerning  diagnosis  may  be  raised  respec-ting  the  ca,ses 
in  the  (ilder  literature.  With  the  newer  objective  \Vas.sernia[ui  anil 
eytologicnl  .symptoms  it  ts  to  he  seen  whether  such  statiomiry  cTises 
e.xist.  Simv  such  arc  found  as  paretics,  It  is  not  improbable  tliat  the 
same  will  hold  true  for  tabes. 

The  cases  with  severe  bladder  complications  usually  (h>  badly. 
The  duration  of  life  has  varied  from  six  months  to  thirty*  and  more 
years.    The  general  average  runs  l)etween  ten  to  fifteen  years. 

Forms. — Certain  tj-pes  are  worthy  of  ^cial  mention  as  forms, 
these  are: 

1.  Jnveniir.  takes,  like  juvenile  paresis,  occurs  in  chiWrea  from 
five  to  ten  years  of  age,  or  in  young  adults  apparently  up  to  alx>iit 
twenty-five  years.  The  higher  age  incidence  is  rare.  The  pupillary 
sigas  are  early,  and  the  blaihler  is  soon  involved.  Ataxia  and  paralysis 
then  develop.  The  objective  serological  and  c\'tological  chaugcj*  are 
usually  positive — the  iiuuilier  of  ease-s  examined  is  as  yet  too  small  to 
permit  wide  generalizntirms,  but  syijhilis  of  the  parents  is  an  essential. 

2.  Latf  TVi/icjr.— The  apiieiirancc  of  the  disonler  after  the  age  of 
fifty  is  rare,  yet  cases  are  reconie<l  in  which  the  initial  sigius  have 
come  on  as  late  as  seventy  years.  One  case  b  on  recttrd  of  infeetiun 
at  twenty,  talics  at  fifty-nine.  After  all  it  is  mo.stly  a  question  of  when 
infection  tjikes  plat* — since  cases  of  infectitm  at  eight>'  or  over  are 


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kiiuA'i],  it  IS  pruL'tK'ally  impiiAsihle  tu  (IrUinniiu;  tlic  tabt's  h^  liniit. 
No  nntewortliy  s.nnptiiiiuilic  variattiuLs  art*  kiiiiuii  in  lati-  taU's. 

;{.  lltijiiil  TtthcH. —  lU-rc  lilt'  tlisi-jiso  julvana-s  very  nipidly,  reiuleriiig 
t-hf  [wtk'nt  incaiiat'itaUtl  in  a  few  niontlLs.  with  daith  as  a  result 
of  the  paralyses.  Tlar  |mralyscs  aix)  utrt)plm-s  oct-upy  the  forefjnninil 
in  the  picture,  tlie  ataxias  Iteing  less  prominent.  The  pupillary  sijcns 
are  pre.-^-nt.    Death  may  take  place  within  six  months. 

•1.  iS/riir  Cojttji, — These  are  the  more  ii.siml  easei  aireaily  ileserilx^l. 

5.  Stntumary  or  lUnigu  <\t»r». — A  partteular  type  m  which  blind- 
ness eomes  on  early  and  which  follows  a  henign  course  was  first 
descriheti  in  ISSl  by  iieneilikt.  Uejeriiie  and  Martiu  (  These  de  Berne, 
ISWh  called  attention  to  the  fact  that  it  i:*  rare  to  fiiid  a  ease  of  tabes 
begiiuiiuK  wilh  blindness  that  ailvanees  to  the  second  stag:e. 

Inirthemiore,  amaurotic  talwtio  ca.'ws  se<in  to  have  fewer  pains. 
The  [Mithologieal  features  are  tlie  same  as  in  other  rases,  save  as  to 
extension,  and  the  eX]>lan»tion  of  this  variation  is  difficult  to  find. 
A  certain  diiniimtion  in  the  general  s\inptoois  in  amaurotic  tabes  has 
!h'<-h  observed.' 

Diagnosis.— Little  difficulty  exists  after  the  development  of  the 
ArKylUlobertson  pupil,  lost  knee-jerks,  ataxias,  and  Romberg. 
l*raetiealiy  the  only  differential  at  this  stjige  is  a  |)«>lynenritic  proeess, 
principally  of  alci>hoIic  origin.  Here  the  pupillary  tlisturbanco  are 
le-ss  in  evidenw,  but  can  ^ll^■nr,  and  if  pres«*nt  tliere  are  usually  tnon? 
grave  cerebral  symptoms  and  a  diagnosis  of  fal>opuresis  is  more  in 
question.  The  serologieail  and  c>'tok)gicaI  results  determine  a  diagnosis 
almost  at  once.  Still  tlie  most  difficult  casi-s  to  dift'crentiate  are  those 
Kof  alcoholism  complicated  with  .syijliili.^.  Where  the  aki»holism  causes  a 
pseudotabetic  picture,  and  the  .syphilis  gives  its  serological  and  tytologi- 
cal  findings  with  .slight  meningitis  affection  a.s  its  only  spinal  or  cerebral 
rtmt.imdtant,  the  cases  are  diagnosed  only  with  the  greatest  of  difficulty. 

OtiuT  to.\ic  pseinlotabes  offer  few  difHcullies^sucli  as  those  due  to 
erg«H,  diabetes,  lead,  peniidoiLs  aaeniia.  and  the  infectious  toxemias. 
Here  tlie  pupillary  signs  are  absent  fur  the  mual  part,  and  the  serum 
and  spinal  fluid  normid. 

Tertain  cerebellar  atrophies  and  new  growths  cause  sxinptoms  closely 
resend>ling  those  of  taints,  but  tlie  gait  is  more  widely  .swaying,  the 
individual  movements  luive  less  ataxia,  the  absent  kiiee-jerks,  and 
Argyll-lbtbtTtson  an*  wanting,  and  tliere  are,  moreover,  to  be  foimd 
the  definite  signs  of  cerelK-llar  involvement  in  the  n,>'stagmus  and  its 
alteratiotis  to  the  Barany  vestibular  tests.  Normal  serum  or  cord 
finding:^  an;  to  be  expt^*le<l. 

Multiple  sclerosis  can  occasionally  cause  a  tabetic  syndrome  if  a 
patch  should  involve  the  sensory  neuroas.  but  here  the  other  svmptoms, 
the  nystagmus,  the  signs  of  spasticity,  masked  by  the  h\potoinis, 
Babiu.ski  phenomena,  etc.,  shoulil  alford  the  clue.  lEare  sclerotic 
patches  in  the  p*ins  and  midbrain  regions  have  causeil  uiiilatend 
Argyll-Rolwrtson  pupillary  pictures. 

'  Mnlim<^':  Journal  ot  Nvrwun  iinil  Mmlal  Db««»e,  191),  idi 


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SYPHILIS  OF  THE  NERVOUS  SYSTEM 


S\-rinK<jmyelia  occasionally  develops  mth  an  initial  tabetic  picture, 
hut  M<Min  the  classical  (iissiicmtioii  shows  itself,  antl  permits  n  (Mafitiosifi. 
The  lilooil  anil  spinal  titiiil  fimlinKs  are  als«i  to  lit*  n-ckfjiittl  witli. 

Hysteria  as  an  astaiiia  abasia  occasionally  causes  difficulty,  but 
here  carpfiil  ("xamination  can  exclude  the  entire  tabelie  symplora- 
Btology. 

Pseudotabetic  neuritidcs  and  eye  sijtns,  t.  f.,  irregtilar  pupils,  pistric 
crises,  inay  m-cur  in  inaskeil  rnj-xttlema  (,hjTM)thjToidisni)  of  later 
years. 

Pathology  and  Pathogenesis. — Both  OlliWcr  d'Angiers  and  f 'nivcilhier 
gave  dcstriptioiis  4»f  the  ^eueral  jiross  Htiatorny  and  both  recognized 
tlie  sH-lerosis  (if  the  imsterior  cohunns.  Tiidd  ussnciuted  the  sclerosis 
with  the  ata\iii.  Uurdoii  and  Kuys^  (1801)  called  atteiitiuu  to  the  rela- 
tion of  the  sclerosis  of  the  posterior  roots,  ontl  the  iwstcrior  column 
sclerosis,  since  which  time  the  development  of  knowledge  concerning 
the  patholngica!  ])nx!esHes  in  tabes  liave  been  most  actively  studied, 
although  be  it  said,  without  yet  arriving  at  general  uniformity. 

Seen  with  the  nak(^  eye,  the  cord  is  usually  niarkwlly  atro]>hied, 
hence  the  origin  of  the  old  term  consumption  (tabes) ;  the  |>osterior 
roots  arc  atrophied,  sometimes  more  marked  in  one  region  than 
anotlier.  The  tliniiiuitiun  in  volume  of  tlic  cuni  also  varies  in  places. 
being  more  pronounced,  as  a  rule,  in  the  dorsal  and  aaerolunibar  regions 
than  the  c-ervical,  and.  as  Cruveillucr  noted,  the  atrophy  prcpimderatcs 
markedly  in  the  p4)sterior  columns.  The  pia  and  arachnoid  are  some- 
what swi»Uen  but  translucent  with  slight  opalescences  or  cloudiness. 
Meningeal  iuv<il  vein  cut  is  very  frequent;  a  fact  brought  out  more  in 
recent  years,  and  in  strict  confnnnity  with  the  findings  of  the  cellular 
contents  in  the  cerebnwpinal  Huid. 

Tlu^ughout  the  entire  leugtli  of  the  cord  one  finds  a  graying  dls- 
coltiratiiui,  the  margitis  are  slightly  sunken  below  the  normal  level, 
and  the  discolored  areas  are  hanicr  to  the  touch.  Ilie  atrophy  seems 
to  cc-ase  with  the  sensorj'  meilullary  nudei^aave  in  those  cH.ses  where 
cranial  nenes  are  markedly  affected  when  irregular  atrophies  are 
encdiuitered  in  the  up|>er  sensorj'  neurons. 

IlisktUiffirall}/  the  picture  is  fairly  unifurni.  'Iliere  is  a  mild  inflam- 
matory thickening  of  the  pia  and  anichnoid  with  IjTnphoc.vte  am 
pla.sma-cell  infiltrates.  This  leptomeinngitis  varies  considerably  in 
its  localization,  and  in  its  intensity,  and  tlie  vessels  are  not  infrequently 
involved.  The  whole  process  closely  approaches  that  of  a  s>i>liilitic 
meningitis,  but  is  less  intense,  and  is  not  accompanied  by  the  pre.sen< 
of  spir<ielietes. 

The  posterior  roots  are  irregularly  atrophied;  the  sacral  and  lunilmr 
roots  may  not  show  a  single  unchanged  fil>er.  whereas  the  cervical 
nK)ts  are  less  involved,  save  in  the  ca.'w  of  cervical  tabes,  where  the 
reverse  holds  true. 

The  posterior  columns  show  the  most  luiifonn  lesions.      ITiese  ai 
greatly  diminished  in  volume.    There  is  a  gradual  degeneration,  often, 


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TA  HF.S 

however,  more  intonso  on  one  siHo  than  thr  othrr.  The  iitmphy  is 
luit  universal,  fur  iTUUiy  IiIhts  art-  iiilart.  *^lu■^L■  nw  usually  cuElatiTals, 
originatitif:;  within  the  riml  itself.  The  ciirect  Hlmis  in  tJie  eoUimns 
of  Goll  anil  Burdadi,  from  the  ctegeneraled  posterior  r*>i)ts.  are  those 
I'liiefly  inviilve*!.  A  great  <leal  of  viiriahility  exists  ns  to  the  respecti%'e 
distribution  of  llie  Htn)phie  ileKenerulwi  fihen*,  liul  sueli  hear  u  ciircet 
proportion  t4>  the  distnhiition  of  the  <le(ieneratc<i  posterior  roof*. 
('erta.in  in)rtii>tis  of  the  voni  e^it-ajK-.  due  to  atmtoinieul  reasons;  these 
are  more  particularly  the  nimmis-sural  zones,  Flechsig's  centrum  ovale, 
(tonitjault  and  I'hillippe's  triangle  in  the  lumbosacral  re^im,  the 
eonuuomtnissurul  /.ones,  Schultze's  eonima  tract  and  the  fascicles  of 
Iloclie.    (See  Plate  IX.) 

As  a  result  of  the  disappearance  of  the  fihers  a  secondary  neuroglia 
infiltration  takes  placT.  This  eonsi!>t<>  of  glia  with  6ne  prolongations, 
and  also  spider  cells.    In  the  cases  of  taboiwresls  one  finds  lympho- 


1-|<;.  3Ttf. — Talielic  chiuiuw  iu  ronl  id  purtwis. 

■cytes  iind  plasma  cells  witliin  the  cord  substance.  With  a  limited 
tal>etic  pniccss  they  are  not   usually  encountered,'    Many  ganglion 

cells  of  the  posterior  lionis  sliow  denenenitive  changes.  They  are 
diminished  in  size,  there  is  definite  cliroinatophilia,  or  vacuoliz-iition, 
and  other  signs  of  degeneration.  The  <«IIs  of  tiie  column  of  Clarke 
are  diseased  only  to  a  slight  extent. 

!n  tabes  with  cranial  nerve  signs  the  degeneration  can  be  traced  in 
the  riiiiltilla  and  p(jns  with  seojndary  atniphy  of  the  beiisory  nuclei. 
Atrophy  uf  the  optic  nerve  is  not  infrequent. 

Jendnissik,  Schaffer,  Epstein  and  Kranss  have  also  shown  that 
tlic  brain  cortex  is  not  uninvolved  even  in  typical  tabes.  There  is 
Q  diinimitiun  ui  tlie  nerve  fibers,  itnd  nltcrations  in  the  vessels  an<I  piu 
^there  may  be  Ivinphocyte  and  plasma-cell  uifiltration  even  in  the 

'Allhcimer:  N.  Atb..  i,  14. 


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SYPIIIUS  OF  TUB  SERTOrs  .SYSTE\f 


alMeiin*  of  pmnouiK-ed  inrntiil  ».Mnptc»nis.  rt-n-b<>IIar  dc^'iu-nitions; 
are  al**»  knowii.  The  ameriar  Iu»m  a^U  <lu  itoi  always  t'-HntjH*.  In 
the  paiieiits  with  pr(>n<iunce»]  atn>phy  many  motor  i-ells  nf  th«*  Hiitrrinr 
hums  art*  fouml  ilrgfi»THt«sJ.  Similar  rliauf;t*s  are  ktiown  wht-rt-  there 
are  hulhar,  laryngeal,  ur  other  cmnial  nerve  palsies.  The  (vrt:hrus)HiiHl 
Huj»i  also  shows  tlie  effeets  of  tlu*  mild  intlainniatxiry  prtKfsa  by  its 
increased  lyniphtH-ytosis;  a  count  of  over  10  cells  to  the  cubic  centi- 
meter (Kiichs  anil  Hosenthal  chanibiT)  Is  to  Ik*  ri-jfiinle*!  ns  positive, 
SO  to  100  are  not  unusual.    Plasma  cells  are  h\so  to  be  found. 


-fX 

Sffinml  Cord 

■'k ^ 


Dura 


Anft/r'er^t 


'tAmc/iNoid. 


Posterior  /{o&/. 


Anltrhi'Root 

M'Bn'tis..., 


Gi/z/y/ia/t 


>    i/tiohtdin'/it&es^ 

•  T  -FQiitn'ori^oot 
J  Xruritis. 


fX' 


Fio.  377. — Macroltf's  srhcnie  K'preaentiiiK  the  location  nf  the  chM  leidnn  of  ta 
in  th«  potfterior  root  wu». 

Serologically  a  positive  Wassermann  is  to  be  expected,  although 
here  the  number  of  positive  results  would  seem  to  fall  below  ilmt 
obtained  in  paresis.    Possibly  paresis  indicates  a  more  acute  pnKtrss. 

Noiinc  phase  I  n'action  is  also  fretiuently  positive. 

The  posterior  ganglia  are  also  affected  in  many  cases,  altliouj^h 
not  uniformly.  There  is  atrophy  and  destruction  of  tlie  cells,  ami 
proliferative  inflammatory  exudates  of  tlie  cai>3ule.  'Hie  ehan(fes  are 
not  sufficiently  constant  to  pennit  one  to  assume  that  the  priiuury 
part  of  the  disonler  is  located  in  the  i»oaterior  jpmglia. 


J 


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SYPUIUTIC  MByiS'OOMYEUTlS 


086 


The  peripheral  nerves  are  also  frequently  found  degenerate*!; 
Xonno  says  conatantly;  thus  ahoi^ing  the  complete  degeneration  of 
the  sensory  neuron,  central  as  well  as  ptripheml. 

SympiUhHic  Si/Mem .~'V\m  shares  in  the  general  destruetiun.  and 
shows  particularly  in  the  regions  involved  by  gastric  or  other  visceral 
crises. 

Pa/Aof/nw-jr?*.— rnanimity  of  opinion  has  not  yet  been  reached. 
'ITic  various  hy|M)th(^*s  cvokwi  have  upheld  vascular  (meningeal), 
nip«lullari',  radicular  and  neuritic  theories,  not  to  mention  the  idea 
of  a  primary  system  intoxication.  The  general  tendency'  is  to  regard 
as  funtlamrntal  a  ])rimary  syphilis  involving  partii-nliirly  the  posterior 
roots^n  modifii'd  syphilitic  radiculitis  in  the  most  constjint  feature  in 
the  pathogenesis.  The  process  is  one  of  chronic  specific  poisoning  in 
wliirh  there  is  (1)  an  involvement  of  the  posterior  radicular  fibers,  and 
of  the  peripheral  ner\'es.  (2)  an  extension  to  the  vegetative  nervous 
system  fibers  both  sympathetic  and  autonomic;  {'<i')  to  the  motor  nerve 
system. 

ronceming  the  nature  of  this  poison,  if  present,  little  is  knouni.' 

7.  Syphilitic  Meningomyelitis. — Xontie  has  devntcil  a  large  portion 
of  his  note<l  numograph  to  u  consiileration  of  the  lesions  of  sj-philis 
of  the  spinal  cord  and  its  membranes.  This  is  a  general  indication 
of  their  extreme  frequpntry,  yet  most  patients  showing  s\T>Mlitic-  lesions 
of  the  cord  also  show  signs  in  the  brain  or  its  meninges.  They  are 
nearly  all  examples  of  cerebrospinal  s.vphilis.  For  practical  purposes, 
however,  it  has  been  found  of  value  to  arbitrarily  divide  this  large 
conglomeration  and  rliscuss  it  under  two  captions:  eei-ehrni  syphilis, 
arnl  spuial  syphilis  or  mcniugi>ni>eliti3.  This  means  simply  tluit  one 
is  dealing  with  cerchrospinul  syphilis  with  predominant  cerebral  and 
minor  spiiial  symptoms  on  the  one  hand,  or  with  pretJominant  spinal 
and  nerve  root,  with  less  prominent  cerebral  signs  on  the  other.  It 
again  seems  advisable  to  accentuate  the  purely  prnginntic  eharaettT^ 
of  all  sui-h  clas^sifications. 

Symptoms. — In  CMUsidering  meningomyelitis  as  a  unit.  fiu"ther 
emphasis  may  be  put  uikhi  separable  s^iuptuui  groups.  Within  tbta 
conglomeration  again  clinical  neurology  shows  four  fairly  clear 
tendencies: 

1.  SjTidromes  due  to  prtmounced  meningeal  implication. 

2.  Syndromes  due  to  root  and  cauda  equina  disease.  Uiulieulitis 
and  neuritis.  Syphilitic  ostcimrtliritis  of  the  spine  is  a  frwpicnt  factor 
in  these. 

3.  Myelitic  syntb-omes  due  to  iiKliscrimuiate  transverse  disease. 

4.  Syndromes  of  less  extensive  transverse  lesions  and  fiber-tract 
isolation.    System  syndromes. 

A  combination  of  all  would  make  a  complete  men ingo myelitic  syn- 
drome.   This  is  a  not  unusual  picture  in  a  rapidly  developing  case;  in 

'  See  Urad:  Dniti.  1913. 


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SYPHILfS  OF  TBS  NERVOUS  SYSTEM 

its  mort'  ehronif  course  tlie  emjihasis  seems  Ut  be  laid  upon  one  ur 
another  of  the  just -mentioned  groupings. 

Those  are  elmrueteristic  syndromes  of  the  early  and  secondary 
stages  of  .syphilis.  The  syndromes  may  develop  witliin  a  few  months 
after  infection,  or  only  come  on  after  many  jears.  In  the  former 
case  the  acute  mycHtic  changes  are  frequent,  also  root  lesions  (many 
neuralgias,  sciatica,  etc.).  The  later  devclnpitig  cases  show  more  the 
systemic  lesions  and  gradiuilly  advancing  nicniugojmthics  (later 
secuntlary  ineiiiogitis)  with  compression  (apaslic)  phenomena. 

Iti  hII  one  expects  to  obtain  a  positive  Wasscnnann:  cerebrospiiml 
fluid  Wassemiaim  is  negative,  save  with  large  quantities  of  fluid; 


Flu,  37H. — MvuiiiK'^iiiyulitu.     Rsdieiiliti*.     DogeuerAt ioii  of  Burbncb's  columtu. 

lymphoc)'tosis  is  frequent — often  the  cell  count  being  very  high, 
always  indicating  the  grade  of  meningeal  involvement.  The  lympho- 
cytes arc  not  found  before  the  .stage  of  roseola;  are  ahundant  in  the 
active  .secondary  suiges,  and  less  frequent  in  the  tertiary  stages  of  a 
meningomyelitis.    The  protein  content  varies  considerably. 

1.  .\frniugml  Sf/iKfrtme/i.—  iieveTe  pains  are  .sigiis  of  meningeal 
involvement.  They  slHK)t  arrtiss  the  slmulilrr-blatle,  in  the  neck, 
aiToss  the  hips,  dart  down  the  arnis  or  legs  and  cause  ii  stiifncss  of 
the  neck,  the  shoulders  and  the  thighs.  The  spiiuil  column  i>  usually 
sensitive  to  pressure,  and  to  percussion,  and  local  intensities  may 
show  both  these  signs,  and  ais<)  the  peripheral  signs  of  a  definite  zone 
localization. 

Pain  is  frequently  preceded  by  po.re.sthesiic,  like  the  crawling  of 


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SYFUIUTW  MENINOOMYELI 

aiita,  Duiiibiieiis,  and  coldness.  There  is  a  f^radual  intTease  in  the 
reflex  excitability  nf  the  cord,  due  to  pressure  and  eWdencerl  hy 
iiicrfa.srd  kjiw-jVrks,  possible  Bahlnski  sign,  Oiipenheim  or  ("Iiaddock 
sipiis.  U'hcn  prewurt-  is  t-xcrti-d  i[i  tbe  sarnd  segiiierits  bladder  and 
rectal  distiirlmuees  are  frequent. 

With  chronic  meningeal  thickening  these  pressure  sjTnptoms 
increase  markedly,  and  spastic  paretic  phenomena  augment,  oiR-cially 
when  gummata  add  their  special  pressures.  Ciuinniata  may  give  rise 
to  a  "cord  tumor"  syndrome. 

2.  Hoot  Syiulromes. — Here  pain  is  frequent  ami  neuritic  atrophies 
appear.    Sensory  losses  of  a  rotit  distribution  arc  in  e\idence.    Many 


\y 


Kki.  379. — RAtUouIar  diatribulion  of  sensory  lum  in  Inlx-it,  iiarUcultirly  Ui  Inrrilf  pntn 
aad  tlivrnuil  »n»ti)n]iiy.     [Dt-iprinv.} 

shiiw  the  characteristie  reversal  of  epicritic  touch  loss  being  less  exten- 
sive than  protojMitbic  (vegetative  6bcrs)  pain  loss  as  pointed  out  by 
Head  a.s  characteristic  of  radicular  localizations. 

Tiie  ainiphy  of  the  muscles  also  follows  the  radinilar  distribution. 

Many  obstinate  neuralgias  are  <luc  to  syphilitic  radicular  disease. 
Possibly  one-half  of  the  sciaticas  are  of  this  nature.  Dejeruic  has 
put  them  as  high  as  80  per  cent,  in  Paris.  A  very  large  proi>orti<)n 
of  the  brachial  neuralgias,  so  long  hjoked  upon  as  rheumatic  or  gouty, 
or  what  not,  are  due  tn  a  syphilitic,  nxit  meningitis. 

Xeuritic  muscular  atrophy,  from  pre^ssurc  on  the  anterior  n)ots, 
is  fiu^hcr  cumplicatcil  by  pressure  on  the  anterior  horns  by  the  tliick- 
ened  meninges.  Thus  ver>'  anomalous  atrophies  result.  When 
occurring  in  the  eighth  cer\-ical  and  first  dorsal  region  one  olrtains 
classical  Klumpkc  pamlyais  with  dilatation  of  lite  pupil,  and  narrowing 
of  the  palpebral  fiasure  of  tite  affecteil  side.    L,owcr  localizations  result 


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SYPHILIS  OF  THE  NBRVOVS  SYSTEM 

in  intercostal  palsies,  back  muscle  atrophies,  hip  jfirdle,  tlii;tli  or  cftuila 
lesions.  In  tins  latter  situation  strikinp  dissociutions  an*  obtained, 
as  in  the  upix-r  iinii  rcfjinn.  aiitl  railicular  sensory  ilisturbuuees  and 
lost  reliexes  are  the  ni3e  witii  atrtiphies. 

3.  Myelitic  .SV»rfmwff.<f.— These  indicaU'  the  cimipkix;  involvement 
of  the  cord,  and  also  point  to  intraspinal  vascular  disease,  rather 
than  to  a  meriiiiReal  lesion.  Complete  Haccid  palsy  is  the  ufiiial  result. 
This  is  combined  with  sensory  loss  as  well.  The  eoiiipleteiiess  of  the 
scnsorj"  loss  varies  crmsiderably,  and  indicates  the  severity  of  the 
lesion.    Absence  i>f  a  lymphocytosis  points  to  a  purcl,v  vascular,  and 


Fio.  380. — FiirliyiiM'niiujitis  byiierttuiihicA  oeniralis. 


usimlly  focal  lesion  within  the  cord.  The  hladrier  and  rectal  functions 
are  implicated  as  well. 

In  the  regrcshive  sta^i*  an  increase  in  spasticity  marks  the  sub- 
sidence of  the  inHammatnry  reaction,  and  many  anouialous  !<>ndrome 
mixtures  result.  Thi.s  phase  of  mcniuponiyelitis  offers  abnmlant 
opportunity  fur  very  lieterngpiinns  syiiflronies.  \  Brown-S6qiinr<| 
complex,  poliomyelitis,  taU'lic  syndrouic  with  atrophy,  umyutropbic 
latcnd  8clon>sis  s\i»lrome — these  are  but  a  few  nf  the  possible 
combinations. 

4.  Sj/xUm  Syndrome^.— These  occur  not  so  much  as  residuals  of  the 
previous  myelitic  changes,  nor  as  due  to  meningeal  compressions,  but 


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oogic 


CONOENITAL  OR  HEREDITARY  SYPHILIS 

represent  disease  in  or  about  the  long^  motor  tracts,  tractus  cortico- 
spiiiulis.  esiH-fittlly.  Tlicy  jcivc  rwc  to  the  forms  of  pTimary  lalenU 
sclerosis  (Krl>),  some  combined  wleroses,  and  particularly  to  cliniciii 
pictures  cl(>»'ly  rfsemblinp  multiple  sclerosis,  ('ombineri  diseas*?  of 
the  posterior  and  litteral  columns  is  quite  apt  to  be  syphilitic. 

Special  localixntiun  of  am>  or  more  of  these  forms  4if  meningeal 
syphilis  jti\es  rise  to  the  special  fnniis  of  hypertrophit:  cervical  pachy- 
meningitis, which  have  iRt'n  (lescril)etl  by  JoH'roy  and  <'har<;ot,  and  to 
Kahler's  diiicase. 

The  anterior  horns  may  be  predominantly  involved  usually,  howe\'er, 
as  a  result  of  a  transverse  myelitis  (Xonne)  giving  the  picture  of  an 
anterior  poliomyelitis. 

In  hijjiprtmphiv  rcrvwai  inKhifineningiivi  an  enormous  thickening 
of  the  meniTiges  is  fouinl  with  or  without  gummata.  and  liKaited  in  the 
cerviea]  R-gion.  Here  root  and  tvmprcsaion  symptoms  are  present. 
Pains  in  the  neck  and  shoulder,  stiffness  of  the  cervBcal  spine,  shooting 
jjiiins  down  the  anus.  .Sensory  loss  may  then  show,  particularly  to 
pin  prick,  with  relatively  intact  sensibility  to  c<ttton-wno].  The  ulnar 
and  meiliaii  are  |>articuUrly  implicated.  I-lbrillary  uontractiim  of 
the  muscK's.  atniphy  and  loss  of  electrical  cxritidjility  oixrnr.  The 
special  tjiw  of  deformity  known  as  preachcr-haud  is  one  uf  the  frequent 
expressions  of  the  involvement  of  the  bracliial  plexus  in  the  wrvical 
meningitis. 

8.  Congenital  or  Hereditary  Syphilis.  — Eflect  ot  Heriditftry  Syphilis. — 
.Serologitiul  studies  have  thniwn  much  light  tm  the  question  of  the  mode 
of  transmissitm.  Tliis  cannot  be  entered  upon  here.  These  studies  as 
particuhirly  c«rric<l  out  by  Plant,  Motf.  and  others  have  shown  the 
cnfvrnions  importance  of  transmitteci  syphilis  in  the  ix-niiciuus  elfeits 
upon  the  ncr\ous  system.  Linser.  moreover,  has  shown,  that  two-thirds 
of  the  children  of  syphilitic  imrents  show  up^Bitivc  Wasscnuanri  reac- 
tion, althougli  much  fewer  show  signs  of  congenital  syphilis. 

It  may  be  re<-!illcd  that  Kournier  stated  the  pmjmrtion  as  high  as 
1>S  per  cent.,  and  that  08.5  ]>er  cent,  of  the  children  died.  This  does 
not  Include  the  al>orted  ofTspring.  Should  these  be  reckoned,  one 
ct»uld  obtain  a  Irm^  idea  of  the  morbidity  of  syphilis  in  the  young. 
Hwhsinger  reports  an  interesting  group  of  cases  in  this  connection. 
In  11  families  there  was  patcriutl  syphilis.  The  mothers  were  not 
sj-philitic.  Jievcnty  mothers  gave  birth  to  li()7  children  -HO  still- 
born, IWi  s>-phUitie,  and  31  healthy.  The  healthy  were  all  the  last 
Itorn  save  in  four  instances. 

Of  the  children  of  tulx-tics,  one  obtains  the  same  story  from  Molt, 
Mendel,  and  otluTs.  Either  no  children,  many  abortions,  many  dead 
children,  few  living,  and  no  one  kjiows  as  yet  tlie  fate  of  these.  Cer- 
taiuly  one-half  are  iloomed  to  disease  ami  disorder  of  the  nen'otis 
sj-stem. 

It  woidd  appear  that  the  common  effect  of  such  »\'philitic  infection 
is  to  reduce  the  resistauoea  of  tlie  body  and  its  powers  for  full  develop- 

44 


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090 


SYFHILIS  OP  TBE  NERVOUS  SYSTEM 


ment  hnlh  in  tlie  griipml  U>ily  aiifl  nervous  tissues.  Sj-philis  iliinin- 
Lihes  tin,*  vital  t'iierj:y  of  tlie  gtTUi  pta^jiii  prior  to  t*orijiination,  iiiui  am 
cause  patholoitical  variutions  in  nervous  structures,  just  as  it  fun 
transmit  the  disease  through  the  gemi  cells.  The  abundant  studies 
on  alcohol  and  its  inlluence  on  the  Fonii  cell  affords  an  analopy  in 
understuiiditig  how  this  tiikes  pimie  with  another  ly|je  of  toxemia.. 


*  *T^ 


i~iA#  66666 


Fio.  381. — CvuBCliIlat  lO-pIitUs:  Jurviiitc  |mrcib,  at  fint  ouiwIdC'RKl  a^  '  inilirt^lc.* 

(Moti.) 

The  classical  formula  of  Foiirnier  seems  to  hold^ahortion.  dcai! 
child,  early  drjitli,  living,  healthj'  child.  This  is  in  need  of  imien.l- 
iiictit;  it  is  worse.  The  furniula  rca^ls:  Complete  sterility,  miscar- 
riage, ahortitiii,  stillliinliN.  i-hilihiit  dyini;  in  iiifjiiicy  or  riiiiviil.si(»ii.«, 
marasmus,  meningitis,  hydrocephalus.  1  hen  follow  children  who  are 
comparatively  healthy,  hut  who  in  hitcr  life  develop  late  hereditary 
sjTjhilis. 


FlM.  383. — CoiiitenituI  syiiNili"-  Thn'*  iiiiftCMrriagw;  then  5vc  cbildrvii  bum  olivo 
kikI  wwll.  Lnm,  I'liilil  Miiiifniw,  Hiil('li)ii.-«)ii  UH*lh.  Did  wHI  in  m-IiihiI.  tlirii  tlplrrinml^d. 
liuuy,  nii>iiiiiL''iil;  tluiutflit  U'  i>o  imrclir.  Atilopny  nh'rwtiil  itpnuruliivd  i^urrlmiMptniU 
ffininuitiiiin    tcirniiiKiliH,    [H^raiH-uliiht lk.    nntl    i-uilnr(<-nii«.     (Mull.) 

A  study  hy  Ilix-hsinger  (UMI)  says  that  of  2i)K  chihiren  of  syphilitic 
imrciits  who  liad  been  under  ol>si'rvatiou  over  four  years.  SU,  or  43 
per  cent.,  had  some  disease  of  the  ^e^^-ous  system.  Of  these  there 
were  9  t»ses  of  hydroivplmlus.  2  of  Little's  syndmme.  0  rpilcpties.  2 
paresis.  I  taltes,  G  Arg.vll-U«bertsoii  pupil.  iH\  extremely  m^urotic, 
5  hysterical,  14  chronic  headaches,  10  imbeciles.     This  is  in  stratige 


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COfiGBSITAL  OR  BBREDtVARY  SYPHILIS 


091 


contrast  to  the  statements  of  Joiuiathan  Hntohinson,  who,  but  u  few 
years  ago,  tituglit  that  nervous  syphilis  was  negligible. 

It  has  Uvn  Jibutulantly  shown  that  nearly  every  form  of  adult 
syphilis  of  the  nervous  system  c-an  be  encountered  in  hereriitary 
syphilis,  and,  as  Mott  well  says,  if  eouRenital  syphilis  were  not  so 
fatal  l(»  iiifanl  life  the  number  of  ])eople  suffering  from  s>7ihilitie  dis- 
enst'  of  the  brain  wnuhl  Ik*  ap|>alling.  It  would  then-fniT-  Ik-  of  little 
service  to  reiH-at  what  has  already  Ixrn  written  reganling  nervous 
syphilis  of  adults  as  it  appears  in  ehildren,  and  tlie  present  discussion 
will  be  limited  to  a  eonsifleration  of  such  forms  of  juvenile  nervous 


Flu.  'Ah'i.-   Hniiii  <tl  ti  conKi'tiiiiU  ^yiiUilitic  idinLit*  clulil. 

syphilis  as  are  present  only  in  ehildren.  These  are.  partieularly, 
tt-rtaiii  forms  of  fiH-ble-mindedness,  of  h\drnMvplialiiM,  epenil,\[nitis, 
I'Viedreieh's  iitaxiu.  primar>'  optie  atrophy,  and  rut^-pluilitides  nr 
eiKfphalonudaciiis.  leading  to  varluus  hemiplegii-  syndromes,  often 
haisely  grniijR-d  together  !is  IJttie's  disease.  Juvenile  paresis  and 
juvenile  talK'S  are  among  the  commonest  eongenital  disorders  of  later 
iiifan<">'  or  n<hilesfenee, 

(Congenital  syphilis  of  the  nervous  system  may  show  itself  before 
or  at  liirtli;  it  may  develop  In  i-nrliest  iiifaney  or  in  adolescence;  it 
may  <lcvelop  as  Inte  ns  twenty,  or  even  forty-two  to  forty-three  years 
(Miiller).    How  long  ma\  tlie  virus  remain  latent,  (iually  to  devehjp 


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SYPHILIS  Oi 


a  definite  s,\^lhilitic  reaction?  As  yet  the  an-swer  will  dejx'nfl  upon 
the  general  bias  of  the  answerer,  rather  thati  upon  empirical  data. 
It  would  H.p[X'iir  from  tht*  evitlenee  at  hHiul  that  no  definite  age  limit 
can  be  put  upon  the  time  when  such  u  latent  faetor  becomes  aelivatwl 
by  aiuses  as  yet  unknown.  That  an  activator  of  some  aort  playa 
a  role  In  sucii  disorder*  as  tal>es  and  paresis  seems  at  present  a  justifi- 
able hypothesis.  When  u  newborn  chit<i,  knciwn  to  have  been  sj'phihtic 
biologieally.  i^an  Im?  followe<l  throughout  Ufe.  his  serum  reactions  being 
tested  from  year  to  year,  as  is  now  being  done,  then  the  question  can 
be  finally  derided. 

In  this  connection  u  line  may  be  devoted  to  the  subjeeta  of  con- 
geuital  syphilis  "unto  the  third  generation."  While  of  Uite  years 
doubts  have  been  aeeuntulating  relative  t"  ihis  matter,  certain  positive 
cases  are  being  n'portcd.  The  rationale  of  this  seems  plain  in  view 
of  the  observations  of  rewnt  years  made  by  l.*evaditi,  liab,  and  others, 
that  Treponema  pallidum  may  be  found  in  the  ovum,  and  in  an  apjmr- 
ently  resting  stage  similar  to  the  resting  stage  knuwii  for  other  flagellate 
proto'wja  closi'Iy  ulliL-d  to  the  organism  causing  ^yphills. 

The  fact  of  the  whole  matter  is  that  opinions  and  statistics  relative 
to  congenitii]  syphilis  of  the  nervous  system,  supported  by  clinical 
observation  abne.  and  uncontrolled  by  the  available  biological  tests, 
are  insufficient  approximations,  and  very  insecure.  When  relie<l  upon 
for  negative  eondusinns  they  are  harmful  to  the  advance  of  thought, 
and  detrimental  to  the  relief  of  sick  humanity. 

Notwithstanding  the  importAnce,  and  often  the  strikingly  gruesr>me 
character  of  these  late-apiM-ariug  amgenltal  eases,  the  attention  of 
the  practitioner  slioidd  be  riveted  upon  the  numerically  prepondenmt 
mi.scnrriages,  stillbirths,  and  early  syphilitic  deaths,  if  he  wouKI  get  in 
the  right  attitude  toward  the  theraiH'Utics  of  this  disease,  as  it  affects 
the  nervous  system. 

Jn  congenital  sj-philis,  as  has  been  stated,  a  replica  of  what  has  been 
found  in  adult  syphilis  may  be  expecte<l.  Pathologically  speaking,  the 
lesions  an-  tn-arl\'  alwayi^  conibincnl.  There  is  a  variable  cotnjiosite 
of  endarteritis,  of  leptomeningitis,  of  paclij-meningitis.  gnmmata, 
large  and  small,  localized  or  infiltrating  gummatous  neuritis,  diffuse 
degenerative  changes  in  the  cells  of  the  spinal  cord,  in  the  basal  ganglia, 
or  of  the  cortex.  Thus  the  clinical  pictures  arc  apt  to  be  «>nglumernte, 
an<i  almost  nuftnalyzable.  Those  more  accentuated  trends  which 
permit  a  nosological  tenn  will  be  considered  here. 

Ihjdrocephnlns. — As  a  result  of  congenital  syphilis  tlib  condition 
has  been  susjM'ctecl  for  two  hundrc*!  years.  Hasse,  in  IS28,  Cruveilhier 
in  his  Atla.s,  Von  Rosen,  in  l.S*i2,  and  Virchow  reporte<I  definite  examples 
of  it.  It  ari.se-s  in  tliese  congenital  ftmns  largely  fn)m  syphilitic  disease 
of  the  cerebrospinal  fluid -producing  structures — choroid,  ependyuia, 
or  fnjni  definite  obstructive  factors  in  the  cerebral  foramina,  gummata, 
vascular  swelling  obstructing  the  iter,  etc. 

It  is  a  not  uncommon  sequel  of  congenital  sj-phills  and  is  undoubtedly 


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CONOENITAL  OR  HBREWTAHY  SYPHILIS 


093 


more  frequent  than  U  realizwi.  Id  Iloclisinger's  series  of  'M'2  cases  of 
rongenital  syphilis  34,  or  nearly  11)  per  eent.,  showed  liydroe^'phnlus. 
Ill  his  series,  which  afTonIs  a  fairiy  uvtTiiRe  review  iif  thv  situation, 
the  hyilnK-oplmlus  Ix-gan  threi*  ta  t'leven  immfhs  after  hirth;  sunie- 
tiuies  it  was  fetal.  In  11  cases  there  were  no  nervous  syiuptoms, 
1.  e.,  up  to  the  time  of  reporting,  lu  the  others  restlesaness.  sleep- 
lessness, <iironic  vuiiiitiuf;,  convulsions,  C4>T)traclures,  uystagtnu:^,  uiid 
feeble-mindedness  were  the  objective  phenontena. 

The  more  U5UaI  clinical  picture  is  that  of  a  child,  boy  or  girl,  from 
three  to  six  months  cpf  ane,  who  folUtwing.  or  not,  an  insignificant 
blow  on  the  head,  or  some  gastro-inlestiiial  or  bronchial  disturbance, 
develops  within  a  few  days  gnive  cerebral  disturlHincTs.  There  is  great 
irrit(d)llity  and  sleeplessness,  screaming  and  kicking.  The  head  is 
usually  drawm  back,  the  eyes  and  the  fontanelles  are  apt  to  bulge 
s^iincwhat.  Vomiting  is  frequent,  and  there  are  signs  of  m.-nlo- 
motor  involvement.  Intenud  strabismus  from  paresis  of  the  exten;al 
rectus  19  not  unusual.  It  is  frequently  prec-eiied  by,  or  acconi- 
panied  by,  nystagmus  and  irregular  pupils— ^>ften  not  respomling 
to  light. 

l*ain  is  present,  as  the  child  cries  and  .struggle?,  and  not  Infretjuently 
the  active  movements  of  the  arms — often  highly  spasmodic  or  convul- 
sive— .seem  to  try,  in  a  blind  reflex  sort  of  way,  to  get  at  and  brush 
away  the  source  of  it,  i.  c,  the  head,  pulling  tlie  hair,  grasjting  and 
rolling  the  head.  Spasticity,  rigidity,  and  other  signs  of  intrac-mninl 
pressure  may  al  times  Ix-  demonstrated.  Xa  a  rule  the  teiniwniture 
is  only  slightly,  or  not  at  all  raised,  and  the  minor  signs  of  an  epidemic 
cerebrospinal  meningitis,  i  f.,  herpes,  temperature,  tluslied  and  sjiotte*! 
skin,  are  absent.  The  diagnosis  of  all  of  the.ie  infantile  meningeal 
disturbances  is  fraught  with  raucli  4liRiculty. 

Ffieble-tuin(Mtteji.t.~t^^T)h\\\n  undoubtwlly  plays  a  much  larger  role 
in  producing  mental  defectives  than  is  sus[»ecte<l.  The  early  statistics 
are  comparatively  wtirthless.  They  are  quoteil  at  great  length  even 
lit  iniKlcrn  works  on  idiocy,  imljetility,  and  the  Hke. 

The  moa'  currect  appreciation  of  this  chapter  on  s.\*philis  and 
feeble-mindedness  began  witli  the  studies  of  Fournier  on  ])arH syphilis. 
Those  truths,  somewhat  uiiconlrrdlefl,  were  forced  upon  him  by  his 
clinical  observations.  The  early  ICnglish,  German,  and  American  fig- 
ures varie<l  frcitn  0.1  (Sluittleworth)  to  17i>er<-ent.  (Ziehen).  Whereas 
the  results  folloi^ing  sentlogical  investigations  start  with  the  higher 
figures,  and  mount  upwanl,  in  nome  ease.s  a.";  high  as  (iO  per  cent. 
The  AmericHii  figures  available  (.\twood  and  Clark)  showed  that  211 
per  cent.,  of  the  idiots,  imbec-ilcs,  and  niuroas  at  Uaitdall's  Island, 
New  York,  were  sypliilitic. 

Intra-uterine  feeble-mindwlnesa  is  more  or  less  a  contradiction. 
Those  children  whose  tnental  defect  date  to  discAse  going  on  in  the 
uterus  rarely  live.  Plaut  expresses  the  opinion  that  feeble-minded- 
ness may  Ik;  regarded,  so  far  as  sjphilis  is  concerned,  as  the  resuJt 


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SYPHILIS  OP  ftiS  n^RVOVS  SVSfShI 


oi'  Jill  extra-iitpriue  s.\^>iiilitir  disease  iirnlerj?>iu'  in  infiiiicy.  trt 
some  tliiTi-  urt-  at^ns  nf  an  ariite  briiiii  *liseu.s(\  Snint'  instiiiices  of 
recovered  hjdrot-L'phalus  show  the  signs  of  liavuc  jn  tlicir  inalnlity  to 
develop  normally.  Many  others  show  no  acute  stage,  but  fail  to 
develop.  Many  recorded  ob^rvalions  are  a\'ailable  to  sIkiw  the  very 
gradual  <levi^l(ipment  nf  mental  deffrt.,  wit.liuut  intivul«ons  or  fever, 
alto);et!ier  w'itluml  signs  of  organie  disease,  which  arrivet!  at  a  deBiiite 
tenniiuLtioii,  and  wliieh  left  beliiiid  entirely  stationary,  perhaps  even 
impruvable,  idiots  or  iinlieeiJes. 

Tliat  ty|>e  of  liereditary  syphilitic  clnld  without  any  taiiifible  disease. 
for:imlatcil  by  Fournier — his  "  t^nfants  arrieres" — which  is  destrribed 
as  imintelligeiit,  simple,  silly,  limited  children,  always  behind,  nnt 
infrequently  shows  tlu:  \\^i,ssprmann  reaction. 

A():ain,  one  is  couvuiccd  by  the  researches  of  others  that  mental 
defect  in  Icss-niarked  grade,  or  more  properly  speaking,  along  more 
restricted  or  9]x;cial  lines,  is  allied  with  this  broad  (jroup  on  the  basis 
of  conRenital  s.vpliilis.  Thus  Nomie  reports  cases  of  peneral  irritable 
weakness  of  the  nervous  system.  The  patients  are  highly  excitable, 
are  extremely  nen,'ous,  they  are  very  moody,  sutTer  from  headaches, 
irregidjirities  of  appetite,  surlden  fits  of  passion — not  asscicijitcd  with 
other  forms  uf  epileptiform  analogies — itud  for  whom  inercnry  and 
the  imlides  work  wonders. 

Still  another  chapter  has  been  opened  in  this  hereditary  syphilis 
problem  in  its  relation  to  mental  defect.  It  concerns  many  so-called 
psychopathic  children.  These  children  are  bright,  but  they  show 
niarke<l  ethical  <lcfeet-s.  Here  <inr  can  ccinceive  of  the  mental  defect 
in  terms  of  limitetl  cortic-al  (patrol  to  the  affective  response  of  the 
sexuality,  and  to  the  nutritional  iastinots,  Tlie.se  children  want  ami 
take  without  going  aroiuid  by  the  circuitous  routes  devised  by  cultural 
standards.  .A-natoinically  one  can  posit  a  defect  of  certain  cortico- 
corlieal  as.socijition  areas  on  the  basis  of  the  syphilitic  poisoning. 

Taking  the  whole  group  of  feeble-mi ndedness.  it  is  evident  that 
clinicjilly  one  cannot  pick  unt  the  hcreditjiry  .syphilitic  child  in  all 
instances.  Indeeil,  it  should  l>e  eniphasi/eil  that  Uki  nnioh  weight  is 
given  to  the  anonuilies  in  physical  structure— Hutchinson  teeth, 
saddle  uose,  stria*  about  the  mouth,  pronunent  veins,  scaphoid  scapula, 
etc. — if  one  rejects  those  who  fnmi  the  heredosyphilitic  class  fail 
to  show  such  anomalies.  Nor  can  we  recognize  any  wrtaiidy  pathog- 
nomonic psychical  anomalies.  A  careful  neurolr»gical  examination 
frequently  ii'uU  in  enlarging  the  gmup— i>articularly  in  the  stiuiy  of 
pupillary  anotnalies.  The  cv-toUigical  ti-sts  are  nf  the  highest  imi>or- 
tance,  and  every  child  born  of  syphilitic  father  or  nuUher  sJiould  be 
systcnnitically  exaniinc<l  by  these  cylu biological  method.s. 

Treatment.  -  Tlic  treatment  of  syphilis  of  the  nervous  system  api>«ir- 
ing  in  any  of  the  fonns  previously  enumerated  is  often  extremely 
.satisfactory,  lu  fact,  at  times  one  might  say  the  results  are  often 
too  good,  as  the  speedy  relief  not  infrequently  leads  the  patient  to 


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695 


for^o  further  treiitJiit'iit.  or  causes  htm  to  pursue  hU  course  lialE- 

heartc^llyj 

("erebral  syphilis  for  the  most  part  is  accompanieti  by  active  spiro- 
chetes; hence  the  therapy  is  to  be  directed  against  this  organism. 
Mercury,  arsenic,  and  iodine  are  the  best  available  spirocheticidal 
dnif^K.  Mercury  ami  jirscnic  are  active,  iodine  is  very  weakly  toxic, 
but  NeisHer's  most  n*ct-tit  studies  tetul  to  shejw  that  it  Las  uetions  other 
than  that  usujilly  ascribed  to  it,  iianiely,  to  promote  the  taking  away 
of  breaking-dowTi  syphilitic  tissue  or  its  product— its  so-called  resorp- 
tion action.  Neisser  shows  that  imlides  in  large  doses  are  toxic  to 
spirnclietes  as  well. 

The  treatment  of  nervous  sj-philis  then  should  be  an  attempt  to 
follow  out  a  general  antLsyphilitlc  treatment,  with  s|>ecial  attention 
to  certain  structural  peculiarities  of  the  nervous  system.  These 
peculiarities  arc  of  much  iinfwrtance.  In  the  first  platT,  small  Icaions 
ill  the  central  nervous  system,  by  inipitiginn  uii  important  centers, 
bring  al)out  disastrous  results,  optic  atrophy,  |x)ntinc,  incdullary 
heinurrliages,  etc.  The  enormous  importance  of  correct  nervous  and 
mental  functioning  in  the  struggle  for  existence  is  self-evident.  The 
diflicuUie-s  in  the  way  of  rp|»air  in  ner\ou.s  tissues  an-  enonnous — at 
times  iii.su [wrable.  Hence  one's  attack  upon  nervous  syphilis  should 
!«'  prompt  and  complete.  .\  complete  sterilization  is  desirable — and 
thi.s  is  often  extremely  difficult  to  bring  about  in  nervous  tis.sues. 

It  must  always  be  lionie  in  mind  that  cerebral  syphilis  is  often 
pres<*[i1  with  a  negative  Wassermami  reaction — this  finding  then  shoulil 
not  deter  oik  if  there  are  clinical  sigiis  of  diagno!>ti<'  import.  Not 
infrctiuenlty  active  antisyphilitic  treatment  (salvarsiin)  causes  the 
appearance  of  a  positive  blood  reaction^how  often  this  occurs  is  not 
yet  known. 

Study  of  the  cerebrospinal  fluid  is  often  a  letter  guide  to  the  correct 
appreciation  of  the  .-iiiuation  as  well  as  a  reflection  of  the  activity  of 
the  process.  L>Tiiphoc>tosis  is  often  present  months  or  years  liefore 
any  definite  nervous  signs.  Lmnbar  punctiu*'  is  too  often  neglected 
in  cerebral  syphilis.  Many  authors  state  that  if  the  blood  is  negative 
to  the  Wassernmnn  test  there  is  little  occasion  for  studying  the  ivrehro- 
spinal  Huid.  This  leads  to  bud  results.  Vascular  arul  meningovascular 
pn>eesscs  may  progre-ss  for  years  in  nervous  tissues  without  giving 
rise  to  a  positive  Wasscrmann  reaction.  Here  is  an  occasion  in  wliicli 
this  symptom  fails  to  l>e  present. 

An  energetic  treatment  should  therefore  \*p  carrie*!  out  if  there  are 
suggestive  signs  of  nervous  syphilis,  even  should  there  he  a  negative. 
Wassermann  test. 

In  certain  patients  rapid  action  seems  imperative;  in  cithers  the 
need  for  this  rapidity  is  not  so  much  in  evidence.  Granted  a  knowledge 
of  these  requirements,  the  choice  of  remedies  is  not  as  simple  as  it 

*  White  mid  JclltlTfi:  Kor  mora  complota  diBCuaauo  connilt  Mcxlvm  Trvntmeiit  i>t  Ner- 
vnuM  mill  MeiiUil  Diso^aitt's,  vnl.  U. 


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SYPHILIS  OP  TUB  SSRVOUS  SYSTEM 


might  swni.  ludiclfs  yiveii  by  tin-  month  in  tlost's  of  30  grains,  2 
grams  a  day.  show  evidences  of  activity  in  about  une  week.  JMertniry 
by  inunction  showT^  results  in  aKiut  five  d&ys,  while  the  newer  arscoical 
preparations  show  reactive  cajwicitics  in  about  forty-ei^ht  to  seventy- 
two  hours.  None  «if  these  ti(jure.s  slioultl  be  aecepted  as  final,  so  far 
as  curative  aetiuti  is  coin-eriied,  nevertheless  they  are  worth  something. 
It  is  nut  apparent  that  iodides  have  a  rapid  toxic  action;  hence  in 
lesions  whicli  ur-  cliaracteristic  of  the  more  florid  aspect**  of  spiro- 
chetal prowth— basal  meniiijieal  tyix's  of  acute  onaet  particularly — 
they  should  not  he  chosen  in  the  initial  attack. 

iniifu-tiim  Meihvd. — For  years  neiu-ologists  have  taught^-ohiefly 
iinder  the  influence  of  Krli — that  nervous  syphilis  is  l>est  attacked  by 
the  iiniiietion  niclhod — coiiibinwl  with  iodides.  In  those  situations 
in  which  the  time  element  is  of  less  moment  this  Httitikte  s^ins  jus- 
tifiable, especially  for  gmnmatous  ly{K;s  of  the  disease. 

Oleate  of  Memtrp. — The  oleate  of  mercury  is  ol  value  in  tliat  it  is 
comparatively  cleanly  and  produces  results  as  rapidly  a*  other  mercuriai 
preparations  api»licd  to  the  skin.  A  dram  of  the  10  i>er  cent,  oleate 
is  to  be  used  night  and  nuiniing  for  four  days.  The  patient  then  tukes 
a  vapor  bath  nnt\  the  same  dost^  is  nscil  once  a  day  for  four  days  more. 
If  spoiiginess  and  soreuetis  of  the  gmns  <lo  not  appear — with  cleaned 
teeth  and  jjums^the  double  dose  may  be  continued;  otlierwi^e  a  single 
d(we  should  be  utilize*!.  In  asinji  the  oleate  one  usually  employs  a 
small  piece  of  flannel  in  the  rtibbinj; — the  first  dose  should  be  larger, 
as  the  Hannel  absorbs  it,  and  the  same  piece  of  flannel  should  l>e  used 
conlinuously. 

The  oleate  may  irritate  the  skin,  but  as  it  is  nhsorbefl  fairly  well 
from  all  parts  of  the  IxkIv  one  can  shift  artiiind  more  rendily  with  it 
tlrnn  witli  other  mercurial  ointments,  .\nother  object  of  using  the 
oleate  is  on  the  ground  of  sccrecj'. 

This  line  nf  treatment  should  continue  at  least  six  weeks;  after  the 
first  week  10  grains  (0.(i  gram)  of  pota.ssium  iodide  t.  i.  d.  should 
be  luhninislcreil  during  tlie  course  of  treatment.  There  is  very  little 
advantage  in  nusing  the  amount  of  iodide  abi>ve  liO  grains  (2  grams) 
a  day.  .Vfter  sL\  or  eight  weeks  the  treatment  should  l)e  discontinued 
absolutely^to  be  renewc<l  not  later  than  three  montlis  after  the  ter- 
mination of  the  last  treatment.  .\  thin!  and  fourth  course  is  advisable, 
even  imi>eralivc  if  a  positive  Wasaermann  test  is  present  in  the  bltMid 
or  lynipliocytes  above  10  to  the  cubic  millimeter  are  obtained  from 
the  wreljrospinnl   fluiil. 

Vngurniuin  Ih/tlrargifn. — rnguentuin  I  lydrargj'ri  is  much  used 
and  widely  rcconuncmlcd.  It  has  the  disadvantage  of  Ijeing  dirty 
and  of  attracting  iittcntion.  The  latter  may  be  partly  obviated  by 
adding  aome  non-^tai liable  coloring  matter,  or  some  smelling  compound 
such  as  haL^am  of  I'eru.  .Attention  can  thus  be  diverted  from  its 
cliaracteristic  color.    The  ointment  is  used  in  daily  doses  of  from  3j 


I 


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(4  (frams)  to  3ij  (8  (frama)  best  rubbM  in  iii  the  evpuiiig  in  a  fairly 
definite  manner,  ami  in  places  where  the  skin  in  more  permeable.  Otic 
uses  the  inner  surfjut-s  of  tJie  arm  aii<I  forearm  fnr  the  first  rubbings, 
covering  them  with  baatlages.  then  tlie  insiiie  <tf  the  proin,  then  the 
]H»[>liteaf  spuee.  then  the  alMlomen  and  back.  The  fifth  or  sixtii  clay 
tlif  [mticnt  omits  his  nibbuig — takes  a  Turkish  bath  unii  then  starts 
over  the  same  course.    This  course  is  kept  up  for  thirty  <loses. 

Other  lh'taUs.—^V\vi  care  of  tlie  sVXn  arui  of  the  mouth  is  naturally 
to  be  kept  in  mind.  The  blood  Wassermann  reaction  should  l»c  tested 
at  the  en<i  of  the  i)erio(I,  and  if  strnnRly  positive,  or  if  spinal  puncture 
shows  active  lymphorrtnsts,  or  if  clinit-al  signs  seem  slow  in  respond- 
ing, the  inunctions  should  be  continued  at  least  two  or  three  weeks 
Jonj?er. 

Checking  up  by  the  Wassermann  test  and  luinlmr  puncture  three  or 
four  montlis  later,  or  any  increase  in  clinical  signs  should  determine  a 
n'i)etition  of  llic  tn-'atnient  along  itlentical  or  more  stn-nuons  lines. 

Iodides,  :iO  grains  daily,  are  to  l>e  given  tliroughout  the  c*»urse  of 
the  inunctions.  All  medication  should  cease  at  the  end  of  the  cure, 
unless  there  sxv-  definite  indications  for  its  continuant. 

Other  mercurial  inuncti<ni  mas-ses  may  l>e  use<I.  Those  of  value 
are  the  hydrargyri  vasenol,  vasogen,  mitin,  resorbin,  which  Iwvc 
s|)eci!il  imlications  which  may  render  them  particularly  valuable. 

ftijpctiim  Trrotiiu'iit.^luict^ion  treatment  attempts  an  even  more 
rapiit  and  energetic  attack  U|>ou  ihc  spirocheU-.  Many  battles  have 
Vtcen  fought  among  syphilugraphers  as  to  the  com|Hinitive  merits  of 
the  insoluble  or  soluble  salts.  Wlien  so  much  diversity  of  opinio?i  can 
be  found,  it  usually  indicates  that  the  real  differences  are  usually 
minimal.  Hence  ease  of  administration,  safety,  painlessness,  etc., 
determine  the  choice  of  the  remedy  in  each  ease. 

Calomel,  mercury  ssdicylate.  and  tlmnol  acetate  are  among  the 
more  favored  in.soiublc  salts.  ("aloind  has  occupied  a  high  rank 
and  can  be  utilized  in  the  following  forms: 


Q— HydranoTi  «hlori(li  tuitU SI)  cm. 

f^ixlii  cbikiriili S.O  gni. 

A<),  dMt AQ  0  Bni. 

Mu>-ilnsi"  nmbici ,     .  '2a  riu. 

U  — HyrlrnrioTi  chloridi  inili*. 

Ol.  iH.<Baii)i.  ]U  per  (.'etil. 

Pravaz  sjTingcful  every  second  or  third  day,  preferably  into  the 
muscles  of  tiie  thigh  or  buck,  for  12  to  15  doses. 

The  hjiJodcrmic  use  of  calomel  is  often  accompanied  by  much  pain. 
Abscess  and  necrosis  is  not  uncommon,  and  lung  emboli  may  occur — 
with  care,  however,  calomel  given  l»y  hj^podemiic  is  free  from  danger. 

Creams  nf  ciilomel.  devised  by  I.4iml>kin,  have  lH*n  exteiusively 
usetl,  as  they  cause  less  pain  and  give  rise  to  no  i-ompHcatioius  if  blood- 


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m 


sYPnius  OP  tun  Ksnvovs  systbh 


vcsst'Is  art'  avoided.    These  crcains  should  be  sterile, 
uf  some  in  use  are  as  follon'n: 


The  Fomiulic 


n — (?alnnvi'l    , 

Cniiipborie  add 
Paltnitin  . 


o  Ulll. 

20  icm. 

20  Btn. 

100  ictn. 


IiijiN^.  lUm  of  iliiH  rrcniti  iin'H>  ii  ms>k  Tur  ixie  moiitli,  to  \k  rpplaci'd  b>-  tbe  (uUnwtnc: 

R  — UydrurtO'n  (invlullk-) Ill  Kin. 

CiTOBOW 20  em. 

('aniphi>nc  acid 20  sni. 

PiilniilLn  .      . I(N)  em. 

Tbw  it  iiij«<?lixl  tu  dntvm  of  lOtH  twi(<e  ■  week  for  Uir«o  wweka. 


iVftiT  six  doses  have  been  (riven,  stop  for  two  months.  Four  injcr- 
tiotw  of  du!  metallic  iTemn  are  then  givtii  at  fon.iiightly  intervals. 
Then  a  rest  for  four  months.  Then  four  injections  as  before,  unci  a 
rest  for  six  months.  Then  n  repetition  of  four  fortnightly  tloscs — 
Hti  interval  nf  (ine  numili.  iiikI  u  final  series  uf  four  mi-lallic  ercam 
doses. 

Kiigli->U  syphilojiraplHTs  Imve  fotuuJ  tlicsc  cresuiis  adiiiirublc  in 
anny  and  navy  work.  They  are  adapted  for  early  .stiifres  better  tlian 
for  ner\*ous  syphilis,  but  are  worthy  of  more  extended  trial  in  nerve 
s>*philis. 

The  u.se  of  the  iii.si>lub[e  salt-s  lias  l}ie  iulvantafte  of  a  inueh  more 
[iri)ti)ngO(i  ac-tiuii  of  the  mercury.  'J'licy  also  have  the  ilisadvantage— 
all  mereuriul  salts  share  in  this,  however — of  irritation  of  the  kidneys. 
If  allnirnici  is  fuiini!  In-fore  the  use  <)f  niereury  one  should  look  for  a 
syphilitic  iilbuminiuia.  Tuberculosis,  dialwtes,  alcoholism,  marked 
cachexia  arc  luhliiiorml  factors  to  be  carefully  dealt  with.  (laatro* 
iit.testinal  distiu'bances  are  fre<)uent,  but  it  is  extremely  rare  thai 
mercury  cau.ses  a  neuritis. 

Thorough  cleaii-siug  of  the  mouth  and  the  use  of  a  chlorate  of  putasli 
tin»iL(li  wtish  is  imperative. 

The  soluble  salts  in  use  are  very  numerous.  They  include  ihe 
auzoiofJolale,  bicldoride.  lactate,  succLnamicle.  binifMlin.  iH'iuuinule,  and 
c>'amde.  Kournier  listi  about  ^IK  They  may  be  injected  n-ithin 
the  muscles  or  into  the  skin,  supc'rfieially.  All  are  somewhat  painfid, 
and  accidents  are  ptKssible.  In  Kcneral  the  dosage  is  fnau  \  to  ^  of 
a  grain.    The  injections  are  given  twice  or  three  times  a  week. 

Genertil  Scheme  of  I njectum.— The  following  general  scheme  is 
suggestefj : 

1.  The  site  usually  chosen  is  the  iH>sterior  third  of  the  buttock,  to 
avoid  the  sciatic  nerve  ami  vessels. 

2.  The  skill  should  be  scrubbed  with  alcohol  or  ether. 

X  The  injection  should  l>e  made  deeply  into  the  muscle,  using  ench 
buttock  alternately. 


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TltKATMnSf 


> 


4.  The  sTiTiiiRc  and  imtoii  should  pivferabl.v  He  oF  glass,  easity 
sU'rilizi-d.  arul  the  iiwHIe  of  platinuni  iriiliuin.  alx>ut  I^  indies  tii 
lenpth,  iiiul  stcrili?*'^. 

5.  After  iiisertiiin  «f  tlie  needle,  the  |>ist(m  shutdil  I>e  sliplitly  wlth- 
drami.  anil  if  any  hloorl  app*'ars  the  needle  should  be  reinserted  in 
order  tc»  avoid  inje<:tion  into  a  hl(K>dvessel.  The  inje<'tion  vi  the  sohi- 
tion  free  from  air  hiihhies  ran  then  take  plai:e. 

Sdtiitio]^. -  -Xar'itms  sidutions  4ire  in  u.se.  Only  a  few  vau  be  men- 
tinned  hen-. 


R — Hyftmrayri  wgwiodoLaM um.  0.2 

HtxUi  ioJidi Km.  0.3 

Aq.  (itwt sm.  10. fl 

D«w — 10  to  2V  niiiiinu  cvmtitutc  the  duanno. 

It — H>'<lrarKyriliictatu ,      .  mn.  0.2 

A<i.  dofli C.C.  W.O 

Dow — 10  lo  26  iniuinUL. 

If — Hydrarityri  NucciiuunMli pii.  0.2 

A<|.  diwt I'.c.  10. 0 

r.low — 10  1(1  so  miiiJRM. 

R — HydrnrjoTi  chlimdi  mmmvuni  ....  icm.  ri  .^ 

Sodii  rtiloridi loii.  -i  U 

At),  clnrt Km.  HW-0 

OMe— 1  to  2  o.e.  daily  or  nltvriMle  diij's. 


KT.iiJ 

W.  V 

5Ii« 


Iff,  viy 
ler.  xlv 
Siij 


The  use  of  coiroiMvc  siiblinmte— foiluwing  Ia^-wiii— is  usually  very 
painful. 


B — HydrttfTtj'ri  cynuidi 
CViPttiii  hydrtichloriHi 
Aij.  J«il. 

I)UM( I       III     2      I'.V: 


nd 


RUl. 

l.O 

gr.  XV 

fOIt. 

0.3 

tr.  V. 

icm- 

100.0 

Siij 

A  useful  vnriant  of  thi.s  rnmbines  the  ryanide  with  nrsenie  and 
strjchniue,  as  fdllows: 

t^ — ^Hydmrgyrl  ryMnidJ, 

StO'ch.  ftrx>nnli« ftl     mn-      0.6     H&     4cr.  ix 

Coi-niji  iiiiiriiir ttni.      0.:i  icr.  v 

Aq.  dMi Kni.    00.0  Su 

Diiae — 6  tu  10  iiiJuinui  every  nthn  day  fur  20  tu  2!i  tbam. 

Cocain  may  be  added  to  &ny  of  the  soluble  salts.  Its  additioa 
lefvsena  the  pain. 

Fournier  has  always  advocated  the  use  of  the  binioiiide  di.sftolved 
either  in  sterilized  oil  or  tn  water.  It  is.  he  claims,  paiiilt-ss.  sure,  and 
free  fruin  daiigiTs.  In  24.")7  iiije'itiims  (inly  9  prfiduird  pain.  Sneh 
results,  however,  obtain  only  when  the  physieian  is  very  careful. 


1 


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700 


srpBrus  OF  the  f!BRroirs  sr.sr^jir 


Careless  uae  with  the  binuKlidt-s  will  prtMluw  all  of  the  :u*t:i(1ents.  pain. 
absccHH,  etc. 

R— Hydrargyri  hinliidido gm,      tl.^l  bt.  vj 

Olive  oil  (ntcrilised) gm.     10.0  31iM 

D<i«f> — Uao  l*nvai  3>*rinKetul  ovory  other  clny. 

I|— Hy()rari!:>Ti  1>iDi<idide nn.      0.2  gr.  iii 

SotUi  ioditlL- gm.      O.'i  Itr.  uj 

All-  <li<!<[.  em.    10.0  3ii"H 

D<HK>— 1  U(  2  c.r.  tlaily  or  mi  (ilti-mnU-  t\a.y»,  wirli  KnMJu&J  cl*vaUon  of  the  doae  If 
BttmiatitU  or  Raaim-iuteeiinal  §iKiifl  nn>  uut  in  ovid4?ur«.  Twenty  Ui  tweuly-Gvc  injoo- 
tioiM  constitute  n  coum  of  tr«Ktmont. 

I) — HydrarRyri  Ixtuinatja  .      , gm.      1.0  gr.  xv 

Soclii  chktriili kiq.      2.5  gr.  xlv 

A*|.  dost gm.  120.0  Jiv 

DoBo^l  to  2  p.c.  daily  or  ou  nltoruiit«  daj'H. 

Combined  arsenical  and  mercurial  injections  M.*ere  very  mtic^  in 
vo^ni'  before  the  IntrfKhK-tirni  of  the  walvarsun  prepa  nit  ions.  One 
of  tlie  must  popular  c»f  these  ha;-  lieeu  the  arsenical  salicylate  or  enesol. 
This  remedy  has  laeeii  used  widely  in  nervous  sj-philis  and  often  widi 
siirprisinfjly  good  results.    .Sfhaffer  speaks  ven.'  highly  of  it. 

The  eoinbiiieil  use  of  the  eaeoilylaten  and  of  mercury  has  lieen 
observed  to  give  fjood  results.  The  early  reports  of  optie  nerve  ilisease 
apparently  foUowinn  the  use  of  the  eac-odylate.'*  served  to  force  these 
salts  into  the  background.  Iruusumeh  as  such  optic  nerve  citanges 
apparently  fxrurred  hi  other  than  syphilitic  patients,  it  would  not 
ap|>eiir  thai  they  are  to  lie  interpreted  as  ijistJiiices  of  those  neuroreci- 
dtves  which  have  been  so  actively  discusseil  since  salvarsan  has  been 
introductxl. 

Saitarsan  and  Nemalrarsan. — Any  attempt  at  an  exhaustive  sum- 
mary {»f  the  various  reports  upon  this  remedy  hi  the  treatnicnl  of 
nervous  syjihihs  would  require  a  ^iK'tial  vohunc.  A  simple  enumeration 
of  the  bibiioprnphy  alone— bent  obtained  in  brief  in  Lewanduwsky's 
Ilandbuch  dcr  Xeurologie,  articles  by  Forster  and  .Schaffer  and  others — 
in  Xonnc's  discussion,  nfemd  to  later,  would  require  ctozens  of  pageii. 
Only  the  present  (1917)  drift  of  opinion  wilt  tiere  Ix*  exjm'sse<l. 

In  the  exudative,  hyperplastic,  gummatous,  nud  arterial  forms 
salvarsan  is  by  far  the  most  efficient  remedy  possessi.'d  at  the  present 
time.  One  form  needs  to  l;>e  excepted,  that  of  tlie  large  gummata, 
for  which  surgery  alone  is  adequate.  It  would  also  ap|jcar  that  much 
larger  doses  of  salvarsan  are  retniired  for  nervous  s\*phili8  than  were 
used  in  the  earlier  stages  of  its  julministration.  Since  the  use  of 
adequate  dosage  the  so-called  neurorecidives  have  almost  entirely 
disappeared.  It  is  the  present  trend  of  oi)inion  that  mercury  uud 
salvarsan  eoudiincd  gives  the  Ijest  results.  Whether  or  not  arsenic 
and  mercury,  both  active  spirochetal  drugs,  supplement  each  other  in 
this  itimbined  iwe  is  not  eertiiin,  but  the  results  obtained  have  in  many 
instances  been  very  satisfactor>'. 


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needs  to  be  obstrxed  tht 


llxT  of 


stTvecl  tiiat  a  miinlxr  ol  patients 
s  (if  tlu-papy  in  iiervnns  syphilis  have 


At  the  same  time 
liavf  n'Ia]>st'(],  ami  tht-  final  rcsu 

been  far  from  U'iiig  as  hu[*cful  as  had  first  appeared.  Beaiuije  tliis  has 
H'  been  so  is  no  reawjn  why  it  sliouliJ  remain  so.  The  most  obvious  reason 
H  that  stands  out  in  many  of  the  recent  disrussions  that  have  taken 
H  place  relmive  to  this  jjoint  is  that  the  patients  have  been  insufficiently 
'  treate<i.  Finally,  salvarsan  ha-s  not  been  lonRenonph,  as  eompareii  with 
mercury,  in  use  to  Wiirnint  anything  but  a.s  yet  tentative  ei>ne]u.sinns. 

With  this  short  siimmnnr'  of  cnnchisions,  a  few  words  may  Ik*  said  as 
to  its  applieiition  and  dosaRe.  Whitther  neosalvarsan  is  to  replace  sol- 
varsjin  or  not  cannot  yet  l>e  detcmiiiM-d.  The  intravenous  adniinis- 
tration  of  salvarsan  is  the  lxt>t  method  of  p^'i^K  't-  It  should  not  be 
given  unless  the  patient  is  under  some  sort  of  supervision — in  a  hosjiital 
or  remaining  in  iK'd— and  minute  attention  to  the  teehnic  is  absolutely 
no(*ssar>*  to  avoid  certain  dangers.  It  is  highly  important  thai  fresh, 
distiltcd  water  be  employed  if  salvarsan  is  to  be  ttsed  intravenously. 

'i'o  kill  spirochetes  in  the  nervous  system,  however,  is  one  thing, 
and  to  overcome  the  results  of  tissue  ehaiifies  is  quite  a  difTerent  one, 
and  this  atmve  aSt  is  tlie  sttimblinR-bttK^k  in  the  treatment  of  nervous 
tissue  syphilis.  NVvertheless.  if  nerve  tisNues  have  not  t)een  extensively 
destroyed,  one  can  hope  for  excellent  results  by  a  proper  combination 
of  salvarsan  therapy  with  mercury. 

Salvarsuii  must  be  uat'd  in  much  larger  quantities,  Itowever,  than  was 
at  first  thought.  At  the  end  of  this  section  the  outlines  of  an  ener^tic 
combined  therapy  U  given,  and  reference  may  be  made  to  those  pages 
for  the  general  indications  of  such  a  course  of  treatment.  Mi>diHca- 
tions  to  a  le.ss  active  mercurial  salt  than  calomel  may  have  to  I>e  made. 
Every  patiertt  needs  indt\idual  treatment. 

Notwithstanding  the  very  evident  fact  tlmt  salvarsan  and  neosal- 
varsan are  active  s]i)riK'lielicidal  dru);js,  it  is  still  an  in^^Hirtant  problem 
how  to  reach  them  in  the  nervous  s>"stem.  Tarcful  chemical  invc»- 
tigation  of  the  cerebrospinal  fluid  has  hen*tufore  failed  to  obtain  any 
trace  of  arsenic  wlicn  salvarsan  has  Ijeen  given  in  the  usual  manner. 
One  may  infer  that  the  arsenic  has  become  fixed  in  some  chemical 
combination  which  fails  to  react  to  the  usual  chemical  tests.  It  is  not 
yet  fully  comprehensible  why  ner\'oiis  .sj-philis  is  so  resistant  to  treat- 
ment and  why  the  hope.<i  aroused  by  the  striking  results  of  salvarsan 
therapy  in  general  syphilis  seem  not  to  liuve  been  borne  out  in  nervous 
sj-philis. 

.Swift  and  Ellis  Irnve  attempted  to  ])Ihiv  a  spirwheticidal  solution 
directly  into  the  (■erebrospinal  Huid.  Salvarsan  and  neosalvarsan 
were  employed  by  direct  injection  into  the  spinal  canal  through  the 
Quincke  lumbar  puncture.  This  method  they  found  wa.s  to  Iw  con- 
demned. It  failed  to  give  any  beneficial  results,  and,  moreover, 
eaus*'<l  marked  pains.  It  is  probably  a  dangerous  prmredure,  as  animal 
experimentation  has  shown. 

All  attempt  was  then  made  to  introduce  into  the  patient's  cerebro- 


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SyPflTUS  OP  THE  NERVOUS  SYSTEM 


spiiuil  fluid  some  of  his  own  blood  serum  which  Itad  previously  been 
mixer!  witii  thr  siiKarsau  by  intravfiious  infusiou.  This  procedure  is 
farric'd  out  in  the  iisiml  uianrnT.  After  a  certain  lenjrth  of  time— one 
hour  was  found  to  i;ive  the  most  artivc  scrum — blond  was  withdniwii, 
se|>arated  from  its  corpusi-les,  afti'r  twenty-four  hours,  dihitLv)  with 
40  per  pent,  of  normal  .saline,  und  then  heated  to  51;°  C.  for  thirty 
mitintes.  A  Inmhiir  pinu-ture  is  then  m«dc.  and  from  5  Uj  \n  c.c.  of 
wrehrns]mHiI  (hiid  is  withdrawn,  r  <'■•  until  the  pressure  falls  to  31) 
mm.  of  merenry.  Thirty  cubic  millimeters  of  the  wiirined  serum  U 
then  injected  intci  the  subarachnoid  spaces.  The  patient  must  lie 
quiet,  the  foot  of  the  bed  usuiilly  Ix-ing  raised,  .\ftcr  ten  days  tn  twit 
weeks  the  injeeticms,  which  are  usually  well  borne  are  to  be  n-jH-alrtl. 

They  thus  obtained  very  striking  results  in  the  aerlon  upon  the  sero- 
hiulo(»ie-aI  factors  kmiwn  to  accompany  (rerebral  syjiliilis.  Then  a  more 
crucial  experiment  was  plaiuied.  This  (vjiisists  in  the  introduction 
into  the  siiharachneiid  sjiai-es  of  serum  taken  from  another  individual, 
usually  a  secinidary  syphilitic  under  treatment.  The  tedmie  beinn 
that  just  outlined.  In  the  treatment  of  tabes  by  a  heterulugous 
Mcrum  most  excellent  results  have  been  obtained  in  some  rases.  In 
others  they  have  been  nil  or  positively  c]aiipen>us.  Wfiy  the  striking 
ehanit-ter  of  the  re.sults?  for  it  is  at  once  evident  t^uit  the  amount  of 
spiroelietic'idal  subsfiimv  in  a  frw  rnliic  eentimeti-rs  of  scrum  taken 
from  the  body  of  another  patient  who  hml  ri'ceivcd  the  usual  intra- 
venous salvarsan  therapy  must  be  very  small  indeed,  i.  e.,  retfkoned 
as  arsenic.  If  other  fuetors  than  the  salvarsan  itself  enter  into  the 
situation  these  are  as  }et  unknown.  One  significant  fact,  however, 
would  tend  to  indi<-ate  that  other  fora-s  nrv.  operative.  Kxtensive 
experiments  carried  on  by  Swift  and  Kills  with  the  heated  uni!  unheatetl 
serums  show  that  the  heated  sera  are  three  times  as  spiroehctiridal 
to  SjiiriM-firfti  iliittiitih'  iti  mice. 

In  the  lrt.'iiLinciit  of  tabes  the  intnisphial  method  Is  often  ver>' 
efficacious.  Again  it  is  disadvantageous.  The  advantages  outweigh 
the  <li.sjulvantages.    Excessive  pain  is  sometimes  the  Krst  reaction. 

In  the  treatment  of  paresis  intracranial  injections  of  salvarsan! zed 
serum  offer  increasing  evidences  of  amelioration.  These  injections  may 
be  iiitervciilrii'vilar  or  intradural.  The  indications  are  crystallizing. 
The  general  trend  is  to  make  a  rapid  attack  by  iiitmveiions  methods, 
which  if  Linavailing  ean  be  foDttwed  uji  by  the  Intracranial  ruute. 

The  most  striking  suggestive  result  is  an  atmo.st  immediate  diminu- 
tion in  the  imniber  of  pathological  cells  in  the  cerebnwpina!  fluid.  The 
globulin  reaction  diminishes,  |x>sitive  Wasserraanas  of  the  cerebro- 
^piirnl  fluid  with  small  quantities  of  Huid  require  larger  quantities  to 
sliow  positive  or  lM"e*>me  negative,  and  the  nnielioration  of  tlw  symp- 
toms has  in  H  few  ea.ses  I«hmi  rapid. 

yfrrriin/  hi/  thr  Mouth. — Mercury  by  the  miiutli  will  alwn\s  renuiin 
one  of  the  simplest,  and  yet.  at  the  same  lime,  least  elHclenl  methixls 
of  treating  syphilis  of  the  nervous  system.    Here  again  one  has  a  rich 


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TftEATMKNT 

chdH-e  of  remedies.  Thoac  most  in  use  are:  protoiodide  fc'rsiu  J  to 
J,  snbliniHtc  jcniiix  g'j .  calomel  2  to  5  jcrnins.    Various  vehicles  are  used. 

The  disjid vantages  of  treatment  by  meaiis  of  the  intestinal  eiinal 
arc  many  chief  (if  wliieh  i.s  the  slow  anfl  weak  jietion  of  the  remeniiea 
employed.     Muretjver,  the  giistn>-intestinal  tract  sutfers. 

The  fhief  ad\'antage  is  that  mercurj'  may  be  ciimbined  with  the 
io<litIes.  Fwrthennure,  nitivenienees  of  nieilientiuii  must  often  eori- 
atrain  one  to  use  tliia  mo<Ie  <if  pvinjj  antisyphilitie  remeihes,  but  only 
as  a  necessary  choice. 

In  nervous  syphilis  it  would  apjiear  that  mercury  medication  by 
mouth  is  not  ra<lical  enough.  (llie  may  use  it  after  an  energetic 
treatment,  by  The  methods  outlined,  has  been  employed,  but  oral 
administration  is  nirely  a  uiethod  of  certain  vniuc,  and  hence  is  not 
Hxlvisiible,  save  under  particular  cireiim stances. 

Ami>ng  the  newer  merciyy  preparatiuns  wliieh  futuri-  experience 
may  prove  to  Iw  of  value  are:  Mercury  dicarboxylate.  two  forms  of 
which  are  on  the  market,  with  pronounced  toxic  action  on  spirochetes 
in  rabbits.  It  ii*.  claimei)  to  be  twenty  times  as  toxte  to  spir<fclietes  as 
corrosive  sublimate,  and  yet  shows  no  action  on  the  body.  Its  dosage 
huA  not  yet  fweu  wurkeil  out. 

Ifxiutfs. — Sodium  and  [wtassium  i«lide  have  been  use<I  in  the  treat- 
ment rif  sypliiH>  of  the  ner\ims  system  for  years,  and  often  with  good 
results.  Acconling  to  .\eisser  the  iinlides  are  weak  spirochetal  poisons. 
Our  belief  in  its  rcsorptivc  jxjwcrs  is  justifie<l  on  empirical,  if  not  cm 
phami an ) logical  grounds.  IVrsonal  ex[>erience  does  not  confinn  tlie 
belief  in  the  efficiency  of  specially  large  doses,  although  that  is  the 
American  pn'ference. 

The  use  of  the  imiides  in  doses  of  from  10  t<i  3f)  grains  t.  i.  d-  ciim- 
bined with  mercury  is  particularly  xaluable  in  the  gummatoiLs  type 
f)f  cenibral  syphilis.  It  is  folly,  however,  to  try  to  do  awiiy  with  large 
gummata  by  means  of  massive  dose.s  of  iodides. 

The  flosage  nf  tlie  i«»dides  will  dci)cnd  uiMin  the  itidividiial.  There 
are  numy  idiosyncnisies  to  be  lH)nie  in  mind.  At  times  small  duses 
cause  marked  disturbances  and  cannot  be  bonie.  Here  one  may 
employ  other  combinations  than  those  of  sodium  or  potassinm.  TIencc 
strontium,  nibidiutn.  and  organic  iodine  prepjiratiims  have  come  into 
use.  lofiopin,  sajiMlin.  iothiglidin.  iixtoval.  iothicitin,  iodustarin  arc 
among  the  newer  of  these  aimbinations. 

IrHlopin  may  l>c  injected  as  well  as  admini.sterefl  by  mouth.  In 
the  former  easo  it  is  u.se<l  in  quantities  of  10  c.c.  on  altenuite  days, 
or  smaller  doses  i  U>  .1  c.c.  at  nn»rc  frY'ipiciit  iTiler\'als.  In  giving  it  by 
li.vptKlennic  both  the  syringe  and  the  remedy  should  be  slightly 
warmed,  the  needle  :»liould  luive  an  lunple  bore,  and  the  drug  be  intro- 
duces! slowly.  It  is  also  given  by  the  mouth  in  3j  doses.  In  the  form 
of  iiMlitpin,  liirge  (piantities  of  iodine  may  Ik-  introduced  without  toxic 
effect.    Its  action  on  nervous  sj-philis  has  m»t  been  extensively  .■<tudie<l. 

loiiovftl  anil  iodocitin,  the  latter  a  lecithin-albumin  comi^und,  have 


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704  SYPHILIS  OF  THE  NERVOUS  SYSTEM 

been  found  to  be  borne  well  in  the  course  of  salvarsan-mercurial  treat- 
ment. The  former  is  given  in  doses  of  about  5  grains  t.  i.  d.  throughout 
an  energetic  salvarsan-mercury  treatment — the  latter  in  about  the 
same  doses. 

Plan  of  Intensive  TTeatment.—'Saxov&  syphilis  is  treated  too  gin- 
gerly by  most  practitioners.  It  is  difficult  to  kill  the  syphilis  organism, 
hence  an  energetic  course  of  treatment  is  here  outlined; 

First  day 0.03  calomel  (or  other  mercurial)  h^'podermically. 

Third  day 0.06  calomel  (or  other  mercurial)  hypodermically. 

Fifth  day 0.4    &alvarBan  intravenously. 

Seventh  day 0.5    solvarsan  intravenously. 

Ninth  day 0. 1)5  calomel  hypodermictilly. 

Kleveiitb  day   ....  0.05  calomel  hypodermically. 

Thirteenth  day      .  0.4    salvarsan  intravenously. 

Fifteenth  day  .      .  0.5    salvarsan  intravenously. 

Seventeenth  day    .      .      .  0.05  calomel  hypodermically. 

This  should  be  continued  for  six  weeks,  or  until  at  least  5  gms. 
of  salvarsan  are  administered.  The  whole  course  can  be  com- 
pressed into  three  weeks  if  a  soluble  mercury  salt  is  given,  and  at 
least  5  gms.  of  salvarsan  can  be  administered  in  that  time.  The 
patient  should  be  watched  verj-  carefully,  especially  with  reference 
to  the  kidneys.  Furthermore,  there  are  patients  who  do  not  bear 
calomel  well.  \'agotonie  individuals  react  excessively  to  mercurj', 
especially  to  minute  doses.  (Compare  article  on  Sj'philis  of  the 
Nervous  System  in  Modern  Treatment  of  Nervous  and  Mentcd  Diseases, 
White  and  Jelliffe,  Vol.  II). 


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PAKT  in. 
PSYCHICAL  OB   SYMBOLIC  SYSTEMS. 

NEUROSES,  PSYCHONEUROSES,  PSYC^HOSES. 


Introduction. — In  di-uling  witti  the  individual  at  the  psyuhological 
Ifvel  it  bewmics  necessary .  for  the  first  time,  to  u«  tenns  which  refer 
to  the  individual  iw  a  whole.  In  fact  that  is  nidy  another  way  of 
HesiKnatinR  what  i>sychnloffy  is.  At  tlie  physifnchemical  and  the 
sensiiriiTinlor  levels  it  was  jmssihle  iti  deal  with  isolated  jihennnieua 
so  far  only  as  n-lateil  tti  the  (mrtieiilar  and  irntiiediiite  mil  uf  tin-  rime- 
lion  umier  consideration.  Vor  example:  tapping  the  |»atella  tendon 
pr<Kiuecs  an  extension  of  the  Icff  on  the  thi^h,  which,  if  avcraKC  In 
extent,  indicates  a  normal  nurtor  pathway  to  the  quadriceps.  .\t  the 
I>!'ycholojri<-al  Ie\'el,  however,  it  i.s  no  lonj^er  ixwsible  to  deal  with  parts 
of  the  imhxidiial  in  this  way.  but  the  whole  individual  comes  at  once 
umler  eoiisideration.  Thus  it  may  be  u  question  tif  desire,  of  failure, 
of  regret,  nf  ineffieieney  (»f  all  sfirts,  hut  it  is  always  a  desire,  failure, 
regret,  or  what  ititt,  of  the  individual  The  imliviilual  as  sueli  has 
failwl  in  elTeeting  an  ndequatt'  adjustment.  The  failure,  it  is  true. 
may  have  been  txiiiditioned  by  bad  vessels,  by  vlscvral  disease  of  all 
sorts,  but  the  eou.sideration  of  these  factors  is  a  consideration  at  the 
physiolojncal  level.  As  soon,  however,  as  the  pmblem  is  expressed 
at  the  psychnlojrical  level  it  is  of  netvssity  expresse<l  in  tenns  that 
refer  to  the  iridlvidiml  as  a  whole,  as  a  soelal  unit. 

A  few  paragraphs  devoted  tn  an  atH-ount  of  the  developmcEit  of  these 
tendencies  of  the  whole  individual  l)efore  taking  up  &  conaideratioD 
of  the  disorders  al  this  level  will  be  useful. 

The  baby  in  its  mother's  uteru.s  has  no  desire-s;  it  has  to  do  nothinfr 
for  itself,  not  even  to  breathe;  it  rest^  quietly,  far  remove<l  from  sources 
of  outside  stimnlattou  and  irritation,  every  function  being  performed 
for  it  by  the  mother.  After  the  Ijaby  is  bom  this  condition  of  affairs 
still  continues,  or  at  least  an  effort  is  made  for  it  still  to  continue.  The 
baby,  to  be  sure,  has  to  t>egin  to  breathe  for  it.self,  to  eat  for  itself, 
to  pcrfomi  the  functions  of  digestion  ami  elimination  for  it.self,  but 
on  the  other  haml,  there  stand  about  the  army  of  the  hoiLsehold.  not 
satisfied  to  wait  upon  desire,  but  with  every  heartstring  of  emotion 
ten.se  ttt  forestall)  tt.  lie  is  ^^'ailetI  u|kiii  hand  ami  foot  by  all;  he  is, 
in  the  sense  that  every  desire  is  satisfieil,  truly  omnii>f>tent. 

As  the  days  gi)  by  and  development  proceeds  apace,  as  the  sense 
organs  Iwcome  more  acute,  the  nuiseiilar  adjustments  more  refined, 
45 


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PSYCHICAL  OR  SYMBOLIC  SYSTBMi 


the  baby's  rontnct  with  the  wririd  booomo;*  proprcssively  and  increas- 
ingly foinj)lcx,  and  try  as  they  wiU  the  loving  attendants  cannot  fore- 
stall all  of  his  desires,  find  so  there  mme  times  when  fund  is  not  offered 
at  the  instant  it  is  nce(le<l,  when  sleepiness  ovcrlakci  the  Uiby  but  lie 
cannot  woo  it  if  he  is  in  a  hrijtht  and  noisy  street  or  on  a  clattcrinj? 
car  far  from  his  soft  l»ed.  And  so  tliere  arises  in-sidiously  btit  neces- 
sarily the  meitta]  state  of  desire,  things  vrished  for  because  they  are 
not  had. 

Still  even  in  tliis  stage  oF  deveti>|>inent  tlu-  discTepaney  between 
desire  and  attniiunent  is  not  great.  Attauuiient.  in  fact,  is  usually 
very  near  at  hand,  the  hunger  is  not  permttted  to  last  Jong,  the  baby 
does  not  have  to  I>e  kej>t  awaVe  by  noises,  excejrt  for  a  brief  pcrio*f, 
while  in  the  matter  of  other  desires,  such  for  instance,  as  the  <iesire 
to  empty  the  bladiler, ,  that  is  indnl^xl  in  ffirthwitti  «-ithi>\it  any 
further  eonsideration  of  the  matter.  As  devehipnient  progresses,  how- 
ever, desires  become  more  and  more  nuiucrous,  because  the  baby 
touches  reality  itt  more  numerous  jMiints,  and  each  one  of  these  {>oints 
offers  a  new  possibility  for  a  frustrated  or  delayed  desire,  while  with 
such  matters  as  emptying  the  bladder  there  soon  steps  into  the  situa- 
tion the  .social  repressinns  represented  by  the  prohibitions  of  the 
mother. 

Thus  growuig  up  in  the  life  of  the  baby,  Ijcginning  even  in  the  earliest 
days,  an  ever-inereasing  discrepancy  between  desire  and  attainment 
takes  place,  and  as  the  years  go  on  it  will  be  seen,  without  the  neees.sity 
for  further  illustrations,  that  the  amoral,  egocentric  baby  must  grad- 
ually take  into  considenition  the  world  about  him.  He  is  forced  lo 
lay  his  conduct  along  certain  lines  which  imply  a  putting  off  of  the 
satisfaction  of  desin'  into  an  e\'er-reeeding  future.  Later  in  life,  when 
he  is  hungry  and  wishes  to  «it,  he  can  only  satisfy  this  rlesire  pmvidetl 
he  has  worked  and  earned  the  wlierewithal  to  buy  food,  and  if  he 
endeavors  to  satisfy  it  otherwise  by  taking  any  food  that  may  Ix'  at 
hand  he  (tffcnds  the  social  usages  and  becomes  a  thief.  If  he  wishes  to 
empty  his  bladder  he  has  to  watt  imtil  he  gets  to  an  appropriate  place; 
it  cannot  be  done  anywhere  and  at  any  time.  He  has  to  adjus^t  himself 
to  the  requirements  of  society  or  run  serious  risks  if  he  fails.  As  he 
Iteeomes  progressively  ninre  complex,  as  his  desires  bwome  niiire 
and  more  difficult  of  fulfilment,  as  he  demands  more  and  nmre  of  the 
world,  tlie  in<lividual  finds  that  he  has  to  put  otf  fulfilment  further 
and  further  into  the  future  and  be  satisfied  to  struggle  perhaps  for 
years  to  attain  some  specific  end. 

Conflict  is  therefore  at  (lie  \ery  Itasis,  the  very  root  of  mental  life; 
the  adjustment  of  the  iniJiviihiul  to  the  world  of  reality  is  by  no  means 
the  passive  nntlding  by  cxteriml  forces,  but  the  individual  Is  eoiLstaiitly 
and  actively,  in  hit  mind  at  least,  reaching  out  and  trying  to  mold  the 
world  to  suit  himwU. 

It  is  from  this  ba.sal  fact  of  conflict  that  there  take  origin  two 
foniis  of  thinking,  an  understanding  of  which  is  of  great  importance 
for  the  comprehension  of  the  psyelioneuroses,  in  fact  for  all  behavior. 


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rsrnoovcTios 

sick  or  well,  'lliinking  whidi  is  dominated  by  the  renlity  motive,  the 
thinking  which  Is  a  conscious  intentional  effort  at  eflicient  relation 
with  ri-;Uity.  i;?  the  ihinklnj;  lo  whioh  the  won:!  thinking  is  usually 
apiilini.  Hut  there  is  aticither  kind  of  thinkiiifi.  the  thinking:;  |>y 
phantasy  fiiriimtion,  whieh  is  of  great  iiii|)(irtaiKr.  In  thi.s  fonn  of 
thinking  it  is  not  the  reality  riiotivi*  that  flominates,  but  tiie  pleasure- 
pain  nii'tive.  The  other  honi  of  the  omflict  is  here  representefl,  anti  in 
nionicnt:^  of  quiesc-entr  whrn  the  real  world  :*lips  awiiy  fnmi  our  vitiiori 
and  we  s«'ttle  hark  wilhin  ourselves,  our  thoughts  flow  without  refer- 
ence to  this  outside  world,  they  come  ami  ^o  without  critlcjue  (in  our 
part.  We  Hradreantiiip,  perhaps  in  sleep  or  perhaps  in  wakings  and 
these  fancies  which  come  at  these  nionieiits  of  runiiimtton  are  oil  wish- 
fulfiling  fancies  contn>lle<l  by  the  pleasure  motive  and  represent  tlie 
satisfaction  of  desires  which  are  either  put  off  or  r^-ndered  incapidile 
of  fulfilment  in  the  real  worl<i.  The-se  thoughts  are  not  only  the 
thoughts  that  dreams  an*  made  of,  but  the  thoughts  whieh  the  psy- 
ehoiieunises  are  lUiule  of.  and  are  therefore  of  immeiLse  importance 
for  their  understanding. 

I'Vom  the  very  first  tlie  iinniediate  .satisfaction  of  desire  is  fnis- 
trated,  to  be  technical  it  is  represse*!  and  some  other  form  of  activity 
has  to  be  substituted,  for  example  in  later  life,  to  use  uur  stime  illus* 
tratinn.  instead  of  maintaining  the  immediate  relationship  lH;tween 
hunger  ami  futKl.  there  is  introduced  another  series  of  factors,  repre- 
sented by  work  ami  eompensjition  for  work  in  the  shape  of  money, 
which  mr>ney  may  be  exchanged  for  fowl.  And  so,  instead  of  the 
immeiliate  relationship  that  niiiiiitains  in  infancy  a  more  remote 
relationship  is  uiaintaiued,  anrl  the  activities  instead  of  going  straight 
to  their  g<->al  take  a  more  or  less  circuitou!?  and  involved  i>atli.  The 
original  relalioitship  therefore  tends  t<i  be  lost  sight  of.  and  the  more 
involvod  and  complicated  one  takes  its  place.  There  arc,  therefore, 
gradually  thnnighoul  the  jM-ricKl  i)f  ihrvelopinent,  all  s<irts  of  desires 
being  repix-sseil  which,  thus  ]iut  out  of  consciousucss,  are  replacnl  by 
other  forms  of  activity.  The  desires  which  belong  to  infancy  and  which 
thus  arc  early  repressed  and  substituted  by  other  forms  of  actiWty, 
constitute  the  material  out  of  whieh  tlie  uii'ditMinii^  is  formed  and  tlie 
material  from  which  come  the  activating  moments  for  phantasy  for- 
mation. Tlie  discrepanry  between  d^'sire  and  fulfilmert,  then,  is 
com])eiLsated  in  hiter  life  by  the  wisli-fuliiling  pliantasies  tliat  have 
their  oripn  in  the  repres-seil  material  of  infancy  and  occupy  the  realm 
of  the  unconst'ious. 

Between  thi.s  realm  of  the  unconscious,  wldeli  <-cintains  relatively 
infantile  material  only,  and  the  realm  of  the  clearly  ctmscious,  there  lies 
the  realm  of  the  .so-caUed  foreconsciou.^.  which  coiitaiiis  the  material  of 
recent  experience,  material  which  is  «)uite  easily  made  itmscious.  In 
other  wonis,  it  is  just  out  of  mind  and  it  is  not  difficult  tn  bring  back 
intft  the  focus  of  attention  when  the  individual  so  dcsins. 

Tla-  region  of  the  uncons*.'ious  is  of  very  great  importance  for  an 
lUiderstaiiding  of  the  psyehoneun>ses,  U'cause  it  represents  the  region 


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of  the  (iL'tpest  reprfsskms,  of  tlie  thouf^hts  that  are  least  like  the  present 
conations  thoughts,  and  which,  therefore,  when  they  break  through 
into  con.scioiL<ine,ss,  prndmx-  symptniiis  that  ai*  so  gnitesque  and 
stranjie  appearing  U[khi  the  surface  ami  .iion-iimlerstjiiulable.  not  only 
to  the  (inlonkcr,  hut  to  the  piitient  liiiiiself.  It  is  thrn'forf  drsimble 
to  know  souiewhiit  of  the  nature  of  the  unc<jnHcii)U.s  and  of  its  amteiit. 
To  do  this  certnin  features  in  the  development  of  the  child.  [>articiilarly 
tliose,  of  course,  tluit  are  at  a  later  date  repressed  and  substituted,  by 
other  a<:tivities.  will  liave  to  he  dest^ribed. 

Bcfon'  doing  this,  iiowever,  it  is  necessary  to  point  out  that  all  the 
activities  of  the  individual  lead  in  one  of  two  tlirectioiis,  viz..  in  the 
directitm  of  self-])reservatl(>n,  the  nutritive  activities,  or  in  the  directiim 
of  rni-t'-presiTvatiou,  tlie  sexual  activities.  Tlie  energy  whicli  drives 
toward  these  jjoals  may  be  called  the  Ubi/io  an<l  ?o  it  may  lie  s|x>ken 
of  as  live  nutritive  or  tlie  .sexual  libido,  not  as  liitfereul  kinds  of  euergj* 
but  as  different  directions,  different  pathways  along  wJiich  the  euer?^' 
is  beinjc  use<I.  Now  each  organ  in  the  IwHiy  tends  to  preser\'e  itself  but. 
on  the  other  liahij  must  ^Wf  some  of  its  eiierpes  to  the  preserx'ation 
of  the  whole  individual  just  in  the  same  way  that  an  individual  ineni!»cr 
of  society  whtU'  he  strives  to  take  care  of  liiniself  must  give  sometliing, 
in  tlie  way  of  taxes,  for  the  general  weal. 

Self-preservation  and  race-prcscrvatioti  are  seen  thus  to  be  funda- 
mentally iij>posed  t(t  one  anotJier,  the  former  implying  geltintf  and 
keeping,  the  latter  giving.  One  who  keeps  that  which  he  should  give 
is  ndleii  .selfisli. 

From  the  few  wonis  already  devoted  to  the  evolution  of  the  indi- 
vidual fnim  the  early  wmditioii  of  n*lative  nmnipotence  it  will  be  seen 
how  the  change  has  to  In*  one  of  jiropx'ssivc  socialization.  For  example, 
from  the  infantile  immediate  re-lati<»nsliip  hunger — food  tliere  is  devel- 
oped the  more  remote  relationship  hunger — work  money — fiKxi  in 
conformity  with  the  social  refiuirenients.  'i'he  libido  has  to  be  social- 
ized or  to  use  the  more  fre<|Uent  term,  sublimated. 

In  that  proportion  in  wMfli  the  individual  is  unable  to  effectually 
sublimate  his  libido,  to  break  away  from  earlier,  infantile  ways  of 
pleasure  setikiug  to  higher  social  forms  of  behavior  he  is  crippled  in  his 
capacity  to  live  at  his  best,  and  this  crippling  in  its  uiihler  nianifes- 
tatiims  we  call  the  neun)srs  and  the  psyclnuieumses.  in  its  severer 
fonns  the  psychose-s,  and  in  its  most  severe  forms  tbc  various  grades 
of  defect  extending  to  the  depths  of  imliecility  and  idiocy. 

It  is  quite  obvious  that  the  idiot  and  imbecile  require  the  same  .sort 
of  si)licitous  care  as  the  normiil  Infant.  In  the  higher  gnides  of  ]>erson- 
alitv"  defect,  liowcver.  the  netressity  Ls  cluthcd  in  symbols  which  distort 
and  obscure  the  meanings  in  acconlaniT  with  the  mechanisms  already 
described  us  at  work  in  dreams  {if.  v.).  For  example,  a  patient  <]eveh>piS 
the  necessity  of  a  particular  diotar>*  n+ich  can  only  be  pn>vj<l«|  in 
the  home  and  every  effort  to  go  out  from  the  home  results  in  a  gastro- 
intestinal upset  lu-caiise  of  the  inability  to  obuiin  it.  By  this  s.\Tiibolie 
nieclianism  the  patient  is  therefore  pcrraittwi.  un4ler  the  guise  of 


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7m 


iiiviiliilism,  to  remain,  like  a  little  eliilil.  In  tlie  Imine  sitiiiitioii,  earcrl 
UiT  ami  |m>te<-ti'(l  from  the  world  of  n-ality  l>y  the  parents.  In  such  a 
case,  the  Renerat  rvsult  ))i>irite<l  is  iittt  unly  attainwl  but  anahsis  will 
show  that  there  va?.  a'n  early  fixation  upon  the  gastni-intesthial  ways 
of  pleasure  settkiriK  (a  siJ-ealM  |>artial  hhitio  trend)  wlilcli  determines 
the  partieular  form  of  the  later  symptums. 

'rh<-n  as  regards  the  more  distiiiftly  ratn"-presi.Tvative  or  sexual 
libido;  in  tlie  early  infaney  the  child's  love  is  very  naturally  given 
out  to  the  only  [H^opk- to  all  intents  and  purposes  who  constitute  his 
milieu,  namely  tlie  members  of  the  immediate  family,  the  father,  the 
mother,  the  brother,  sister,  and  jK-rhaps  nurse.  This  love,  etmtrary 
to  the  usual  way  of  thinking  of  it,  is  verj-  definite  in  its  direeti<m, 
and  from  a  very  early  date  presents  certain  sexual  characteristics. 
Of  these  sexual  eharacteristies  jealousy  of  a  younger  bnither  or  sister 
who  eiifufs  ititfi  the  family  atul  delleets  a  certain  amiiunt  of  atVeetion 
which  the  child  wnuld  otherwise  enjoy  is  within  the  observation  of 
most  people,  wliile  the  fa<t  that  the  love  of  the  child  is  given  out  to 
the  mentbers  of  the  family,  ehHnLcteristically  the  jjarent  of  the  opposite 
sex,  is  nut  u  matter  of  such  common  observation,  but  a  mutter  of  threat 
irajOTrtanee  psycholopieally.  As  the  ehihl  <ievel()ps  these  loves  are 
reprcsseil  and  covered  into  that  all-inclusive  amnesia  for  the  infantile 
period,  and  when  adulthood  comes  along  and  the  child  has  grown  to 
manhowl  or  womatduHKl  and  Hiids  its  mate,  the  love  which  had  before 
been  s]ient  upim  the  mernhers  of  tlie  family  now  finds  its  true  object. 

It  is  this  infantilf  lo\e  for  the  inend>prs  of  the  family  that  is  the  n)ot 
for  S4»  many  of  the  incest  phantasies  of  the  psychoneuroses  and  the 
psychoses.  This  love  for  the  jmn-nt  of  the  opiwsitc  sex,  for  example, 
if  it  breaks  through  into  the  clear  realm  of  eonseiiiusness  becomes  a 
horrid  thing  incom(>atible  with  tlie  imilviduars  peace  of  mind.  Such 
things  nTV  quite  common.  For  example,  a  jMitient  marries  a  man 
who  unfortunately  presented  a  number  of  verj'  close  resemblances 
to  her  father.  These  rirsemblances  ser^'cd  to  stir  into  activity  the 
unconscious  love  for  the  father,  and  she  therefore,  in  her  feelings  toward 
her  husbaii*],  is  outraged  beyonrl  all  en<lurance,  for  It  is  as  if  she  were 
married  to  her  father.  Life  with  her  husbaiid  is  quite  uiiemlurablc.  She 
is  constantly  (lying  into  ^mssions,  assiiulting  him,  upbraiding  him,  etc. 

If  this  psychology  is  the  usual  psychology,  why  h  it  timt  all  people 
arc  itol  in  danger  from  such  sources?  Perhaps  they  are  to  a  Hmitnl 
degree,  but  it  is  necessary  t*^  bear  certain  things  in  mind  to  under- 
stau<l  h<)W  the  unconseii>us  becomes  mbied  up,  as  it  were,  in  tlie  daily- 
life  of  the  individual,  as  in  the  case  just  cited.  Indinduals  ^^ith  such 
unconscious  father  complexes  v,i\\  get  along  in  life  perhaps  quite 
well  until  they  meet  some  difficulty.  The  difficulty  drives  them  Imck 
within  themselves,  it  prevents  the  outward  How  of  interest  into  reality, 
makes  tliein  egocentrir-,  iiitn>spective,  they  are  unable  to  make  an 
efficient  reaction,  and  they  therefore  are  driven  back  to  phantasy 
fonnation  where  things  eome  true  and  the  diRiculties  are  all  remove*!. 
The  reason  why  thb  driving  Iwek  of  the  psycho  physical  cnerg.v  \\ithin 


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PSYCnrCAL  OR  SYMBOLIC  SYSTEXfS 

the  iiidiviiltiiil  uiuler  condttinna  of  stress;  the  ruusDii  why  this  should 
.stir  up  a  iMirttciihir  complex,  is  becaiLse  iti  the  life  uf  the  Iii<liW<luul 
Tiion-  lias  \reeu  uu  iiinlue  fixutirin  ut  that  puiiit  ui  the  ifuir^e  of  <ic\fli>{»- 
nie'iit.  '\l\p  iwitii'iit  just  i-itcd  \in<\  iifver  \hvu  jihle  to  emancipate 
herself  as  she  should  huve  from  the  i]L'fe**ity  for  ihc  loving  c-are  ami 
temleniess  ami  iirotw'tiuii  of  the  fatlu-r  ami  to  go  out  into  the  world 
and,  so  to  spi'ak,  stand  upon  her  own  feet,  and  wht»n  difficulties  arose 
in  her  life  and  she  was  thro^ni  hatk  upi>n  herself,  sht-  wrut  back  to 
tliHt  point  lit  whiefi  there  had  been  iiii  infantile  Hxution. 

I'Voni  the  few  words  of  (lesffiptloii  of  this  [jatient's  coiiilitiun,  who 
Lad  syinbollddly  married  her  father,  it  will  be  aeen  Low  iiuportant  ic 
becomes  to  know  the  content  of  the  phantasies,  and  this  is  best  rleter- 
niined  by  a  study  of  tlie  dreams,  and  without  going  inUj  the  priiiciples 
of  dream  analysis,  which  are  out  of  place  lierc,  it  h  well  to  remember 
that  the  nennwis  or  the  psyrhotieunpsis,  like  tlie  dream,  is  not  only  a 
eonipniniise  JR-tween  defiire  and  fulfilmeiLt,  but  it  is  a  wish -fulfill  iig 
niechaiiisin  that  brings  to  pass  the  fulfilment  both  of  the  wnsh  In  the 
forecoiiscious.  the  wish  with  refereiicf  to  the  iUfficulty  ihnt  caused  the 
introversion  in  the  tirst  place,  ami  also  the  wish  in  the  uiK*(>ii?;c)ou.>i, 
the  wish  at  the  tixation-|>oiiit,  which  scn,cs  as  a  pull-back  once  the 
introversion  has  started.    (See  I'sychoaniUysis  in  Chapter  11.) 

Hearing  these  hu-is  in  mind  it  will  be  easy  to  understand  that  iJie 
child's  (irst  sexual  feelings  have  rvfcretiee  to  its  own  Imdy,  it  is  aut4»- 
erotic;  that  next  its  sexual  feeUugs  are  tnmsferred  upon  those  imme- 
diately about  him,  upon  someone  most  like  himself,  therefore  of  the 
same  sex  (homosexual  narcissistic  stage).  It  seeks,  in  other  wortis, 
outside  of  itself,  but  still  an  object  as  nmeh  like  itself  as  i)ossible.  And 
finally,  the  jxriod  of  abject  love,  when  fulfilment  is  had  in  an  entirely 
dltTerent  individual  and  of  a  different  sex  (heretosexual  stage). 

In  addition  to  the  above  facts  the  child  not  only  passes  tlirough  these 
various  stages  of  psyehosexual  develtipTueut  nientiontHl.  but  in  Its 
eirlicst  infantile  state  it  is  susceptible,  theoretically  ut  least,  of  ileflee- 
tion  in  any  direction.  So,  for  example,  at  the  period  when  the  love  is 
given  out  to  those  in  the  immediate  surromidings  it  not  infrequently 
is  given  tuit  to  a  member  of  the  same  sex;  differences  in  sex  are  not 
appreciated  in  these  early  days  aui!  come  only  with  later  development. 
Otlicr  tlitl'crences  are  equally  indefinite.  The  erogenous  zones  nf  which 
the  genital  orgiuis  are  only  one,  ami  the  anus  and  the  lips  eonstitulr 
the  most  im|wrtant  additional  ones,  are  still  more  or  less  nidefinite, 
and  sexual  erethism  may  be  predominantly  focalized  in  any  one  of 
them.  And  so  tlie  roots  of  the  various  so-<-alleil  [KTvcrsions  are  found 
in  these  early  fixations.  The  determining  factor  in  the  early  fixations, 
the  niechaiiisms  that  have  brought  them  about,  In  short,  their  uncov- 
ering, can  only  be  aecomplishwj  by  fathoming  the  unconscious.  This 
is  the  Work  of  iwyeboanalysis  and  the  most  prominent  means  iit  its 
disposal  at  the  present  lime  is  by  the  analysis  of  dreams.  (See 
Chapter  I!  on  Alental  Kxamination.) 


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CHAPTER  XV. 
THK  I'SYCHONKUUOSK.S  AND  ACrU.\L  NKUROSES. 

Tub  field  of  the  ueuruses  bh<1  the  psychoiieuroses  is  not  only  the 
broa<lest  field  in  i>sychiatry,  but  jKrhaps  the  broadest  Held  in  all 
medicine.  Not  only  is  the  field  an  extensive  one  in  point  of  the  actual 
number  of  persons  who  sulTcr  from  these  alHictions,  but  It  is  u  field 
of  verj'  great  imp<<rtaiice  for  the  understanding  of  mental  phenomena 
htitli  in  the  reahn  of  disease  iinil  tii  the  realm  of  the  heultliy.  It  is 
ill  the  manife:^tation»  of  these  dworders,  which  havf  been  well  termed 
borderlaml  states,  that  the  early  departures  fmm  the  normal  can  be 
found  ami  studiwi,  which,  hi  much  more  aggravated  form,  appear  in 
the  psychoses. 

Then  a^jdn  problems  that  lend  themselves  much  more  satisfactorily 
to  therapeutic  attack  are  to  be  found  here.  Thus  with  conditions 
which,  although  they  may  represent  pmctieally  any  degree  of  depjirture 
from  the  normal,  are,  as  a  rule,  capable  of  material  alleviation,  if  nut 
actual  cure  by  therapeutic  measures.  When  the  immense  number  of 
IX'ople  who  are  atTecled  by  neuroses  or  psychoiieuroses  is  eonsitlerwl, 
tlie  great  amount  of  suffering  that  these  diseases  entail,  the  impaired 
efficiency  in  which  they  result,  and  then  consider  that  they  are,  for 
the  most  pftrt,  sujiceptible  of  great  improvement,  if  not  actual  cure  by 
theroi)cutic  endeavor,  it  will  be  seen  that  this  department  of  medicine 
is  not  only  the  most  attractive,  but  is  one  whicli  perhaps  oilers  most 
in  the  way  of  results. 

The  number  of  people  actually  afflicted  with  these  conditions  is 
difficult  to  estimate.  The  frank  cases  of  the  psych (uieun>ses  and  the 
actual  neun)Ses  are  very  numeroiLs,  as  are  also  more  or  less  larvated 
conditions,  while  on  the  other  haml,  every  specialist  in  metlicine  is 
dealing  constantly  with  manifestations  of  these  conditions  as  they 
appear  upon  the  physical  side.  Perhaps  these  physical  manifestations 
are  best  known  to  the  gastro-entcnjlogist,  the  g>'riec<»logist.  and  the 
geni to-urinary  surgeon,  but  the  ophthalmologist,  tlie  lar^-ngologist, 
the  internist,  and  in  fact  e%'ery  specialist  has  liis  share. 

In  the  following  chapters  the  disorders  at  the  symlKilic  (psycholog- 
ical) level  will  be  discussed.  It  Ls  a  fundamental  tenet  of  this  book, 
however,  that  the  three  levels  trcatoil  hen'in,  viz.,  the  vegetative,  the 
sensorimotor,  and  the  symbolic  arc  not  mutually  distinct  but  only 
did'crent  aspects  of  tlie  strivings  of  the  individual  and  the  compoueut 
parts  thereof  as  e.\pres3ed  by  the  various  furnis  of  solutions  and  com- 
promises made  in  the  processes  of  integration  and  adjustment.    (See 


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PSrCHONEUROSBS  AND  ACTUAL  NEOtKiJiES 

IcitrfKliU'tiuii.)  Not  only  are  the  tliffereiit  levels  not  ilistitift,  hut  llie 
same  sjTiiptom  niiiy  arisf  as  a  result  of  (li.stiirl)ninT  at  imy  out-  i>f  the 
levels.  For  exiimpk*  coustiimlioii  may  Ite  due  to  a  liisturhaiK-e  at  the 
vej^tative  level  (vagototiic  spa,stio  coiistipjition).  <ir  at  the  sjTiibolir 
level,  a  purely  psychogenic  sjTiiptom.  Kurtlier  than  this,  purely 
emotional  causes  if  severe  or  of  long  <luration  may  produce  structural 
changes  from  which  recovery  is  very  slmv  or  impossible  or  may  pre- 
cipitate, by  alfordiiig  favorable  t-onditioii^.  si.'\ere,  even  fatal  infei-tiuiis. 
In  nil  of  these  coiHlitions  the  indixidual,  us  such,  is  more  or  less  :ieverely 
crippled  hut  the  understanding  of  the  syiiiptoms  and  tbcir  proper 
treatment  must  depend  upon  a  comprehension  of  the  me<'haiiisms 
involved  In  their  produnion. 

THE  PSYCHONEUROSES.    (HYSTERIA  AND  COMPULSION 
NEUROSIS.) 

Hysteria.— ^Hifltorical.— To  wriU'  the  hi.'^tory  of  hysteria  wnuM  mc&t 
prarticidly  to  write  the  history  of  nit'diciiii-,  for  hysteria  sljinds  thn>ugh- 
out  tlie  ages  IIS  the  tyjic  of  functional  disturbance  of  the  n<'r\'(>ii.s 
system  which,  protean  in  its  uuiiiifestations,  is  found  associated  with 
all  f^cat  therai^utic  movements  in  mc<Iie.iDe.  Whether  it  Ik?  tlie  thcrn- 
(M'utics  of  relipious  conversion,  of  I'erkin's  tractors,  or  h\-]»notisni,  or 
inore  rwently  of  persuasion,  a  considenihle  projMtrtion  of  the  patients 
who  recover  and  thereby  become  largely  responsible  for  the  vo^ne  of 
the  particular  therapeiutic  measure  involved,  belong  to  tJie  great 
clinical  givup  of  hysteria. 

Hysterical  manifestations  have  been  prominent  in  mental  epi<lemics 
that  have  swept  over  whole  eont'uients,  while  the  more  spccilic  and  the 
more  Rrotescpic  symptoms  have  always  betm  observe<l  and  describe*!. 

The  modern  perioti  in  tlie  history'  of  h>*steria  might  lie  said  to  have 
begun  with  <'harcot.  This  period  is  still  so  recent  as  to  be  withiii  the 
memory  of  many,  and  the  influence  which  the  Clmrrot  school  exerted 
is  still  all  too  dosninaiit  in  ivrlain  quarters.  The  picture  of  hysteria 
as  rharcut  drew  it,  particularly  of  the  grandf  hjsU-TU'  with  its  regular 
march  of  histrionic  attitudinizing,  as  set  forth  in  the  world-renowned 
pictures  of  Ilicher.  is  familiar. 

For  many  years  following:  Charcot  the  most  brilliant  work,  in  elu<*i- 
dating  the  hysteria  prolilem  was  tlone  in  I'rance.  and  many  illustriiHts 
names  are  crowded  int<t  a  few  years.  All  sorts  of  exjilanfttions  were 
fonnulated.  tlieorics  that  were  physiological,  that  wen."  psycho lu)(ival, 
and  that  were  biological,  with  numerous  variants  of  each,  Tlie  most 
illnminatiii);  worker  in  this  field  for  numy  yean*,  the  one  whusc  theories 
produced  the  greoitest  infiucncc  in  the  stu<Iy  i>f  this  disease  was  i'iorre 
Janet,  of  Paris.  His  was  a  theory  of  dissociation,  and  he  believed 
hysteria  to  be  purely  a  mental  malady.  Tt  was  due  to  a  p(H»r  s.mthesii* 
of  the  persimality  which  enable<l  wrtain  gn>ups  of  ideas  to  drop  euny 
from  effective  association  with  the  main  portion  of  the  persoiiulity- 


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HYSTKRIA 


713 


ami  (Utnipy  ti.  reginn  which  Janet  tertneil  the  subcrtiiscioiis.  itiul  there 
fxidtinc  iiiore  nr  Icms  in<!*.'[)ejMleiiti\',  pnKhuT  thoir  result:*  irn':<iHTtive 
of  c»rrtftioiis  from  the  rt-st  of  tlic  ])crs<)nality,  Thr  hysterical  innnifes- 
tatioas  then,  were  the  manifestations  of  these  split-i»fT  parts  of  the 
porsonulity.  Janet's  views  were  n  preftt  orlvance  ujx)!!  the  rurrent 
ctmcepts  of  hysteria,  hut  althoujih  they  renden-ii  pussihle  a  dee|»er 
insight  into  the  ruiture  uf  the  ilisease  mid  the  disease  pnxTsses.  they 
were  still  largely  descriptive,  though,  of  i-ourse,  the  deseriptiuii  was 
much  refined  frora  that  of  Charcot. 

Various  kinds  of  dissociation  theories  have  been  built  up  by  investi- 
gators Aince  Janet,  and  the  H  bwociation  theon'  was  variously  elaborated, 
partiruUirly  in  thi>  eonntr>'  by  Sidis,  White,  Prinee  and  others,  It 
reinninefi,  however,  for  a  Viennese  physician,  Sigmund  Kreud,  to  get 
beyond  tlie  puiiit  uf  deM;riptiun  into  a  true  uiter|>retative  attitude 
toward  tlie  disease. 

Frt;n<l  showed  llrnt  the  reason  for  the  dissodation  n'aa  that  the  dis- 
sociated ideas  were  init  of  harmony  with  the  rest  of  the  personality,  lliat 
they  represented  ideas  that  were  in  eoiiHiet  wltJi  tlie  ideas  forming 
the  WHisciousneAs  of  the  inilividiial,  aial  that  they  were  therefore 
repressed.  UcprMmm  became  with  Kreud.  then,  the  fundamental 
factor  at  tlic  bo>iis  of  hysterical  manifestations,  an  active,  not  a  pjissive, 
mental  factor  which  tended  to  put  out  of  mind  certain  inacceptable 
gn>u|>s  of  ideas,  and  was  therefore  the  cause  of  the  disswiatitm. 

The  Mechanism  of  Hysteria. — Starting  with  dissociation  as  the  most 
fnndinnental  dewriptive  term  applicable  to  tlie  hysterical  state — the 
dciiibliiig  of  the  perstuiality,  in  the  sense  of  Janet^t  has  Utu  showil 
that  tliere  is  at  the  Iwisis  of  this  process  of  dissociation  an  active  pnK'CSS 
called  repression,  which  lias  as  its  fiuictiun  tlie  splitting  ulT  of  inac- 
ceptable i<lea -constellations — complexes^from  the  main  body  of  the 
personality,  and  thus,  so  to  speak,  putting  them  out  of  niin<l.  It 
has  also  been  intimated  that  these  split-ofT  cf«mplexes  because  of 
being  split  off,  do  not  therefore  cease  to  act.  .As  a  matter  of  fact  they 
go  on  functioning,  hut  the  functioning  i.s  independent,  more  or  less, 
of  the  balance  of  the  perwnialily. 

This  pHK-ess  of  repression  and  dissociation.  foll<)wing  ujwn  conflict, 
i:^  a  vcr>'  general  one  and  is  fomid  in  divers  mental  states  ami  is  in 
fact  a  normal  process.  It  is  not  these  processes  or  meclianiam-s  which 
are  characteristic  of  any  ]>articular  mental  distjrder.  but  it  is  tlie 
way  in  which  the  split-off  ctnuiAfies  manifr»t  iJinnsrlre.s  that  prmluces 
the  different  types  of  mental  disonlers. 

From  what  lias  iM^'n  said  it  will  Ite  seen  that  if  the  imlividual,  or 
more  specially,  the  psyche,  be  consideretl  as  In-ing  a  complex  uf  adaptive 
mechanisms  which  is  always  making  an  cfTiirt  to  come  into  closer 
adaptation  with  die  envin>nnient,  then  the  meaning  of  a  conflict  is 
that  there  enteni  int(>  thi.^  niwhanisin  certain  factors  to  which  it  can- 
not, make  efficient  adaptation.  This  results  in  repression  ami  splitting, 
but  tlie  whole  tendency  of  the  machine  is  to  reailjiLst  effectively  by 


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brlii^'uii);  litKkUt  in  some  way  ii  new  stjitc  of  utTairs.    In  the  conflict 
thcrf  an*  two  (;n>u|is  of  tciidcmics  in  tlit^  jisyi-hc  which  iin^  (luiiuctri- 
cally  uppo.M-tl  one  Ui  the  nther.    No  si»Iiilioii  uf  rlio  conHict  can  |>«>ssibly 
hr  hnnij;ht  utmuT  hy  a  fiiltilmciil  of  (nir  of  thrsr  grfiuiw,  Uecau.sc  mani- 
festly tlic  ciiiiliicl  wiiuld  still  reinuiii.    Thurefon*  any  rt'u«Jjii.stinrnl 
tliat  takes  pliu'o  must  in  some  way  brici^  to  pass  the  tenrloncies  of  both 
linmps,    Inasnmdi  as  these  ^mu|»s  are  oppose*!  to  each  ntlier.  such  a 
result  caruiot  actually  he  hnm^lit  to  pass  in  the  world  of  reality  at  the 
level  of  the  conHict.    Therefore,  unless  an  adetjuatc  adjustment  can  l>e 
brought  about  by  an  all-inchiBive  sjTithcsis  at  a  higher  level  an  artifi- 
cial w»^^ld  which  Is  not  povernrd  by  the  strict  laws  of  reality  has  to 
beliroiiyht  ioto  cyistenee  wherein  these  opposing  forei-s  c«ii  both,  as 
it  were,  allej^orically  find  their  ends  attained.    This  is  well  shown  In 
tlie  followitiydirniti:    The  patient  said  "she  siiw  hersi-lf  tlviul,  h'mfi  in 
a  coffin,  with  a  red  rose  in  her  hand."    The  red  rose  syuiUtlized  her 
sweetheart  lietaiise  of  the  frequent  iirescnts  of  Tvd  roses  which  he  liad 
made  to  her.     Ueinj?  deail  in  a  ci}i\\u  prohahly  has  .st-veral  meaniiif^, 
but  among  others  has  the  meaning  r>f  a  regression.    The  coliin  is  the 
matrix,  it  symlwlizes  a  jioing  back  to  the  protcc-tion  of  the  nuither, 
and  *>  the  dream  s>^nh^lliKes  the  two  opposing  desires,  one  infantile, 
the  other  adult  and  recent. 

In  the  ditVercnt  nieTitiil  <!is<irders  this  end  is  hrouplit  about  In  differ- 
ent ways.  The  tiysterital  mechanistn  is  dilTerent  from  the  other 
mechanisms  inasmuch  as  while  it  is  a  general  rule  that  the  painful 
affec"t  <>f  the  split-otT  complexes  is  drafteil  ofF  by  various  channels  and 
thus  fintis  expression,  antl  while  It  is  a  geneml  rule  that  this  expression 
is  not  coiLscktusly  assoeiateil  with  the  idea  cuiiteut  of  the  complexes 
themselves  so  that  the  ijatient  is  saved  from  a  realization  of  their 
true  nature,  is  thus  coiiservetl  from  an  appreciation  of  the  ]>aiiL  tluit 
would  result  if  they  were  iinderstmHi  at  their  true  value,  in  h>'steria 
thi-  painful  alfect  is  drafte<l  ojf  into  bodily  iiuierviition,  thus  priMlueing 
the  somatic  ]iheiU(inenA  of  liysteria.  Tins  is  the  prcK-ess  of  ciHirerjrioH 
aud  is  characteristic  of  hysteria.  The  so-to-spcak  straagulatvd. 
iuut»icted-to  emotion  of  the  split-off  complexes  manif^ts  itselJf  as  the 
physical  symptoms  of  the  psyehimeurosis  and  in  this  way  the  strong 
affect  of  the  split-ort  complex  is  weakened.  The  complex  is  robI»e*1 
of  its  affect,  which  is  the  real  object  of  conversion  and  hentie  its  value 
to  the  individual. 

This  is  iKThups  a  somewhat  involve<I  statement  but  a  simple  example 
will  make  it  clear.  A  patient  ought  to  make  a  call  up<»u  a  recently 
Ivereavol  friend.  This  is  recoguized  as  a  distinct  obligation  but  the 
patient's  infantile  necessity  of  escaping  reality  ami  seeking  pleasure 
makes  the  iliitj"  seem  a  very  onerous  affair.  Thus  arises  a  coixHict 
lietween  duty,  l>orn  of  consciou.s  appreciation  of  the  stK'iul  obligation, 
and  desire,  iMirii  of  the  childish  iimblHty  to  make  the  necessjiry  sjierifice 
of  |KTsonal  oimfort.  .\s  a  n*.sult  the  patient  develups  a  headache,  and 
so,  being  III  does  not  have  to  go.    The  selfish  desire  is  thus  giuned  and 


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ut  the  same  time  t}w  soviai  tlemuiuls  are  sntlsfitKi  Ity  the  Dhii-ss  which 
otTiTs  Jill  H(tx-ii1iihl(M-Xf'iiHi.-,  whili-lhc  j}uiiiriilrti'(i);iiitliiti  of  the  imtiftil's 
own  si'lHshiiess  is  fcmverted  into  thr  iMiin  In  (he  innu\.  Tlie  jillWt  is 
thiis  displaci^l,  the  whule  sitiiatiuu  symholit-ally  dislnrtfd  and  the  two 
oppofiing  tendeni-ies,  conscious  and  unconscious  Ixith  satisfied.  Inci- 
deiitiiUy  the  pain  in  the  head  is  a  srlf-punishment  for  not  obeyiiifj  the 
stfciaily  asehil  and  nnsoltish  demand  and  has  jls  a  function  the  temioncy 
to  drive  the  individual  alung  the  path  of  development,  for  only  by 
following  this  path  can  the  pain  be  avoided.  An  adequate  adjustment 
by  a  synthesis  at  n  higlier  level  would  result  in  making  the  cidl,  and 
wanting  to  make  it.  and  deriving  pleasure  and  satisfaction  from  liaviuK 
(Mmforted  the  l>rreaveil  jjerson. 

This  is  such  an  e^uimple  as  everyone  has  constantly  presente*!  to 
him  by  all  manner  of  persons  place<l  in  ilisagreeable  circnmstnncea. 
The  tendency  to  develop  some  niiiHir  physical  ill  as  an  excuse  antl  an 
escape  from  a  recognized  duty  is  used  very  wiilely.  one  is  templet!  to 
say,  at  times  by  ahiiust  exeryone.  It  b*  the  fundamental  hysterical 
(conversion)  mechanism  which  throws  upon  the  body,  makes  it  the 
scapegoat  of,  the  re.-ijH>rwibility  fur  our  moral  failures.  And  yet  more 
than  this.  It  produces  sutferiuR  and  pain,  which  here  as  elsewhere. 
piniit  the  way  of  relief  by  nioking  the  wrong  [>ath  as  unattractive  as 
jMissibh'. 

Symptoms.— The  sjinptomatolt^-  of  hysteria  is  naturally  a  very 
complex  one,  but  from  what  has  l)ccn  said  it  will  be  seen  that  it  tends 
to  group  itself  more  esix'cially  uliout  disturbances  of  motion  and  of 
sensation.  In  atUlition  to  this  it  also  tends  to  manifest  itself  in  c-erlain 
crises. 

All  forms  of  paral>'ses  and  jmestliesias  may  manifest  themselves. 
Paralj'stw  of  tlic  limbs,  eillier  .singly  or  iK^niiplegia  with  or  without 
contracture,  are  common,  while  anesthesias  may  be  distributc<l  in 
almost  any  way,  involving'  tlic  superficies  or  the  special  senses.  As  a 
rule,  of  course,  the  distribution  of  these  various  phenomena  do  not 
follow  the  anatomical  areas  of  nerve  supply.  They  show  some  sjinliolic 
gnmping. 

The  dUturhottrc  tif  gmitihiHl!/ aw  of  many  rf>nns.  Very  cluinicteristlc 
are  the  glove  and  stocking  anesthesias,  involving  the  extremities  uf  the 
limbs,  liands.  a  lower  part  of  forearm  and  feet,  and  lower  portion  of  It^. 
Patches  of  anesthesia  may  be  foun<l  upon  any  portion  of  the  cutaneous 
surface  and  they  may  be  wi<Icly  distributed  and  often  not  constant 
in  location  but  varying  with  different  examinations.  Hemianesthesia, 
especially  of  the  left  side  of  tlie  body,  crossed  and  alternating  forms 
are  fomid.  Light  touch  is  more  often  involved,  frequently  deep 
pain  also,  while  inscnsitiveness  to  heat  and  cold  also  occurs. 

A  clmracteristic  fonn  of  anesthesia  which  is  very  frequently  fomid 
is  concentric  limitation  of  the  field  of  vision. 

These  anesthesias  do  mit  follow  anatomical  areas  and  ex[H.Timents 
will  readily  determine  tlmt  the>'  are  psychological.     If  fw  example 


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an  aiK'stlK'tic  area  is  ^tiintiluted,  the  patit-nt  will  say  he  fet-ls  nothi 
but  if  iiskt^l  til  triH'ss  tin*  nature  of  the  stimtihis,  will  show  a  siirprtsitif; 
miinber  of  oorrwt  rei)Iies. 

lUpot'StlH'sins.  h\'j«Tfstlifsin.s,  various  forms  nf  iicurnldia,  especially 
viswFul,  ftiid  hi-adachf  are  also  frt'queiitly  h>'Sterical. 

Thf  diatarhaneei  nf  viotUiiy  are  lately  various  fonns  of  paraljfsb. 
Ileniipk'gui,  moiioplepa  and  paraplegia,  with  or  witliout  contraeturty, 
art*  llie  txvmmoiicr  fonn^.  .\sta.siii  jihasia  is  a  characteristic  hysterical 
<Y)ruliti<>ii. 

S])a.sins  of  various  parts  are  not  infrequent.  SpAsms  of  the  tnngue, 
nf  the  fate  ami  of  the  extremities  when  nnt  demonstrably  of  organic 
origin  ar**  liy.sterir-al  as  a  rule,  'rreniors,  myasthenic  tj^ies  of  n'uctiitn. 
and  pasy  fatigiibilily  are  frequt-rit.  Choreifunn  movements,  ti<-s.  hihI 
tertaiii   otvupatiim    sjwisms   art-  often    liystcriral. 

The  speech  is  involved  frequently.  Hysterical  aphonia  is  n-cU 
kne)wn  and  usually  a  diagniwis  is  warrantcil  if  the  patient  can  only 
whls[x'r  replies  to  questions  and  an  examination  discloses  healthy 
vocal  corcls.  Stutteriuj;  is  frctjuently  h>'^terical  and  an  analysis  will 
show  that  the  words  with  whi<li  there  is  difficulty  have  esp«ciaJ 
siijnificance  for  the  patient.  Other  respiratory  disturbances  of  no 
asthmatic  character  may  also  be  hysterical. 

I'LifTni!  iliHtiirfmurr.t,  csjK-cially  of  the  nastro-intestinal  tnu-t,  many 
of  the  false  pistropathics  with  jjastrie  msis  of  vomiting  and  diarrhi-u. 
aw  quite  frctpient.  There  ina\  also  be  hysterical  attacks  siniuliitinj; 
renal  or  hc^wtic  injlic,  gastric  uh-cr.  etc. 

Vasomotor  disturbances,  localized  edemas,  disturbed  reflexes,  fever, 
secretorj'  and  trophic  diwmlers  have  all  Ix-en  described. 

Symptoms  which  cannot  Ik"  accounted  for  on  anatomical  and 
pathological  grounds  should  always  lead  to  an  analj-tic  examination 
of  the  [>syche.  Kven  marked  disturbances  may  have  nriginateil 
in  the  psyche  and  continue*!  sa  long  as  to  produce  organic  chiinges. 
as  for  example,  muscular  atrophy  from  pmlungefl  disuse  of  a  limb, 
the  iMiralysis  of  which  was  of  psyelu)geni<'  origin. 

.Vinong  the  episodic  phenomena  are  found  disturbances  of  enmtion, 
cither  exaltation  or  depression,  wlueh  can  he  rniderstiMxl  liecua'<e  of 
the  displacement  of  tlie  afTect.  There  are  various  t.v'pes  of  delirium 
which  may  or  may  not  be  associated  with  conviUsive  seizures.  phkIuc- 
ing,  especially,  when  long  drawn  out,  the  so-called  somnamhulism.t, 
during  which  all  sorts  of  ideas  may  be  manifested  and  the  |>atieAt 
be  quite  disoriented.  Dream  states  not  infrequently  occupy  the 
field  and  lead  by  development  to  all  sorts  and  degrees  of  double 
iwrstinality,  which  is  simply  a  more  elabornlt-  expression  of  the  split- 
off  complexes,  indicating  that  they  form  a  reliitively  lai^e  part  of  the 
personality.  In  fact,  these  split-otf  systems,  provided  recovery  is  not 
[ws-tible,  tend  to  gather  to  tliemselves  more  and  more  of  the  person- 
ality and  thereby  to  lead  a  more  and  more  itidepcndcnt  and  bnuuicr 
exUtenoe. 


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AnuiesiHS  of  course  are  frequent  in  the  s.vTiiptoinatology.  Any 
portii>n  itf  tlie  penwinHlity  whirh  is  active  may  Ytf  nnuiesic  for  any 
|H)rtinn  of  the  ix-rsoiiality  whk-h  is  op|>osed  to  it  in  tlie  ojiiflict. 

In  tlie  analysis  of  hysterical  sv-mptoms  it  is  relatively  easy  to 
account  for  iheni  logically.  Wliile  tlie  sjTiiptoins,  on  the  surfa(«, 
often  rtscmble  tlcmentia  prcaw,  one  is  not  so  often  brought  face  to 
face  with  the  eniHe  outcropping  of  the  unronsoious.  It  is  more  fre- 
qnently  fonml  that  the  sxTiiptouis  leail  tlirectiy  Imek  to  at-tual  situa- 
tions, us  in  the  case  of  Luey  R.,  published  by  HreuerniMl  Kreutl.  This 
patient  was  distiirbeil  by  a  subjective  sensation  i)f  smell,  which  was 
traceil  Ijack  to  a  smell  of  burning  pastrj*  in  a  perfectly  well -recollected 
scene  where  the  children  had  forgotten  the  pastry  and  it  had  become 
burnt.  Why  the  smell  of  burning  pastry  should  be  chosen  for  hyster- 
ical conversion  was  again  traced  to  tlie  young  woman's  love  for  the 
children  for  whom  she  was  governess  and  the  repressed  wish  that  slic 
might  take  the  mother's  place  as  the  result  of  her  love  for  her  muster. 
And  in  the  ens*-  of  Freud's  <tP  ElixulH.'th.  who.  wliiU-  i-tigiiged  in  nnrsing 
her  sick  father  spen<ls  one  evening  away  from  home  at  the  soli<itation 
of  her  family.  I'pon  this  occasion  she  meets  a  young  man  and  on  her 
walk  home  with  him  gives  herself  up  to  the  happiness  i»f  the  situation. 
(hi  the  return,  however,  finding  her  father  much  worse,  she  hlttorly 
reproaches  hers»'lf  for  forgetting  him  in  her  rnvn  ]>lea-su!'e.  This 
tinjught,  however,  is  ivpresse<l.  In  ibe  eourse  of  Jier  earetakiiig  she 
had  each  morning  to  change  the  dressings  on  her  father's  swollen  leg. 
To  do  this  she  took  his  leg  ujion  her  right  thigh.  The  suppressed 
complex  seized  upon  the  fe<'ling  of  weight  and  jwin  of  her  father's 
leg  ni>on  her  thigh  as  an  efficient  avenue  of  expression  for  her  repressed 
wish  which  thus  comes  into  eouseiousnt-iis  under  the  disguise  of  a 
painful  area  on  the  right  thigh  corresponding  in  extent  anrl  loeation 
to  tlie  place  ui>on  whieh  tlie  father's  leg  n'stwi. 

From  these  exiiniples  it  will  l»c  seen  that  the  hysteric  is  the  victim 
of  the  spontaneous  and  alKTmnt  activity  of  n'presse<l  and  split-olf 
complexes  that  have  to  do  with  past  events  in  the  patient's  life  and 
that  the  expression  of  these  complexes  produces  the  sjTnptoms  of  the 
psyehoneiirosis.  and  that  so  far  as  the  hysterical  man ifestat ions  are 
coiurriM-d  the  hysteric  may  be  said  to  live  in  the  past,  for  each  access 
of  sjinptoms  is  but  a  reanimation  of  ]>ast  experiences. 

Like  all  psychoneurotics  the  hysteric  is  infantile.  In  utiier  words, 
there  is  a  certain  defect  in  psychoscxual  development,  and  the  difficul- 
ties which  they  meet  in  life  tend  to  drive  them  back  uprm  themselves, 
to  cause  an  intniversion  of  the  libido,  that  is.  to  remove  their  interest 
from  the  attual  world  of  readily  and  to  center  it  Iwick  again  in  theni- 
fii'lves.  As  already  exiilained,  this  intnnersion  ])nH.-ess  tends  to  reatni- 
mnte  progressively  lower  psychoscxual  levels,  and  with  a  patient  who 

'  Frvud.  ii.:   Solvctcd  l^i>eni  oti  Hj'KlmM  and  Other  PsyrbotwunMCn,  Norroua  sod 
MirrttiU  DiMeuw  Mdimftnipb  SetiM,  No.  4. 
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is  almiily  iiifantiU'  Ihe  Itiuieiiey  to  reanimate,  for  example,  tht*  aiidi- 
ert'tif  level  is  en?ily  manifest.    This  is  well  shown  in  eeruiin  s\TnI>oIi<;^ 
mnsturbntory  wets  which  recur  during  the  hysterical  seizures  of  \vhicn| 
pr<>hahly  involuntary  mictiiritican  is  one. 

The  symptcinmttjlagy  of  hysteria  is  then  the  symptomatolofO'  of  the 
activity  of  (he  split-off  rlifwociated  idea  constella lions  or  coniplexes  and 
their  manifestation  hy  the  nietliaiiLsni  of  convei-sion  thereby  pmdiicing 
symptoms  of  physical  tlisorJer. 

These  spHt-ofT  comj)lexes  tend  always  to  lKX.*(>mc  dynamic  and  niani- 
fcst  themselves  episodically  in  the  hysterical  seizures.    The  profiess  of  ^ 
dissociation  or  splitting,  onre  bcRun,  tends  to  continue  and  new  material  ■ 
tends  constantly  to  be  added  to  these  split-t»ff  elements  by  further 
cleavage,  and  thus  this  new  |>orlioii  of  the  personality  conliinirs  Ut  gn>w 
at  the  fxiM-nse  of  tlie  total  jicr-scinality.    Enerf^y  aerumnlatcs  in  these  fl 
split-4ift'  systems,  and  when  it  becomes  sufficient  in  amount  it  breaks   " 
llimugh,  so  to  speak,  and  produces  the  attacks.    These  attacks  are 
nnidc  up  characteristically  of  a  living  over  apain  of  those  experiences 
ivliich  constituted  the  etiolojji<'al  moments  of  the  psyc.honeur«>sis.    In 
hysteria,  as  has  been  pointcfl  out,  the  breaking;  through  of  tht»  energy' 
from  the  split-off  complexes  manifests  itsi-lf  in  hiHlily  Iimcrvation — the 
symptoms  of  the  disease  are  physical. 

Aside  from  these  epis<idic  manifestations,  llie  crises  or  paroxysms 
of  the  disease,  there  are  the  so-called  interparoxysmal  symptoms,  which, 
harkinf!  back  to  a  nnddle  uj;e  (Icnionolo^^y  arc  still  tenne<l  stiginiita. 
These  are  most  characteristically  various  anesthesias,  anesthesias 
which  are  rarely  complained  of  by  the  patient,  often  entirely  nnkiiowii 
to  him,  being  only  bmnght  i»ut  uimn  t-xaminatinn.  It  is  Int^tuse  of 
this  latter  fact  ttiat  Itabiiiski  has  been  Icil  Inln  the  error  of  sup]Hisin^ 
that  they  were  entirely  the  result  of  the  examination,  a  position  the 
erroncousncss  of  which  «tnc  can  demonstrate  to  one's  own  satisfaction. 
Even  though  it  were  abs*>lutcly  true,  the  fundamental  fact,  the  why 
of  the  sjTiiptoms,  the  reason  fnr  certain  patients  reacting  in  such  a 
way  1^)  an  cxaniitiatiot\,  remains  unexplained  by  this  renownied  Krcnch 
neurologist. 

All  analysts  of  the  stigmata  shows  also,  ani\  usually  without  much 
fijffif'uhy.  a  logical  (-onnectioii  with  jirecciling  cxiwriences,  as  for 
example,  the  smell  in  the  case  uf  L-ucy  !{..  or  the  anesthesia  of  the  thigh 
in  the  case  of  KiiKiibi'th.  already  cited. 

There  is  another  group  of  s>-mptoms  which  follow  of  necessity  as  a 
result  of  the  splitting  of  the  persfmality.  It  can  be  easily  seen  from 
this  djiiamic  c<niee])tii>n  of  the  nature  of  the  diseji.s<-  that  a  |KTstin  who 
is  not  at  one  with  bimsclf  has  unt  at  any  one  time  the  full  t}Uota  of  his 
enerj^ies  available,  and  therefore  it  is  found  that  the  geucnd  clRnejicy 
of  this  class  of  jmtients,  particularly  in  the  psychic  sphere,  is  very 
greatly  reduced;  it  is  reduced  in  pr(»portion  to  the  amount  of  the 
IK'rstiimlity  which  is  representeil  by  these  split-off  complexes.  These 
imtients  therefore,  are  not  cfjiial  to  the  task.s  they  once  oi>uld  do. 


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Tliey  are  nervous  and  irritable,  they  lire  easily,  they  lack  caiMHty  for 
ponseputive  ftpplii-atinn,  niiil  furget  tva/lily,  Tlicsc  nrc  gt-iu'ral  syrni>- 
trinis  of  the  t*oriciiti<iii,  set-orulMry  s^THjitimis,  tlie  result  of  uiiy  splitting, 
nnd  whifli  arc  luUled  to  the  priniary  sjinpttims  which  nre  exprvssioiui 
uf  thf  actual  a>iiflict. 

A  t-oiinceting  link  l»ctween  the  two  portions  of  the  j>crsonality  is 
seen  ill  the  hystt'rii-al  pimnla.sics  and  also,  of  wiursp.  in  the  dreams 
which  themselves  belong  to  the  realm  of  ])hantasy  formation,  phaii- 
ftasies  whirh  are  thoughts  that  romp  without  being  hidden  at  moments 
of  meiital  abstriiction,  thoitghts  that  (hiw  along  without  volitional 
choice,  that  replace  one  anntJier  without  the  exercise  of  critique,  in 
other  Words,  day-ilrcamiiig  or  night-tlreamiiig  as  the  case  may  be. 
These  phantuaies  represent  the  activity  of  the  submerged  txjraplcxes 
as  they  break  through  and  manifest  themselves  in  the  upiwr  con- 
sciousness. They  arc  of  great  importance  in  discovering  the  nature 
of  the  conflict  and  are  very  common  features  of  the  hysteric,  although 
u.sually  the  patient  does  not  realize  it  until  his  attention  is  a<ldresscd 
to  these  vagrant  mental  manifestations,  because  they  not  only  eome 
unbidden,  but  when  they  go  they  leave  no  tell-taJe  traces  in  tlie  con- 
scious memory.  A  further  connection  between  the  uneouscious  uinl 
conscious  are  the  eonscioiis  phantasies.  'i'hese  are  phantasy  fonna- 
tious  which  apparently  lie  in  dear  consciousness  and  are  nut  repressed. 
Phantaaies  of  this  sort  arc  [termitted  in  dear  consdousness  only  because 
they  are  not  umlerstotMl  at  their  true  value.  They  really  represent 
chiefly  repressed  material. 

To  resume,  hysteria  is  the  result  of  a  splitting  of  the  i>ersonality  in 
which  certain  split-off  complexes  are  sexually  determineil,  ai;d  leading 
an  existence  more  or  less  independent  of  the  total  personality  express 
themselves  by  the  mechanism  of  ciHiversiou  in  Iwdily  iimcrvation. 
The  hysterical  symi»toms,  then,  become  the  represcntBti4»n  through 
conversion  of  the  unconscious  phantasies  which  ejriguiate  i[i  the 
repressed  complexes,  while  the  structure  of  the  hysterical  attack  is  in 
every  way  similar  to  that  of  a  dream.  The  attack  is  the  breaking 
thn>ugh  of  the  energy  of  the  repressed  systems  and  manifests  itself 
by  a  wish-ftilHIing  dcliriinn.  the  elements  of  which  may  lie  over- 
fleterniinetl,  displacftl.  and  iuvertetl  for  purposes  of  disguise,  as  are 
the  elements  of  a  dream. 

Compulsion  Neurosis. — Compulsion  neurosis  eoutains  probably  tlie 
niaj[)rrty  of  that  complex  gnmp  to  which  Janet  gave  the  name  of  psych- 
asthenia.  Janet's  group,  however,  contained  not  only  the  L-*>nipul- 
sion  neuroses,  but  a  number  of  other  things,  particularly  the  anxiety 
neun>ses,  probably  many  anxiety  hysterias,  perha|)s  some  tieunis- 
thenias,  schizophrenias,  ami  hysterias. 

The  characteristics  of  the  crmipulsion  neurosis  are  the  presence  in 
the  mind  of  certain  c«in)pnl.sive  tendencies  to  act  or  think  in  certain 
ways.      Tlie  iwitieut  is  forced  against  his  nill  and  ■ftilhoul  api>urent 


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rcftsiui  t()  think  certjiiii  ulea^  or  certain  thoughts  or  to  do  certain 
thingti.  The  rompulsion  iiicrfasc-s  until  it  is  yielded  to,  then  a  |>eriod 
of  calm  follows  which  may  he  of  variable  length,  until,  so  tc)  speak,  the 
energy  liaa  again  accumiilattKl.  when  the  compulsion  again  manifests 
ititelf  and  must  again  be  relieved  Uy  yielding.  The  jHitient  has  iK*rfect 
hi»ight  int(»  the  matter,  knows  the  whole  business  is  foolish,  but  he 
cannot  help  it. 

Mechanism  of  Compulsion  Neurosis.  In  hysteria  the  repressed 
materiiil  manifests  itself  by  conversion.  The  ac-ciunulated  aiFect  of 
the  split-utT  complexes  is  draintxl  off  thnmgli  iHHJily  innervation.  The 
I^ijisical  s\*mptom  is  made  the  scapegoat  to  save  the  more  imi>ortant 
mental  adjustment.  The  highly  affect -iadenerl  complexes  an»  thus 
deprived  of  tlicir  eumtion.  'Phe  hysterical  uttai-k  is  a  wish-fiilfiling 
dclirinm  which  brings  to  pass  in  a  sort  of  allcgimcal  riramatt/^tian  the 
fulfilment  of  Imth  elements  in  the  conflict. 

In  contradi-stinction  to  these  eharoctcri sties  of  hysteria,  in  the 
compulsion  neurosis  there  is  no  conversion.  The  affect  of  the  repressed 
complexes  is  HndnMi  off.  not  thr^uigh  hmlily  innervation,  but  by  attach- 
ment to  otherwise  imlifTerent  ideas.  The  affect  is  ilispJacetl  to  a  sub- 
stitute. Tin's  snbstitutinn,  (juitc  as  in  the  itniversiiiri  of  hysteria,  is  a 
di.st<(rtion  mechanism  and  serves  eciniilly  with  it  to  disguise  from  the 
patient  the  real  snurce  of  the  alTect. 

Tlien  Hgain,  while  in  the  hysterical  attack  both  elements  in  the 
conflict  come  to  contemporaneous  fulfilment,  such  unifieation  thn)Uf;li 
the  symptoms  is  less  e\ident  in  the  compulsion  neurosis,  although  the 
attempt  is  made  to  bring  it  about.  What  occurs  on  the  siirfnee.  at 
least,  is  a  constant  alterriatimi  between  the  ascendency  of  the  two 
facttirs  in  the  cnnflict,  %vliich  two  factors  in  tlicir  nltiinale  unulyiits 
resolve  themselves,  perhaps  always,  into  love  and  hate.  ] 

The  cctmpulsiou  neun>sis  is  a  tnie  (lefense  neunisis  and  its  s>'mptoms, 
at  least  the  compulsive  acts.  whi<h  develop  late  in  the  course  of  the 
disc)nler  are  of  the  naturt^  of  ceremonials,  which  not  only  serve  to  di*- 
gni.se  the  true  situation  frtim  the  patient,  but  sfi  to  siieak,  atone  for  evil. 

Freud  has  very  well  said  that  it  is  much  mure  correct  to  speak  of 
obsessive  timiking  thati  of  obessivc  ideas.  It  is  the  obsessive  element, 
the  compulsion,  the  so-called  Zwangof  the  (jennaiis  which  is  the  essential 
thing  in  this  neurosis,  and  whicli  um>'  express  itself  in  all  ixissible  ways. 

The  mechanism  of  the  production  (>f  the  s>'mptiiuis  of  the  atmpul- 
sion  neurosis  is  a  quite  complicated  one.  It  cannot  be  expressed  lictter 
than  by  quoting  the  language  of  rreurl.' 

The  extracts  fnim  Kreud.  which  arc  Taken  from  hi."*  original  forniu- 
latinn  of  the  (iMnpnlsiiin  ncnrosis  (^mcejit.  arc  somewhat  involveil  and 
diflicult  to  utiderstarid  .so  the  plan  will  W  followed  of  interspersing  them 
with  comments,  explanations,  and  illustrations  for  the  purpose  of 
simplification  and  classification. 

'  ftitiirhniiiiin:  I-*rpud's  ThcoriM  of  tlic  NeurcMPe.  NrnoiuiKiK]  Mrnul  Divonw  Muuo* 
itr(|>li  ScriM,  Now  York. 


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"Sexiial  experiences  «>f  early  ehiklhoocl.have  the  same  significance 
in  tlie  etiology  uf  the  compulsion  neimisis  as  in  hysteria,  still  we  no 
longer  ileal  licre  with  sexual  i>HSNivit\  hut  with  pleasumbly  ivceiiiii- 
pli:ibeci  aggresainiLS,  anil  witli  pleasurahly  ex[ierienciNi  partieiiNitioii 
in  sexual  acts,  that  is,  we  deal  here  with  sexual  artivity.  It  is  due  to 
this  dilTerence  in  the  etiological  relations  that  the  masculine  sex  seems 
to  he  preferred  in  the  compulsion  neurosis. 

"The  compulsion  neurosis  is  developerl  in  its  full-hlnwn  fonn  as  a 
type  of  expiatory  t-ereuionial  for  acLs  guiltiiy  participiiled  Ju,  i.  e., 
acts  in  which  the  patient  took  an  active  part  if  only  by  atrquiescciicc 
and  for  which  he  therefore  holds  himself  responsible. 

"  In  alt  my  cases  of  aiinpidsion  neurosis  I  liave  found  besides  a  sub- 
soil of  hysterical  .symptoms  which  couhl  be  traced  to  a  ijlcasurable 
action  of  sexual  pa.ssi\ity  from  a  preeedent  scene.  I  presume  that  this 
Mjinclilence  is  a  lawful  one  and  that  jiremature  sexual  aggression  always 
presup[M)ses  an  experience  of  swluction.  Hut  I  am  iinaUe  to  present 
as  yet  a  complete  dcscriirtion  of  the  etiology  of  the  coniinilsion  neurosis. 
I  only  believe  that  the  fnial  determination  as  to  whether  a  hysteria 
or  compulsion  neurosis  should  originiUe  on  the  basis  of  infantile 
traunms  flepends  on  the  temporal  relation  of  the  development  of  the 
libido. 

■■'rhe  essence  of  the  compulsion  neurosis  may  he  expresseti  In  the 
following  simple  fonnula:  Obsessions  are  always  tmnsfonneil  rfjinifu-hf^fi 
returning  from  the  represMon  which  alwaj's  refer  to  a  pleasumbly 
accomplished  sexual  action  of  ehildhiKxi.  In  order  to  eluci<late 
this  sentence  it  will  he  necessary  to  describe  the  t>^Jit■al  course  of 
compulsion  neurosis. 

"'I'he  cumpnlsive  ways  of  thinking  an4l  acting  are  only  substitutes 
for  the  reproaelies  which  are  sjTnholical  distortions  in  or<ler  to  prevent 
a  recognition  on  the  |jart  of  tJie  jwtient  of  the  real  meaning,  in  order 
to  keep  from  his  ffnisciousuess  a.  realiwition  of  the  artual  lirciim- 
stanecs  of  his  guilty  conduct. 

"In  a  first  period  i>eriod  of  cliildish  immorality  — the  events  con- 
taining the  seeds  of  the  later  neurosis  take  place.  In  the  earliest  child- 
hood there  appear  at  first  the  experiences  of  sexual  seduction  which 
later  nialics  the  n-pn-s^iioii  ptissible,  and  this  is  folluwe<l  by  tbf  actions 

sexual  aggressions  against  the  other  sex  which  later  manifest  them- 
elves  as  actions  of  reproach." 

The  original  exjHTience  here  referre4l  to  as  one  of  "sexual  :*e<luction" 
must  be  understood  in  a  much  broader  wnse  than  is  usually  given  these 
terms.  The  term  sexual,  for  example,  refers  to  the  whole  realm  of  the 
race-preservative  libido  as  previously  outlined.  The  listening  to 
"nasty"  stories  might  therefore  Jk*  such  an  original  form  of  "sexual 
seduction'*  which  easily  has  its  wrongfulness  emphasi/^tl  by  fiiiling  to 
tell  the  nuithcr  all  the  things  the  U>ys  nt  school  (aik<ii  to  him  aUait, 
although  warnwl  by  bcr  to  do  so  for  the  ver>'  oI>vious  reason  of  i}re- 
veniing  this  very  form  of  auto-erutic  indidgcnce.    I^tcr  on  the  ver>' 


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of  txt'lmii^riK  «H\fiHt'nces  anil  having  secrets  of  a  sexual  imtiire 
with  other  hoys  het-onies  a  matter  for  fulurt-  reprimehcs.  This  is. 
of  «nirsc,  hut  one  of  inniiMicrablc  tv-pcs  of  exi>criciice  which  may  hnng 
ahuut   similar  mwhanisms  of   defense. 

"This  period  is  hroiipht  to  an  end  by  the  appearance  of  the — often 
self-riiH'iiitl — sexual  'maturity.'  A  reproach  then  attaches  itself 
to  the  memory  of  tlmt  pleaHumhU-  Hetioii,  itml  the  eonneetion  with 
ihe  initial  experience  of  passivity  makes  it  possible — often  onK'  after 
conscious  and  rctollected  efTort-to  repress  it  and  replace  it  by  s 
primary  sjitiptom  of  defense.  The  third  periwi,  that  of  apparent 
healthiness  hut  really  of  successful  defense,  begins  \sith  the  sjitijitomR 
of  scrupulousness,  sluniie  mid  diilidence. 

"The  next  perioil,  the  fllsense  is  characterized  by  the  return  of  the 
repressed  reminiscences,  henw  by  the  failure  of  the  defense;  but  it 
remains  undecided  whether  the  awakening  of  the  same  is  more  fre- 
quently a<ridental  and  siMintaneous.  or  whether  it  Hp|>ears  in  conse- 
quence of  actual  sexual  disturhantvs,  that  is,  as  additional  influences 
of  tlie  same.  But  the  revived  reminiscences  and  the  repmaches  furnuvl 
from  them  never  enter  into  consciotisness  unchan^,  but  xvhat  Itetomes 
conscious  as  an  obsession  and  obsessive  affect  and  substitutes  the 
pathogctiii-  inetnory  in  the  conscious  life  are  comprtnuist'  formations 
Iwtweeu  the  repressed  and  the  repressing  ideas." 

An  example  will  make  this  clear.  .\  young  man.  when  a  vcr>*  young 
boy,  was  subjected  to  a  homosexual  assault.  The  affair  occurred  in  & 
portion  of  a  nwm  the  floor  of  which  was  covered  with  a  white  In'ar- 
skin  rug.  I'nllowing  this  epismle  sliame  au<l  iliflidcnce  became  marked 
cliaracter  traits.  Later  on  he  iiidulgo<]  in  the  habit  of  niastufbaiing 
and  for  the^e  occasions  would  select  a  dark  rooDi.  While  engaged  in 
this  forhiddeu  practiw  he  would  fear  disTOverj'  and  imagine  he  could 
sec  tlie  bright  eyes  of  his  accusers  looking  at  him.  The  whites  of  the 
eyes  were  their  worst  feature.  Here  we  find  the  later  return  of  the 
repressed  reminiscences  sjnnlinlically  expressed  by  the  fear  of  white 
in  the  fancie<l  eyes  of  the  discoverer  of  his  habit.  Still  later  this  fear 
became  genemlized  into  a  dislike  ami  fear  of  wliite  objects  ui  general, 
especially  the  whites  of  eggs.  This  phobia  is  therefore  not  only  a 
s\inbalic  expression  of  the  repn-saeii  reininisceatrs  hut  a  defense 
against  the  pain  of  their  recognition.  It  is  also  a  mechanism  for 
turning  the  imlividual  from  his  auto-erotic  practices  upon  the  healthy 
path  of  psychophysical  development. 

"  In  ortler  to  descril>e  clearly  aral  probably  convincingly  the  prt>- 
ccsses  of  repression,  the  return  of  the  repn-ssion,  and  the  furinuiiou  of 
the  patlutlogical  ideas  of  (.-omprouiise,  we  woidd  have  to  decide  upon 
ver\-  definite  hy|«>theses  conceniing  the  substratum  of  the  psychic 
occurrence  and  wimciousnesa.  .As  long  as  wc  wish  to  avoid  it  we  will 
have  to  rest  i-ontent  with  the  foilciwing  rather  figuratively  under- 
stood observations.  l)ei>ending  on  whether  the  memory  (x>iitent  «f 
ihfi  repwacbful  action  alone  for<xs  «.u  eutruuce  ii»to  conaciouaness  or 


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wlietlitT  it  takes  with  it  tiie  accompanying  reproachful  affect,  wc  have 
tw'o  forms  of  compukiou  neurosis.  Tlic  first  represents  the  typical 
obsessions,  the  content  nf  which  attracts  the  patient's  attention; 
only  an  indefinite  displeasure  is  perceived  as  an  affect,  whereas  for 
tlu"  rimtcnt  df  the  iil>ses,sii.iii  the  only  sullahle  aiTect  would  Ih'  one  of 
reproach.  The  content  of  the  ohsession  is  (h>uhly  distorted  when 
cumpnreil  to  the  content  of  the  infantile  i-onipulyivc  act.  First,  some- 
thing actual  replaces  the  past  experience,  and  ;«econd,  the  sexual  is 
substituted  by  an  anulogous  non-^xuiil  experience.  These  two 
changes  are  the  results  of  the  ctmstant  tendency  to  the  repression 
still  in  force  which  we  will  attribute  to  the  'epo.'  The  influence 
of  the  nnived  pjithogenic  memory  is  showii  by  the  fwet  (hat  the 
content  of  the  obsession  is  still  jmrtially  identical  with  the  repressed 
OP  can  l>e  traced  to  it  by  n  correct  stream  of  thought.  If.  with  the 
help  of  the  psychiMiualyti<'  nu-thmi.  we  reconstruct  tlic  orijcin  of  one 
individual  ob3e.-*sion  we  Kiul  that  one  actual  impression  instigated 
two  diverse  streams  nf  thnujiht,  and  that  the  one  which  pn.ssed  over 
the  ri'pressird  niemorj-,  though  incajMible  of  l•()usciou^ues3  and  cor- 
rection, proves  to  be  just  as  correc-tly  fonncd  lopically  as  the  other. 
If  the  results  of  the  two  jwycluc  oix'rations  dlsji;:n'c.  the  tx)ntradictton 
between  the  two  may  never  be  brought  to  logical  iidjustment,  but  as 
a  compromise  Iwtwccn  the  resistance  and  the  pathological  result 
of  thought  an  apparently  absurd  ob.'iession  enters  into  (x>nsciousnes8 
Iteside  the  normal  result  of  the  thought.  If  both  streams  of  thought 
yield  the  same  result,  they  reinforce  each  other  so  that  the  normally 
gtiimi)  result  of  thought  now  U-haves  psychieally  like  an  obsession. 
Wherever  neunitie  compulsion  manifests  itself  psychically  it  originates 
from  repression.  The  obsessions  have,  as  it  were,  a  psychical  course 
of  compulsion  which  is  due,  not  to  their  own  validity,  but  to  the  source 
from  whieh  they  originate,  or  to  the  source  which  fumLshes  a  part  of 
their  validity. 

"A  second  form  of  comi>ulsion  neurosis  results  if  the  repressed 
reproach  and  not  the  repressed  content  of  memorj'  forces  a  replace- 
ment in  the  cons*-ious  psychic  life.  Through  a  psychic  admixture,  the 
affect  of  the  reproach  can  change  itself  into  any  other  affect  of  dis- 
pleasure, and  if  this  (HX'urs  there  is  nothing  to  hinder  the  substituting 
affect  from  becoming  conscious.  Thus  the  reproach  (of  having  per- 
Fonneil  in  cIiildhotKl  .S4>nie  sexual  actions)  may  be  easily  transformed 
into  shame  (If  sinneone  el.se  becomes  aware  of  it),  into  hypochondriacal 
anxiety  (iH-eaiusc  of  the  physical  harmful  (H^nsifiucnccs  of  those 
reprimcliful  actsj,  uito  social  anxiety  (fearing  puni-^hment  from  others), 
into  religious  anxiety,  into  delusions  of  observation  (fear  of  iK'trayiiig 
those  actiotLs  to  others),  into  fear  of  temptations  (justific<l  distrust 
in  one's  own  moral  ability  of  resi.staniv).  etc.  Besides,  the  memory 
eontenl  of  thi*  reproaehful  action  may  also  be  represented  in  con^-ious- 
nes.s,  or  it  nmy  Im*  altogether  eoncealed,  which  makes  the  iliugnosis 
very  diffieuJt.    Many  cases  wluch  on  superfiinal  examination  are  taken 


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as  ordinary  (neura*'thenic)  hypochondria  often  Iielong  to  this  groups 
of  <-ompiilsive  affcHts;  the  very  frequently  so-t-alleid  'perioflic  iieuras- 
theiua'  ur  'periodic  meliiudiolia'  e,-i]iei ially  st^em  to  lie  exphLiiieil  hy 
compulsive   aiTcn^ts   or   obse-ssions,   a    reL-oj^iiition    not   unini|K>rtant 
iheniijeuticttlly. 

"Beside^s  these  eiimproinisc  symptoms  whieli  si)(nify  the  return  of 
the  rei)re.ssiijii  uud  hence  a  failure  uf  Uie  oritfinally  achievwl  defense, 
the  compulsion  neurosis  /onus  a  scries  of  oilier  symptoms  of  a  tntaNy 
(hlFerent  oripin.    The  ego  really  tries  to  defent)  itself  aKaiiii>t  those 
descendants  of  the  initial  repressed  reraiiiiscenee,  and  in  this  conflict 
of  defense  it  pn>duet*s  symptoms  which  may  be  comprchcuded  as 
'secondary   defenne.'       These  are  throughout   'protectivf   measures' 
wliich  have  performed  good  service  in  the  strupj!h'  carried  on  against 
the  obsessions  and  the  obsessing  affects.    If  these  helps  in  the  conflict 
of  the  defense  really  succeed  in  repressing  anew  the  s\-mptoms  of 
return  obtrudinR  themselve-i  on  the  ego,  the  rompuUion  then  trails- 
mits   it.Ht'lf  im   thr  imiteutive   measures  themselves  and   iinxluces  a 
thinl  forin  uf  thi'  'eompulsiou  neurosis,'  the  ci)m]»ulsive  action.    These 
are  never  priinary^  they  never  contain  anytliin^  else  but  a  defense, 
never  an  aKgresaion.    Psychic  analysts  shows  that  despite  their  pecu- 
liarity tlicy  can  always  be  fully  ex]}laineil  hy  nuluction  to  the  com- 
pulsive reminiscence  which  they  oppose. 

"  One  example  instead  of  muny :  An  eleven-yearnild  boy  hjLS 
obsessively  arnitigeii  for  himself  the  foIKnvinK  eeremonial  before 
going  to  bed:  lie  could  not  fall  asleep  UTiJess  he  related  to  his  niutber 
most  nii[uitcl\  all  exiK'rieiu-es  of  the  day;  not  the  smallest  Sixap  of 
pajHT  or  any  other  rubbish  was  allowed  in  the  evening  on  the  carpet 
of  his  bedroom.  The  bed  ha<l  to  be  moved  close  to  the  wall,  three  chairs 
had  to  »tnnd  in  front  of  it,  and  the  pillows  ha<l  to  He  in  just  aueh  a 
[xwition.  lu  order  to  fall  asleep  he  had  to  kick  nith  both  legs  a  number 
of  limes,  aiitl  tlicn  had  Utlieon  the  side.  This  was  ex|»laine<I  asfuHuws: 
Years  before,  white  putting  tltis  pretty  boy  to  sleep,  the  servant 
girl  Dtaile  \i&c  of  this  opportunity  to  lay  over  him  and  assault  Itim 
sexually.  ^Tien  this  reminiscence  was  later  awakened  by  &  recent 
exT>erienee  it  made  itself  known  to  consciousness  by  the  contpulsion 
in  the  above-mentioned  ceremonial  which  sense  could  really  be  sur- 
mised and  the  details  veriKed  by  psych<Minalysis.  The  chairs  before 
the  1x^1  which  was  dose  to  the  wall-  so  that  no  one  ctiuld  have  access 
to  it;  the  amingituent  of  the  pillows  in  a  definite  manner — so  that 
they  should  be  differently  arranged  than  they  were  on  that  evening; 
the  motion  witli  the  legs— to  kick  away  the  person  lying  on  him; 
sleeping  on  the  side— becau.*ie  during  that  scene  he  lay  on  his  back; 
the  detailed  confession  to  his  mother— l>ecause  in  eonsequen<-e  of  the 
pniliibitiun  i>f  his  swluctpess  he  com^aled  from  his  mother  this  and 
other  sexiud  exjKriences;  finidly,  keeping  the  Moor  uf  his  Iwdroom 
clean — because  this  was  the  main  reproach  winch  he  had  to  bear 
from  his  mother  up  to  that  time. 


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"The  scoomIar>'  defense  of  the  oUsesaioiis  can  be  brought  al>uut  by 
a  forcible  deviation  to  other  thouftht.s  of  pns-sihly  contrary  conttMit; 
lience  in  rase  of  surress  there  is  a  rompiilsive  reasoning  regularly, 
concerning  abstract  and  trunscendental  subjeets.  because  the  re|>reRse<l 
ideas  Hlwsys  oeeiipied  themselves  with  the  sensiiuus.  Or  the  patient 
tries  to  l)ea>nie  muster  of  even.'  compulsive  idea  tliron^;!!  logital  Itihor 
and  by  ap|x'aling  to  his  conseious  memory;  this  leads  to  compulsive 
thinking  and  examination  to  doubling  mania.  The  priority  of  the 
perception  before  the  memorj'  in  tliese  examinations  at  first  induce 
and  then  force  the  patient  to  collect  and  preserve  all  t)l>jeets  with 
which  he  comes  in  (-ontact.  The  seotmdary  defense  against  the  eom- 
pidsi\e  affects  results  in  a  greater  number  of  defensive  mciisiin's  which 
are  capable  of  being  transformed  into  compulsive  actions.  These  can 
be  grouped  according  to  their  tcndcnc>*.  We  may  have  measures  of 
penitence  {irksome  ceremonial  and  observation  of  nmnbers),  of  pre- 
vention (diverse  phobias,  superstition,  pedantry,  ag^avation  of  the 
primary  sjTnptom  of  scrupulousness),  measures  of  fear  nf  Ix-trayal 
(collecting  |Mi|>ers  and  shyness),  and  mcasiires  of  becoming  ua«m- 
sciout)  (dipsomania).  Among  these  compulsive  acts  and  impulses 
the  ptiobias  play  the  greatest  part  as  limitations  of  the  patient's 
existence." 

That  a  line  of  secomlary  defenses,  so  to  speak,  becomes  necessary 
means  that  the  original,  the  primary'  defenses,  were  not  sufficient. 
These  primary  defenses  were  broken  down  and  a  more  vigorous  effort 
has  hail  to  be  made  by  the  psyche  to  pnitect  itself.  The  psyche,  in 
other  words,  itdi>pt»  mechanisms,  which,  s<>  far  as  ]«wsible,  kcej)  the 
libido  from  seeking  infantile  ways  of  pleasure  seeking  and  fuee  it  along 
the  path  of  social  u.sefulness. 

The  phobias  keep  spreading  out  as  in  the  case  cited  in  which  the 
fear  of  white  originally  symbolically  attachwl  to  the  whites  of  the  eyes 
becAuie  a  fear  of  all  things  wliite,  and  tend  to  more  anil  more  limit 
the  patient's  actlnties  by  closing  an  ever-increasing  munber  of  paths 
of  expressiou. 

Tlie  ceremonials  in  the  form  of  peculiar  succ-essions  of  movements, 
as  in  the  case  of  the  boy  cited  above  by  Freud,  the  various  ticj*.  the 
saying  over  of  formula*,  etc.,  an*  very  numerous  and  infinitely  varied. 
Among  these  the  various  cleansing  ceremonials  are  common.  One 
patient,  because  her  thoughts  were  unclean  was  in  constant  fear  that 
she  would  offend  (io<i  by  allowing  some  particle  of  secri'tion  from  her 
bcxly  to  come  between  her  and  Ilim.  Tears  for  instance  might  have 
been  i\\\c  t*)  midean  thoughts  and  so  the  greatest  care  in  washing  had 
to  !»e  exercised  before  she  spfike  Go<rs  name  or  prayed.  This  necessity 
cxtcndc<!  to  all  the  secretions,  and  so  a  great  deal  of  time  was  occupied 
in  most  detailed  and  painstaking  processes  of  washing  and  avoiding 
all  forms  of  pollution. 

"There  are  eases  in  which  wc  can  oljservc  how  the  compulsion 
becomes  transferred  from  the  idea  or  affect  to  the  measure,  and 


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other  t-ases  in  which  the  comjjulsion  osfillat*^  between  the  retumiriff 
symptoms  of  seromlary  flefense.  Kiit  tlicre  are  alsn  rases  in  which 
no  obsessiuns  are  n-ally  formed,  Imt  tlie  reiiri-sse*!  reiiiinis(vnfe  imme- 
diately Iieeonies  i-eplaeed  hy  tlie  HpiMireiit  priiiuiry  defensive  iiieasiire. 
Here  that  stage  is  attaiiienl  at  a  bound  which  utlierwise  ends  the 
course  of  the  compulsion  neurosis  only  nfter  the  conflict  of  the  defense. 
Grave  eases  tjf  this  affection  end  either  with  a  fixation  of  eeremonial 
actions,  funeral  doubting  mania,  or  in  an  existence  of  etx«ntririty 
conditioned  hy  jDhnhias. 

"That  the  obsessions  and  e%erythin>;  ckTived  from  them  art*  iu)t 
believed  is  prttbably  due  to  the  fact  that  the  defense  symptom  of 
scrupnlousness  was  formeil  during  the  first  repression  and  k^<'><*<1 
amipulsive  vulirlity.  Tlie  cerLainty  uf  having  Uvctl  nutrally  tlinmtrh- 
out  the  whole  i>erio(l  of  the  successful  (U'fcnse  makes  it  impossible 
to  (five  credence  to  the  reproach  which  the  obse-ssion  really  involves. 
Only  transitorily  duruig  the  appearance  of  a  new  obsession,  and  now 
and  then  in  nM-lancholic  exhaustive  states  of  the  epo  do  the  morbid 
syniptiiins  t>li  the  return  also  enforce  the  lielief.  The  'coinjadsiun'  of 
the  psychic  fonnntiniis  here  tlcscrilied  has  in  general  mithiuj:  to  do 
with  the  recognition  through  belief,  and  is  not  to  be  mistaken  for  that 
moment  which  is  designatcil  as  '  strength'  or  '  intensity'  of  an  idea. 
Its  main  characteristic  lies  in  its  inex plica bleness  through  psychic 
activnties  of  conscious  ability,  and  this  character  undergoes  no  change 
whether  the  idea  to  which  the  cum]»ilsion  is  atUiched  is  stninger  or 
weaker,  more  or  less  intensively 'elnctdated/'suppUcti  with  energy,' etc. 

"The  reason  for  the  uoassailableness  of  the  obsession  or  its  derivai- 
tive  is  due  only  to  its  connection  with  the  rcprcsseil  memori-  of  curly 
childhood,  for  as  soon  as  we  succeed  in  making  it  conscious,  for  wliieh 
the  psychotherapeutic  methods  already  seem  quite  sufficient,  the  com- 
pulsion, too,  becomes  detache<l." 

The  mechanism  of  the  compulsion  neurosis  is  therefore  seen  to  l»e 
an  extremely  complicated  one  and  one  whicli  proihices  a  great  variety 
of  sjinptoms,  with  all  possible  ramifications  of  ineaniiig. 

Tliis  mechanism  as  set  forth  in  this  rather  intricate  statement  by 
Freud  may  be  more  simply  statwi  by  saying  tlmt,  in  distinction 
from  h.>steria  in  which  the  disguiae  is  brought  about  by  a  transfer 
of  tiie  repressed  inatcrial  into  symbols  of  iKHiily  ailment — conversion— 
in  the  compulsion  ncnn)sis  the  tlisfignreineiit  is  kept  wholly  within 
recognised  psychological  territory.  The  distortion  is  produced  by 
displacement  of  the  atlcct  upon  indifferent  iileas  (substitution)  ami 
the  development  of  a  purificatory  ceremonial.  Fear  of  Hiitmais  (snakes, 
mice,  etc.),  may  be  the  a<-ccpte<l  conscious  equivalent  tif  fear  of  s«-x- 
uality  with  a  t.vpe  of  ceremonial,  and  is  well  ilhisiratal  in  the  case  of 
the  eleven-yea r-i)ld  boy  citeil. 

The  extracts  thus  far  cited  from  Freud  were  from  his  entire  paper 
(1894-5-C).    A  more  recent  pniH-r  ( llKtO)'  carries  the  suhject  somewhat 

■  Abitnct«d  ill  the  PayeboMiAtytio  Boview,  Juiuaty,  11)10,  iii,  No.  I. 


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furtlnT.  Ill  this  p;i]it'r  lit  discusses  furlhiT  tlic  (iistortiim  l>.v  wliirli  the 
affcit  is  displaces!  from  the  matter  of  real  moment  to  a  substitute  »{ 
little  importAnce  and  how  through  this  mechanism  the  ccremoiualit 
finally  grow  up. 

As  a  n'sult  of  his  further  studies  Frei«l  believes  that  the  fundamental 
elements  that  are  opposeiJ  to  one  another  ui  the  rompnlsinn  neurosis 
are  love  and  hate.  This  fundamental  conflict  arises  very  easily  and  is 
coinlitioued  by  the  necessity  on  the  [mrt  of  the  cliild-  Thus  the  rhild'a 
love  is  frequently  replace<l  by  hale  for  the  parent  who  interferes  with 
him  and  pnthihits  him  from  exercising  some  ]ileasurti  activity.  The 
cimstaiit  ulteniatioDS  between  h>ve  and  hate  pnKluoe  the  indeeiaion 
which  these  imtients  so  constantly  show.  They  are  in  constant  doubt 
aa  to  the  course  of  action  they  should  pursue,  their  rejd  doubt  being 
their  doubt  of  their  power  to  love.  I>ove  ami  hate  exist  side  by  side, 
love  never  liaving  fully  succeeded  iu  dumiaating  but  ouly  in  repressing 
the  hate  into  the  unconscious.  This  same  doubt  makes  matters  lead 
to  uncertainty  in  the  carrying  out  of  the  various  protective  and  defen- 
sive measiin^s  and  necessitates  the  endless  repetition,  a  typical  char- 
acterislie  oF  the  cerenionials. 

The  compulsion  neurotic-s  arc,  us  a  rule,  superior  persons  who  are 
striving  witli  tremendous  energy  to  attain  to  higher  things.  The 
mechanisms  they  use  are  use*l  more  or  less  by  all.  but  for  reasons  which 
are  as  yet  not  fully  worke<l  out,  lead  to  this  ]ieculiar  I'onu  of  illness. 
Freud  sugge.sts.  proNnsionally,  that  there  is  a  connection  between  the 
unconscious  hate  and  the  sodistie  component  of  the  sexual  in.stinct 
whicli  was  ex(vpticmally  developwl  and  w^a*!  prematurely  and  too 
pnifoMiully  repressetl. 

Symptoms. — ^The  symptoms  of  the  c<.)rnpulsion  neurosis  are  very 
varied.  They  have  to  do  with  all  types  of  ol>sessii)ual  thinking  anci 
acting,  that  is,  thiukhig  and  acting  which  takes  place  aside  from  t}ie 
volition  of  the  patient^  which  he  cannot  prevent  hut  which  he  must 
yield  to,  as  already  described.  This  is  the  compulsion  element  which 
givcM  the  name  to  the  neurosis. 

The  symptoms  have  lx*en  variously  dividerl  and  may  be  rlesrribed 
under  the  form  of  motor  symptoms,  obsessive  acts  of  various  sorts; 
tics,  spasinwlie  tortit-ollis,  even  epileptic  attacks;  sensory  symptoms, 
obsessive  sensations,  amounting  at  times  to  well-marked  hallueiiia- 
tioas;  alfective  symptoms,  obsessive  emotions,  more  particularly  those 
of  doubt  and  feur;  and  ideational  symptoms,  obsessive  ideas,  such 
as  amluiual  questioning. 

The  commonest  and  best  knon'n  of  tlie  oUsessions  are  the  phobias 
or  fears  which  usually  refer  to  some  very  "ipecifie  object  or  set  of 
conditions  which  acquire  their  quality  of  fear  as  the  result  of  taking 
over  an  affect  by  displacement  which  is  of  deep  tliough  unconscious 
significance  to  the  jMitient.  'ITius  there  are  tnisoph^liift  (fear  of  dirt 
or  oontarainationi,  meUtllophobia  (fear  of  metal,  do*>r-knobs.  money. 
etc.),  a^yrnphiiliia  (fear  of  wide  or  open  spaces),  rluuntntphnliui  {fear  of 
narrower  cinsed  sjwicea),  pymphob'ta  (fear  of  firej  and  so  on  indefinitely. 


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The  obsessions  of  thtiihl—fitlir  <fc  /{iwte^are  common  am!  result 
in  a  state  of  mind  in  which  the  patient  is  torn  between  two  courses  of 
conduct  and  t-aniiot  fhiH>s<\  nr  IiHvinj;  doiw  sonicthinjr,  sucli  as  turn 
out  the  i!,iiA  iH'fore  goiiiK  to  IhiI,  is  seized  with  a  doubt  its  to  wJiether 
he  reidly  did  du  il  or  nut  and  niiint  yet  up  and  sjnisfy  liint^H'lf.  I'den 
doubts  when  they  refer  to  religious  or  philosophical  mutters  lewl  lo 
coiitinuiu);  qufstioninjp*  aiul  eluborate  i>rooessc3  of  reasoning  from 
which  the  patient  cannot  free  his  mind. 

(juite  allied  to  the  ]>lmbiiLH  and  <loubts  itre  certain  moral  obsessions 
siirh  as  overronscientioiisness  imd  exaggerated  scnipulosity. 

Of  the  various  obsessional  activities  tl»e  so-calletl  maniiuf  are  best 
known.  Thus  there  are  klfpUtmatiin  (a  compulsion  to  steal),  pi/ro' 
vittnia  (a  coiupulwin  to  set  soinctUiag  on  (ire),  dipsunmtiut  (a  com- 
pulsion to  drink),  etc. 

Ill  addition  tliere  are  all  sorts  of  less  easily,  classifiett  aiul  more 
complex  forms  of  obsessional  wa,yn  of  thinking,  feeling  and  acting. 
There  arc  romplicnted  ceremonials,  such  as  that  of  the  eleven-year- 
old  bo>"  already  cileil,  ways  of  amiiiging  tilings  iliat  must  l>e  carriefl 
out.  Strange,  and  to  the  patient  iiiexpliriihle.  attractions  and  rc]iul- 
sions,  dislikes  for  certain  kinds  of  food,  or  persons  with  a  particular 
color  of  huir,  all  manner  of  tics,  habits,  mannerisms,  cerenioniab,, 
tlie  netrssity  for  touching  things^/#'/irf  de  Unicher — fixed  ideas, 
hj-pochondrias.  etc. 

Such  jKiychtilogical  phencjniena  must,  of  course,  have  a  reason  for 
their  existence,  and  as  the  reason  is  not  apparent  it  cannot  be  explained 
by  the  patient ;  it  must  l>e  sought  by  psychoanalysis  in  the  unconscious. 

These  obsessions  j>nKlu('c  a  tn-inenilons  amount  of  mental  unreal 
and  suffering  if  tl]cy  are  not  yieUlc<l  to.  and  a  sense  of  r^-lief  is  expe- 
rienced when  ihcy  arc  yielded  to,  oftentimes,  however,  with  a  following 
sense  of  remorse  for  lla^'ing  yielded. 

The  compulsive  ideas  and  acts  represent  compromise  fonnation.s 
which  permit  the  jiatient  to  obtain  satisfactions  in  infantile  ways,  i.  r,, 
to  revert  to  old  ways  of  gaining  pleasure  whtt-li  were  aetive  and 
important  in  infancy  when  the  erogenous  zones  were  as  yet  not  clearly 
differentiated.  Hen-  an?  fouiul  the  e>plaimtiou  for  urinary  and  fecal 
pliantasics.  for  certain  cutaneous,  anal,  and  gastro-intestinal  satis- 
factions which  are  used  as  ways  of  getting  pleasure  when  driven  away 
from  reality.  They  bei-ome  infantile  ways  of  reacting  to  reality 
situations  and  so  are  inefficient,  sick  ways. 

Anxiety  Hysteria.— Anxiety  hysteria,  as  the  name  indicates,  occupies 
a  midposition  between  eonversion  hysteria  on  the  one  hand  and 
anxiety  neurosis  on  the  otiier.  There  Is,  so  to  sijcak.  a  combination 
of  the  tv,'o  conditions,  although  this  is  not  quite  the  situation.  In 
conversion  hysteria  the  affect  of  the  repressed  complexes  is  drafted 
into  IxKlily  inner\"ation  and  produces  the  phj'sical  s>7nptoms  of  the 
disease.  In  aiLxiety  hysteria  the  affect  remains  in  the  mental  sphere, 
pr<.Mtucing  there  various  phobia.s.       In  anxiety  neurosis,  as  will  be 


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seen  lutt>r.  the  anxiety  has  its  orighi  not  at  the  psychical,  hut  at  the 
pliysiolo^icHl  level  and  is  n  reprc!<entation  in  the  psychic  sphere  of  a 
(listnrhiinci;  in  tlie  stiniatic.  In  aiixiety  hystt-ria,  tlie  (inxirty  is  also 
priHliiix'd  at  the  pli^'sioliijcical  level,  Imt  it  is  a  secondary  syniploiii  and 
is  the  a-sult  of  the  physiological  accompaniments  of  the  emotions 
which  go  with  the  phohias,  such  as  difficulty  of  breathing,  cardiac 
palpitation,  etc. 

Anxiety  hysteria  Is  one  of  the  most  widely  distributed  diseases. 
It  Ls  particninrly  the  iluteosc  which  nianifesls  itself  in  childhoLui  and 
frora  which  most  of  the  so-ealletl  nervons  children  suifer.  It  is  much 
more  easy  of  approach  I  hempen  tii-nlly  than  tlie  compulsion  neurosis, 
its  ucc"essibility  heinp  comiMirable  to  that  of  hysteria,  ami  so  offers 
greater  opportunities  for  treatment.  i'n>bably  many  cases  of  tliis 
disorder  are  included  under  Janet's  psychasthenia. 

THE  ACTUAL  NEUKOSES  <ANXIETT  NEUROSIS  AND 
NEURASTHENIA). 

Aiudety  Neurosis. — The  anxiety  netirnsis  wa.s  separated  from  the 
(lefieral  jjroup  of  actual  neuroses  and  psyehoneuroses  by  Freud.  The 
imme  aiuciety  neurrwis  indicates  that  tlic  s>'mptums  all  group  them- 
selves alwnt  t!ie  iimlinal  syii)])tom  tjf  aitxiety.  and  it  is  si^nificiint 
of  this  ansiety  thai,  while  it  is  a  psycliic  fact,  it  is  still  not  of  psychic 
but  of  somatic  oripn.  The  urwicty,  therefore,  is  not  susceptible 
of  beintJ  mialyzetl  into  psychic  comi>onents.  but  its  source  can  only 
be  found  at  tlie  physiological  level.  This  anxiety  arising  at  the 
physiologieiil  level  and  manifesting  itself  \\\  the  psychic  sphen-  then 
be«rtnes  a  "free-floating  anxiety"  winch  may  attadi  itself  to  any 
iilea  and  therefore  Hpp«-«r  to  be  of  psvdiic  origin.  On  the  oilier  Imnd. 
it  may  express  itself  simply  as  aiLxiety  without  ideational  content. 

Anxiety  may  tiius  be  seen  hj  be  the  correlative  of  fear.  Wliile  fear 
is  the  emotion  which  corresponds  to  a  danger  threatening  the  organism 
from  outside.  .niLxiety  corresponds  to  a  danger  which  threAtens  the 
organism  fmm  within. 

It  will  help  to  make  understandable  what  has  to  \ye  siiid  uImiuI  the 
aaxiety  neurosis  if  it  is  understwKl  at  the  start  that  the  whole  sex 
relatiorisiiip  whidt  is  consunmiateil  by  the  sexuid  act  consists  of  two 
])arts.  a  somatic  and  a  psychic.  In  contrast  to  neurasthenia,  which 
rc-sults  when  the  discharge  of  energy  is  inade(iuate  uihhi  the  somatic 
side,  anxiety  neurosis  occurs  whenever  the  dischai^e  is  inadequate 
in  the  psychic  sphere. 

Symptoms. — ^The  following  is  ihe  description  of  the  sjinptomatology 
of  anxiety  neurosis  as  given  by  Trend :' 

"  1.  (iittrntt  lTriUihility.~T\\h  is  a  fretptent  nervous  symptom, 
common  an  such  to  many  nervous  states.  It  is  mentioned  here 
because  it  constantly  occm^  in  the  anxiety  neurosis  and  is  of  thco- 


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n-ticul  sif,'iiiHi'ima*.  IntTCiisi'il  ipritjiliility  jitways  puiiits  to  an  nmi 
HUilutiiiii  of  fxcitniient  or  to  an  inability  to  Iwar  utrumulHtion.  Iienn 
to  an  absolute  or  relative  awuinulation  of  excitement.  The  cxprcs-j 
aiuti  of  this  increased  imtability  thnm^li  iiii  Hiiiliton'  hyiKTesthfsia  is 
especially  U'orth  mentiunlTiK;  it  is  an  overseiisitiveness  fur  iioi.ses, 
whicli  symptom  is  certainly  to  Im'  explnineH  by  the  ("onpcnital  inti- 
mate n-hitionship  iH-tweeii  iiuditnry  impressions  uml  fright.  Auditory 
hy(x'resthesia  is  frequently  found  ns  a  cause  of  insomnia,  of  whieli 
more  than  one  form  belongs  U)  atLxiety  neurosis. 

"2.  AnxiouH  E.t]KvUiUim. — I  cannot  better  explain  tlie  conditiun 
that  I  have  in  mind  than  by  this  name  and  by  some  appended 
examples.  A  woman,  for  exjimple.  who  suffers  from  anxious  expec- 
tatiun  tliink.t  of  infitienza-|>neum(»tit:i  whenever  her  husband,  who  is 
afflicted  with  a  catnrrlml  (MMuiiliiin,  has  a  eiiujjliing  spell;  ami  in  her 
mind  she  sees  a  passing  funeral  pn>cessiiim.  If  on  her  wa\  home  she 
sees  twit  persons  staniling  tcigether  in  front  of  her  luwise  she  cannot 
refrain  frum  the  thought  that  one  of  her  children  fell  out  of  the  window; 
if  she  hears  the  bell  rinj;  site  thinks  tluit  someone  is  brinKin^  her 
mournful  tidings,  etc.;  yet  in  none  of  these  cases  is  there  any  .^tpt^'ial 
reason  for  exiiggerating  a  mere  possibility. 

"The  anxious  ex|)ectation  naturally  reflects  itself  ctmstantly  in 
the  nnrmal,  and  embraces  all  that  is  designate*!  a.s  ' utieasiiiess  and 
a  tendency  to  a  pessimistic  conception  of  things,'  but  as  often  as 
possible  it  giH's  beyond  such  a  plausible  iincHstness,  iiiul  it  is  frec|Uentiy 
recognized  as  a  part  uf  conHtraint  even  by  tlie  jMitlent  hinn^df.  Kor 
one  fonn  of  anxious  cxi>ectation,  namely,  tliat  which  refers  to  one's 
oftn  health,  we  can  reserve  the  old  name  of  h\-ptwhondria.  Hypo- 
chondria does  not  always  run  parallel  with  the  height  of  the  general 
anxious  exiwetatitui;  it.s  a  pifliniinary  stipulatiun  it  re<inires  the 
existence  of  paresthesias  and  annoying  somatic  sensations.  (iN-piv 
chondria  is  thus  the  form  prcfernxi  by  the  genuine  neurasthenics 
whenever  they  merge  into  the  anxiety  neurosis,  a  thing  which 
frequently  happens. 

"As  a  further  manifestation  of  anxious  expectatiiin  we  may  men- 
tion the  fretpient  tendency  obser^'ell  in  morally  sensitive  fn^rsoru*  to 
pangs  of  conscience,  scrupulosity,  and  pedantr\',  which  varies,  as  it 
were,  from  the  nurmal  to  its  aggravation  as  douliting  niuiiia. 

"Anxious expectation  is  the  most  essential  symjitom  of  the  neurosis; 
it  also  clearly  shows  a  part  of  its  theory.  It  am  jx^rhaps  Ix:  saiil  that 
we  liave  here  a  quantum  of  frwly  floating  anxiety  which  eontn>l.'«  the 
choice  of  ideas  by  expectation  and  is  forever  ready  to  unite  itself 
with  any  suitable  ideation, 

"3.  This  ib  not  the  only  way  in  which  the  anxiousness,  usually 
latent  but  constantly  lurking  in  consciousness,  can  manifest  itself. 
On  tlie  it>ntrary  it  can  also  suddeidy  break  into  consciousness  with- 
out being  aroused  by  the  issue  of  an  idea,  and  thus  provoke  an  ntta<^ 
of  anxiety.    Such  an  attack  of  anxiety  <x>nsisLs  of  either  the  anxious 


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feeling  nlonr  without  any  asftorintcd  idea,  nr  of  the  nearest  interprrta- 
tioii  of  tiie  lermiiiation  of  life,  sut-li  as  the  ulea  of  *  suiUieii  death'  or 
threatenioj;  iiisjmity;  nr  the  feelinp  of  anxiety  liecoiiies  niixerl  with 
some  jHiresthesia  (similar  to  the  hysterieul  aura);  or  fiiisilly  the  anxious 
feeling  may  he  conihiiieil  witli  a  di.stiirlwEK'e  of  one  or  many  somatic 
functions  sueh  as  respiration,  eanliac  aetivity.  the  vjisoinotor  inner- 
vation, and  the  ghiiidular  activity.  From  this  combination  the 
patient  renders  especially  prominent  now  this  and  now  the  other 
moment.  He  complains  of '  heart  spasms/  '  heavy  hreathinp,' '  profuse 
perspiration,'  'inordinate  appetite,'  etc.,  and  in  his  description  the 
reeling  of  anxiety  is  put  to  the  hackgrormd  or  it  is  rather  vaguely 
deseribefl  as  'feeliuK  Imdly,'  'um-onifortahjy,'  etc. 

"4.  What  is  interestinji;  and  of  diagnostic  signiiic-anre  is  the  fact 
tliat  the  amount  of  lulnuxture  of  these  elements  in  the  attjick  of 
anxiety  varieis  fxtraonlinarily,  and  that  almost  any  accompanying 
symptom  can  alone  constitute  the  attack  as  well  as  the  anxiety  itself. 
AcTordiiiply  there  arc  rudimentary  attacks  of  anxiety,  and  c<[uivaifnts 
fur  tlie  attack  of  anxiety,  probably  all  of  equal  signifR-am-e  In  showing 
a  profuse  and  hitherto  little-appreciated  richness  in  forms.  A  more 
thorough  study  of  these  lan'atwl  states  of  anxiety  (Ilccker)  atul  their 
diagnostic  dLviftiun  fntm  itther  attacks  ought  soon  to  l>ecome  the 
necessary  work  for  the  neuropathoUtgist. 

"I  nmv  add  a  list  uf  thovv  forms  of  attacks  of  anxiety  with  which 
1  am  aci|uainted.    There  are  attacks: 

*'  (a)  With  disturbances  of  heart  action,  such  as  palpitation  with 
trensitory  nrrhytlunia,  with  longer-c-ontinned  taebyciirdia  up  to  grave 
states  of  heart  weakness,  the  differentiation  of  which  fnirn  organic 
heart  alTection  is  not  always  ea.sy;  among  such  wc  lka\e  the  pseudo- 
angina  pectoris,  a  delicate  diagnostic  sphere. 

"{/;)  With  disturbances  of  respiration,  many  forms  of  nervous 
dyspnea,  astlima-like  attacks,  etc.  I  assert  that  even  these  attacks 
are  not  always  accompanied  by  conscious  aiLxiety. 

"  (c)   Of  profusiT  pci-spiration,  often  nocturnal. 

"(rf)  ()f  trvmbling  and  shaking  which  nuiy  rewllly  he  mistaken  for 
hysterical  attacks. 

"  [e)  fK  inonlinate  appetite,  often  wnibined  with  dizziness. 

"  if)  Of  attack-like  upj>earuig  diarrlica. 

*■  ig)  Of  l<icomDtor  dizzmess. 

"(A)  Of  so-callerl  congestions,  embracing  all  that  was  culled  vaso- 
motor neurasthenia. 

"(t)  Of  pan'sthe.sia.s  (the.He  are  seldom  without  anxiety  or  a  similar 
discomfort). 

"5.  Wry  frequently  the  noetunml  frights  (pavor  noctunuis  of 
adults)  usually  coinbinnl  with  anxiety,  (ly.spneu,  perspiration,  etc., 
is  nothing  other  than  a  variety  ttf  the  attack  of  anxicTy.  This  dss- 
turbainr  dctertniiu's  a  second  form  of  insonniia  in  the  sphere  of  the 
anxiety   neurosis.     Moreover,   I   became   convinctsl   that  even   the 


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puvnr  TUR-lunuis  uf  chililrt'ji  evinces  u  form  heloiiKing  to  t)ie  anxiety 
riciinisis.    'I'he  liystiTic-nl  llngc  and  the  connection  of  the  fear  witJi  tJw 
n.'pnHinrtioii  of  appropriate  exix-rienw  or  <in'am,  makes  tiie  pavor 
noctiimus  of  ehiMren  appear  as  something  ))eciiltar,  but  it  also  occurs^ 
alone  witliout  a  dream  or  a  recurring  hallucination.  " 

"6.  '  Vertigo.' — This  in  its  lightest  forms  is  better  designated  as 
'dizziness,'  uAsnnies  a  prominent  plare  in  the  group  of  .s>'niptciins  of 
ftiixiety  neurosis.  In  its  severer  foniis  the  'attack  of  vertigo.'  witli 
or  without  fear.  Itelongs  to  tlie  gravest  symptoms  of  the  neurosis. 
The  vertigo  of  the  anxiety  neurosis  Is  neither  a  rotatory  dizziness  nor 
is  it  confinni  to  certain  planes  or  lines  like  M6ni^re*8  vertigo.  It 
belongs  to  t)ie  locomotor  or  coordinating  vertigo,  like  the  vertigo  in 
paralysis  of  the  ocnlnr  muscles;  it  t-oiisist-S  in  a  six-clKc  feeling  of  dls- 
Cfinifort  which  is  aceonipiuiied  hy  sensations  of  a  heaving  ground, 
sinking  legs,  of  the  impossibility  to  continue  in  an  upright  position, 
atul  at  the  same  time  there  ia  a  feeling  tluit  the  legs  are  as  hcn>'j*  as 
lead,  they  shake,  or  give  way.  This  vertigo  never  leads  to  falling. 
Oii  the  other  liand,  I  would  like  to  state  that  such  an  attack  of  vertigo 
maj'  also  be  substitute<l  by  a  profound  attack  of  .^tyncope.  Otlier 
faintlng-like  states  in  the  anxiety  neurosis  seem  to  de[>etul  on  a  t^nJlac 
ci)llaps<'. 

"The  vertigo  attack  is  frequently  accompanied  by  the  worst  kind 
of  anxiety  antl  is  often  combined  wltli  canliac  and  respirator^'  dis^ 
turhances.  Vertigo  of  elevations,  mountaias  and  precipices,  can  also 
he  frequently  observed  in  anxiety  neurosis;  moreover,  I  do  not  know 
whether  we  are  still  justified  in  recognizing  a  vertigo  of  stoniachie  origin. 

"7.  On  the  basis  of  the  chronic  anxiousness  (anxious  expectatitin) 
on  the  line  hnnd,  jmd  the  tendency  tn  vertiginous  attacks  of  arLxiety 
on  the  other,  there  develop  two  groups  of  typical  phobias;  the  first 
refers  to  the  general  physiological  menaces,  M'hile  the  seccmil  pefen 
to  Kn-omotion.  To  the  first  group  belong  the  fear  for  snakes,  thunder- 
storms, darkness,  verniin.  etc.,  as  well  as  the  typical  moral  over- 
scrupulousness,  and  the  forms  of  doubting  mania.  Here  the  available 
fear  is  merely  used  to  strengthen  those  aversions  which  are  instinctively 
implanted  in  every  man.  Hut  usually  a  eoiupulsiveiy  acting  phobia 
is  fontKfl  only  after  a  reminiscence  is  athled  to  an  expiTietice  in  which 
this  fear  could  manifest  itself;  as,  for  example,  after  the  .patient  has 
experienced  a  storm  in  tlie  open  au-.  To  attempt  to  explain  such 
cases  as  mere  continuations  of  strong  impressions  is  incorrect.  What 
makes  these  cxi^riencea  signifieimt  and  their  reminiscences  durable 
i.s  after  all  only  the  fear  which  could  at  that  time  apiKiir  and  can  stso 
ftpj)ear  today.  In  other  words,  such  impressions  remain  foreeftd  only 
in  i)er.sons  witli  'anxious  expectations." 

"The  otlier  group  contains  agoraphobia  with  all  its  accessory 
forms,  all  of  which  are  cliaracterized  by  their  relation  tn  locomotiun. 
As  a  determination  of  the  phobia  we  freriuently  find  a  prci-edent  attack 
of  vertigo;  1  do  not  think  that  it  can  always  lie  ]x«?tulate<|.    Oct-a- 


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siuimtly,  lifter  a  first  attuck  of  vertigo  without  fear,  we  sec  that  though 
locomotion  i?  always  acconipuiik'd  by  the  sensation  of  vertigo,  it 
retnaiiis  possible  without  any  restrietions.  but  as  soon  as  fear  attaches 
itself  to  the  attack  of  vertigo,  locomotion  fails,  under  the  eonditions 
of  heinc  nlone.  luirrrtW  streets,  etc. 

"Tfie  rclatiim  of  the-se  phobias  to  the  phuhiu^  of  cibsessious,  which 
mwhiiiiisirt  I  diwusaed  above,'  is  as  follows:  The  JiKreement  lies  in 
tlie  fart  that  here  as  there,  an  idea  Vktouk's  obstssive  tliruugh  its 
connection  with  an  available  affect.  The  meehanism  of  transposition 
of  the  ftlYeet  therefore  holds  true  for  both  kinds  of  iihobiiis,  Itut  in 
phobias  of  the  anxiety  neurosis  thb  affect  is  (1)  a  inonotonotis  one, 
it  is  always  one  of  anxiety;  (2)  it  does  not  originate  from  a  rrpresspfl 
idea,  and  on  psychological  analysis  it  proves  itself  not  further  rctiucibh', 
nor  can  it  be  attackwl  throuf^h  psychotherapy.  The  mechanism  of 
substitution  does  not  therefore  hold  true  for  the  phobias  of  anxiety 
neurosis. 

"lioth  kinds  of  phobiiis  (or  obsessions)  often  occur  side  by  si<Ie, 
though  the  atypical  phobias  which  depend  on  oluiessiuns  need  nut 
necessarily  develop  on  the  basis  of  anxiety  neurosis.  A  very  frequent 
ostensibly  complicated  mechanism  appears  if  the  content  of  an 
original  simple  phobia  of  aa\iety  neurosis  is  substituted  by  another 
idea,  the  substitution  is  then  sub3e(]uently  added  to  the  phobia.  The 
'protective  measures'  originally  employed  in  combating  the  phobia 
are  most  frequently  used  as  substitutions.  Thus,  for  example,  from 
the  effort  to  ])r(ivide  one's  self  with  cnuiiter-evidt-nce  that  one  is  not 
cniay,  contrary  to  the  assiTti<)n  of  the  hypnchoiidriacal  phobia,  (Imtc 
results  ft  reasoning  mania.  The  besitiitions,  doubts,  and  the  many 
repetitions  of  the  fnUr  du  doute  originate  from  the  justified  doubt 
coucenung  the  certainty  of  one's  own  stream  of  thoughts,  for,  through 
the  compulsive-like  idea  one  is  surely  coii.soi«»us  of  so  oKstinate  a 
dLstnrl>ance.  etc.  It  may  therefore  Ih-  ctaiuitHl  that  many  syndromes 
of  compulsion  neurosis.  like/rWif  de  doute  and  similar  ones,  can  clinic- 
ally, if  not  noiioiialty,  lie  attributc<l  to  anxiety  neurosis.' 

"8.  The  digestive  functions  In  anxiety  neurosis  are  subject  to  very 
few  but  characteristic  disturbances.  Sensations  like  nausea  and 
sickly  feelinj;  an'  not  ran',  and  the  symptom  of  inonlinate  a[>petite 
alone  or  with  other  congestions,  may  serve  as  a  rudimentary  attack 
of  anxiety.  As  a  chronic  alteration  analogous  to  tlie  aiLxlous  exi>e<'ta- 
tions  one  finds  a  tendency  to  diarrhea  which  has  occa.sioried  the 
queerest  diagnostic  mistakes.  If  I  am  not  mistaken  it  is  this  diarrhea 
to  which  >Ioebius^  has  reivntly  calle*!  attention  in  a  small  article. 
I  believe,  moreover,  that  I'eyerV  reflex  diarrhea  which  he  attributes 
to  a  disease  of  the  prostate  is  notliiug  other  than  the  diarrhea  of  anxiety 

'  Die  Aliwclu-N'fiimiii.vrliiitti'ii.  Nwiirol,  (VnlmMil..  IRIM,  No.  10,  ii.  ii. 

>  Ncun>patbolo«ii«'hu  BdLrAice.  IfUM,  ii,  Hfift. 

'  Di*  tMrvBaeo  Aftektionon  dva  DKratCH,  Wi*ncr  Klinik,  1602. 


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Tieurosis.  The  deceptivp  reflex  relation  is  Hue  to  the  fact  that  the  same 
faftors  which  nrr*  nrtivr  in  the  origin  of  such  prastAtie  affections  aJAU 
ctjine  into  phiy  in  the  etiology  of  anxiety  ncumsis. 

"The  behavior  of  the  pistn>-iiiTeHtina!  function  in  anxiety  iieiirosts 
shows  a  sharp  contrast  to  the  influcnee  of  tliis  same  function  in  neuras- 
thenia. Mixed  cases  often  show  the  fatniUar  'Huctuatioiis  In-twefcu 
diarrhea  and  eoiustipatton.'  The  desire  to  urinate  in  anxiety  neuroais 
is  aTialdfioiis  to  the  ciiarrhea. 

"9.  The  paresthesias  which  necompany  the  attack  of  vertigo  (ir 
anxiety  are  interesting  liocause  they  associate  themselves  into  a  firm 
sequence,  similar  to  the  sensations  of  the  hysterical  aura.  But  in 
contrast  to  the  hv'sterical  aura  I  find  these  associatnl  M-'iisatiaiu 
atypical  and  chauircable.  Another  similarity  to  hysteria  is  shown  by 
the  fact  that  in  anxiety  ncurosiJ!  a  kind  of  conversion'  into  bodily 
sensations,  as,  for  example,  into  rhenmatte  nnuwlei*,  take*  place  which 
otherwise  can  be  overltmkei!  at  one's  pleasure.  A  lari^.*  number  of 
su-called  rheiiniatics,  who  are  moreover  demonstraible  as  such,  ri'ally 
suflVr  from  an  anxiety  neurosis.  Besides  this  aggravation  of  the  sen- 
sation of  pain  I  have  observed  in  a  number  of  cases  of  anxiety  neurrisb 
a  tendency'  towanl  Imllueiiuitioiis  which  conhl  nut  he  explained  as 
hysterical. 

"  10.  Many  of  the  so-ealled  s^-niptnms  which  accompany  or  sub- 
stitute tlic  attack  of  anxiety  iils«)  ap|H*ar  in  a  chronic  manner.  They 
are  then  still  less  discernible,  for  the  anxious  feeUng  aeeompanyinif 
tliern  a]>ix'ars  more  indistinct  tliati  in  the  utt-aek  of  anxiety.  This 
csjH'ciHlly  holds  true  for  the  diarrhea,  vertigo,  and  ]>aresthesia.s.  Just 
as  iIlc  attack  of  \crtigo  can  Ik;  substituted  by  an  attack  of  s>iicoi>c. 
so  can  the  chronic;  vertigo  Iw  snl>.stituted  by  the  continuous  feeling  of 
feebleness,  lassitude,  etc." 

The  Etiology  and  Oocnrrence  of  Amdety  tieurosis. — The  following 
rcninrks  on  titc  cti()l(iKy  and  occurrences  ttf  anxiety  neurosis  arc 
quoted  from  Frcnrl's  original  pajjer:- 

"  In  some  cases  of  anxiety  neurosis  no  etiology  cau  readily  be  ascer- 
tained. It  is  noteworthy  that  in  such  cases  it  is  seldom  difficult  to 
dcmnnstrate  a  marked  hcralitary  taint, 

"  Where  we  have  reason  to  assume  that  the  neurosis  is  acquired  we 
can  find  by  careful  and  laborious  examination  that  the  etioh)gicnUy 
effective  moments  are  based  on  a  series  of  injuries  and  inilnenecs  fn>m 
the  sexual  life.  These  at  first  appear  to  l)e  of  a  varieii  nature  but 
easily  displaye<I  the  common  character  which  explains  their  boino- 
gencons  effect  on  the  nervous  system.  They  are  found  either  ahine 
or  with  other  baiuil  injuries  to  winch  a  reinforcing  effect  can  Ik*  attrib- 
ute<l.  This  sexual  etiolog>'  of  anxiety  neurosis  can  be  demonstrateil  so 
preponderantly  often  that  I  venture  for  the  purpose  of  this  tirief  com- 
munication to  set  aside  all  eases  of  a  doubtful  or  difTcrent  etiology'. 


■  Freud:  Abirebr-7fouropey«ho««a. 


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"Piir  the  itiorv  precise  description  of  the  etiological  cletermiimtions 
under  which  anxiety  neurosis  occurs,  it  will  he  advisahle  to  treat 
separately  tliose  oecurring  in  men  ami  those  occurrinR  in  women. 
iVnxiety  neurosis  appears  in  women — flisreganling  their  pre(lls[)tisition 
— in  the  following  ntse,s: 

"  (a)  As  virginal  fear  or  anxiety  in  adults.  A  nuinher  of  uneriuivocal 
ohs<'r\atiaiis  showed  me  that  an  anxiety  neurosis,  wlneh  is  almost 
tJ^^i^■uIly  eomhiiied  witli  Itysteria,  ean  Ik*  evoke<l  in  maturing  pirls, 
at  (he  first  eneounter  with  the  sexual  pn>blem,  that  is.  at  the  sudden 
revelation  of  the  thinps  hitherto  veiled,  hy  either  seeing  the  sexual  aet, 
or  hy  hearing  or  reading  something  of  that  nature. 

"(/')  As  fear  in  the  newly  married.  Young  women  who  remain 
anesthetic  during  the  first  eohahitatiim  not  seldom  merge  into  an 
anxiety  neunksis  which  disappears  after  the  anesthesia  is  displaced  by 
the  nonnal  sensation.  As  most  young  W(Hnen  remain  nndisturlied 
tlinaigh  such  a  beginning  anesthesiH,  the  produrtion  of  this  fear 
requires  determinants  which  I  will  mention. 

"  (r)  .\s  fear  in  women  whose  husbands  .suffer  from  ejaculatio  precox 
or  from  diminished  potene>*. 

"(//)  In  those  whf>se  hiisbantjs  practice  coitus  interruptus  or  irser- 
vatus.  These  eases  go  together,  for  on  analyzing  a  large  numlwr  of 
examples  one  ean  easily  be  convinced  that  they  only  dejK'nd  on  whether 
the  woman  attainwl  gratification  during  coitus  or  not.  In  the  latter 
ease  one  finds  the  determinant  for  the  origin  of  anxiety  neurosis. 
On  the  other  hand,  the  woman  h  .spai-erl  from  the  neurosis  if  the  hus- 
band afilicted  b\'  ejat-ulatio  prcciix  can  rejwat  the  nmgrcss  nith  lietter 
results  immediately  thereafter.  'Hie  congressu  reservatus  by  means 
of  iJie  condom  is  not  injurious  to  the  woman  if  she  is  quickly  excited 
and  (he  husband  is  very  (Kitent;  in  other  cases  the  noxiousness  nf  this 
kind  of  prt-ventivc  nieasuro  is  not  inferior  to  the  others,  t'oitus 
intermptus  is  almost  regularly  injurious;  but  for  the  woman  it  is 
injiiritrus  only  if  the  husband  practises  it  reganlless.  that  is,  if  he 
interrupts  coitus  as  soon  as  he  comes  near  ejaculating  without  con- 
eeming  himself  about  the  determination  of  the  exeiteinent  of  his 
wife.  On  the  other  Irnnd,  if  the  husband  Wiiits  until  lus  wife  is  gratified, 
tlie  coitus  lias  the  same  significance  for  the  latter  as  a  normal  one; 
but  then  the  Iiu-sband  betxtraea  afHicted  with  an  anxiety  neurosis. 
1  have  collected  and  analyzed  a  numk-r  of  cases  which  furnished 
the  materLiI  for  the  above  statements. 

"(f)  \fi  fear  in  widows  and  intentional  abstainers,  not  seldom  in 
typical  combination  with  olK^essiims. 

"(/)  As  fear  in  the  climacterium  during  the  last  markeil  enhanee- 
nietit  of  the  sexual  de-sire. 

"The  cuscH  fc),  {(/),  ami  (r)  contain  the  detormiiumts  under  which 
the  anxiety  neurt»sis  <»riginateH  in  the  female  .sex  most  frequently  and 
most  indeiK-iulently,  of  here<litary  prei|js|)osition,  1  will  ciulcavor  to 
demonstrate  in  these — eura\)le»  acquired — ca.<se3  of  anxiety  neuro^ 


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that  the  discovered  sexual  injuries  really  represent  the  etiolu^cal 
moments  of  the  neurosis.  But  hefore  pnirfH^linf;  I  will  mcntinti  the 
st'Xtinl  (leU'nniTitiiits  uF  aii\iuty  iieurt)»is  in  men.  I  uoiild  like  to 
formulate  the  following  groups,  everyone  of  which  fiiirls  its  aiiatog>'  in 
women: 

"  (a)  Kcar  of  the  intentional  abstainers;  this  is  frequently  oombineil 
u-ith  symptoms  of  defense  (obsessions,  hysteria).  The  motives  win'rh 
are  decisive  for  intentional  abstinence  carry  along  with  them  the  fact 
that  a  number  of  hereditarily  hurdene^]  eccentrics,  etc.,  Iielong  tu  this 
category. 

"  (h)  Fear  in  men  with  frustrated  excitement  (during  the  engagement 
period),  imtsoiis  who  out  of  fcur  for  the  consequences  of  sexual  rela- 
tions satisfy  themselves  with  handling  or  looking  at  the  woman. 
This  group  of  detenninaiits  which  can  moreover  be  transferred  to 
the  other  sex — engagement  periods,  relations  with  sexual  forbearance 
— furnish  the  purest  cases  <»f  neurosis. 

"(f)  Fe:ir  in  jnen  wlio  iimciii/e  coitus  iatcrniptus.  As  observed 
above,  coitus  interniptus  injures  the  woman  if  it  is  practised  regard- 
less of  the  woman's  gratification;  it  l>ecomcs  injurious  to  the  man  if 
in  order  to  bring  atxiut  the  grstification  in  the  woman  he  voluntarily 
controls  the  coitus  l)y  dcLiying  the  ejaculation.  In  this  nmiuier  we 
can  understand  why  it  is  that  in  ci^uplcs  who  practi.se  coitus  Intemiptus 
it  is  usually  only  one  of  thenii  who  becomes  ufHicted.  Moreover,  the 
coitus  interniptus  only  rarely  pnwhtces  in  man  a  pure  anxiety  neurosis, 
usually  it  is  a  mixture  of  tlic  same  with  neurastlienia. 

"  (d)  Fear  In  men  in  the  senium.  Tliere  arc  men  who  show  a  climac- 
terium like  women,  and  merge  into  an  anxiety  neurosis  at  the  time 
when  their  potency  diminishes  and  their  libido  increases. 

"  Finally  I  must  mid  two  more  cases  holding  true  for  both  sexe-^: 

"  (f)  Xeunisthcnics  merge  into  anxiety  neurosis  in  consefjuence  of 
raastiU"bation  as  soon  us  they  refrain  from  this  manner  of  sexual  grati- 
Scatiou.  These  persons  have  especially  made  tiieniselves  unfit  to 
bear  abstinence. 

"What  Is  important  for  the  understanding  of  the  anxiety  neurosis 
is  the  fact  that  any  notewnrthy  development  of  the  same  cKvurs  oidy 
in  men  who  remain  potent,  ami  in  non-rttiesthetic  women.  In  ntniras- 
thcni(^,  who  on  account  of  nia.sturbation  have  markerlly  injured  their 
iwtency,  anxiety  neurosis  as  a  result  of  abstinence  occurs  hut  rarely 
and  limits  itself  usually  to  hypochondria  and  light  chronic  dLzzincs.s. 
ITie  majority  of  women  are  really  to  be  considered  as  "potent;*  a 
real  impotent^  that  is,  a  real  anesthetic  woman,  is  also  inaccessible  to 
anxiety  neurosis,  and  bears  strikingly  well  the  injuries  cited. 

"How  far  wc  are  [K'riia|>s  justifii'd  in  assuming  constant  relatione 
lM>tweei!  individual  etiological  ininneiits  and  intli\~idual  sxnnplnms  from 
the  complex  of  anxiety  neurosis,  I  do  not  «tre  to  discuss  here. 

"  (J)  The  last  of  the  etiological  dctenninants  to  be  Dientione<]  seems, 
in  the  Hrst  place,  really  not  to  be  of  a  sexual  nature.    Anxiety  neurosis 


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oriRinates  in  hotli  sexes  ihruugh  overwork,  exhaiwtive  exertion,  as, 
for  iiistunt-e,  after  sleepless  ni^ht^,  nursing  the  sick,  and  e^'en  after 
serious  illnesses." 

Neurasthenia.— The  term  iieunisthenia,  since  it  first  came  into  use 
only  a  little  over  a  generntion  ago.  lm.s  been  applied  to  almost  every 
aHKri^abtc  rtHuiitioii.  Almost  all  illnesM^s  are  accoinimnietl  \>y  a 
certain  amount  of  easy  fatijpability.  emotional  instability,  and  a  general 
out-of-sort.s  feelinji.  All  combinations  of  tlus  kind  which  cannot  be 
speeifically  diajiuowd  and  plaeeil  under  some  well-knowii  caption  are 
easily  dmppeil  into  the  niiscellatieons  group  of  neurasthenia.  Not 
only  have  all  sorts  of  conditions,  tlien'fure,  been  included  unrler  this 
term,  but  the  most  varied  symptoms  have  been  thereby  'lesiKuated  as 
neurasthenic.  N'ot  only  liave  thti  more  pronounced  physical  condi- 
tions been  ineludeil.  such  as  jfeneral  arteriosclerosis,  but  it  is  not 
uncoTnmon  for  some  of  the  more  serious  psychoses,  cs|>ecially  In  tlieir 
milder  inanifestatioiLs.  as  the  cyclothyuiias,  to  be  diajciiosed  as  neuras- 
thenia. It  is  highly  desirable,  therefore,  to  limit  the  application  of 
the  term  to  a  definite  condition. 

It  is  better  to  consider  neurasthenia  as  the  expreiwion  of  a  verj' 
marked  auto-erotic  fixation,  as  a  return  to  that  infantile  period  of 
dcvelo|)ment  in  whidi  the  cliiUl  takes  a  prejMmderating  interest  hi 
its  own  Ijoily.  Masturliation  is  quite  liable  to  l>e  Indulged  in  as  a 
means  of  nuto-erotic  satisfaction,  but  the  physical  net  of  masturlmtion 
is  perhaps  R-Iatively  unimportant  as  etjmpattil  with  the  crippling 
effects  of  the  auto-erotic  introversion. 

This  cothlitiou  is  knowni  as  a  primary  fatigue  neurosis  and  has  cer- 
tain quite  cbara<tcristic  and  coustaiit  symptoms  which  arc  in  the 
main  a  feelnig  of  pressure  on  the  top  of  the  head,  more  or  less  insomnia, 
spina!  irritation,  with  perhaps  pain  in  the  back,  certain  paresthesias, 
easy  fatigability,  emotional  irritability',  and  some  tiepression. 

This  Cfjndition,  despite  outwanl  evidence  tn  the  contrary,  has  lieeii 
tntctrd  in  most  instances  xvhere  careful  analysis  tif  the  symptoms  has 
been  made,  to  a  specific  sexual  etiolog>",  namely,  to  exces.sive  mastiir- 
liation  or  frcipient  ]iollntions.  In  contrast  to  the  etiology  of  the 
aiLxiety  neurosis,  which,  as  lias  been  said,  is  dependent  uptui  an 
inadequate  utilization  and  incomplete  diseliarge  of  the  energy  of 
t]»e  sexual  act  in  the  psychic  ,sphere.  in  neurasthenia  the  specific 
etioloR}'  is  dependent  upon  an  inadequate  discharge  in  the  physic:al 
siihere. 

One  lia.s  to  think  in  addition  to  the  specific  etiology  uf  the  fact  that 
in  most  instances  where  ma.sturbatitin  is  practised  into  a<lulthoo<l  there 
is  a  serious  moral  conflict.  The  individual  feels  asbamcil,  chagrined, 
humiliated  by  having  yielded  to  the  physical  demand.  This,  of  course, 
adds  to  the  difficidty  liy  increasing  the  amount  of  energy  (Hs.sipatcd. 
In  addition  to  this  tlie  moral  conflict  is  usually  very  greatly  enharu-ed 
eitlicr  by  being  told  or  reading  of  the  iiv.iii\  residts  of  this  habit.  This 
is  especially-  so  when  these  results  are  tokl  to  the  chit<l  in  order  to 
4T 


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PSYCHONRUROSES  AND  ACTUAL  NEVROSRS 


friKlitcii  liim  into  dt's"istiu(t  ant)  are  Hcconiimnlt-d  by  tlin-ats  of  cutting 
otT-  till'  (irjran  aritl  tlif  likf. 

It  must  not  ]}0  Lost  ^ii;lit  of  in  dealing  with  thiK  Ha.ss  of  patient-^  that 
a  Tnf«iemte  anintint  of  maptiirbntion  iliiring  infanry.  alM>iit  the  third 
or  fourth  year,  at  tho  end  of  u'hfit  Freud  oalls  the  first  latency  period, 
is  normal  iirid  prnl))ihly  has  as  its  function  the  ftiealiT'.ation  nf  the 
Sexual  erethism  upon  the  sv\  organs.  It  will  I>e  rememlxTe*!  that 
l>efore  thi:*  time  the  vitrimis  erogenous  zonc^  of  the  body  fiuch  us  the 
sex  organs,  the  lips,  the  anus,  are  of  practically  equal  significance.  For 
the  ftmction  of  reprocinetion  the  sex  organs  must  emerge  with  a  pre- 
ponilerant  erethism,  otherwise  si>me  one  nf  the  pen'ersions  will  take 
the  place  nf  imnnal  wxuality.  It  seems,  therefure,  the  function  of 
inastur!>nti(Hi  t<i  help  pnxluee  this  result. 

\Mieii  niastiirljHtion,  however,  is  indulgeiJ  in  about  the  iieriod  of 
puberty  and  later  on  into  adult  life  it  has  certain  dangers  in  addition 
to  those  whicii  are  more  nearly  at  the  physio Ingicai  level  and  which 
an*  priKh»-tive  of  neuriisthetiia.  The  individual  in  his  ]isychi>sexunl 
development  passes  through  an  auto-erutic  jx-riod  when  he  finds  his 
sexual  interests  in  himself,  then  through  a  period  in  which  his  sexual 
interests  are  transferred  tu  the  inmieiliate  uienil>ers  of  the  family,  the 
[jeriod  of  narcissism  in  which  at  first  he  is  most  interested  in  those 
members  of  the  family  most  like  hiniself,  namely  of  the  same  sex. 
Passing  through  this  homosexual  and  narcissistic  period  he  fuially 
reaches,  after  ha\ing  passed  the  period  of  puberty,  to  the  |x>ssibiHty 
of  giving  his  love  out  to  someone  else,  not  only  besides  himself,  but 
someone  removed  fr*)m  the  family  circle  and  someone  of  the  opposite 
sex.  He  lieeonies  norm.illy  heterosexual  and  attains  the  period  of 
olijcet  love.  Now  one  of  the  sitIuus  dangers  of  masturlMitinn  is  the 
ilaiiger  it  has  of  fixing  the  indtvichial  at  some  intermeiiiate  point  in 
his  psychosi'>ual  developisieiit.  The  principal  daugiT  is.  of  course, 
fixation  at  tlie  infantile  auto-enjtic  period,  which  is  naturally  the  par- 
ticular quality  of  sexuality  that  masturbation  ministers  to.  This 
fixation  not  only  prevents  the  proper  psychttsexual  development,  but 
drags  the  whole  jHirsonality  back  upon  itself  and  prevents  that  open, 
free,  and  outwanl  manifestation  which  is  es.srntinl  to  success  in  life,  to 
0  finding  of  one's  place  in  the  world.  These  ix-ople  aw  t(H<  tlioroughly 
occupit'd  with  themselves  to  he  able  to  deal  with  the  outside  world  of 
reality  with  any  degree  of  eHiciency. 

In  the  act  of  masturbation  the  individual  is  both  the  subject  and 
the  object.  He  has  to  supply  the  energies  from  both  sources,  not  only 
the  energies  from  within,  but  all  of  the  energies  and  stimuli  which 
iu>mially  would  come  fmm  without  from  the  persiui  of  another.  The 
term  inasturbatinn.  from  these  iH>nsiderations,  it  wilt  1h'  seen,  nmst 
l)c  considerably  broadened  in  its  meaning.  Musturbatioti  is  an 
essentially  aulo-erotic  phenomenon.  From  this  i»oint  of  view,  sexual 
intercourse,  which  has  only  the  meaning  of  self-indulgence,  is  mastur- 
bation.   Intercourse  only  reaches  its  full  biological  significance  when, 


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in  wMittoii  to  airunllii};  iiulividiial  Knitififjition,  it  jpves  something 
which  is  of  social  iK'rieHt.  C'oncrvtc'ly,  of  cminic.  this  in  the  case  wheii 
its  object  is  the  procluctiou  of  a  chilil.  Equally  U  thiis  true  when  it  is 
an  expression  of  love  which  serves  to  deepen  the  union  and  mutual 
uiulersiumlinfr  between  two  persons  so  that  they  !)e<'(>nie  of  greater 
servire  tn  cjich  nther  and  thus,  by  their  f«nnhine<i  and  reinforced 
efTiirts,  to  tile  ntiT.  Purine  his  indiilKcmt^  the  niaslurbiittir  develops 
all  manner  of  phaiitasii-s  and  these  phantosii-s  often  throw  u  con- 
siderable light  upon  the  nature  uf  his  p»ychosexual  development,  quite 
aimilnrly  as  do  the  dreams  in  those  patients  who  suffer  from  fretiuent 

)H)lhltic)ILS. 

It  will  he  seen,  therefore,  that  in  neurasthenia  there  is  n  condition 
that  is  by  no  means  simple  nnd  that  retjuires  careful  analytical  study 
in  order  to  he  able  to  rieal  with  it  intelligently. 

A  final  word  as  to  the  causes  of  neurasthenia:  The  allcKeil  causes 
of  this  dis4inler  have  Ixfu  as  nuiltiforni  as  the  t-onditions  which  liave 
Ikeen  ranged  under  it.  There  arc  a  large  group  of  cases  which  are  sup- 
posed lu  l)e  <lepcndcnt  upon  injuries,  traumatic  neurasthenia,  and 
another  large  gniup  that  is  supposed  to  be  de))endent  upon  over\\'ork. 
Although  it  is  not  quite  possible  to  speak  dogmatically  with  regaril  to 
the  traumatic  gniup  at  this  time,  still  frnni  analogy,  as  the  result  of 
eases  studied  in  the  group  sujuMised  to  lie  ileiienileiil  npoii  overwork,  it 
will  he  seen  that  the  same  reasoning  applies  to  both  and  It  is  again  the 
same  reasoning  tlmt  ma\  apply  to  anxiety  neurosis,  or  in  fact  to  any 
of  the  coHflitions  described  in  this  chapter,  but  more  particularly 
perhai)s  to  the  actual  neuroses.  The  traumatism  or  the  overwork,  as 
the  i-ase  may  l>e,  or  any  other  apparent  assigned  cHVi.se  can  be  said  not 
to  be  the  true  cAUtv  of  the  neurosis,  but  only  its  oeeasion.  The  trau- 
matism or  the  overwi>rk  conlil  not  prtxluce  thv  neurnsis  in  the  absence 
of  the  specific  etiology.  It  is  (piile  unilerstarulablc  that  a  K'^'t'n  Indi- 
vi<lual  may  stand  a  series  of  sexual  trnumatisiiis  over  a  eonsidemble 
IHTitHl  of  time,  but  be  strong  enough  to  resist  the  development  of  a 
neurosis.  On  the  occasion,  however,  of  having  his  resistance  rwlueed 
as  the  result  of  an  injury,  or  as  the  result  of  long-continued  overwork 
the  neurosis  croj>s  out.  This  is  the  explatiation  f«jr  nmiiy  *>f  these 
rr>nditions.  and  it  is  the  reason  why  a  iMinal  cause  may  develop,  a 
n-siilt  that  is  out  of  all  pru|)urtion  in  both  tfunntitti  am!  tfiiolUit. 

Mixed  Neuroses.— Hysteria,  the  compulsion  neurnsis,  anxiety  neu- 
rosis, nnd  neurasthenia  have  been  described.  If  the  etiology  and 
mechanisms  of  these  four  con<litions  be  considered  it  will  he  seen 
that  they  do  not  of  necessity  mutually  exclude  one  another  and  as  a 
matter  of  fact  not  infrequently  certain  admixtures  are  fount!  in  clinical 
exiierience.  Anxiety  b,\'steria,  for  example,  has  takeii  a  rather  definite 
place  among  these  conditions,  while  as  \viil  be  readily  seen  from  the 
nature  of  the  etiulojjical  nioinervts  uenrasthcnia  and  anxiety  neurosis 
are  not  infrwpiently  found  asstK-iated  in  \arious  proportions,  while, 
of  course,  it  follows  that  Uie  etiological  moments  of  the  actual  neuroses 


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are  not  exchideij  fruin  operating  in  the  sonie  patient  who  may  hu\'e  a 
psychoneurosis.  Such  combinations  are  tiiercfore  of  not  uncfiminon 
occum-nce. 

Aside  from  the  possibility  of  the  mixture  of  the  neuroses  it  should 
also  not  be  lost  sight  of  tliat  the  eiioloyical  imnnents  of  the  neuroses 
may  also  operate  in  persnns  who  are  suffering  from  the  more  severe 
psychoses,  as  for  example,  manic-depressive  ]xs\chosis  and  dementia 
preeiix.  We  quite  commonly  find  hysterical  sjinptoms  in  the  prei-ux, 
\vhile  neurasthenic  and  aiuicty  states  are  not  infrequent  in  the  depres- 
sions of  manic-(lepre;)sive  psychosis.  Other  eomhiiiations,  of  t^ou^se, 
might  be  mentioned.  The  important  thing  to  ln-ar  in  mind,  howe^'er, 
is  the  nature  of  the  etJoIoRical  moment  and  the  meehanism  of  the  con- 
dition, and  then  these  will  be  retoguized  wlien  tlie  indivi<lual  patient 
is  under  analytic  observation. 

Finally,  tlie  purely  psychic  element  is  found  more  and  more  in 
asfloriatinn  wnth  the  actual  neuroHes.  This  was  intimatwl  in  the 
deseriptlon  of  tlie  etiology  and  mechiinisnis  of  neurasthenia  ami  it  tiaa 
also  been  spoken  of  in  the  description  of  the  an>iety  neurosis.  More 
will  he  said  ua  this  pi>int  under  the  head  of  Trewtment. 

Treatment  of  the  Neuroses. — In  the  treatment  of  the  actual  neuroses 
the  main  tlurt^^.  as  indicated  by  the  description  which  has  l)wn  gi^'*"". 
is  to  correct  the  sexual  life  of  the  patient.  In  dealing  with  neuras- 
thenia the  hnbit  of  masturbation  (using  this  term  in  its  bniailer  sig- 
nificance), if  it  be  present,  must,  of  course,  be  dealt  with  before  any- 
thing definite  can  Ik*  accomplished,  while,  of  course,  with  both  neuroses. 
tiuittcrs  of  coitus  iutcrruptiis,  ejaculatio  precox,  alistineiice,  etc.,  nmst 
be  carefully  inquired  into  and  the  sexual  life  modifiwl  as  indicated  so 
that  the  evil  cH^ccts  which  result  from  them  may  \w  remedie*!.  These 
are  the  simple  things  to  do,  and  in  many  cases  will  produce  marked 
betterment,  if  not  apparent  recover^'. 

Of  iiiurse  in  dealing  with  these  cnuditions  it  is  not  meant  simply 
that  (rrtain  itincR'te  physical  ways  of  indulgence  shouM  simply  l>e 
stopped.  It  Ls  essential  that  the  whole  scheme  of  living  should  be 
raised  to  a  higher  plane  based  upon  an  understanding  by  the  patient 
and  his  orientation  toward  healthier  ideals. 

Rest  cures,  hydrotherapy,  massage,  electricity,  exercise,  and  all 
such  therapeutic  agents  have  their  phwe  in  the  treatment  of  the 
neun»se.s,  particularly  the  actual  neuroses,  but  their  place  is  a  second- 
ary one.  It  has  alremly  been  indicated  tlut  the  preeipituling  factor 
in  the  outbreak  of  a  iiennwis  may,  for  example,  Ijc  ovenvork,  but 
that  the  neurosis  would  not  eventuate  in  the  absence  of  the  spe<'ifio 
etiology.  The  explanati(ni  of  tliis  occurrence  was  that  the  pjitient  was 
strong  enough  to  stand  up  under  tlie  results  of  .sexual  traumata  until 
his  general  reaistiuicc  was  reduced  by  overwork  and  tlien  the  neiin>sis 
npIK'jiretl.  It  will  be  seen,  therefore,  tluit  the  usual  methiKls  of  treat- 
ment very  frequently  bring  about  a.  cure,  but  not  in  the  way  in  n'hieh 
they  arc  supiwsed  to.    By  changing  the  patient's  sexual  habits, 


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ffmoving  him  from  his  surround tn^,  acnHing  him  away  to  a  sani- 
tarium, oftentimes  the  seMial  situation  is  in(in_'  ur  less  well  sulvni 
teiiijNirnrily.  Now,  if  iluriii^  this  i«Tii"i  of  resilience  in  a  snitituriuiii 
he  is  on  careful  diet,  given  n-gular  exereise  with  batlis  ami  massage, 
it  is  (KTfectly  uiifierstandahle  that  his  general  ri'sistnnee  will  be 
incrtuised  so  that  he  may  overeonie  the  elFeets  of  the  sexual  traumata. 
In  this  way  he  may  pet  well  without  any  direet  attack  upon  the  factors 
of  the  s]M:eific  etiology-.  This  is  the  principle  whieh  is  oftentimes  seen 
in  oj)eratinii  in  the  improvement  and  alleged  recoveries  of  neurotics 
as  a  result  of  the  rest  cure. 

Iiiusnuieh,  however,  as  even  the  actual  neuroses  usually  present 
Some  admixture  of  |)urely  mental  symptoms,  either  primary  or  second- 
ary in  origin,  it  may  be  necessary  ultimately  and  before  satisfactory 
results  can  be  obtained  to  deal  with  these  mental  symptoms.  If  so, 
they  ma-it  lie  dealt  with  in  pKTJsely  the  same  way  as  the  mental 
symptoms  of  the  psycboneii roses,  namely,  by  psychoanalysis. 

The  main  principle  involved  iii  jwyehoanalyais  may  he  said  to  be 
an  analysis  of  the  patient's  mental  condition  sufficiently  complete  to 
thoroughly  understand  the  sxTiiptomatie  manifestations  of  his  malady. 
Heforc  psychoanalytic  methods  were  employe<i  usually  uo  explanation 
was  sought  for  mental  symptoms  and  ajiparently  it  rarely  entere<l  any- 
one's mind  that  they  hud  any.  'I'he  i>alient  whti  had  a  phobia  or  a  tie 
was  simply  looked  upon  as  Itehig  ner\'ous,  perlmjis  having  had  some 
fright  or  bad  impression  earlier  in  life,  and  was  usually  treated  by  tonics 
or  rest  or  travel  or  simmc  other  such  means  tlmt  was  nut  addresse<l  to 
the  solution  of  the  problem  in  Huy  way.  From  what  has  already  been 
said  about  the  psychic  development  of  tlie  individual  it  will  be  readily 
appreciated  that  no  mental  fact  can  fail  to  have  a  thoroughly  logical 
and  understandable  reason  for  its  existence,  and  it  is  one  of  the 
objects  of  psychoanal>-sis  to  finii  this  out. 

lirieily,  the  technic  of  psychoanal>'sis  is  about  as  foUom's,  being 
of  eoursi!,  modified  in  detail  to  some  extent  by  the  exigencies  of  the 
occasion  and  as  the  residt  of  the  sptrial  predilections  of  the  physician 
practising  it.  When  the  patient  calls  upon  the  physician  the  physieiaii 
should  let  the  patient,  its  far  as  possible  without  interrupting  him  by 
questions  or  otherwise,  detail  to  him  his  difficulties.  Tliis  may  take 
only  u  few  minutes,  or  may  be  quite  a  leugth.v  recital,  but  it  is  usually 
worth  while  to  listen  carefully  to  the  whole  tiling,  perluips  oc-casiou- 
ally  by  a  suggestion,  keeping  the  patient  to  the  ]X)int  if  he  tends  to  be 
too  eirtnimstantial.  This  original  statement  contains  a  description  of 
the  things  from  which  the  patient  is  suffering,  and  if  careful  attention 
is  paid  to  it  one  may  get  many  hints  as  to  how  to  pursue  the  further 
inquiry.  As  a  result  of  tiiis  conversation  and  perhaps  another,  if  it  is 
necessary,  the  physician  makes  up  his  mind  whether  the  patient's 
illness  is  a  suitii!)le  one  for  psychoanalytic  treatment,  and  tf  it  Ls  he  so 
states  and  then  makes  arrangements  for  n-gular  consultations,  prefer- 
ably not  less  than  three  times  per  week,  of  an  hour's  duration  each,  and 


i 


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all  ollu'i-  pn-tiniiiiurk's  sik-Ii  as  the  ftv,  etc.,  are  arruiiKed  too.     Shoul 
it  apix'Hf  that  tliL-  ]>:itUut  has  aiiy  s.\TnptumA  of  pliysiciil  illnf-ss  he 
shoiiLit  Ih*  scut  til  a  roiniK'tfiit  physifiaii  ;>kilk*<)  in  tlu*  piirticular  trouble 
that  appears  to  Ir*  present,  fur  the  psychoanalyst  shuiild   ttiitk'r  no  M 
cirrunistanrr-s  iimltTtakr  to  tix-at  ihr  physiml  c-onditiou.     Th,e  reasons  W 
for  this  will  Hi>pear  later.     It  is  preferable,  too,  that  the  pb^rsical 
condition  be  attetuletl  to  fully,  if  possible,  liefdre  the  psycfioimal.rtic 
treutinciit  K'  taken  up.     In  otlier  words,  it  is  undesirable  to  do  a  psyoho- 
jinalysis  while  the  patient  is  under  the  rare  of  another  physician.' 

Having  arranged  alt  the  prejiniinarifs,  the  patient  calls  at  the 
apix>iiit<*fl  hour  and  the  pwychoarialytie  conversation  proceeds  about 
as  follows:  (tearing  in  mind  the  ultimate  Rnal,  the  i)syehologic»] 
explanatiuii  of  tlie  patient's  syinptcmis,  the  patient  may  be  approax-hcd 
by  b<'giuning  the  diseiwsion  of  one  of  the  symptoms,  either  simply 
asking  about  it  or  else  pursuing  mmw  litie  of  inquiry  that  was  sng>j:(<.'<teil 
in  the  original  conversation.  On  the  other  hand,  the  method  may  be 
pursued  of  endeavoring  to  first  get  a  clear  understanding  of  the  whole 
life  of  the  patient,  lieginning  from  the  earliest  recolleelious  and  trac- 
ing the  devi'lopnient  to  the  present.  It  really  makes  ver>'  little  ditfer- 
enee  how  one  starts,  Ikveusc  in  a  very  short  time  tlierc  will  be  all 
manner  of  suggestions  to  develop  inquiries  along  various  Hues,  and 
these  will  have  to  be  followed  out  for  an  untangling  of  tiie  situation. 

During  llie  course  of  the  psyrhoaiialytie  fon\ersations  one  will  get 
verj'  shortly  to  a  point  from  which  progress  seema  to  lie  inipo.^sible,  fnr 
it  does  not  take  long  to  exhaust  tlie  eonseioiLs  material  of  tl»e  patient. 
One  then  has  to  [tenetrate  the  fureeonseious,  which  is  relatively  easy, 
and  tlip  umxiascious,  which  is  relatively  difficult.  The  methiMJ  of 
procedure  here  is  the  metho<i  of  fa-e  assoeiation.  Perhaps  a  point  has 
been  attained  in  tlie  conversation,  a  situation  has  been  unfolded,  which 
has  no  ap[>arent  explanation.  The  patient  caimot  give  any  reasons 
which  adequately  actronnt  for  it.  I'nder  these  circumstances  the 
patient  is  asked  to,  so  to  s|>eak,  take  the  situation  as  a  starting-point, 
and  then  relaxing  into  a  comlition  of  perfei-t  |»nssivity  observe  llic 
thoughts  that  eoine  lo  Ills  miiicl  nml  ix'count  llieni  ils  fast  as  they 
appear.  In  other  words,  he  is  asked  to  place  himself  in  a  meutid 
state  favorable  to  phantasy  formation,  he  is  askeil  to  relinquish  bis 
grasp  upon  liis  mental  Hfe,  to  permit  his  ideas  to  flow  uatranimelleil 
and  uiisclitted  by  his  volition  and  erili([ue.  He  is  asked,  as  it  were,  to 
become  tlie  ohser\Tr  of  his  own  ideas,  to  .sit  as  if  he  were  sitting  in  the 
window  of  a  moving  train,  recounting  aloud  the  objects  as  they  pn.ssed 
by.  So  he  is  asked  to  observe  his  ideas  anri  to  tell  them  as  they  come. 
This  sounds  like  ratlier  a  simple  procedure,  but  it  is  a  very  diflicult 
one  for  the  patient  to  learn,  and  in  fact  when  the  patient  ctui  do  it  and 
fio  it  easily  he  is  approaching  the  end  of  bis  treatment. 

Kxjierience  shows  tliat  when  patients  are  instructe*l  in  this  wtif 

■.MlilTr;    Trchiiiqiip   of  PB>TJii}aDiilyji»,   NrrviHtH  and    Mftilal   Dupiuc  Mon<w:rai>b 
3mi»,  No.  SO.  Iflir. 


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they  tnke  tlu*  ^Ittrntiuii  as  liirt-vtcd  h,s  a  stiirtiiip-poiiit,  aiul  with  the 
intention  of  telling  the  ideas  thut  eonie  to  tlieir  mind  thev  will  relax 
into  a  condition  of  passivity.  Perhaps  then  for  a  considerable  time 
tJiey  do  not  si)eak,  ant!  if  they  are  askwl  why  they  ilo  not  tell  what 
coines  to  their  mind  they  will  say  that  nothing  eomes.  This  is,  of 
course,  the  interference  of  the  rt^presised  eomplexcs;  it  is  the  resistance 
whidi  they  luive  to  eouiing  into  c-oiiseiousness  whieh  is  manifesting  itself 
in  this  way.  The  whole  thing,  then,  has  to  be  gone  over  again  with  the 
patient-  It  has  to  Ix'  explainetl  to  them  tliat  their  mind  eannot  I*  an 
ahs«jlute  blunk.  and  they  tiavc  to  be  wamett  especially  not  to  exercise 
choice  as  to  what  ideas  tliey  shall  tell  and  what  they  shall  not  tell, 
that  it  makes  no  difference  how  absurd  or  ineonseiiuential  the  idea  is 
that  comes  to  their  mind  they  must  tell  it;  even  if  the  idea  is  extremely 
disiigreahle  tlie>'  must  tell  it,  for  no  matter  how  little  connection  it 
may  iippear  to  have  with  their  trouble,  if  the  startitig-|Kiint  hns  Ih-cr 
from  si>me  problem  in  the  caw  these  ideas  that  come  must  have  some 
connection  with  tliat  problem.  It  must  be  explained  to  them  that,  of 
course,  they  cannot  sec  the  cotuiectioti.  but  that  they  must  tell  the 
ideas  s«  that  the  physician  may  liave  them  and  that  he  will  \ic  able 
to  see  what  bearing  they  have  in  the  situation.  Of  course  he  may 
not  be  able  to  sec  at  onee,  but  it  Is  so  much  material  which,  if  it  doea 
not  come  in  for  utilization  today,  ("an  Ik'^  used  ]ierhapi4  tomorrow,  or 
the  day  after. 

This  is  the  process  of  frer  u-f.-rnrinturu,  out*  whieh  is  very  difficult 
for  the  patient  to  Icam  ami  one  which  requires  much  skill  and  no 
little  art  on  the  part  of  the  physician.  Tfie  phj-sician  must  be  ever 
on  the  alert.  It  reciuire.s  the  must  intense  application  to  the  question 
in  hand,  for  ever>ihing  must  Ik.'  watchetl  with  the  utmost  care. 
Kvery  little  detail  must  1h^  observed  as  ci>ntaiiiiug  jierhups  a  hidilen 
meaning  behuid  it.  Tlie  Jiesitatioiis,  the  stanmierings,  the  mistakes, 
the  slips  of  the  tougue,  all  have  their  significance.  For  example,  in 
talking  to  a  yoxuig  man.  who  told  about  his  pn^vious  illru'ss,  he  said 
tliat  the  physician  had  prescribed  four  quarter-grain  tablets  uf  "quinin" 
for  him.  He  had  no  s^ioner  mentioned  the  name  of  the  dnig  than  he 
imnieiliately  corrected  himself  aud  s:iid  "calomel."  .^n  inquiry  into 
the  meaning  of  quinui  to  him  brought  out  a  most  important  event 
in  his  life,  an  event  undoubteilly  of  signifieam-e  \n  his  neurosis.  The 
repressed  complex  was  struggling,  as  it  idways  is,  for  expn-ssioii.  A 
favorable  opportunity  presented  itself.  Calomel  and  quinin  arc  easily 
mixe<l  in  the  pronunciation,  and  the  repression  slipped  its  moorii^ 
for  a  moment  and  found  expression.  It  remained  for  the  observer  to 
be  sufTicientiy  keen  to  see  the  possibility  of  meaning  in  such  a  mistake 
and  Bnd  out  that  meaning. 

The  most  importjint  single  aid  in  determining  the  content  of  the 
unconscious  is  tlie  tlream.  llic  split-off  conipk*xes  are.  in  acectnlance 
with  the  theory  set  forth,  actively  repressed  by  the  individual,  they 
are  not  permitted  to  come  to  expression  if  he  can  hdp  it.    They  there- 


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fore  r-aii  mily  ox])r<'S.s  thcmwIvcH  in  syniholtr  form,  in  whirh  fomi  tlipj' 
arc  tlispiirieil  not  only  to  others,  but  to  tlio  |>atieiit  liiinself.  In  thi^ 
riiHgiii.swl  fonn  they  are  not  remgni'/eil  for  whfit  they  are.  ami  there- 
fore the  [mliifiihR'ss  tif  their  riTall  to  eoiiseinusness  is  avuided.  A 
previous  nionil  ileUiuiueney  may  thiLs  cimie  to  tlie  surfiwi'  iiiKtrr  a 
complete  (lisgniw*  witliuiit  eaiisiii);  any  partlL-ular  distress,  whereas 
it  would  be  quite  uiibeamble  if  it  came  forth  in  its  true  colors.  It  can 
be  seen  from  this  why  it  is  that  olistacles  are  so  quickly  reached  in 
tlie  p^yclu>ana lytic  priK-rthm;.  The  drenm  is  the  best  and  most  ii.-^ful 
avenue  for  overcomiuK  tins  t\'pe  of  obstacle.  Mere  the  represswl 
complexes  eonie  upon  the  stage  in  all  their  paraphernalia  of  sj-mbolic 
disguise  ami  Knd  an  opportunity'  for  expression.  Tlie  patient,  not 
understanding  what  the  dream  means,  will  pretty  generally  recount 
it  in  all  its  details,  a  thiny  which  he  would  absolutely  refuse  to  do.  in 
many  instances  at  lea.st,  if  he  had  the  slightest  sn^picion  of  what  it 
could  mean.  The  physician  is  therefore,  so  to  speak,  in  a  position  to 
amie  up  on  the  hlimi  f(\Ac  of  the  jMitient.  to  see  the  play  of  his  uncon- 
scious phantasies,  to  l>e  let  Ijehiiwl  the  seene.s  as  it  were.  Now  if 
he  can  penetrate  these  disguises  then  he  not  only  is  eH|mble  of  deter- 
niining  the  niejiriing  of  the  dream,  but  also  he  leaniH  in  this  way  the 
nature  of  the  rei>ressetl  complexes,  arwl  is  tlierefon-  in  a  position  to 
begin  to  read  meaning  uUi>  the  syiitptoms  of  the  neur««is.  The  whole 
matier  of  dream  interpretation  constitutes  a  special  chapter  lu  psy- 
chology and  is  haMly  discussable  in  a  text-book  of  this  sort  with  its 
necessary  limitations. 

In  mldition  to  the  dream  analyses  one  should  also  inquire  Into  the 
phantasy  fonnations  of  the  patient,  phantasies  which  are  formed 
in  the  daytime.  They  an.*  interpreted  on  the  same  principles  as  the 
dreiini. 

The  events  luicoxered  by  the  method  of  free  association  must  be 
dealt  ft-itli  as  facts.  It  makes  little  difference  whether  they  ever  did 
hap^ien  In  realitj'  or  not  the.\"  are  neverthle.-w  psycliolngical  fturU: 
they  represent  the  way  the  patient  thinks  and  so  have  just  as  much 
value  a.s  if  thvy  represented  real  occurrences. 

It  \vi\\  be  seen,  therefore,  that  paychoanalysia  is  a  lengthy,  paliis- 
takiug,  detailed  dissection  of  the  mind  of  t3ie  patient  sutficient  for 
the  explanation  of  tlie  syniptoms,  Tliis  dissection  starts  at  the  surface 
and  may  go  to  prarticalty  any  depth.  Bearing  in  mind  the  princii^es 
already  elucidated  it  will  he  seen  why  it  is  possible  to  effect  an  appar- 
ent cure  at  various  levels;  why  .sometimes  a  single  conversation  may 
apparently  prtKluee  tlie  miracle  of  a  cure,  while  in  other  patients  a  lialf- 
dozen  will  pnxluti-  the  same  effect,  and  in  still  others  months  of  carp- 
ful  work  arc  rc<|uired.  The  individual  has  been  thrown  out  of  adjust- 
ment by  causes  wliich,  bi  their  last  analysis,  have  l)een  operative  tJ»c 
greater  part  of  his  life.  Tp  to  a  eertJiin  point,  liowever,  up  to  a  certain 
(liilicnlty,  he  has  been  able  to  get  along.  Now,  when  this  difheulty 
comes  he  breaks  and  the  neurosis  makes  its  appearance.    If  he  mn 


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745 


[be  patched  up,  so  to  speak  rchahilitatwl,  Imck  to  the  point  where 
the  hr«ik  (icoiirreJ,  mi  appiiroiit  curi'  results,  l-'ur  tlic:*!'  ii[ipai-«nt 
cures  it  will  lir  sin'm  that  it  Is  only  npfr.ssury  to  rarry  tin-  patients  hack 

I  to  u  pnliit  at  wIiIl'I)  they  are  eapalile  uf  itiakiii}^  ailjii^tnu-nt.  This 
is  what  very  ofton  hapjH'tis,  i?s[H'ciaily  in  iiifthiKls  of  treatment  other 
than  the  psyehoiuialylie.  I'or  a  real  eiire  of  the  patient,  however, 
somcthiii);  very  much  more  radical  than  this  is  required:  tlie  analyst 
has  to  proceed  to  ever  and  ever  dee[KT  le^'els  mull  he  has  soufiht 
out  and  found  the  final  stronghold  of  the  neurosis*.  AnythinR  short  of 
this  can  only  ser\'e  to  effect  a  compromise. 

This  seems  to  be  the  most  aflvantA(;pf>"i<  point  to  answer  the  ques- 
tion which  is  constantly  IieiiiK  asked  and  whicli  it  seems  imiKissihle 
to  make  many  people  uiider^taml,  namely,  the  que-ition  of  how  the 
atialysi?*,  the  unraveliiig  of  the  symptoms,  produces  a  aire.  In  order 
to  understand  that  it  is  neressary  to  n-eur  to  the  statement  that  the 
illness  is  due  to  a  eoiifiiet  and  lliat  one  element  of  tlie  coidlict  i.s 
uncoiL-w-ious  to  the  patient;  he  dr)es  not  know  whnt  it  is  that  he  is 
fijihtinj;.  lie  tlierefore  cannot  deal  with  it  frankly,  op*'nly.  intelli- 
gently. One  is  reminded  of  the  story  of  a  certain  king  who  propounded 
the  question  to  the  wise  men  as  to  why  a  bowl  of  water  was  not 
inereaseil  tn  wei;;ht  «lien  a  live  tisli  was  put  into  it,  while  it  was 
increased  in  weight  when  a  dead  fish  was  put  into  it.  This  created  a 
trerneiidons  disCurhaTici'.  All  sorts  nf  arj;iiments  and  n'a.stjus  were 
propounded,  heated  discussions  arose,  and  the  wise  men  were  quite 
generally  out  of  tune  with  one  another.  Finally,  it  oceurred  to  some 
one  tn  try  the  exixTirnent  and  see  what  the  facts  were.  As  soon  as 
the  experiment  was  tried  and  the  facts  were  detertninctl  there  was  no 
hatper  any  cause  for  arftument.  The  conllict  subsided.  This  is  quite 
comparable  to  the  position  m  which  the  patient  finds  him.self,  fif^htinf? 
something  which  is  unconscious  and  about  which  he  knows  nothing. 
The  fsit-ts  in  the  case  in  regard  to  the  fish  in  the  howl  of  water  were 
unknown,  and  as  long  as  they  were  unknown  nothing  hut  chaos 

■  reigned  among  the  wi.se  men.  As  soon  as  the  facts  were  brought  to 
light,  however,  by  proper  ex|M*rimentation,  then  tliere  was  no  longer 
anything  to  fight  about.  In  addition  to  these  reasons  for  the  sul>- 
sidenee  of  the  conflict  there  are  others  that  an-  of  more  or  less  impor- 
tance in  different  cases;  among  them  ia  a  large  element  of  reeducation 
to  which  the  patient  is  subjected  tlirouyhout  the  period  of  psycho- 
analysis. The  cause  of  his  neurosis  implies  that  he  is  somewhat 
iufiuitile.  soniewlvat  undeveloped.  The  physician,  who  should  Im*  a 
man  of  wide  learning,  whose  business  it  is  to  deal  with  the  pnililrni  of 
right  living,  cannot  help  but  infus4*  into  the  patient  in  the  many 
hours  of  conversation  a  philosophy  of  life  which  is  heliiful,  and  tills 
undoubtedly  happens  as  one  of  the  most  imjwrtant  elements  in  the 
reeducation,  development  and  rt-habllltation  of  tlie  ])atient. 

Wlule  the  simple  uncovering  of  the  meaning  of  a  symptom  Is  often 
enough  to  make  it  disappear,  for  the  real  rehabilitation  of  the  |>atient 


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PSYCHOlfEVBOSES  AND  ACTUAL  NBUROSBS 


tlif  wliole  nu-aniiiji  of  iiifuntilf  ways  c»f  rL-jit-tiiip  niiLst  l)e  finally  iinder- 
stocxl  aiui  the  patient  must  l;>c  williuc  to  forego  this  means  of  nhLiiiiing 
pleasure  in  (nrlpr  to  ailvam-e  to  a  hipher  level  of  adjiistment,  t*i  siiive 
tlie  fiiHk-iiltifs  hy  attaiiiiup  a  Iu^Iht  level  wliii-h  nu-ans  at  onw 
reinnH-iation  <iii<l  fultilinetit. 

Ami  finally,  alxmt  tlie  matter  of  transfcivncr.     Tlie  neurotics  un<l 
the  p.syfhone unities  aiul  the  vast  niajority  of  persons  who   require 
psychotherapeutic  treatment,  are  intrtwerted,  tliat  is.  their  interests 
are  turiKHl  within,  upon  tlieinselves,  ami  they  rannnt  he  marlc  over 
into  efficient  people  capable  of  dealing  with  the  outside  world  of 
reality  until  their  interests  cun  l)e  made  to  flow  outside  of  themselves. 
until  they  can  lieeome  iiiteresteil  in  perjiuiis  and  thinf^s  uikI  events. 
In  the  course  of  psychoanalysis,  if  it  is  to  proceed  successfully,  one  of 
the  earliest  thinf;>  that  lmpiM*ns  is  that   the  iiiteri'st  tif  the  patient 
beguis  to  How  upon  the  physician.     It  is  trausferred  to  Inm.     This  is 
a  matter  of  utmost  importance.     It  is  a  matter  which  should  be 
watched  with  the  greatest  can%  for  it  is  the  hanmieter  of  the  relation- 
ship bt^twcen  physician  and  patient.    It  a  the  factor  in  the  |>ersotial 
equation  which  plays  such  a  great  part  and  which  was  supposed  hi 
the  ipld  iliiVN  tit  play  practically  the  only  part,    .^s  souii  as  the  transfer 
begins  to  take  |>liicc  then  the  patient  will  begin  to  bring  dreuni.H  for 
analysis,  and  in  uiWr  ways  t<>  show,  s<i  to  spciik,  every  desire  to  please 
the  pliysieijiTi  hy  doing  as  he  wishes,  and  licfiii-e  long  one  will  generaliy 
find  that  the  dreams  are  occupied  with  the  idea  of  the  physician,  they 
are  transfer  dreams.     Now  in  tliese  dreams  on<r  may  find  exattty  how 
the  ]>hysician  is  hehl  in  the  mind  of  the  patient.     In  .symljoHc  form 
the  trnnsfiT  dream  may  indicate  that  the  phj-sician  is  heltl  in  high 
regiinl  jiml  that  he  is  respecteil,  and  this  is  of  cuurse  as  it  shrndd  be. 
()n  the  other  hand,  lie  may  have  failed  to  deal  with  a  certain  :^itiiu(ton 
adciiuatcty,  anil  the  dream  will  shciw  that  the  patient  is  ilLsappuinted 
or  that  perhaps  some  idea  that  the  physician  suggested  the  [uitient 
thinks  is  ridlcuUms  and  silly,  or  the  pjiysician  may  make  the  mistake 
of  talking  oxer  the  head  of  t]ie  patient  so  that  the  patient  <-annot 
under>tjitid.  and  the  dream  will  say  what  the  patient  could  not  say 
himself,  tlmt  it  is  all  too  deeii  for  him,  that  he  cannot  follow,  and  that 
the  physician  \n  altogether  beyond  him  in  the  wltole  matter,  aikJ  it 
all  seems  cpiite  hopeless.     The  trou-sfer  dream  thcR'fore  becomes  n 
verj-  injportant  mutter  nini  re(|uire3  the  physician  ntustantly  to  l<x»k 
within  and  to  exercise  his  self-critique,  for  he  must  always  realize 
that  if  he  fails  at  a  certain  jxiiiit  the  trouble  is  not  witii  the  patient, 
hut  with  him.seir,  and  iHimetimes  the  dream  will  hidicate  what  the 
trouble  is.    The  meaning  of  the  transfer  is,  of  course,  that  the  (HLtient 
caintot  unburden   his  very  soul,   (rannot  stand  unclothetl  tn  all    ihu 
nakciilness  of  his  real  self,  cannot,  in  other  words,  completely  itmfess 
himself  to  an  indifferent  person.    There  must  be  something  in  ilic 
physician  which  commands  the  patient's  afTeetiun,  respect  and  con- 
fidence, anil  tlierefort!  the  psychoanalytic  work,  while  it  makes  ^rmt 
demaiuls  n]K>n  the  patient  also  makes  great  demands  upon  the  ph>'siciiui. 


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TREATMENT  OF  NEUROSES 

Somtrtimcs  the  transfer  is  of  surh  a  charartcr  htuI  siidic-it* iitly  intense 
of  itself  to  interffrf-  with  the  pro>jrcss  of  tht*  analysis.  I'licler  these 
cirtinnst Alices  it  ^nu^t  l>e  iliseiissetl  witli  tin*  piitioiit,  siiflii-li'ntly 
disciKscii  to  (In  away  with  the  resistaiiecs  it  hiis  rutsfil.  atid  fiiiaHy  at 
the  eoinpletiori  of  the  analysis  the  whole  nintter  uf  the  transfer  must 
be  freely  gone  into  and  analyxwl,  so  that  there  is  no  inisuiKkTstanding 
as  to  wh»t  its  real  uieaiiini;  mi^ht  lie.  The  patient  is  to  he  plueeil  In 
full  and  e)»mplete  possession  of  all  of  the  faets,  whieli  means  u  full  and 
eomplete  possesiiiou  of  liiniself.  Nntliinp  must  he  hidden  from  him, 
the  mirror  miist  beheld  upst)thathe('ansechimM'lf  in  it  in  every  detail. 

It  is  ticcausc  of  the  neeessity  of  transfer  tit  siircessfxil  psyehoanal>tIc 
handhnR  of  a  rase  that  it  is  undesiraliU*  tu  have  another  physician 
treating  the  patient  at  the  same  time.  The  other  physi<-iun  mijjht 
UMjuire  the  transfer,  and  tins  would  pn*vetit  the  psyehoaualyst  from 
aceomplisliing  anythinji;.  This  is  especially  apt  to  be  the  ease  where 
the  other  physician  has  to  do  with  the  physieal  eoiuliti»m  of  the 
piiticiil  iLiid  has  to  i-uine  into  |)en>onal  contact  with  him  in  making 
examinations  and  the  like. 

A.-^  alR'ady  sai<l.  the  tninsfer  is  the  result  of  the  W^inuing  ih)wing 
outward  of  the  patient's  interests  into  the  world  of  reality.  The 
physician  naturally  is  the  one  toward  whom  this  interest  first  Hows, 
lie  therefore,  so  to  speak,  puts  liimself  in  a  position  to  he  ntitintl 
hy  the  patient;  he  becomes  a  hridfie  by  which  the  patient  is  able  to 
fiet  back  into  the  worlil.  At  the  eomjiletinn  of  the  treattm-nt,  wlu-ti 
the  transfer  has  been  fully  analyzed  and  the  pnticnt  understands 
wliat  it  means,  then  the  physician  hy  so  doing  steps  iiside.  Having 
served  the  puqiose  of  a  bridge,  having  gotten  the  juitieiit  back  into 
reality,  he  ste])s  aside  antl  leaves  the  patient  there  to  stand  upitn  his 
own  feet. 

Transference  is  not  an  isolated  nor  an  unusual  phenomenon  nor  is 
it  one  confined  to  the  psychoanalytic  situation.  It  is  a  universal 
psychic  way  of  projfrcss,  the  way  of  interest,  which  takes  the  individual 
from  lower  to  hipher  levels  in  his  way.s  of  tbinkitiy  and  acting.  It 
is  seen  easily  in  the  little  boy's  desire  to  emulate  his  father  and  Inter 
to  take  some  f^real  man  as  his  model  fivr  imitation.  It  is  the  basis  of 
all  interest  in  reality  and  is  the  constant  ttxil  ust'ii  for  affecting  ade- 
quate adjustments  witli  the  initside  world.  Life  is  a  constant  play 
of  transfers  of  inten'sts,  that  is  of  love,  and  in  proiMjrtioii  to  the  capacity 
to  love,  to  give  of  ourselves  to  some  goal,  some  ideal,  are  wc  capable 
of  living  our  hves  at  our  best. 

The  transfer  in  psychoanalysis  is  therefore  a  trememIou.sly  power- 
ful influence  for  gcwxl  an<l  also  for  evil  if  used  ignonintly  or  for 
■\'cnial  ends.  It  is  used  in  this  latter  way  by  those  who  do  not  know 
what  they  are  doing  and  sometimes  by  a  certain  t>*]>e  of  practitioner 
who  uses  it  solely  to  keep  the  patient  coming  to  him  and  paying 
fees.  Psyehoanaiysis  thus  demands  a  high  t\-pe  of  conduct  on  the 
part  of  the  physician.  It  ilemands  that  he  devote  himself  unselfishly 
and  nnstintingly  to  the  sole  object  of  the  iiatient's  welfare.     It  is  only 


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psrcnowEuiiosBS  akd  actual  neuroses 

wlieii  he  i-s  able  to  do  this  that  he  becomes  a  n-orthy  object  of  etnulu- 
tioii  1111(1  so  jilacvs  himself  in  an  uttitiifit-  Toward  the  pationt,  to  utilize 
to  its  fullest  extent  fm-  tlie  [talieiit's  tjoiKl,  the  ^jvuX  pnwer  he  )Misse^i«e» 
in  the  transfer. 

Tlie  great  obstade  to  the  treatiiieTit  of  the  psyulioi»euro«es  is 
the  general  ohstaele  that  the  patient  in  n  certain  real  sense  don 
not  want  to  get  well.  Tlien^  are  two  aintrary  tn-ndH  stniggliug  for 
supa-Jtiacy  in  his  psyche.  He  haa  two  .'iets  of  desires  cacli  trjinj; 
to  gain  fulfilinent  an<i  each  diamctrieally  opposed  to  the  other.  NW 
the  symptoms  of  his  neurosis  constitute  a  rompromise,  and  in  his 
then  state  of  mind  the  only  compromise,  the  only  solution  of  the 
problem  possible  to  him.  Me  therefore,  nlthouRh  he  want»  tn  grt 
away  fniin  llie  ■siifVeritiK  of  Ins  neurosis,  .still  i-*  nnwilliiiK  to  give  up 
the  s\inptoms  which  eomiKMLsate  him,  even  though  ihat  comjN'nsation 
Ih-  iiuulc<pmte.  This  is  illiistriLted  in  many  ways.  For  example,  tlie 
patient  insists  upon  leading  the  physician  back  to  infantile  occiir- 
rences  in  order  to  escjiix-  a  frank  discussion  and  facinp  of  present 
pmblems.  Again,  by  the  free  a.sso('iations  the  patient  will  lead  the 
physician  up  all  sorts  of  blind  alley's  for  the  same  pur|>0!(e.  The 
patient  always  wants  to  avoiil  his  task.  It  is  the  function  of  the 
physician  to  hold  him  to  it.  To  this  end  it  is  important  that  tlr 
physician  should  have  u  wide  knowledge  of  the  meanings  of  symptoms 
and  symbols  !in<l  Ix-  able  fairly  clearly  to  sec  at  once  their  general 
significance  otherwise  he  will  he  let!  into  intermitiahle  and  futile  dis- 
cussions. It  Is  only  in  the  final  stages  of  the  analysis,  when  the  pati»it 
is  made  whole,  at  one  with  himself,  that  he  can  nnderstand  why  it  b 
that  these  things  have  come  alxiut  and  how  it  is  that  he  no  longer 
ntHH^s  his  illness,  but  can  dispt-nst-  with  it.  So  for  a  long  time  the 
physician  has  to  contend  against  i\\\  innate  desire  on  the  patient's  part 
to  retain  the  sjinptonis  of  his  illness.  ITiis  is  particularly  well  seen 
in  the  comptdsion  neurotic.  Here  the  patient  lias  built  up  an  eUb<)- 
rate  strwliire  which  he  considers  cpiitc  as  does  tJie  artist  his  work  of 
art  an<l  he,  equally  with  the  artist,  resents  all  attempts  to  tear  it  down. 

Various  accessory  fomis  of  treatment,  such  aa  baths,  massage. 
sanitarinm  treatment,  travel,  etc..  have  the  same  place  here  a^  with 
tlie  actual  neuroses  mentioned  before.  They  should  iiever  be  tx)ti- 
sidered  priniar\".  hut  only  as  sec-omlary.  If  they  are  utili/ed  without 
a  tliorough  analytic  understanding  of  the  patient  they  are  quite 
as  apt  to  do  bami  as  good,  becuuse  by  no  possibility  can  it  be  forwen 
what  tlie  results  will  be  unless  tlie  matter  which  has  to  be  dealt  with 
is  known  beforehand. 

It  must  be  borne  in  mind  that  the  symptoms  of  a  neurosis  or  a 
psychoneurosis  may  eo\'er  and  conceal  a  true  ps\'ehosis.  This  will 
appear  in  the  course  of  the  analysis,  bnt  cannot  alwaj-B  be  fu[¥secn 
as  the  n'sult  of  the  first  examination.  It  is  a  jKwsibility  that  should 
l>c  iKirne  in  mind  so  that  the  physician  may  be  guarded  in  what 
he  says  in  regard  to  tiie  possibilities  of  treatment  and  the  ultimate 
outeomc  of  the  case. 


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CHAPTER  XVI. 
M,\NIC-DEPUESSIVE  PSYCHOSES. 

The  general  coneept  of  the  umiiic-depressive  psychoses  has  been 
fin  extremely  dift!<-ult  one  for  some  reason  or  otlier  for  many  people 
to  adequately  grasp.  From  the  earliest  times  the  marked  cases  of 
melancholia  and  of  maniacal  excitement  have  of  necessity  been 
observed  mid  in  nuiny  instances  ably  describeii,  and  at  one  i)eri<Kl  of 
time  the  manias  and  the  melancholinjs  constituted  hy  far  the  larjjer 
portiun  of  the  t>'pes  of  mental  disurder.  At  that  time  ill  the  history 
of  psyehiatrv,  when  the  dinpiUKstic  Imir-splitting  was  at  its  lieiKlit. 
ininmicrHble  varieties  of  niniiia  aitd  inelaiichulia  were  descnlRil  itiid 
given  specific  names.  Tlicy  were  differentiated  on  the  basis  of  wlifthcr 
liallneinations  were  ]in.-seiit  or  not.  whether  delusions  were  present  or 
not,  and  upon  like  matters  of  what  seems  now  superficial  observation. 
It  was  observed  also  that  there  were  a  certain  few  cases  in  which 
stales  of  excitement  alternated  with  states  of  depression.  The^se  si»- 
called  circular  types  have  been  recognif*d  for  a  l<)n>t  time.  It  goes 
without  saying  that  during  this  period  when  psychiatry  was  in  a 
purely  descriptive  stage,  a  stage  from  which  it  has  nut  yet  by  any 
means  fully  emerged,  when  the  excitements  and  the  depressions  were 
the  s>7npl<iin.'.  in  evithMU-e,  that  excitements  ant!  4lepressioiis  iK-lorig- 
ing  til  all  sorts  of  condilitms.  dementia  precox,  general  paresis,  nrterio- 
sclerosis,  toxic  and  infectious  psychoses  were  included  in  the  broad 
concepts  of  rnaniii  and  inclaneholia  that  were  ])revalent  and  that  the 
fonuulution  of  the  manic-depressive  group  has  lx«n  the  result  of  a 
gradiml  weeding  out  fn>m  all  of  these  various  sources  of  the  things 
that  belong  together  and  tJie  elimination  of  those  which  further 
analysis  showed  were  not  similar. 

The  mani<-<lepressive  concept,  however,  wa.-*  not  definitely  for- 
mulated until  Kmejielin.  by  a  study  of  life  histories,  described  the 
L-onditiitu  as  a  disease  of  aifect  fluctuations  which  might  at  one  time 
nsaiiifest  itself  by  tlii'  pn>funiide.st  ilepri'ssioii  ajxi  at  aiiofhiT  time  by 
the  highest  grade  of  excitement.  Even  after  this  formulation  nmny 
thoiiglit  that  the  term  nianicHlepressive  psychosis  applied  only  to 
the  so-cull«l  nises  of  "cireular  insanity"  and  faile*!  to  jip]>reeiute 
that  there  were  inherent  and  fundamental  relations  between  the 
two  e;ttremes  of  afTeel  di.slnrbanec.  It  was  difticnil  to  utidcrstand 
how  there  could  be  any  relationship  which  bouiwl  together  cjises  of 
such  unlike  nutwanl  apiwarances  and  they  failed  to  see  that  a  patient 
who  manifestcfi  a  single  attack  either  of  depression  or  excitement 


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MASICDEPRESSIVE  PSYCHOSIS 


could  be  Hio^taseij  as  a  manic^epressive  solely  iMt^iune  th«*  ^tftc- 
sinn  or  the  exciti-ment,  as  the  case  might  !_ie,  presented  tbc  sjtr* 
tuiimtoluf^y  of  the  depression  or  the  excitement  as  found  In  rtkrt 
patinits  who  [irfsciitf<(  h  series  of  »tl«c*k-s  iif  In^th  kinils. 

The  prf.sfiit-<Iny  (tHut'pt  of  the  niani^Mlepres-sivc  j^roup  cottsidcntlvH 
mental  disorders  essentiiilty  of  affect  fluctuations  inanifo^ttinp  tbiv- 
selvfs  sometimes  by  depreA*ion,  sometimes  I»y  excitement,  }«mrtin»^ 
by  a  mixture  of  the  two,  and  filially  the  concept  has  ^^luii  (o  iirluli 
on  the  one  hand,  a  nanicM^lep restive  character  which  tends  to  rmt 
on  the  basis  of  a  labile  affwtivity,  and  on  the  other,  \uriotis  at>"[iit* 
nt»(iif«!stalions  which  present  secondary  syinptoms  that  tend  to  nuA 
the  fuiHtiiini'nlttl  alTective  ones.    And  so  the  «>ncept  cmerj^  td*' 
finds  the  root  of  the  psychosis  in  certain  charncter  tmit-^  that  w>fT 
umount  to  pathuIogicHl  infltiifcstntions,  and  w^rtHin  very  mild  flfirt? 
fluctuations,  the  tycloth.\iniaa,  and  includiriK  wrtain  atj-pitral  varirt 
with  secondary  s>inptoms  of  delusion  formation  and  disorders  of 
iteasorium  that  are  of  greater  jmictical  signifieaiicc  than  the  dtstuib^ 
anees  of  aft'ect. 

Here  also,  as  elrtcwherc.  it  is  seen  that  the  manir-depri'ssive  t.\"pe<^ 
reaction  merges  into  other  types  so  that  reactions  that  closely  re 
the  manicwle])ressive  are  seen  in  certain  phases  of  precox,  w 
various  of  the  deiircssions  and  excitements  from  other  ciitt3C3 
closely  parallel  the  nuinic-deprcssive  t>'pes  in  their  K\-niptoniatok)f!3ri 
With  this  contrpt  of  reaction  types  in  mind,  these  nierjriuKs  intn 
adjacent  territories  are  understandable.  With  the  concept  of  a  disr*'* 
entity,  one  which  looks  upon  disease  as  a  deliiiite  suinethin>;  Iwck  of 
the  s.unptoms  and  which  priHluces  them,  it  is  imiKtssihIe  to  uttde^ 
stand  the  meanings  of  thesi-  attenuate*!  ami  Iwnler  states.' 

Etiology. — In  the  first  place  there  are  certain  liepcthtary  fnctiirt 
to  deal  with  in  this  class  of  cases  as  there  are  in  the  precox  grouii. 
There  are  certain  families  wliich  show  a  preponderance  of  tJie  nianii 
depres^vc  psychosis,  as  there  are  families  that  show  a  prf>|>firidenini« 
of  the  precox  type  of  reaction.  A  recent  study  of  ItiilK-th-  would 
nidieate  that  this  statement  only  applies  to  a  jjivvu  j^'nerution.  While 
manic-depressive  and  dementia  precox  psychoses  seem  not  to  be 
found  in  the  same  generation  of  a  given  family,  the  two  psychone> 
may  occur  in  different  generations,  in  which  ease  dementia  i>reo>x  i 
found  in  the  descendants  of  manicMlcpreisivcs,  hut  the  reverse  reUtio 
sewns  not  to  occur. 

In  harmony  with  the  hereditary  tendencies  which  appear  tn  I; 
pres*'iit  in  this  group  of  eases  it  is  found  that  tlw  group  may  Ite  widely 
differentiated  into  two  extremes,  the  one  in  which  the  constitutional 
factors  a]>pear  to  l)e  predominantly  in  evidence  and  in  winch  Uk- 
various  attacks  appear  to  originate  either  without  any  cause  .at  all 

<  For  l)t<>r«tun)  tnim  lOOA  lo  191U  mx  IMcralv  !<>'  HnmUiiKM.     Ztachr.  (. 
Nourol.  <i.  Payrh..  HuikJ  ii.  lIMt  St. 

f,  f.  d.  gfuntnte  Nvarol.  ii.  P«yrh.  Ori|[..  B4.  xko.  Be(l  4  and  6.  p.  «tV. 


5* 

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or  at  least  without  a  determinable  or  ajjpurent  cause  that  is  sufHcient. 
On  the  ntlier  hand,  there  is  a  (iroiip  which  appears  to  he  more  or  less 
largely  r!etermine*i  by  causes  which  are  apparent,  such  as  the  inability 
of  the  iniliviflual  to  adjust  to  certain  conditions  uf  life,  and  repeated 
lireakdiivviiK  witli  the  ri'tuni  <»f  these  eonditiinis.  It  is  irnporlant  to 
reectgiiiw  these  two  (jniups  of  ruses,  between  which  uf  course  every 
iuteriue<Hiitc  variety  may  be  found,  because  of  the  signilicunt  bearing 
which  the  t.^^w  of  etiidogical  factor  lias  upon  the  probable  outcome 
of  the  therapeutic  attack. 

In  descrilHnf^  these  t\'pes  of  mental  diidurbance  the  two  priucipul 
phases— the  manic  and  the  depressive — will  first  Iw  de?pri(x*d  and 
then  the  various  forms  of  periiwlic 
psychos(«of  the  mani(."-dcpressive 
group  will  receive  eonsideratiou. 
while  filially  certain  less  eommnii 
combinations  of  symptoms  known 
as  the  mixed  states  will  re<'eive 
attention. 

Manic  Phase.  —  The  cardinal 
symptoms  of  the  manic  pliase  nf 
a  niani<>depressive  iwyeliosis  an- 
three  in  number,  namely  ( 1 )  Jili{ht 
uf  itlean,  {'!)  jw/chonutior  kypfr- 
actirity,  ('i)  nmit'innnl  cxnilatwi). 
The?e  three  symptoms  mny  mani- 
fest themselves  with  nn\'  degree 
of  severity,  and  the  severity  of 
tlie  sjinptoms  may  var\'  within 
wide  limits  at  rlillerent  times 
tlmjnjjhout  the  course  of  the 
attack.  The  thrtv  syiriptoni.-, 
too,  may  not  be  all  of  tlic  same 
dejiree  nf  severity,  for  example, 

the  fliffht  of  idejis  may  be  extreme  aiul  out  of  iiro]H)rtion  to  tlie  depree 
of  psychomotor   activity   which    may    show   only   a   slight   increase. 

Taking  the  attack  as  a  whole  the  onlinary  acute  varieties  wry 
generally  desifrnated  as  acute  mania  or  acute  luaniacid  excitement. 
Still  mikler  grades  are  spoken  of  as  bypomania  and  the  more  severe 
grades  arc  generally  termed  acute  delirious  mania.  These  thnM? 
degrees  of  excitement  arc  the  most  convenient  captions  under  which 
to  describe  the  manie  pha.se. 

Hypoinaiiui,  which  is  the  mildest  of  these  three  degrees  merge-s, 
of  course,  upon  the  one  hand  into  higher  grades  of  excitement,  sudi 
a.i  the  acute  matuaeid,  and  on  the  other  into  conditions  of  cyclothy- 
mia, which  may  be  termed  hypouuutiacal,  but  which  constitute  a 
s]>ccial  group  of  tiiis  cln.'is  of  cases  which  will  be  considered  separately. 
In  this  condition,  at  least  in  the  simpler  eases,  tlwre  b  a  di.sorder 


urith  fltglit  of  idcnii. 


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UANIC-DSFRESSIVE  FSVCHOStS 


wliirh  itivulves  the  propesn  of  thinking  more  tlmn  it  lUips  tho  roni 
oj  thmighi.    Tbe  particular  ideas  anU  acts  may  iwt  be  unusual  iin<l' 
yet  almoniuO.    This  state  of  affairs  is  excellently  ilhistrated  hy  the 
hypothetical  case  cited  hy  Mcrcier:'    ''Its  suhject  rises  early,  full  of 
s<'hemcs  of  business  nr  pleasure.     He  fusses  noisily  HlM>ut  the  Itouse,  | 
iiidifrt-reiit  to  his  distnrljancc  of  other  (x-ople's  slumtjers.     He  is  verj* 
impatient  of  delay,  lie  cannot  wait  a  minute  for  anjlhinfi  that  he  wants, 
ami  if  it  is  not  fortheouiinj^  on  the  instant,  he  flies  into  a  rage.     The 
eoiu-se  of  the  post  b  not  expeditious  enough  for  him.     He  eeiids  his  h 
letters  by  telegraph,  and  his  letters  arc  extraordinarily  nuiiierou.s.  | 
They  woiJd  he  numerous  in  any  c*.se,  but  their  number  is   doubled, 
and  more  than  doubled,  by  the  frecinent  changes  of  his  mind,  and  by 
tlie  impulsiveness  with  which  he  acts  upon  everj'  pasf^ng  whim.     He 
determines  to  make  some  purehase.  probably  a  very  iinneceaaaTy*  one,| 
but  one  for  which  he  can  addure  twenty  plausible  reasons*  and  liei 
writes  to  tell  his  solieitcw  that  he  will  tall  the  next  morninR.     Searcelyl 
is  the  letter  posted  when  he  sees  llial  he  will  attain  his  object  moi 
quickly  hy  asking  hia  solicitor  to  lunch.    He  telegraphs  accordingly. 
Before  his  messenger  returns,  it  occurs  to  him  that  lie  had  better  asl 
the  vendor  to  luneli  also.     Another  telegraph  is  dispatched,  and  sin" 
he  cannot  entertain  more  than  one  visitor  at  his  club,  another  niu* 
be  sent  to  the  solicitor  to  iiunouuee  the  change  to  a  hotel.     Ti»ei 
be  remembers  that  he  has  Ixrn  dniwing  heavily  of  late  on  his  iMinkiiii 
account,  and  that  he  may  not  have  the  necessary  funds  uMiilahle.' 
Another  telegram  to  the  bank.     But  if  there  are  iiisuffieient  funds  in 
the  bank,  he  vnW  have  to  sell  stcwk  to  mtse  the  funds;  another  teU'^ram 
to  his  broker.    Then  he  detemiine-s  that  it  will  b<'  better  to  pledge  tht|M 
stock  to  the  Ijuiiik  riitlier  than  to  sell  it,     More  telegrams    to    tbM 
broker  and  to  the  liank.    Tk*  broker  won't  like  the  eont^adicto^^ 
urdcrs^uexer  mind;  ask  him  to  dinner — ask  theni  all  to  dinner.      I'ut 
off  the  lunch  and  have  a  dinner  instead,  and  ask  the  solicitor,  thM 
vendor,  tlie  banker  and  the  broker.    Yes.  and  why  not  Sinxtli  airo^ 
Jones  and  Hobinson  as  well?    More  telegrams ;  and  then,  since  two  out 
(»f  three  of  the  invited  guests  deiTline,  the  whole  thing  is  p«>stponed,  al.w 
by  telegraph.     Meantune,  in  the  intervals  of  telegraphing,  his  humU 
have  btTu  full.     He  has  been  constantly  ringing  the  bell  and  ^i\ing 
orders— giving  tl>em,  modifying  them,  anil  euuntermanding  thcm-^ 
constantly  wanting  sonR-thing  fresh,  ruaning  up  and   tlowu     staii^ 
writing  letters,  haranguing  this  person  and  that.  Hying  into   u   mge 
U|Kin  the  slightest  opposition,  tearing  the  bell  down  on  tlic  slighter- 
delay,  and  talking  almost  incessantly."  fl 
In  this  cxainjile  the  subject's  acts  might,  almost  all  of  the-m.  l^ 
eniisidered  nomin],  with  of  lourse  the  exception  of  ihost?  due  tt)  undue 
irrrtabilitv  or  aiigi-r.     Aside  fnmi  this,  liuwi-ver,  each  act  is   ctuue. 
tently  din'cte<l  to  some  definite  aim.    The  disorder  is  not  in  the  ci» 
tent  of  thought  so  much  as  In  the  process  of  thinking,  atid  mnnifesl 

■  A  Test-lwuk  of  Ituanlty.  Tlic  MBmiDlati  Company.  1914. 


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by  M  rapid  mitl  tou  frequent  change  of  directiun.  This  is  llie 
pht'iinTiH-iHiii  known  iis  fHiffit  nj  iih-nn,  anil  iim>-  Iw  perhniis  better 
illusiniU'd  by  h  skMiojtrani: 

*'  Uo  you  know  1  was  kidiKipix-d  to  bf  *i'nt  licrt"  twiee.  I  saw  a 
I  mock  fuiKTal  (»f  nic  bef(tre  1  left  home.  TMs  was  doin'  because  I  am 
a  yrx'at  invetit:tr.  The  poin.'  of  Rome  is  the  gix-att'st  human  iK-iii^;  in 
Itbf  universe.  He  i.s  tlie  heaf!  of  the  ("athulir  ("hiireh.  My  head 
lassneiiitiDii  of  the  word  head  in  two  <)iirerent  iueaniiifi«|  is  poinl  and 
[smirid,  hihI  1  am  eertjiinly  not  inRitne.  Do  you  hear  the  tii-king  of 
the  eloek?  (Kxternal  association.)  It  sajTj.  'e«]l  the  little  heifer,  the 
heifer  is  slek.'  Did  you  ever  see  the  gloves  veteritnin  snrjieiins  use 
when  they  (hMtor  slek  euws?  (liitertial  asstH-iatioii.)  Say!  what  ure 
you  keeping  me  here  for  anyhow?  I  want  to  go  home.  (Here  he  was 
asked  tiow  he  slept  at  night.)  I  have  slept  extrUcntli"  that  Ls  because 
I  am  of  such  a  strong  constrtution.  The  ronatitution  of  the  (nited 
States  (iusaoeiation  as  alH>ve  with  the  word  head  probably  the  asso- 
eiatitin  is  in  hirp'  part  at  least  a  sound  or,  as  it  is  railed,  a  vtntuj 
asHvciat'wn)  was  signed  by  Thomas  Jcflerson.  He  was  just  ii  man, 
hut  he  was  not  the  inventor  I   \m." 

In  this  phenomenon  of  flight  of  ideas  the  patient  either  has  no  guid- 
ing idea  or  e^e  at  oner  loses  it  so  that  then'  is  no  (vmsistent  and  sus- 
tHiiied  ell'dft  directed  tiiward  attaining  a  goal  idea,  and  the  thought 
therefore  wuuders  here  and  thei-e  under  the  ioHuenee  of  tliaiiw  asso- 
ciations. As  a  result  the  train  uf  thought  instead  of  progressing, 
ehangi's  diredicm,  frequently  returns  ujjon  itself,  and  never  reaches 
a  logieal  end.  The  various  ideas  ar*'  not  on  that  account,  however, 
ineohereuT,  that  is.  they  do  not  fail  to  eohere  or  to  be  eonneeted  with 
one  another,  although  it  may  be  quite  impossible  at  times  to  sec 
wherein  this  eimneetion  lies.  If  the  associations  are  external,  that  is, 
originate  In  the  snrmiincJitigs.  it  is  often  quite  pns^ible  to  plaiv  them; 
when,  however,  they  are  internal,  that  js,  originate  within  the  patient's 
mind,  it  may  U-  quite  inipnssible  tn  eoneeive  what  they  are.  In  lite 
example  just  cited,  while  there  are  many  places  where  the  eomieeting 
link  is  mis-ing,  probably  because  it  was  an  association  formed  entirely 
within  the  patients  mind,  still  the  connection  <-an  Ik*  made  out  in  a 
suilicienl  number  of  Instances  to  establish  the  characteristics  of  the 
train  of  thought.  One  nf  the  princii>al  eliaracteristics  of  this  t.\-pe  of 
the  train  of  thonght  is.  as  we  have  seen,  its  great  tendency  to  eliange 
of  dirtH'tioti.  and  when,  for  examjile.  this  change  of  direttion  takes 
place  under  the  infliK'nce  of  external  a.'^soeiations,  sneh,  for  example, 
as  the  ticking  of  the  clock,  as  notwl  in  the  stentignim  given,  the 
plienomriion  is  kuoun  as  tlistntrlibtlity.  Any  sensory  impression  is 
liable  to  Ije  tlic  starting-i«>int  of  idea  association,  so  that  these  patients' 
trains  of  thought  may  Ije  tunied  at  will,  almost,  by  such  devitvs  as 
shakirn;  a  bunch  of  keyy  Iwforc  them,  saying  some  woni  loudly,  show- 
ing them  a  newApai>er,  or  in  other  words,  momentarily  illstracting 
their  attention. 


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The  cnud'utnal  pxultalion  is  also  wtH  i^luiwn  in  Arcmcr's  rxample. 
Tlie  patient  ift  tiiiistantly  iii)iii|;  tilings  wliich  testify  to  Ins  idea  of  Uh 
uwii  iatiportimw.  Otie  is  struck,  htmevcr.  by  a  s.\iiiptom  in  the 
emotioiml  fieW  which  is  perhaps  more  fundamental  than  the  simijle 
exaltation  aiul  which  correspond.s  to  the  s\Tiiptom  just  cited  and  the 
motility  disorders  to  be  describeil,  that  is,  the  great  lability  of  tbt- 
emotions,  the  rapid  play  of  different  eniotiniial  reaclions.  exaltation 
giving  place  to  irritability,  Iv  anger,  iiniiuyance.  and  the  like.  There 
IB  no  sustained  emotional  attitude,  as  there  is  no  siistaitied  direction 
in  the  train  of  thought.  The  psychomotor  hv-peractivity  is  also  well 
illustrated  by  this  case.  The  activity  of  the  patient  is  seen  to  be  con- 
stant and  unremitting,  but  again  it  has  the  same  qualities  as  tlie  train 
of  thought  and  the  emotional  attitudes  inasmuch  as  it  is  not  sustained 
for  any  length  of  time  in  any  particular  direction,  it  dot*s  not  get 
auywliere,  while  from  time  to  time,  UTitler  the  influence  of  rapid 
changes  of  emotion  the  acts  tend  to  impulsiveness.  There  is  uiarked 
pressure  of  actirity  just  as  there  is  presffiire  of  »peivh,  and  the  patient 
appears  to  be  living  under  terrific  and  unremitting  tension  mifaout 
power  of  direction. 

In  this  condition,  therefore,  the  patient  is  con.stantly  active,  busying 
himself  about  one  thing  and  another,  talking  continuously  meanwbile 
often  in  a  loud  and  rather  boisterous  manner,  while  emotionally, 
exaltation  is  inaniFesteel  by  good  humor,  a  smiliug  countenance  and 
increased  self-esteem,  punctuated  mayhap  b.v  attacks  of  irritability 
or  impulsive  anger  from  little  or  no  cause.  His  coufiderioe  in  his  owti 
ability  is  imquatified  and  is  shown  in  the  outlining  of  all  manner  of 
.schemes  of  work,  investments,  business  enter]>rises  and  the  like.  Might 
of  i<leas  is  marked,  though  not  of  high  degree,  the  ecmversation  changing 
at  frequent  inten"als  from  subject  to  subject  and  the  acii\ities  sJiow 
a  like  characteristic,  there  being  no  consistent  effort  dirtx'ti"*!  at  any 
one  aim  for  any  length  of  time.  Letters  are  often  written  in  great 
nuinlMTS  and  their  contents  exhibit  the  sjime  characteristics  rs  do  the 
ape*^ch  and  (x>nduct.  The  patient  is  fully  (triented,  there  is  no  cloud- 
ing of  consciousness  nor  deliLsions.  hi  spite,  however,  of  the  lucidity 
and  apparent  abundance  of  energy  the  real  efficienej*  of  the  indi- 
vi<lual  is  greatly  n-iluced  because  of  the  lack  of  consecutiveuess  in 
ajjplication. 

CWttiiues  tile  picture  is  complicated  by  tlie  addition  of  sxmptoins 
due  to  alcoholic  indulgence  wliich  is  very  i-ommon  with  patients  in 
thi.s  condition,  many  of  whom  show  marked  moral  delinquencies,  but 
because  of  their  lucidity  ami  facility  of  expression  often  elude  the 
authorities,  being  at  once  discharged  after  examination  when  appre- 
heiide*]  because  of  sup|>osed  mental  disorder.  This  complication 
with  alcohol  will  Ix-  s]H>lsen  of  again  under  the  Itciul  of  Piagiiitsis, 
Sexual  excitement  is  also  quite  frecpiently  and  characteristically  in 
evidence  in  these  cases  and  leads  to  moral  delinquencies  which  show 
a  still  further  departure  from  the   patient's  u.sual   manner  f>f  cou- 


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diicting  himself.  When  conipHcated  with  alc-ohol  the  whole  ciiiicluct 
may  lie  quite  tuHi-umicrstaiuluhli:  cxo('iit  to  those  iminiil  in  the 
refuKiiilioii  of  this  chiss  of  rases.  The  sexual  exeiteiuetit,  of  eoursc, 
is  an  pspt'cially  unfortunate  and  ilaugcn>us  s^-iiiptom  in  young  women 
and  may  lead  to  particularly  regrettable  actions. 

Acute  Mania. — The  next  ^rade  of  maniacal  excitement  presents 
perhaps  the  most  cliaracteristic  picture  of  tliis  phase  of  the  dlM-ase. 
exhibiting  the  sjinptoms  to  best  advantaKc,  though  it  must  be  under- 
stood that  the  symptoms  of  the  <hfferent  grades  differ  only  in  degree, 
intermingle  and  are  found  alike  in  all  the  eonditiou!^ 

In  this  degree  of  excitement  the  flight  of  ideas  is  well  marked  and 
may  even  become  so  extreme  at  time^i  that  t)ie  train  of  thoupht  has 
the  upix-aranctr  of  being  quite  incoherent;  Distract ibllity  is  a  promi- 
nent feature  and  the  patients  are  constantly  divcrtwi  by  inconse- 
quential happenings  in  their  enviroimient.  The  tendency  to  rhyme  is 
quite  frequent  and  the  wonls  heanl  by  the  patient  siwken  by  those 
about  him.  although  they  may  have  no  reference  to  him  or  be  addressed 
to  him  in  any  way  are  often  woven  into  or  fonn  the  starting-point  for 
these  rhjuies  or  for  a-isociations.  The  characteristic  of  thes«  a.ssocia- 
tions  is  their  superficiality  anrl  when  words  that  are  heard  are  intro- 
duced into  their  i-onvcrsation  iIk'  basis  of  their  choice  is  often  nothing 
more  tlian  the  sound  similarity  iclan^  association).  It  is  quite  remark- 
able how  such  R  patient  who  is  ajiparetitly  paying  no  heed  to  wliat  is 
going  on  about  him  will  catch  a  chance  word  or  phrase  uttered  by  some 
one,  perhaps  a  considerable  distance  away,  and  intnKluce  it  into  the 
stream  of  his  conversation.  Consciousness  may  be  «Jinewhat  clouded 
aud  there  may  be  at  least  apparent  disorientation,  panicularly  for  per- 
sons. This  apiwrent  personal  disorientation,  however,  is  fh'|>endent 
in  the  main  upon  tv'o  factors.  In  the  Hrst  instance  the  patient  does  not 
adequately  perceive  the  environment,  he  does  not  dwell  long  enough 
upon  any  one  particular  element  of  it  to  comprehensively  gra.sp  it 
in  the  rapid  and  transitory  surve>'  which  it  receives  from  him;  its 
elements  arc  not  adequately  perceivwl  and  tlicrtifore  are  often  mis- 
understood, partly  because  of  this  suiKrficial  attitude  tou-ard  the 
env'u^nraent  and  partly,  also  probably,  because  of  deeper  reasons. 
Slight  rescmblanws  to  friends  or  relatives  are  often  seen  in  the  patients 
and  nur*cs,  aiitl  these  resemblances  are  magnified  out  of  due  proportion, 
and  so  these  various  persons  are  addressed  by  the  immes  of  members 
of  the  patient's  family  for  instance.  These  resemblances  do  not 
necessarily  result  in  a  perniarent  and  fixed  mistake.  The  person  who 
is  at  one  moment  addrcsse<]  by  one  name  is  a  little  later  addre.<«e<l 
by  another,  ami  not  infrequently  the  whole  situation  is  further  com- 
plicated by  the  wit  reactiiJii  of  tlie  patient  who  gets  n  good  deal  of 
fun  out  of  bis  fafrtious  remarks  and  bis  apparently  meaningless 
mistakes.  These  errors  being  not  firmly  fixed  are  frequently  spontu- 
ue<ms!y  corre-cted  by  the  patient,  at  least  at  times. 

The  disorder  of  attention,  (light  of  ideas,  and  distractiUlity  are 


L 


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MANW-DEI'HF.SSiVE  PSYCHOSIS 


all  clemeuts  wluch  prociiicc  a.  transitor>'  and  a  sup<.'rfic'iul  survey  of  the 
envin>iitnent  by  prohihitin^  any  fixation  or  dwellinj;  upon  any  panicu- 
lar  elenif  lit  of  the  enviminm-nl  or  even  of  the  enn  and  tend  to  pnxltipe 
a  t-ondilioii  nf  the  content  uf  (.-ortsc-iousness  in  which  all  uf  the  ideas 
are  given  tlie  same  value.     No  one  thiiij;  is  attended  1o  long  enou|;h  to 
enhance  its  injportaiice  over  that  of  uthen*.    The  [Miticnt  voices  ideas 
Brst  Hhuiil  this  subject  and  then  aJxiut  that,  changing  from  one  to  tlie 
other,  not  I>e<wiHe  oF  any  appreciation  of  ilifTeremvs  of  iiiiiH)rtanre, 
but  in  response  to  the  pressure  which  makes  it  impossible  for  him  to 
rest  nll^^vhe^e.  so  that  all  iflens  tend  to  reach  the  sjune  level  of  \n\\nic- 
tanre  in  Iiis  rniiseitniMn-ss.     Thcrt'  is  what  is  called  a  lenlimj  uf  ulnts. 
While  liiillnciiintintis  are  not  uu  essential  part  of  the  picture  they 
may  occur,  but  when  they  do.  like  all  of  the  other  elements,  they  tend 
to  I*  only  transitory  and  usually  are  rather  simple  and  elementarj* 
in  character. 

The  dehisions  also  are  Inclined  to  he  changeable.  They  partake 
characteristically,  when  present,  of  the  prundiose  character,  but  usually 
lack  tfii.T  element  of  extreme  improbability  found  in  c(militii»iis  uf 
dementiu  precox  and  general  paresis.  Occasionally  a  jierseculory 
paranoid  system  of  dchisions  develops  in  the  manic  phase  of  this 
diseuse,  but  this  class  of  delii-sions  is  more  apt  to  develop  ami  present 
a  fairly  well-organized  system  in  the  mihler  grades  of  excitement. 

The  psychomotor  activity  is  omstant.  The  patients  are  unable  to 
remain  at  rest  (pressure  of  activity),  they  run  and  jump  and  turn 
soniersjuilts,  wave  the  arms  alxiut,  tear  up  clothing,  destroy  plants, 
bn'iik  furniture,  luiwl  and  yell  all  night  long,  and  ^o  almost  alKsoIutely 
without  sleep.  CJenftid  excitement  may  l)e  pnmn'nently  in  evidence. 
The  exeilement  may  be  so  great  tliat  the  jjatieiit  dws  not  c\X'u  take 
time  to  eat;  food  phiced  twfore  him  is  perhaps  tasted  and  then  thro»-n 
about  like  everj'thing  else  tliat  comes  in  his  way.  so  that  with  the  lark 
of  nutrition,  lack  of  sleep,  and  with  the  unremitting  activity,  emacia- 
tion is  a  constant  feature.  In  less-marked  degrees  of  excitement, 
however,  where  the  feeling  of  well-being  is  the  (controlling  factor,  it  is 
eoriinion  for  the  patient  to  gain  somewhat  in  weight. 

The  emotional  exaltation  is  marked  and  shown  by  btjisterous  laugh- 
ter and  rerujirks  showing  cxaggerute<l  Idejis  of  self-esteem.  Putienta. 
however,  are  sp.i.*anodically  apt  to  be  irritable,  I>ursting  into  attAcka 
of  anger  without  adequate  rea.son  and  often  are  a  eonstnnt  souree  of 
trouble,  annoyance  and  agitation  ujion  the  wards  where  they  are 
confined.  The  emutioiial  condition  is  as  changeable  as  the  trr'ud  <if 
thongfil  or  of  the  din'ction  of  the  activities,  and  emotions  of  radiailly 
itpposed  qualitk's  may  ea;:ily  replace  each  other. 

Prlirvnts  Mania. — This  comhtion  is  merely  an  aggravated  state  of 
the  acute  mania  already  descril)ed.  The  flight  of  ideas  here  ha.s  pro- 
ceeded to  almost  ei»mplete  incoherence.  The  activity  is  unremitting 
and  eon-seiousness  is  more  clouded  and  Imllueinatious  more  in  evi<Iein,v. 
The  hick  of  sleep  and  proper  nourlsluuent,  with  rapid  emoeiation.  aoou 


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leailA  tn  gront  physiral  exiiaiistion,  while  the  coiistnnt  acti\'ity  lint 
iinuMiallv  results  tii  slijilit  wrmmls  wliich.  evvii  tlioiiBli  prnpt'riy 
<in-ssril,  lire  stKHi  ex|)iibe(l  to  infe4!tiiiii  when  the  }mtiful  tours  off  th« 
tln-Hship.  Lucal  ureas  of  suppumtiun  thus  dcvflop,  there  la  n  iiuld 
tk'pnt'  of  infection  with  some  teniixTnlure.  which  cmipleti  with  the 
exhaustiiHi  atnl  llie  loxeiiiiu,  prutlucc  »  pictun.-  nioa-  iHtitiiictly 
(iciiriouy  with  marked  clouding  of  consciousness  ami  jrrcut  incnlien-iire. 

■^rhc  ucutt:  di'lirimtji  nifiuia  which  used  to  be  described  and  was 
rejiurdeil  as  always  fatal,  was  undoubtedly  in  a  certain  pn>portion 
(if  casts  the  liypermania  of  the  mariicHlepn^ssave  psychosis  to  which 
jjcrlmps  ha<l  Iteeii  added,  as  just  desffrilM^d,  symptoms  of  infection, 
ti»xfiiti»,  Hiid  cxhnustiuii,  which  nimle  the  picture  one  of  rlelirttim. 
Many  other  cjiscs  were  undoubtedly  also  included  uuder  this  ^tieral 
caption,  more  jMirticidarly  deliria  ass(K-iated  with  acute  »Usease'4  of 
the  iiiterrml  organs,  such  as  acute  nephritis  or  pneumonia.  One  who 
has  had  c.\]K'riciKf  with  these  cases  can  understand  liow  such  cort- 
ditions  might  ^o  unrecognized,  owing  to  tlie  ahuosi  physical  impossi- 
bility t>f  snV>jecting  such  patients,  in  their  wildly  excited  condition,  to 
an\"thing  approat^hing  an  adequate  physical  examination. 

Chninic  Mania. — 'I'here  are  a  very  few  cases  that  pass  into  a  «)n- 
dilion  of  chronic  mania  and  usually,  though  not  always,  have  mild 
excircmcnts  rtmt  may  last  for  a  immljcr  of  year;.  The.'y  conditions, 
on  the  other  liand,  may  be  prnctiadly  nothing  else  but  character 
aiiomulies,  (mscs  of  constitutionally  heightened  (manic)  mnoii.  Such 
pr(>I{>nged  phases  of  the  disease,  however,  must  be  borne  in  utiud  as 
pMSsibilities. 

DepressWe  Phase. -Like  the  manic  phase  this  pha.str  alstj  maiufests 
itself  by  three  cardinal  symptoms  each  diametrically  op]>oscfl  to  the 
oorre.simnding  symptom  of  the  manic  phase,  namely  (1)  dlfficidUj  of 
ihinking,  (2)  paychomuior  retardation,  i'.i)  eiitntiumd  ilfpn-Mum. 

This  group  of  symptoms  may,  as  with  the  manic  group,  manifest 
its_^lf  with  any  degree  of  severity,  and  the  three  symptunis  muy  sever- 
ally and  individually  vary,  irrespective  of  each  other.  The  retardation, 
for  example,  may  he  quite  out  of  all  pro]x>rtioii  to  the  depression. 

.\s  with  the  niatiic  phasi-.  it  is  convenient  to  consider  the  depressive 
phase  in  three  different  grades. 

Simple  Hctardaiion.—llv:  word  retardation  is  lierc  used  to  refer  not 
only  to  psychomotor  retardation,  but  to  the  diffi<rulty  of  thinking 
also,  probably  quite  similar  phenomena,  the  one  more  particularly  in 
the  .sphere  of  thought  and  the  other  more  pnnicularly  in  the  sf)here 
of  psychomotility.  These  patients  move  and  sjicak  slowly  and  per- 
haps in  a  low  voice,  by  preference  an.'iwirring  questions  in  monosyl- 
lables. These  outward  evidences  of  difliculty  of  thinking  and  moving 
are,  however,  more  marketl  in  the  next  stage  of  the  dcpn'ssive  plinsc, 
that  is,  in  acute  mehmchulia,  while  here  it  is  more  usual  to  see  the 
patients  merely  i)referring  to  be  by  themselves,  disinelinni  to  associate 
with  others,  keeping  to  their  room,  and  quite  unable  to  make  any 


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UAS'IC-DBPRESSIVB  PSYCHOSIS 


im-iitjtl  etfort.    They  are  not  equal  at  all  to  going  on  witli  thoir  work. 

Tliey.niiiy  not.  fur  example,  feel  equal  to  WTiting  letters  or  c\Ten  to 

reading  the  newspaper. 

KTiiutioniilly  these  patients  arc  usually  sonu'what  depressed,  but  the 

(Icprissimi  iiisiy  jint  be  e?<ix^iKlly  nuirkcd,  it  may  only  appi'ar  nn 
questioning.  Consciousness  is  elenr  an<i  the 
patients  an*  fully  nriented  and  often  have  a 
realiztttion  of  their  mental  invaliflism. 

Acuie  Melancholia.— In  this  grade  of  de- 
pression   the    thme    cardinal    s^Tnptoms   arr 
manifested  in  a  muL-h  more  pronountTfl  way. 
'J"he   patients  are  cliaracteristieally  inuetive, 
sitting  by   themselves,  showing   little  or  no 
tendency  to  assojiate  \rith  others,  thetr  move- 
ments are  slow  and  deliberate  (executive  re- 
tjirdation)  and  it  often  takes  u  iNjnsiderable 
time   t»i    initiate   them    (initial    retardation). 
The  speech  is  similarly  affef:ted;  it  is  alow, 
often    monosyllabic,  and   sometimes    almost 
inaudible.      Initial  rctanlation   is  noticeable 
here  also.     The  emotional  deprvssion  is  pro- 
found and  is  indicated  in  the  general  attitude 
of  the  patient  which  is  one  of  flexion  of  the 
body,  the  hands  lying  limp  in  the  lap.  the 
head    incHned   fonvard.  the  chin   resting  on 
the  brciust,  and   a    marked   facial   expn's-s.ion 
of  sadness.     The  subjective   state  of   these 

patients   h   described   by  a   feeling   of  difHcutty  of  thinking   and 

grasping  the  meanings  of  things  and  of  their  feeling  of  inadequacy. 

of  itH-apacity  ftvr  nil  effort,  or  even  thought,    llierc  is  a  marked  feeling 

of  tlecTcast  in  the  mental  activities,  and  the  patient 

does  not  feel  that  he  has  eontrol  of  his  mind  and 

can  use  it  effectively.     In  the  same  way  he  fe«rl» 

an  iiiterfewnce  when  he  comes  to  exert  his  will 

in  the  perfonnance  of  voluntary  acts.     There  is 

lack  of  ciKTgy,  lack  of  ability  to  initiate  or  to  su-s- 

tain  an  act  or  a  series  of  acts,  mid  tn  the  mental 

sphere  alone  the  patient  Hnds  himself  quite  un- 
able; to  carn»'  out  a  series  of  consecutive  mental 

acts  which  lead  to  a   logical   issue.     He  Mnnot 

come   to    conclusions,  he  has   an    overwhelming 

senst'  of  weariness,  of  relaxation,  of  inadequacy. 
This  general  feeling  of  inadequacy'  and  difficulty 

4>f  thinking  as  above  described  fits  into  and  fonn.s 

a  part  of  tlic  emotional  attitude  and  acts  wth  it  in  determining  the  cliar- 

acter  of  the  delusions.     The  delu.'iions  are  tj-picAlly  .sclf-accnsatory  and 

h>Txx-htindriacaI.    The  pjitients  think  themselves  resp*msible  few  all  the 


Fia.  :i86.— S«\'««(  do- 
prraaion  of  wveral  yean* 
duration. 


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sin,  wifkednesR, privation  nntl  siiffi-riiin  in  the  wiirld;  ihf.v  are  tlieuiiitse 
of  tin*  unfortimatc  (imilitinii  itf  their  fi-Iliw  pHttciits;  tlify  tliniiselves 
have  miminittt'd  sunif  ^rreat  sin  Jtml  tlittr  simls  art*  forever  l(*st.  As  tlu'.v 
occupy  themselves  with  their  owni  moral  states  so  they  wcupy  them- 
selves n  irh  their  Ixxiily  mmlition  and  belif  ve  themselves Hufterers  from 
incurable  disease,  think  that  their  orftait^  are  dcfayed,  somethinu  has 
happened  to  their  brains,  their  bowels  are  stopped  up,  their  Iwrnes 
bri)ken,  iiml  other  sucli  somntopsychie  ideas.  ^^  hen  the  organic 
sensations  are  altered  patients  have  strange  feelings  which  they  inter- 
prut  as  indicating  some  mysterious  thing  going  on  within  their  bmiy, 
and  such  scasatinns  may  be  at  the  basis  or  a^fsociated  with  some  of  the 
h.NpiKliondriacal  ideas.  The  emotional  depression  may  at  times  reach 
a  very  high  grade  and  express  itself  in  anxiety  attacks,  moixls  of 
&p]>rehenAion,  fear  of  impemling  danger,  a  nameless  dread  of  something 
going  In  happen,  and  the  like.  The  whole  world  is  look«l  at,  so  to 
speak,  throngli  bhic  glasses.  The  sad.  depresseil  motxl  cLilors  every 
jHTfcption.  and  so  the  pereeptioiis  are  more  or  less  incorrect  and  dis- 
torted to  fit  the  mood. 

IfaUucijiations  may  occur,  but  consciousness  is  usually  clear  and 
the  patient  well  oriented.  There  may,  however,  be  a  lack  of  orienta- 
tion toward  their  surroundings  dependent  upon  the  fact  that  they 
arc  wrapi>e<l  up  in  their  own  thoughts  and  the  enviroimient  is  not 
attended  to. 

FhyxicaUy  there  is  alniast  always  constipation,  a  coated  tongue, 
hidicanuria.  poor  appetite,  loss  ()f  weight,  disturbed  sleep,  and  often 
circulatory  disturbances  with  cold  extremities. 

Deprc^fiirc  Stuffor. — This  is  the  third  and  most  severe  grade  of  the 
depressive  phase.  In  this  condition  the  retardation,  both  in  the  6eld 
of  p.sj*chomotilit>*,  anri  in  that  of  tlwiight.  ha.s  proceeded  to  the  extent 
that  the  patient  lies  wholly  inactive  and  mute;  be  has  to  he  tube  fed, 
and  his  i-verj-  want  minlstcretl  to. 

During  this  periofi  of  absolute  inactivity  it  may  be  that  the  patient 
is  sull'cring  from  delusions  and  hallucinations  of  a  depressive  and 
horrifying  nature  which  perhaps  are  shadowed  forth  by  an  anxious 
expression  of  countenance,  but  the  tlet^ils  of  which  can  only  be  learned 
after  the  patient  has  amiiseil  sufficiently  from  his  .stupor  to  be  able  to 
express  himself.  The  hallucinations  may  appear  to  the  patient  much 
as  ill  a  dream  and  absorb  his  attention  to  a  very  great  extent.  This 
condition  of  stujHir  is  not  uncommon  in  the  (hiutsc  of  the  depressive 
phase,  but  usually  occurs  as  an  episode  ratlicr  than  as  a  distinct  form 
of  the  discftse. 

Chjvnic  liejnfmion, — There  are  certain  patients  who  present  for 
long  peritida  of  iin^e  a  depressed  mood.  Tliese  cases  may  l>e  mild 
depre-ssive  phases  of  manic-ileprcssive  psychosis  or  they  may  be 
character  anomalies,  cases  of  cnnstitutionally  depresses]  iiiimkI.  and 
so  shiiw  the  close  intcm'latiou-s  iR'twwn  the  normal  lluctuations  of 
emotion  and  those  that  are  pathological. 


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The  Periodical  Types. 
tliL-  iuankM]L-])rfssive  [>.'*ycIiosis  whieli  fruin  time  to  time  have  bt 
svwniWy  tipsrnhwl  as  Wiurrent  mania,  pcriodiL-  mania,  intcrmitt* 
miiiiia.  rci-urreiit  iiii'lancholia,  insanity  of  double  form,  alterniiti 
iiiSHiiiTy,  t'ii-cnlar  insanity,  etc. 

AH  of  tliest-  iwychoses  are  merely  rlifferent  maniffistations  nf  niM 
depressive  psychosis,  the  manic  itml  depressive  stages  being  represinl 
in  ^■a^Io^ls  relutionn,  nhvw  sepaniti*d  by  a  recovery  internal.  t% 
recurrent  nnmiii  \voiild  lie  recurri'nt  attacks  of  a  nianie  pliase  separati 
liy  well  inlerviils,  .similarly  for  rccnrrcnt  melancliolia.  wliilc  alci-rim| 
insanity  wduIcI  coasittt  of  manic  hihI  dcpres.^ttve  attacks,  each  fnlh 
hy  a  recovery  Interval;  circular  insanity,  on  the  other  hand, 
cycles  »f  miinie  and  ilepn-ssive  pha.ses  without  intervals  of  sejuinitiol 
wbih'  insanity  of  doiililc  form  wtmlii  consist  iif  cycles  of  excitation  aa 
depressiun,  eacli  cycle  followed  by  a  luci<l  interval.  Other  varieti< 
mijtlit  be  desLTibed.  but  it  suffices  to  say  that  the  three  phases— maiw 
depres.-*ive.  and  lucid  interval^may  be  combined  in  any  possible  way 
and  that  further  in  a  jiiven  case  any  degree  of  the  manic  or  depressiv 
phase  niay  occur.  It  is  cKninioii,  t<m.  to  see  durJnj;  attack,.'*  nf  th 
manic  pluise  transitory  attacks  of  depression,  while  during  the  depre* 
sive  phase  it  is  equally  common  to  see  tran.sitory  periods  of  euphoria 

111  a  numlMT  of  these  cases  the  attacks  repnxince  themselves  oftci 
at  very  definite  intervals  with  practically  phuttigraphic  ncc-umoy  s 
thai  the  patient  leads  a  life  the  events  of  which  can  Ix-  prcclictei 
with  almost  absuhite  preci.*don.  Such  )MitientH  not  infrequently  knoi 
some  little  time  beforehan<I  when  an  attack  is  cnmitig  on,  and  th 
physician  nmy  be  able  to  see  the  approach  of  an  attack  the  nmmer 
he  steps  into  such  a  patient's  nmni  by  a  little  dliferenee  in  the  arraui 
meat  of  things  that  indicates  (he  way  matters  are  going. 

It  would  seem  that  the  patients  who  present  such  definite  c; 
occurring  at  statcii  intervals,  each  exactly  like  the  others,  belf>ng  1 
the  group  of  cases  with  severe  constitutional  taint.  In  the  other  k^ou 
of  c'Hses.  that  group  in  which  external  conditions  seem  to  pla.\-  a  larj 
part  in  the  etiologj-  of  the  several  attacks,  there  is  much  less  tenilenc 
to  repidarity  in  their  (Kxurreutr,  aitd  as  heretofore  iEitiniated. 
greater  hope  fur  the  results  of  thera|Hniti(s. 

The  fiillmving  is  the  account  of  an  intelligent  woman  at  her  feel 
in  Imth  periods  of  excitement  and  dciiression: 

"I  have  suffered  all  my  life  from  excitements  and  dcprt^sioa 
although  it  W1U4  not  until  [  was  fifty-eight  years  of  age  that  my  famil 
and  I  realized  I  was  really  mentJilly  sick,  and  recpureil  institutiom 
care.  During  youth  and  middle  age  my  excitements  were  of  a  mil 
chamcter,  and  during  these  periods  1  I'onsidcrcd  mysi-lf  normal, 
felt  ])eeuliurly  happy  and  care-free.  I  managed  m\  htm.seIiold  alTau 
with  the  greatest  ease.  I  entertained  and  unugted  in  K(K-iety  witi 
pleasure  and  zest.  I  was  lively,  talkative  and  1  liave  reason  to  beliov 
I  WBH   witty  and  entertaining.     I  couki  work  without  an  efftirt. 


3 

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i<  lenc 


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at  timc.'i  acTumplisheil  iilmust  Herttileaii  taskii.  On  one  m'c-a.su>n  I 
reinenilMT  preparing  ami  rtnulurtiiif;  a  rhiiroh  cntopfjumncnt  \yy  o'liu-h 
thf  simi  (if  S.S(H)  vviis  ruisi'il.  (Jf  latr  yi'iLrs  nty  rxt-itfiiu-nts  liiive 
grown  more  -scvprr.  I  bef;in  by  tnkinj;  nn  ovt-rartive  interest  In 
ever^tliiiijc  jtoiiifr  on  urouii<)  rae.  Evtrythinn  seems  nwy.  I  feel 
liiippy  unti  iiothiiifi  lieprcsscs  me.  1  feel  propelled  by  stpme  imknonn 
force  to  constant  itctinn.  I  am  possessed  with  the  idea  of  rightinK 
wnmfjs  and  stralphteninji  out  tliinps  in  peneral.  All  The  faults  in  the 
adrainiittrfttiun  of  the  wani,  the  hospital,  and  the  (rovemment  must 
Vie  eorreete<L 

"  My  excitements  have  never  led  me  to  commit  any  aets  of  violence. 
I  otTUpy  myself  largely  in  talking;:  and  writing  lettei-s.  My  room  is 
often  in  disorder  because  1  caimot  stay  at  one  job  Icng  eiiou(:h  to  com- 
plete it.  Aa  [  feel  these  excitements  approaching,  1  recfuest  the 
physician  in  charge  of  me  to  take  up  my  pari>le,  as  I  know  I  iihall  be 
moved  to  do  and  say  many  foolish  things  of  which  1  will  \w  aslianieil 
later.  Nn  one  whti  has  not  had  experienc-e  can  realize  the  mortiliea- 
titiii  of  having  bwn  insane. 

"My  depressions  in  early  life  were  as  mild  as  my  excitements,  the 
onset  was  gradual.  I  felt  a  disiriclinatioii  to  niingte  in  society,  \\nien 
forced  to  do  so  1  sat  like  a  'dummy"  and  could  think  of  nothing  to 
say.  My  household  duties  l>ecanu'  a  burden.  One  after  another  of 
these  was  dropped  until  (he  care  of  the  household  was  entirely  given 
over  to  relatives  or  ser\'ants.  1  learned  from  experience  a  treatment 
of  my  own.  As  soon  tus  I  felt  a  depression  approaching.  I  (jnanptly 
dropiHtl  everything  and  left  home  for  a  time.  1  found  b\  gt-lting 
away  frtmi  family  cares  ami  respoTisiliilities.  and  from  the  dennuHJs 
of  Sijciety.  to  some  quiet  spot,  I  amid  shorten  ihc  duration  of  tliese 
depressions.  In  recent  years  the  depressions  have  appeaml  suddenly. 
One  day  I  went  to  town  to  do  some  shopping  for  a  friend.  I  went  to  a 
grocery  stt)re  lo  make  some  pun-liases.  It  suddenly  )>ccnrre<l  to  me 
that  I  could  make  these  to  much  better  advantage  at  the  market 
only  a  block  away.  .Suddenly  I  reatizA-d  that  I  did  tmt  havr  sufficient 
energy  to  go  to  the  market,  and  that  another  <lepressiim  was  npcin 
me.  It  was  with  the  greatest  difficulty  that  I  onlcred  the  gmwls.  ])uid 
fi)r  them  and  came  home.  At  the.se  times  my  brain  fecl>  paralywil. 
I  ha^e  not  the  strength  or  ambition  to  do  anything.  1  am  apprehen- 
sive lest  some  harm  has  befallen  the  members  of  my  family,  hut  to 
save  my  life,  1  could  not  write  or  telephone  to  find  out  if  my  fears 
are  true.  I  have  the  impulse  to  act,  but  it  seems  as  if  suinetldng 
shuts  down  aii'i  i>roliibils  action.  I  see  my  clothes  becoming  ^oile^i 
— I  know  I  sliouhl  change  them,  but  [  cannot  puU  out  the  drawer  of 
my  bureau  and  get  clean  oik"^.  This  inertia  is  gn*ater  in  the  nmriiing 
than  at  night,  fiefore  1  came  to  tlie  hospital  for  treatment  I  had 
servants  who  -ilept  at  liuine,  and  came  to  my  house  early  in  the  morning. 
When  my  luisliand  was  away  and  my  children  wen^  Hniall,  it  ilevolvwl 
upon  me  to  admit  the.se  servmits  early  iti  the  morning.     I  knew  that 


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wlicn  morning  came  to  dress  nnd  go  down  stnirs  would  be  iinpu:»ible^ 
I  s((lveil  tlu'  difliculty  l)y  drfssiiig  tlu'  \\\^\\i  \ivUyrc  uti<l  altt^pinj;  in  mj 
c-lotlics.     \SW\i  the  depression  is  most  profoun<l,  I  move  in  a  fixcd| 
KTimve.     I  never  xary  u  hair's  brpadth.    At  first  I  havt-  n  ilesire  to    ■ 
reraain  in  lied.    Om-e  this  is  overcomf  1  have  no  choicv  hut  to  remain     ' 
up.    I  sit  ill  the  same  seat  and  in  the  same  attitude  for  weeks.    Aifl 
I  come  dijvvn  stairs  in  the  iiiurning  I  am  apinvhviisive  lest  my  >t*at  He 
taken,  and  I  wonder  wlmt  I  shall  do  if  it  should  be  oivupied,  althougli 
the  sitting  room  va  well  supplied  with  comfortable  seats.      I  bring  a 
shawl  witli  nie,  and  plac*'  it  in  the  thair  s<j  that  no  one  will  approi>riat« 
it  while  I  am  at  hreakfast. 

"  After  each  depression,  I  sutler  from  intense  [Miin  in  my  back,  side, 
shoulders  aTid  arms.  This  is  dull  and  aching  in  charaeler,  and  remains 
with  uie  for  weeks  after  the  depression  has  disappeared.  After  the 
last  depression  I  siilleix-d  from  a  severe  attack  of  the  shingles.  The 
skin  eniption  has  now  dLsappeared,  but  the  pain  still  remains." 

The  Cyclothyinias.  This  group  of  cases  presents  the  mildest  excile- 
meiits  and  depressions.  They  (ieviate  less  from  the  nornuil  than  the 
other  groups  and  are  only  ex)nsidered  separately  because  of  their 
gnmt  praetitid  inijxtrtance.  They  are  quite  usually  not  reragnized 
and  the  symptonis  are  attributed  to  all  sort*  of  things  other  tluin  the 
real  trouble.  It  must  not  be  lost  sight  of  in  mnsidering  these  miki 
maniiMiepressive  fUictiiLitions  (hat  a  slight  depression  may  re<ur  with- 
out the  psychosis  cxprc.tsing  itself  by  a  fluctuation  to  the  opposite 
condition  of  excitement,  and  net:  urm.  So  lluit  the  picture  is  seen 
of  patients  presenting  from  time  to  time  mil<l  degrees  of  depression 
or  mild  degrees  of  excitement  without  anything  approaching  delu- 
.sinnal  ftirmation  or  disonlcrs  of  the  sensoriuni  and  tiierefore  attnictitig 
no  [wrtieuUir  attention  from  the  mental  side.  The  fallowing  example 
illustrates  this  exceedingly  well:  He  is  a  man  who  devotes  luuself 
liirgi'ly  to  literary  work,  and  the  Huctuiitioiis  in  his  mental  state  are 
shown  excellently  well  by  his  ability  to  wTite.  The  onset  of  a  deprcft* 
sivc  phase  is  usually  shown  by  a  gradual,  though  more  or  less  rapid, 
falling  off  in  his  literarj*  ability.  He  is  lirst  unable  to  compose,  then 
he  get*  pmgressively  less  able  to  write  until  he  is  only  able  to  UTile 
the  simplest  things.  It  is  the  same  waj'  in  his  reading.  He  gravitates 
all  the  way  from  reading  connecteil  with  his  work  down  thnmgb  the 
different  grades  of  literature  until  he  gets  to  fiction.  He  finally  finds 
himself  quite  incapacitated,  sitting  for  hours  gazing  out  of  the  wiudow 
or  at  a  blank  wall,  and  while  rather  enjoying  company,  it  is  almost 
impossible  for  him  to  initiate  the  procedure  that  is  necessari-  tti  go 
anjTvhere.  He  finds  it  almost  impossible  to  dress,  to  get  out,  to  take 
the  ears,  and  the  like.  This  state  is  one  almost  entirely  of  retanlaliou 
without  marked  emotional  depression.  During  the  opjiosite  condi- 
tion of  affairs  he  has  a  feeling  of  well-being  and  efficiency  in  marked 
contHLst  to  his  feelings  during  tlic  depressive  |jeriod,  and  findb  himself 
quite  able  to  work  for  long  inter\'al3  very  effectively. 


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''Hic  rfiiiarkiihlf  transitions  from  phase  to  pha:%  are  shown  well  by 
OHO  of  hia  t'xperiem-es.  One  day,  liavin^'  \tevu  writiiij;  all  of  tin-  afttT- 
noon,  ho,  as  usual,  wt-iu  oul  lu  diiiin-T.  leavuitj  lils  pai>ers  on  the  table, 
intentling  to  resume  work  on  his  return.  When  he  v&mv.  haek  ami 
took  up  the  p«?n  to  write  he  found  that  the  incuhus  of  his  ileprcsslnn 
wius  upon  him.  He  hod  difficulty  in  finding  words  and  finally  after 
two  limirs'  rlfort  lie  gu\  e  it  up.  This  was  the  begiiniing  of  y  depression 
whieh  lusted  about  a  month.  During  this  time  he  con-stantly  tested 
hb  ability  for  composition,  but  without  favorable  resiJt.  /Vlmost 
exactly  a  month  after  this  incident  he  undertook  to  answer  some 
personal  letters,  intending  to  MTite  only  short  letters  of  perhaps  three 
or  four  pages,  but  when  he  started  to  write  them  he  found  himself 
writing  ejislly  and  his  letters  spontaneously  ex|>anded  to  eight  or  twelve 
pages  and  he  went  on  into  his  work  again. 

The  hi/perihymit  types  show  exaggerated  activities  in  the  way  of 
the  usual  business  oceupations,  writing  letters  and  the  like.  'Hie 
ju<lginetit  is  apt  to  be  rather  [Hjor  at  these  times  and  many  of  the 
busuiess  ventures  come  to  grief,  tliough  not  necessarily  so.  Wuck  is 
easily  done,  'nithout  having  made  effort,  and  the  patient  expends 
enormous  emnunts  of  energy  over  long  i)eriods  of  time,  rertaio 
types  of  cases  arc  meddlesome  and  troublestmie,  tending  to  engage 
in  disputes  and  altercations,  and  to  bring  law  suits,  while  exaggerated 
criticism  ami  alcoholit;  predilections  ofteutimejs  very  considerably 
color  the  picture. 

In  i\K'/hiifthiftnii'  (jz/w/t  arc  found  the  depressions  which  are  attributed 
in  large  part  to  neurasthenia  and  to  various  viscE-ral  disturlMinces. 

These  eyeloth>niiie  cases  not  infreciuently  show  fluctuations  at 
periods  of  recurrent  plij-siological  activity  such  as  the  menstrual 
[K'riod,  while  it  must  never  be  lost  sight  of  that  not  a  few  .so-called 
dipsomanias  arc  really  recurrent  manicMlepressive  attacks  in  which  the 
alcohol  is  resorted  to  shortly  after  the  attack  commences  and  then 
quite  usually  all  the  sjinptoms  from  whieh  the  |>atient  suJfers  are 
attributefl  to  the  alcfibolic  indulgence.  It  is  ini[>ortant  to  Iwar  this 
class  of  cases  in  iniiid,  not  only  for  diagnostic  purjKJses,  but  In  onler 
that  the  patient  should  be  dealt  with  fairly  as  a  sick  man. 

Perhaps  the  most  important  of  the  disturbances  in  this  group  of 
cases  arc  the  visceral  disturbances.  There  are  a  large  number  of  con- 
ditions, particularly  the  false  gastropatbies,  enteropathies,  cardi- 
opathies of  I>cjerine,  etc.,  many  of  which  Iwlong  here.  Inasmuch  as 
the  psychosis  is  not  recognized,  tliese  conditions  are  quite  naturally 
credite<l  with  being  the  cause  of  the  condition  of  the  patient.  I'aiients 
with  mild  depression  are  called  neurasthenic,  those  with  mild  excite- 
ment are  called  nervous,  and  the  ftrcompanylng  physical  condition  is 
crediteil  with  makuig  the  trouble.  The  patient  and  the  relatives 
consistently  take  this  attituile  and  the  jihysician  naturally  falls  into 
it.  No  one  wishes  to  acknowledge  the  i»ossibility  of  u  mental  dis- 
order, and  therefore  these  other  explanations  are  readily  accepted. 


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In  fact,  tlic  condition  is  hawily  rcfoirnizahk'  at  its  tnic  value. 

the  ])riuiis«i  obaervcr.  unle.ss  u  full  att-omit  nf  tlie  patient's  liU 

available.  f 

After  a  wliIlc  the  -iwnptrinis  of  vLscfml  dUturhjuK'e  rlrar  up  alOT 
with  tilt'  ilisiippfunince  uf  the  iiHMitiil  symptoms,  aix]  the  (.•haii>p' 
nttrii>uteii  t<i  sdinc  form  of  treatment,  n  sjieeiut  dietary  rej^nie,  i 
whatever  lias  been  res4)rted  tu  fi>r  the  relief  of  the  syinplnnis.  Ili-rc  i 
B  gmup  of  easi'S  who  diiriiiji  their  iittuckt.  repilarly  ^-ek  tlie  spfciali^ 
and  are  subjertei)  to  all  s«irts  of  pastro-inte^itinal  treatment,  ^a^tri 
lavage,  special  ilictaric-s,  p.\"necoloj!icJtl  mjuiipiiliitions  of  one  sort  nnc 
another,  metalmlism  experiments,  en(lo(Tiiu>i>athie!»,  auto-iiitoxicntioa 
eye-Atntin.  and  almost  everything  in  (he  eatPHf»r>"  of  medical  sptrialism 
and  yet  viiHrarteristieaily  in  these  cast-s  nothing  is  fmnid  in  the  ph.v^i- 
eal  condition  that  uder|iiately  lutTiuiits  for  the  symptoms.  Anothei 
group  of  the.-ie  cases  are  the  paranoid  types.  These  patients  prtr«ii1 
typieal  paranoid  symptoms  with  emotional  atx-onipanimcntH  thai 
seem  to  he  hanlly  in  excess  of  what  is  demanded  a-s  nonnnl  rc:u-tioii 
to  the  delusional  state.  This  is  the  protip  of  fa.ses  that  has  piv^^n 
orijjin  to  a  an-nt  deal  of  recent  discussion  with  rejEanl  to  the  real  Inisis 
of  paranoia,  its  relations  to  inanieHiepressi\e  psyeiitisis.  the  ulTcctive 
orijiin  of  paranoia,  and  its  basis  in  what  Specht  calls  the  "affect  of 
su^picionsness." 

The  Mixed  States.— The  mixed  states  are  forms  of  nianic-<lcpn»*ive 
psychosis  in  which  the  three  cardiiml  symptoms  itf  the  nuinic  and 
depressive  phases  are  mixeil  so  that  the  resulting  state  is  neither  one. 
They  are;  (1)  manimal  &iupar,  (2)  ngitakd  drprexitian.  (3)  impTo- 
dnrtlrf  irntin'iit  (i)  flrprmnirr  nuiiiia,  (5)  <iei}rps.nv}i  ivifh  flight  oj  idniM, 
{Vi)  al'lnelir  mania.  It  will  suffice  to  merely  mention  the  f^yniptoi 
of  these  groups. 

Mamarnf  .S^//A!»r.— Emotional  exaltation,  decreased  psychomt 
activity,  diihculty  of  tlnnkinp. 

AgUatFfi  /V;>rp,'f,»(Vm.-  Emotional  depression,  increased  |xsydi<iui< 
activity,  itlij;ht  of  idciis. 

UnjirtxiiteliTr  .l/uwrVi. — Kmotional  exaltation,  increased  psychomotoi 
activity,  diffictdty  of  thinking.  ■ 

rtefirrintiri'   Miiniu. — Emotional   depression,  difTicnlty   of   thinki^ 
increased  psychomotor  activity. 

Ihprr.txifut  with  Flight  of  Idms-  Kmotional  depression,  flight , 
ideas,  decreased  psychomotor  activity. 

Ak-iiiftip  Mania. — Kmotional  exaltation,  flicht  of  ideas,  di 
psychomotor  activity. 

Still  the  possibilities  are  not  exhausted.  It  is  quite  unconunoii 
to  see  any  one  of  the  conditions  ulready  descril>ed  continue  pure  from 
the  commencement  to  the  end  of  the  attack.  In  the  nuinic  phase 
sjnnptoms  of  depression  not  infrequently  crop  up  and  occupy  ihf 
field  temporarily,  while  during  the  depressive  phase  it  is  quite  ^ 
common  to  note  transitory  iicriods  of  excitement.    Then  it  is  qi 


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common  for  manic  attacks  to  be  preceded  by  a  longer  or  shorter 
attat-k  of  depression,  an(]  sometimes  sutrh  a  prrioil  of  ileprvssion 
folloH's.  not  infreqncntly  but  partial  depression,  uf  the  tj-pc  of  unpro- 
diii-'tivf  matiia.  The  depressive  jjhiLsp  shows  similiir  vHrialions.  more 
|>articulnrl.v  it  is  foUowed  by  a  sliort  period  uf  uxaltuti<»ii.  Then, 
SKain,  at  any  stajtt'  of  tht'  disease  a  mixed  state  may  crop  up  for  a 
time,  so  that  we  may  see  durinp  the  course  of  the  manie  phase  jwycho- 
motor  retardation  occur  or  during  the  phase  of  depression  emotional 
exflltfttkon  may  develop,  while  tn  the  various  forms  of  the  periodic- 
|wyetioses  it  is  quite  the  rule  to  iind  thesir  nibccd  states  at  the  transi- 
tion places  fntm  one  phase  to  the  other,  all  of  the  s.\Tnptoms  of  one 
phase  not  fnually  anil  eontemi)orane<His]y  gnuhiating  into  their 
upposites.  Thus  during  the  course  of  a  circular  ]jsyi-Iu>sis  the  aifevt 
may  cliauge  from  depression  to  exaltation  i>efore  the  ps\'ch(murtor 
retardation  has  given  place  to  increuscd  psycliomotor  activity,  thus 
prodncinp  a  tmiponiry  mixed  state. 

Involution  Melancholia.  The  prnup  of  cases  comprise*!  under  the 
term  involution  melancholia,  which  was  originally  usctl  by  Kracpeiln, 
has  now  been  pretty  generally  concecJed  to  belong  to  the  manie- 
depressive  group.  The  characteristics  of  tiie  disease  are  those  of  an 
anxious  depression  occiuriiig  in  later  life.  The  group  is  such  a  con- 
siderable on''  ami  of  such  practlenl  importance,  however,  that  It  will 
be  sjK'cially  considered  along  with  other  depressions  of  later  life  in 
another  chapter.    (See  Chapter  XXIV.) 

Pathology.  There  arc  no  sperific  pathological  findings  in  tins  psy- 
chosis, although  certain  degenerative  products  have  l)een  descrilied 
in  cases  of  de;iTh  from  depressive  stupor.  Patients,  however,  cl»ar- 
acteristically  r*^cover  from  this  condition,  or  if  they  die  during  attacks, 
tlie  death  Is  due  to  some  intercurrent  disease  which  itself  wouhl  pro- 
tlnce  changes  in  the  nervous  s>>item  that  would  grarlually  cloud  and 
perhaps  entirely  obscure  any  pathology  that  the  psyclinsis  might  have. 
A  eouflitinn  itroijiicing  death  itself  must  iirotUu^  serious  alterations  of 
the  central  nervous  system,  that  must  sensitive  of  rcatliug  portions 
of  the  human  body. 

Nature  of  Manic-d«presaivd  Psychosis.— This  psychosis  (>irliaiw.  as 
tlmniuglily  as  any  other,  has  withstood  tkroughout  the  years  any 
attempt  at  understanding  it,  wliile  as  opposed  to  dementia  precox 
the  symptoms  of  which  appear  quite  tmpsychological,  the  s>Tnptoms 
of  the  inaniodepres.sive  psychosis  in  either  one  of  its  pliases,  more 
piirtieuinrly  iH-rhnps  in  tlie  depressive  phase,  are  ([uite  i>sychologi(!al, 
that  is,  fpiite  nmli-rstundable.  The  ])atients,  to  Ijegiu  with,  present 
largely  average  t\-|)es  of  penitjualily  before  the  advent  of  the  psyrfiosis, 
and  during  the  symptoms  of  the  psyehtwis  tlicy  ordinnrily  an*  not  so 
far  disordered  in  their  conduct  or  in  the  charaHer  of  tlieir  ideas  as  to 
place  ihcHi,  MI  to  speak.  In  a  class  by  themselves.  Tlicy  arc  still  <iuite 
like  the  rest  of  us.  Tlie  roots  of  the  psydiosis  appi'ar  to  spring  more 
di.stinctly  from  the  usual  life,  the  fluctuations  of  the  emotions  lieing 
quite  comparable  to  the  fluctuations  tliat  occur  in  everyone. 


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MANW-DEPRBSSIVE  PSYCHOSIS 


Hffwever,  it  sw-med  quite  impossible  to  understand  how  the  imtieiiLt 
cuiild  viiry  from  out*  i,'XtM'nu'  to  its  tliuinctricHl  opijositc  and  what  could 
possibly  be*  the  explmiation  of  such  shifts  of  iMtsitioii.  Kor  many  ye»rs, 
umier  the  ilominatioii  of  Moynert,  thf  changes  were  supposed  to 
(lf{H'Tid  upon  chfinjit^s  of  blixxl  supply,  np<in  anemias  and  hyperemias. 
When  psythiatn',  however,  advanced  l>ey(md  such  erass  t>-pes  of 
explniiation  it  was  It'ft  practically  with^mt  (inxtliiiip  to  fall  back  ii|>oii. 
lU'ti-ntly.  limvevcr,  the  suggestive  work  of  lUrulrr'  has  st-rmed  to 
indicate  what  may  at  bottom  be  the  true  evplanatiou.  He  has 
demonstrated  what  he  calls  the  amhipulcrwy  of  ideas.  This  ambiv- 
aleiicy  gives,  as  he  understands  it,  to  the  same  idea  two  contrary" 
feeling  tones  and  invests  the  same  thought  simultaneously  with  a 
positive  and  a  negative  eharaeter.  Along  with  this  ambivalency 
there  is  an  amhilettdemy  which  sets  free  with  every  tendency'  a 
counter-tendency.  Witli  tliis  bsisa!  supjiosition  it  can  be  understood 
why  the  fluctuation  ttf  the  mniiic-<lcpressivi'  is  a  fluctuation  between 
conditions  which  are  diametrically  opposed.  If  each  idea  has  asso- 
ciated with  it  by  preference  the  idea  which  is  absohitely  its  opposite, 
if  each  feeling  has  associated  with  it  by  preference  the  feeling  which 
represents  its  exact  antithesis,  then  there  is  reason  for  understanding 
how  tlie  raanie-<lepressive  gravitates  liet^veen  these  two  extremes. 
It  is  the  jtnth  of  ojtpDxiti'.i  wliich  is  met  with  at  every  tnrii  in  j*sychi- 
atric  experience.  Nothing  suggests  white  more  surely  than  does  black, 
nothing  suggests  love  more  readily  than  hate.  The  opposed  icleas 
and  feeUngs  stand  with  relation  to  each  other  in  the  path  of  least 
resistance,  and  when  one  would  go  from  a  certain  idea  or  a  certAin 
feeling  in  any  direction  he  finds  the  path  to  the  antithetical  idea  or 
feeling  more  ea-sily  passible  than  the  jiath  to  any  utlier  goal. 

Assuming  the  hj-pothesis  of  ambivalency  and  ambitendency,  still 
what  is  the  explanati(»n  of  the  aETi-et  fluctuations  in  this  [wyi-hosis? 
Here  as  elsewhere  in  the  mental  fiehl  some  fimdaineiital  (wychic  von- 
dict  uniluublcdly  has  to  be  soiight  to  which  the  patient  is  making 
etTorts  oi  adjustment.  This  Is  prc-'iscly  the  starting-p4iint  fr<»m  which, 
for  example,  dementia  precox  has  to  be  viewed.  But  here  are  indi- 
viduals who  present  a  different  possibility  of  reaction,  a  different  n^ac- 
tion  type  to  the  conflict  than  do  the  prei-ox  patients.  This  statement, 
of  eourse,  must  not  be  taken  as  meaning  any  more  than  a  mere  putting 
into  words  of  what  is  found,  because  it  is  not  understood  what  the 
differences  are  that  make  diiferent  i>eopIe  react  in  different  ways. 
Psychiatrists  arc  only  upon  the  verge  of  being  abk  to  a.sk  such  a 
question  intelligimtly.  They  are  not  yet  able  fully  to  answer  it.  An 
indication  of  what  is  at  the  bottom  <rf  the  manic-depressive  reaction 
may  perha|»s  be  renclied. 

'Hie  rnaniivdcpressive  psychosis  may  be  conceived  of  as  an  effort 
at  compromise  and  at  defense,  resulting  from  an  endopsyehie  conflict. 

'  lliv  Th«ur>'  "^  tkhisuiibrouic  Neiwlivi»tu.  Nerrmai  Nnd  Mental  Durass  MoiiMcraph 
Sonet,  No.  11. 


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the  depressive  phase  the  affect  has  broken  through  and  iriva^Ies 
ooiiHL'iouaness.  wlilie  hi  thi*  tiiHTiif  phasn"  the  pjitient  by  feverish  and 
restless  nctivit>%  by  n  cniLstant  nlcrtness,  fights  ntf  every  approjich 
that  nii^ht  toucli  him  on  a  painful  [Miint,  tlmt  niijjht  readi  ii  vuhier- 
able  spot.  It  would  swm  as  if  he  «cru  wiljly  bt-atintt  about  to  keep 
off  all  intruders,  not  only  real  intruders,  but  all  ixwsible,  prosiJeirtive. 
or  thoupht-of  intruders.  And  st>  the  manic  patient  is  already  quite 
jniuressible  and  all  of  his  reactions  are  especially  superficial,  a»  witness 
the  word  assnoiatinns  and  the  clang  associations,  lie  moves  over  the 
surface,  wliieli  he  eudenvorw  to  cover  completely  in  order  to  prevent 
pein'tratitiii  at  any  ]Miint. 

This  eonstanl  activity  of  the  manic,  however,  has  another  a.si)ect 
than  simply  that  of  defense.  In  this  constant  activity  of  which  such 
symptoms  ni*  flitclit  of  ideas,  clang  ai*so"iatioii.  and  distractibility  are 
t>*pe9  the  patient  is  constantly  otxupied  with  reality.  lu  fact  lie  is  so 
acutely  interested  in  reality  that  little  that  occurs  about  him  escajjes 
him  and  he  is  constantly  showing  extremely  keen  powers  of  observa- 
tion. This  might  be  termed  a  flight  into  reality  as  a  means  of  escap- 
ing from  the  confli:-t  and  as  such  stamps  the  psychosis  as  belonging 
tn  the  vxtroverifd  tj^w  a.«i  distinguished  from  the  inimverted  type 
(of  which  prei*o?t  is  the  hcsi  example)  in  which  the  libido  turns  l»aek  to 
reanimutc  fhamieLs  in  which  it  used  to  How  but  which  have  long  since 
been  abandoned. 

The  consideration  of  the  manic-depressive  reaction  from  the  point 
of  view  of  an  cxtntversi'on  tyjie  of  psychosi?  is  extremely  helpful  in 
atl'ording  a  baas  of  explanution  for  many  of  the  miM>ted  points  which 
have  Ix'cn  raised  in  the  recent  literature  regarding  this  much  discussi-<l 
psychosis.  In  fact  it  would  appear  that  a  great  deal  of  the  ditficuliy 
encountered  by  obseners  depends  upon  dealing  with  the  psychoses 
solely  at  the  descriptive  rather  than  at  the  interpretative  level.  There 
is  a  good  deid  of  ctT^irt  heing  expended  in  tr\-ing  to  split  up  the  whole 
group  into  smaller  subdivisions  awl  undoubtedly  the  future  will  show 
an  increasing  success  in  these  efforts.  Still  it  is  already  not  difficult 
to  see  why.  for  example,  one  should  find  hysterical  symptoms  asso- 
eiated  with  the  more  purely  manic  since  hysteria  is  also  an  extro- 
version psychosis  as  is  well  shown  by  the  extremely  strong  phenomena 
of  transfer  exhibited  by  hysterics. 

Of  special  iinportauw.  however,  seems  the  relation  of  extroversion 
to  the  relatively  benign  nature  of  the  attacicH  as  compared  with  the 
relatively  malignant  ehararter  of  the  introversion  in  precox.  The 
fact  that  the  patient  attempt-s  to  escape  from  his  (s^iiflict  by  a  Higlit 
Into  reality  rather  tlian  by  a  jwtli  that  leads,  by  introversion,  through 
the  conflict,  as  is  so  often  the  case  in  precox,  seems  to  insure  that  he 
again  and  again  is  able  to  ivlmbilitate  himself.  The  efliciency  of  one's 
relation  to  reality  is  the  measure  of  one's  nnnnality  and  so.  in  this 
psych{)sts,  the  tionstaut  effort  to  plunge  into  reality,  to  become  Immersed 
in  it,  to  «ieal  with  it  at  every  point,  becomes  a  savi  ng  grace  and  i»  largely 
accountable  for  the  frequent  recoveries. 


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Undoubtedly  ft'rtain  groups  of  sympturns  in  this  great  mass  at 
niiiterial  will   l»e  found  to  Imiig  together  with  sufficient    certainty 
iiikI  fn*(|Uifnry  to  Ur  classed  as  dist-ase  typos  but  still  the  luatuV'- 
deprcssive  way  of  rfiuiiou  may  still  be  considered   as  such  aside 
from  such  jrroLps.    When  so  aiiisidercd  it  would  seem  that  it  con- 
stitutes a  method  of  handling  the  confli<:t  that  belonpt  relatively  hiph 
in  the  scheme  of  the  psychic:  orf;ani'/iLtion.     In  other  words,   tie 
maiiif-depresstvp  patient  lielopfjs  to  a  relatively  snperiitr   t.\"i»i-  »,if 
persunality.     This  is  se-en  by  th«  comparative  normality  of  tlie  fjcr- 
sonality  types  involvwl,  by  the  iwyrrlioloKiciiI,  that  is,  uiidcrsinndable 
character  of  the  symptoms  which  seem  to  be  only  exa^S^nitions 
of  normal  n'octi*»iis.  and  also  perhaps  by  such  a  fact  as  that  bn>uxht 
out  by  KielH'th  (see  Ktiolojiy)  that  while  manic-depressive  psychosis 
is  found  in  the  ascendants  of  preo«>x  the  reverse  <locs  not  seem  to  occur. 

Still  consideriti};  the  maniKMlepressive  reaction  as  an  extroversion 
ty])e  one  is  prf|wired  to  find  in  iiidiviiluai  cases  that  the  symptoms 
do  uot  netrssiirily  run  pure  to  type.  It  is  lUHJerstandable  that  in 
some  cases  there  sliouhl  bo  a  mixture  of  Introverted  niechanisms  atiil 
when  this  inx-urs  it  can  be  seen  why  such  a  symptom  as  nepitivism 
shotdd  be  apt  to  appear  because  the  symptom  belonft*  to  the  catatonic 
tyjM'  of  precox  which,  like  niant<-  reaction  se(?ks  to  solve  the  mnHict 
by  nmnini4  away  from  it.  although  in  a  different  direction.  In  the 
sanu'  way  manic-like  Mights  in  certain  cases  of  (-atatonic  excitenteiit 
may  be  exp<*cted. 

The  nianic-<Iepressivc  way  of  reacting  may  also  be  seen  in  paresis. 
arleriosi.lcro.>ts,  and  (dher  organic  conditions  and  als4)  in  certain 
psychopathic  aiul  ilcgeiierativc  tyfjcs  as  in  the  prison  psychosis. 
eertaiEi  litigious  parauolaes.  and  pseudologia  phuntustica.  In  all 
these  rases  the  extreme  activity,  the  constant  rxHiipation  with  reality, 
and  the  K*^ncrally  esalted  mood  indicate  an  extroversion  which  must 
hi'  further  stnijicd  in  its  roots  to  know  its  real  meaning. 

Tiu'  fibiisinit  itinAiiuinn  have  Iieen  dwelt  on  more  parliculurly  in 
discussing  the  cycltith>'nuas  because  here  the  physical  symptoms  (xrupy 
the  foreground.  In  the  more  severt'  psychotic  disturbances  ph>'«ica1 
symptoms  if  present  may  easily  be  over](M)ketl.  The  anami>esi3  will 
show  very  frc<|ucntly.  it)  the  prodromal  pcricxl.  such  symptoms  as 
headjtchc,  neiiral^as.  herpctifonn  erupti<)ns.  etc.  It  is  not  infrwiucnt, 
lujwever.  to  see  markeil  evidences  of  bioloj^ical  maladjustment  in  the 
way  of  the  general  habitus  of  the  opposite  sex.  evidences  of  ciido- 
crinopathy  (glundnliir  imbalance),  and  Ixtmosexual  s.xinbolizutiotts  at 
the  psychological  lc\i-|. 

Course  and  Prognosis.— The  individual  attacks  vary  in  duration  from 
a  few  days  to  several  months.  Hccovery  fnmi  the  single  attack  is 
^  nile,  while  the  likelilKxHl  of  suhse*)ueiit  attacks  is  wnsidrnihle. 
In  gcni-ral,  thcrcfur-r",  the  pn»gn»isis  is  giMKl  for  the  S4'iMirale  attacks 
tmd  is  nttlicr  piMir  as  to  ultimate  free<li>m  from  attacks.  As  iiointcd 
out  prt-viously,  the  severe  constitutiotial  t.yi>es  have  a  worse  progtn»i» 
than  those  t>'pes  in  whicli  the  etiological  factors  arc  capable  of  rcmuvui. 


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In  tlie  severe  ciiiislihitional  types  also  the  recurrent  attacks  tend  to 
rej>eat  with  pluitogniphit!  awurHpy  preoeclinp  attacks,  while  in  the 
long  niii  the  jft'iicral  liiiilfiicy  is  for  an  iiin-ea-se  in  the  len^li  of  attacks 
and  a  dccrea.sc  in  the  length  of  the  free  intervals. 

The  {]iM;a;$e  pursues  its  course  without  any  special  temlctiey  to 
deterioration.  Although  mild  {grades  of  dementia  have  been  describeil, 
teniiinatintt  protracted  attacks,  the  dementi;)  which  u.sualiy  su|jer- 
venes  in  the  rour^  tif  the  diticase  is  that  which  is  supcra<lde<l  as  the 
result  of  the  cluinges  incident  to  arteriosclerosis  and  the  senium. 
Inasmuch  as  this  psychosis  tends  to  recur  throughout  life,  not  a  few 
of  tlie  patients  ultimately  reach  seneseenec. 

Differential  Dia^riiosu. — ^The  manic  phase  in  its  mildest  forms  is  often 
mistaken,  fsiHxiully  wliere  it  leads  to  alcoholic  and  sexual  excesses, 
for  a  form  of  moral  obliquitj'.  In  the  somewhat  more  pronouiitiil 
attacks  it  may  lie  difhciilt  to  differentiate  it  fnim  other  excitements, 
more  particularly  catatonic  excitement.  In  general  the  manic  excite- 
ment i?t  in<ire  free  and  ojien,  there  is  less  tendency  to  cotiNtraint  akmR 
any  particular  line,  wjiile  tlw  pnxlnetivity  and  the  psychoiimtility  are 
not  as  ineaningtess  or  non-uaderstandable  as  with  dementia  pn-cox. 

The  depressive  phase  in  its  milder  manifestations  is  not  infre<]ueiitly 
mistaken  for  neurasthenia,  and  in  its  more  pn>nouiiced  form  it  is 
extpcmcly  difficidt  to  differentiate  it  from  the  depression  of  dementia 
pre<*ox.  This  is  particularly  so  because  the  feeling  of  inadequacy  of 
the  manic-*lepressive  is  ver>'  clos«'  to  the  empty  feelings  with  toss  of 
affect  of  the  precox,  while  the  bltK-king  of  movement  and  expn-ssiori 
in  the  latter  condition  outwanlly  closely  resemble  the  n'tartlation  in 
manic-depressive  psychosis.  The  stupor  of  catatonia  outwiinJIy  also 
closely  resembles  the  manic-depressive  stupor,  except  that  it  is  more 
apt  to  l>e  iLssnciated  with  marked  negativism,  muscular  letision.  and 
perhaps  grimacing. 

The  greatest  diRicnIty,  as  between  mauie-ilepreRsive  psychosi-s  and 
fU-mcntia  pnviix.  lies  with  the  dilTerctilintion  of  the  mixcil  states. 
Here  the  resemblances  are  quite  close  and  prubuged  observation  often 
necessary  to  make  the  differentiation. 

It  must  not  lie  forgotten  that  the  manie-depresfuve  psn'chosis  is  by 
no  means  a  clear-cut  definite  entity,  that  it  merges  in  all  directions 
into  other  conditions,  and  that  its  closest  affiliation  uith  the  other 
IMrv'choses  appears  on  the  surface  to  he  with  the  dementia  precox 
group.  There  are  quite  a  considerable  number  of  eases  in  which  a 
study  of  the  individual  atta<.'k  leaves  one  in  iloubt  as  to  which  group 
to  place  the  patient  in.  manic  excitement,  for  example,  being  asso- 
riatcd  with  wrtain  catatmiiforni  symptoms,  catatonic  excitement 
presenting  a  fairly  typical  flight  of  ideas  and  the  like.  In  general 
tlie  principle  of  ditferentiation  is  first,  the  history-  of  previous  attacks.^ 
ami  next  to  this  history  of  n'|M*ale<l  attai-ks  Is  a  liistor>  of  attacks  of 
both  manic  and  depressive  <-hariicter  f>ct-urring  in  the  inilividual  and 
showing  no  markeil  tendency  to  deterionition.  IVaclically,  however, 
it  is  quite  im[K)Ssible  to  make  a  differentiation  in  many  cases  and 
4» 


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fHitii'tits  that  are  at  one  time  placed  in  one  proup,  for  example,  in  the 

nianitMlfpressive  group,  are  fotimi  Inter  to  probably  helon/j  In  the^ 
precox  group,  bcranse,  for  example,  of  the  appeAranee  <if  rlcterioration.  V 
Ami  so  the  history  of  the  diagnosis  in  these  twi>  groups  shows  a  con- 
stant teudenry  to  fluctuation,  at  one  time  the  dementin  prfcox  ^lUp 
beinj;  enhiUK-ed  tiy  cases  whith  at  another  tune  are  placed  in  the 
manic-depressive  group.     And  so  the  situation  fluctuates  back  hiuI 
forth,  the  best  evidenc-e  of  an  inherent  relatinnsliip  between  the  two. 
The  reasons  for  this  state  of  aft'airs  have  been  set  forth  in  the  section  ■ 
on  the  nature  of  the  psychosis  while  a  consideration  of  the  extmxersion      . 
features  »if  the  reaction  as  iigainst  tlie  intniverted   featuns  of  the 
precox  type  will  materially  aid  in  the  understanduig  of  the  meanings 
of  the  i^'jniptutns. 

The  most  important  group  from  the  practical  stand-point  is  the  ■ 
cycl<)th\Tiiie.  Tlicse  patient^!  are  practically  always  wrongly  dia|(- 
nosed  at  first  ami  often  ctver  ami  over  again  fttr  <roiiHi«lerable  [M'riods 
of  time.  Most  geiieraUy.  as  already  mentioned,  they  fall  into  tl»e 
hands  of  the  specialist  under  the  theorj'  of  some  dis«>nlcr  of  the  inter- 
nal orgaius.  When  an  attempt  is  made  to  really  understaial  the# 
patients  one  is  impressed  with  their  close  reaemblanees  to  the  ribscs- 
sionai  neurosis.  It  nmy  hi*  quite  impossible,  at  least  by  any  ineaits 
other  than  a  very  careful  and  detailed  study  of  the  patjeiit.  to  diflfer- 
enliiitc  l;x.-tween  the  two  conditions,  and  from  the  discussion  on  the 
nature  of  the  manie-depressive  psyehosis  it  will  Iw  seen  why  ihb 
similarity  exists.  It  should  be  borne  in  mind  also  that  it  is  not  diffi- 
cult to  ii)nfusr  mild  cycluthyniic  jittjicks  with  the  anxiety  neunisL%. 

It  should,  of  course,  he  adiled  that  one  ^ul^t  he  careful  and  not 
confu.se  excitements  nnti  depressions  that  may  have  other  origins  as, 
for  example,  particularly  paresis,  the  symptomatic  aiul  toxie  psychoses 
and  the  more  clearly  ps\  chogenic  states  such  as  pristm  psychosis — the 
so-called  situation  psychoses. 

Treatment.^ — There  has  l>een  the  general  feeling  in  years  past  about 
this  psychosis  that  the  attacks  were  self-linute(J.  This  has  probably 
(wen  dependent  to  no  small  extent  at  leii.st  upon  tin*  extreme  regularity 
of  the  attacks  in  certain  patients.  These  jmtifuts,  however,  are  the 
jwtients  with  the  more  profound  constitutional  taints,  and  it  is  perlmps 
generally  true  that  in  this  class  of  patietits  attacks  do  tend  to  run  a 
regular  course,  each  attack  tieing  approximately  of  the  same  duration 
as  the  former  similar  one.  With  the  more  frankly  reactive  t^'pes, 
however,  this  Ix'aimes  progr»*ssively  le.'is  true,  sii  that  the  matter  of 
treatment  litre  easily  becomes  something  more  than  mere  intelligent 
custodial  care. 

In  the  very  mild  types  of  the  disease  the  patient.H  have  to  be  care- 
fully safi-guarded,  because  their  eundttioa  is  not  appreciatnl  by  oUa'rs. 
In  the  excited  phases  alcoholic  and  sexual  excesses  are  es|R'eiall_\'  apt 
to  occur,  and  it  must  never  l>e  lost  sight  of  that  during  what  out- 
wanlly  appear  to  be  the  mildest  depressions  suicide  is  a  possibility. 

In  tile  more  pronounced  attacks  the  handling  of  the  patient  ciillb 


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[for  the  very  greatefit  amount  of  tact.  During  the  excitement  the 
patient's  strength  miBt  be  pimrdod.  as  insnmnia  is  a  eonstant  s^inp- 
tom,  unci  Fotnl  may  he  taken  in  insutKcifiit  quantities,  Mechanical 
restraint  shoulii,  of  course.  l)e  avoideil  if  iKissihle  mid  it  may  !»  said 

tthat  it  is  pmcticially  m-vi-r  necessary.  Us  application  in  thf  lii^h 
degrees  of  excitement  is  often  not  vniderstWKl  by  tlie  patient,  and 
produces  an  increase  of  excitement  and  resistance,  and  perhaps  a 
state  of  anxious  apprehension,  aiai  even  terror,  f'heniieal  restraint 
is  equally  uiidesinible  as  it  tends  to  shut  out  the  real  world  and 
thereby  increase  the  difficulty  of  adjustment  to  reality.  Hypnotics 
may  be  necessary  and  such  simple  ones  as  veronal  are  the  licst^ 
parattlehyd.  trionat.  snlphonal.  chloralamid  are  useful,  hut  opium  and 
its  derivatives  should  be  avoideil  if  ixwsihle.  Whereas  the  various 
kinds  of  restraint  are  highly  undesirable,  isolation  may  be  resorted 
to  and  is  not  infretpiently  welcomed  by  the  patient.  All  th»t  may  be 
neri'ssary  is  simply  to  put  the  patient  in  a  room  by  himself  without 
locklnp  the  door.  lie  ina\'  be  very  ^lad  to  stay  tliere  and  so  escape 
from  outside  sources  of  irritation. 
'It  is  in  the  a)nditioii  of  excitement  that  the  continuous  bath  is  so 
vaJnablc.  The  patient  is  plaee<l  in  a  tub,  preferably  one  constructe<l 
especially  for  tlic  purpose.  In-iriK  lonji  cnnu^tli  to  ix-rinit  the  body  to 
lie  in  it  withtait  the  limbs  Winp  Hexed.  The  water,  which  should  <-over 
the  body  completely,  is  ke]>t  at  a  temperature  of  from  Wt"  to  QH"  V., 
that  is,  jusfalwive  the  normal  surface  temperature.  It  ailds  t:>  the 
oomfiirt  of  the  patient  if  a  r-anvHs  lianunock  can  Ir*  ;lunj<  in  the  tub 
on  which  he  eim  lay,  and  a  rubber  air  pillow  lie  plained  under  his  licad. 
The  warm  water  of  the  continuous  bath  is  the  best  sedBtive  treat- 
ment we  have  for  this  cla.ss  of  patients,  as  it  produces  sedation  without 
any  clouding  of  cnii-sciousness  or  other  disagreeable  features.  The 
piiticnt  may  be  left  in  the  tub  for  such  a  peritKl  of  time  as  is  deemed 
necessary,  usually  ttirec  or  fcair  hours  at  a  time.  On  the  Continent 
patients  are  not  infrequently  kept  in  the  tub  not  only  for  days,  but  even 
months,  sleeping  in  the  tub  and  being  fed  in  it.  On  the  whole  the 
patients  enjoy  this,  the  warm  water  is  .soothing,  and  they  are  grateful 
for  its  cjilming  influence. 

It  is  in  the  excited  pliases  lliat  the  nurse's  ingenuity  will  be  taxed 
to  the  utmost,  and  if  she  is  not  tactful  all  sorts  of  artificial  sym[rtoms 
will  be  created  In  the  way  of  antagonisms  toward  the  niu^.  increased 
irritiibility,  etc..  so  that  the  adjustment  of  the  nurse  to  the  patient. 
])nrticularly  iu  excited  conditions,  becomes  an  important  practical 
problem. 

In  the  depressed  phase  of  the  disease  the  patient  is  often  best  treated 
in  bed,  particularly  if  the  depression  approaches  the  stuponms  stage. 
Under  these  circumstances  refusal  of  fixxl  is  a  common  s\inptom  and 
tube  feeding  must  be  resorted  t<i  at  regular  intervals.  With  the  tube 
feeding  it  is  easy  to  give  such  medicines  us  may  be  required,  either 
hypnotics,  cathartics,  or  anj-thing  else  indicated. 
One  must  remember  that  in  endeavoring  to  prube  the  consciousness 


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of  depressed  piitieiits  the  ilepression  may  be  incrcikse«l  ami  if  suicidal 
temlencios  arc  present  this  sliuuld  be  bome  in  mind  and  guardeil 
against. 

]f  the  patients  are  stiiponms  the  usual  precaution  should  be  taken 
to  see  tliitt  the  pdsitifin  iff  the  hoily  is  chati^ed  from  time  to  time  and 
that  the  bladder  and  rectum  are  not  permitted  to  become  overloadeil. 

'J'he  dnuRer  nf  suieido  in  depressed  renditions  is  an  ever-present  one. 
The  only  safe  way  to  deal  with  thene  patients  is  to  assume  that  they 
ore  all  suicidal.  Prohably  one  of  the  «.'as«ns  why  more  patients  in  this 
condition  do  not  ccjnniiit  suicide  is  iK'tuiusc  of  the  markeil  relardniiou 
which  makes  it  so  difficult  for  them  to  initiate  any  form  of  activity. 
It  is  the  depressed  patienls  who  are  suicidal  who  most  frequentiy 
require  to  Ije  sent  to  a  hospital,  although  their  general  condition  may 
not  seem  to  wamint  sueh  a  move.  Hie  watcliing  and  the  earing  for 
depressed  patients  with  a  view  tn  preventinp  them  from  ciimmitting 
auieide  is  pnictically  only  understtHKl  in  institutions  for  the  treatment 
of  mental  disease.  The  general  hospital  nurse,  the  general  practitioner 
and  the  family  rnn-ly  have  any  idea  of  llie  degree  of  watclifulness  that 
is  necessary-  and  for  this  reason  alone  oftentimes  the  patients  mu^ 
be  sent  tn  institutions. 

During  the  period  of  eonvalescence,  occupation,  outdoor  exercise, 
and  the  like  are  all  in  order.  Core  should  be  taken  not  to  force  the 
patient  too  fast. 

I  lere  as  elsewhere  in  mental  medicine  an  attempt  shoukf  Ik*  madi*  to 
analyze  the  mind  sufficiently  at  least  to  understand  the  nature  of  the 
disturbing  factors  that  are  at  work,  and  if  possible  the  way  in  which 
they  have  brought  atiout  the  psycliosis.  This,  of  course,  u  essential  to 
an  intelligent  treatment  of  the  patient.  Such  anaK*sis,  however,  is 
ahnost  impossible  with  many  patients,  particularly  <luring  the  attni-k, 
and  can  only  l)e  resorted  to  when  the  patient  is  at  least  apprtuiehitig 
the  normal  condition.  All  the  information  gained,  however,  is  vabiaUe 
as  pointing  the  way  towiu^  regulating  the  patient's  life  and  in  nmny 
instances  as  indicating  tlic  natiuv  of  the  etiological  factors  and  thereby 
showing  what  nnist  \tc  avoided  in  the  future  if  further  attacks  are  to 
\io  prevented.  Of  course  much  more  is  to  Ik-  hojjed  for  in  the  frank 
reactive  than  in  the  profoundly  constitutional  t,\'pes. 

Pro|ihylaxi8. —  IVophylaxis  resolves  itself  into  two  parts:  first,  the 
prevention  of  the  disease,  and  second,  the  preveTition  of  subsequent 
attacks  after  the  disease  has  manifested  itself.  TIr*  prevention  of  tlie 
disease  is  a  problem  uf  eupenies.  Verj'  much  more  information  is 
neetled  as  to  the  way  in  which  the  manic-depressive  psychosis  <-un(lucts 
itself  with  reference  to  the  laws  of  heredity.  It  has  not  as  yet  been 
adequately  worked  out  so  that  definite  advice  is  jKissible. 

As  to  the  prevention  of  subsc*Luent  attacks  the  nwst  imjjortant 
tiling  is  to  prevent  if  possible  the  recurrence  of  the  etiological  factors 
that  have  l)een  found  to  play  a  part  by  the  psycbuanaliilie  stuily  of 
the  imtkmt. 


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CHAPTER  XVli. 
THE  PAltANOU  GIIOIP. 

Per!IAPs  ih>  terra  in  psychiatry  lias  undergone  wider  variations 
of  riifaiiin^  tlmit  t\v  term  puriiiioia.  In  its  earlif-st  days,  in  tlie  Grec^k 
{leriud,  it  meant  little  inure  than  jiust  criiziness,  altliuuj^li  p4.ThiL}is 
it  may  liave  been  used  somewhat  mure  specifically  iu  some  instances, 
and  later  on,  well  into  the  middle  ages,  it  was  still  a  term  that  was 
not  infrequently  iised  to  include  the  whole  group  of  the  so-called 
insanities. 

'I'hi'  term'  did  not  come  into  Kencral  use  as  applied  to  a  special 
giiHiping  of  mental  symptoms  until  the  early  part  of  the  nineteenth 
century,  wlien  a  German  psychiatrist,  Hcinnjth,  \niu\v  an  eiTurl  lu 
classify  various  mental  diseases  and  gave  paranoia  a  distinct  place- 
me[it  in  his  scheme.  The  clussificiitions  of  this  day.  htnvcver.  were 
extremely  simplex  and  there  was  a  marked  tendency  to  follow  the 
dichotomous  method  with  its  binomial  nunicnckUure.  which  had  come 
into  such  iKipular  vopue  with  the  appearance  of  the  work  of  the  j;reat 
Swedish  botanist,  L.iiutaeus.  in  the  niUtdle  of  the  eighteenth  wntury. 
A  disease  that  was  elassifieil  under  the  sjx'ciHr  names  of  jmlhuriimton*', 
confu^intiHl.  depn>ss«tl,  or  what  not,  might  ehangt'  its  name  and  its 
nature  overnight,  ns  it  were.  This  le*!  to  gri-at  i-onfusion  and  to  the 
final  throwing  out  of  the  whole  scheme  by  the  Krench,  utidi-r  the 
leaiicrship  of  Pinel,  who  reduced  the  classification  to  manias,  melari- 
choliiLS.  and  dementias.  Kstjuirol  followed  with  his  monomania,  under 
which  the  paranoias  fouial  a  place,  and  this  term  hits  been  in  iisi* 
ever  since,  largely  by  the  Knglish  school,  ami  it  still  finds  applmtion 
in  the  courts.  It  is  base*!  ii|H»n  the  simplistic  conwption  that  the 
brain  is  one  organ  and  that  it  has  one  disease,  iitxl  that  ihseaac  is 
insanity,  and  not  only  simplistic  to  this  extent,  but  that  the  disease 
may  affect  any  part  of  the  organ  and  therefore  a  iK-rson  may  be  insane 
upon  one  subject,  conceptions  which  arc  hanlly  worthy  uf  a  school 
boy,  but  >*et  art*  still  held  in  some  quarters  today. 

From  this  time  on  the  general  concept  of  paranoia  became  some- 
what more  definite  and  it  tended  more  and  more  tn  coiiivntnite  and 
crystallize  itself  about  a  condition  which  prcstMitcd  essentially  delu- 
sions, more  or  less  clearly  formed  and  of  a  persecutory  tyjw  generally 
associated  with  hallucinatioaSt  es|)ecially  auditor.-.  Even  this  eon- 
O'pt,  however,  inetuded  .such  a  ma.ss  of  material  of  such  dissimilar 

■JeUiffo:  Study  nf  Ui»  Oriciti.  Tnuufomiaiiotu  Mid  Prtsent  Day  Trenila  of  tha 
rxmrntin  OtDCApU  ^oiir.  Swv.  niiH  Mont.  Dis..  1013. 


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typi's  tliat  it  nover  bei-atiit'  very  wi'il  definftl.  Tlit  piimtioia  rniiti 
versy  during  tliif^  period,  namely  from  thr  muidle  to  thi-  end  of  the' 
nineteenth  crntun.-,  is  larfit-ly  tuki-u  up  with  u  diseussitm  upon  the 
basis  of  the  okJ  faculty  psydiolog>'.  and  the  division  of  the  mind  into 
three  parts,  the  intellect,  the  emotions,  and  the  will.  There  tuul 
already  been  a  tendency  to  consider  [mranoia  as  a  primar>*  intelleo 
tual  disorrler.  The  di^us.'tion  took  up  the  question  as  to  whether 
the  eniationti  wen-  iuvohed  priomrjly.  setoudarily,  or  at  all.  This 
whole  Ixiotless  procedure,  based  upon  the  faeulty  psycliolog\-.  of 
course  earne  to  naught,  simply  because  the  mind  is  not  split  up  into 
inutuatly  excluMve  compartments.  Another  one  of  the  concepts  upon 
which  such  discussions  were  based,  atul  which  was  assumed  in  the  dis- 
cussion, was  that  there  were  such  things  as  mental  disease  entities 
whifh  had  as  much  indivichmlity  and  definiteness  in  the  conception 
of  the  psychiatrist  as  tumors  Inul  in  tlie  mind  of  the  pathologist. 

Without  going  into  a  description  of  the  dilTeivnt  idejis  of  paranoia 
W'hich  have  been  extant,  and  wliich  in  their  hucr  developmcut  will 
be  descrilied  iti  the  body  of  the  chapter.  It  mrd  only  be  added  tliat 
the  general  result  of  all  this  discussion  is  first  that  the  brain  is  not  a 
single  oi^aii.     It  is  a  great  nuinlwr  of  organs  crowded  int4>  a  v&ry  close 
space  and  the   functions  of  its  different  parts   need   be  no  niort 
closely  reliited  to  one  another  than  the  functions  of  the  uilrenal  glands 
and  the  liypophysis.     The  corU-x  alone  consists  of  at  least  fifty  his- 
tologically (liiferentiuted  organs,  while  the  thalamus  is  composed  of  at 
least  nine  ganglia.    The  ret!  nucleus  is  an  organ  by  itself,  as  are  the 
different  portions  of  the  lenticular  nucleus,  and  the  separate  ganglia 
innervating  the  ocular  muffcles.     In  some  way  or  other  there  is.sues 
htnn  thi-H  eimiplex  t)f  organs,  or  ntore  pnii>erly  is  ass(»ciated  with  it, 
the  plienumenu  of  niinil.     Mind  is  not  a  single  thing  any  more  tluin 
is  the  braiu.     It  is  not  only  as  complex  as  the  organ  which  subser\^es 
its  function,  but  infinitely  more  ctmiplex  than  this  organ  as  it  is  known 
today.     The  mind  cannt)t  l>e  coutviveil  a.s  divi<|ed  into  comport- 
[nents  like  the  will,  the  intellect,  and  the  feelings,  each  presided  o\"er 
by  a  mythoEogical  demon,  so  to  si>eak,  hut  mu.st  be  cH>nc*ived  of  as  a 
complex  of  a«iaptive  mechanisms  interrelated  with  one  another  in  the 
most  intricate  manner,  so  that  the  mind  must  be  €s»nceived  of  as 
capable  of  having  not  only  one,  but  many  kinds  of  disorders,  which 
disorders  are  not  entities  in  the  sense  of  foreign  bodies  or  diseases 
which  enter  from  outside,  but  are  inefficient  ways  of  functioning, 
special  combinations  of  mechanisms,  aiwi  so  there  are  not  so  much 
mental  disease  after  all  as  t}^x.•s  of  mental  reaction.    The  discaae  is 
not,  therefore,  something  which  comes  from  without,  but  it  is  a  func- 
tion of  the  uiterrelation  between  the  individual  and  his  environment, 
and  oiJy  in  proportion  as  this  interrelation  is  inetticieut  may  it  be 
conceived  of  as  disease,  and  only  in  accordance  with  llie  type  of 
mcchunisni  which  is  utilized,  the  special  tren<l  of  reaction,  can  a 
disease  tje  spoken  of  in  any  specific  sense  at  all.    This  Is  quite  parallel 


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witli  tlip  wini-^'pts  iin  iIh'  phy>iciil  side  nmJ  Ks  inipfirtant  to  l»ear  in 
iniiid  if  ocie  is  not  f<>  Ik-  ensl»veij  by  a  liiiittitig  UTiiiititilugy. 

'ITie  most  recent  itdvaiiccs,  tlit'irfore.  iii  the  concept  of  pamnoia 
art',  a  gftting  awjiy  from  llic  ctmsidrration  of  it  as  a  iHsease  entity, 
«>r  as  involvinK  a  s]jceial  faculty  of  the  mind,  nr  as  a  nterely  mono- 
symptomatic  classi^cation,  and  a  coming  to  consider  it  as  a  type  of 
reaction  which  iimiiifests  it^-wlf  in  certAiii  individuals,  prolwhly  as  the 
result  of  ceruiin  specific  types  of  noxa.  The  descriptive  attitude 
toward  the  problem  is  beiiiR  replaced  by  the  intt-rprctative.  This  is 
signifii'ant,  a^  paranoia  bus  long  been  the  stronghold  for  descriptive 
psycliiatry  and  it  has  been  the  last  to  yield  to  an>thing  like  an  inter- 
pretative approach. 

Deacripti(ai.--Thc  general  concept  of  paranoia  which  has  been  preva- 
lent for  many  years  is  that  of  a  psychosis  pre.scnttng  ilelusions  of  jkt- 
secnlion  i>f  a  pn-tty  clearly  defined  tyiK*,  well  supiM)rtcd  and  defended 
by  the  |»attent,  in  other  words,  systenuitized.  Tliese  delusifnis  generally 
involve  a  more  or  li-ss  circinnscrilx-d  [xirtion  of  the  mentality,  altlumgh 
they  tend  to  spread  out  slowly  and  involve  more  and  more.  With  this 
state  of  mind  there  is  no  marked  tendency  toward  deterioration,  shs 
ilisease  having  essentially  a  chronic  course  and  remaining  unchanged 
for  }*ears.  Associated  ^^^th  the  delusions  and  harmonized  with  them 
in  content  are  frequently  auditory  halhk-inaticjna — voices. 

This  is  the  general  conwpt  of  the  disease  which  has  received  various 
modifications  and  descriptive  clothings  by  difrprciit  authors.  Knr 
niau>'  years  the  lUUre  vhwni'fUf  a  rcviutiun  ^rystemati'im'  of  Maguau 
in  Kninee  and  the  iwranoia  of  Krufft-Kbing  in  Germany  have  been 
the  para<iignia  under  which  the  various  forms  have  been  arranged. 
The  delirc  cbronique  of  Mngnan  was  a  disease  which  progres.sed 
regularly  through  four  stages;  first,  a  hypochondri;K'(il  stage,  or  stage 
of  subjective  analysis;  scconti,  a  stage  of  persecution;  third,  a  stage  of 
Iransfonnation  of  the  personality;  and  sometimes,  fourth,  a  stage 
of  deterioration. 

In  the  first  or  the  bj^jochondriacal  stage,  or  stage  of  subjective 
aiial.i)'?iis,  the  patient  is  selfK-eiitcred  and  depressed  and  has  ideas  of 
reference.  He  also  complains  of  many  physical  s>Tnptoms,  such  as 
dizziness,  weakness,  headaches,  etc.  Kverjthing  that  hapiwns  about 
him  tends  to  l)e  referreil  to  himself,  so  that  he  is  in  a  coa^tant  state 
of  morbid  introsi)eiTtioii  almnt  things  which  he  dm*s  not  UTKlcrsUiiid. 
In  the  seetmd  stage  the  explanation  of  all  these  things  finds  itself  in 
the  ilelusions  of  persecution.  The  reasons  why  people  have  slighted 
him.  why  they  have  said  disagreeable  things  about  him,  why  they 
tiUk  about  hint  ami  spread  rumors  about  him  is  all  niiderstandabic 
because  of  the  conspiracy  which  there  is  against  him.  These  delu- 
sional idea.>(  are  reeriforced  by  hallucinations  of  hearing,  and  he  hears 
ac-tuid  evidences  of  all  of  the  things  which  are  being  done  to  annoy, 
to  ptTsfcnte,  or  to  destroy  him.  Kxplanatory  delusions  follow  which 
^ve  the  reasons  to  tlie  patient  why  he  is  thus  persecuted,  and  usually 


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whicii  oliHie  they  think  the  term  paranoia  applimlile,  lULiiifly.  the 
(ieliriuui  of  inlrrpn'lnfion  ftiul  thft  thliritim  nf  rrnnftinition.  [u  tlie 
di'lirium  tjf  intcrfjrctaliun  the  patient  has  iik'its  iif  refereiKX*.  and 
because  f>f  his  hick  uf  critique  uud  pyuceiitricity  conies  to  all  stirts  of 
false  interpretations  of  what  is  KoinR  »n  alMnit  hira.  These  delusional 
interpretations  become  systematizc<i  and  reAch  more  or  less  coherency 
without  any  special  dejwndcnce  upon  <lisorders  of  the  scnsoriuin. 
lliere  is  no  deterioration,  and  lucidity  is  maintjiined  throughout  the 
evolution  of  the  psychosis.  Unlike  certain  other  paranoid  conditions 
the  false  interpretations  have  their  orij^n  in  actual  facta. 

In  the  delirium  t/J  rcrindrcadim  a  chronic  systematized  psychosis 
wliirh  takes  its  origin  in  a  fixed  idea  appejirs.  It  is  a  nionoideism,  and 
its  various  runuHaitions,  like  thf  other  form  of  paranoia,  do  not  tend 
toward  dementia.  TTiey  describe  two  varieties  of  this  psychosis,  the 
egocentric  iyye,  the  subjects  of  which  are  usually  [wrseeuturs  making 
claims  for  wrongs  suiTered  that  may  or  may  not  have  some  founda- 
tion in  fact.  Then  there  is  the  altruitttic  tijife.  characterized  by 
abstractions  and  impersoaial  theories.  To  this  group  belonir  the 
inventors,  the  reformers,  and  the  prophets,  becoming,  however,  in 
their  endeavor  to  reaUze  their  ideals,  oftentimes  dangerous  fanaties, 
mystics,  anarchists,  regicides. 

In  (Germany  Kraepelin  limited  the  paranoia  concept  jwrhaps  more 
than  anyone  else.  He  njnfined  the  term  to  a  very  (ircuniscribiil 
and  very  f^niall  group.  His  conception  of  the  disease  is  a  chronic 
incurnblc  psychosis  of  insidious  origin  developing  slowly  by  the 
gmdual  systematizing  of  endogenous  delusions.  This  system  of 
delusions  is  enduring  and  unshakable  and  exists  along  with  the  reten- 
tion of  the  I^^c-al  and  orderly  procx'ss  of  thinking.  There  is  no 
marked  tendency  to  mcntjit  deterioration,  and  hallucinations  play  no 
essential  part  in  the  picture. 

Kraepelin  has  recently,  in  the  eighth  edition  of  his  work,  still  more 
clearly  defined  his  ]mram)id  group  by  describing  a  group,  paraph  run  ur, 
wliich  contains  certain  paranoid  tyi)es  that  closely  re.semble  his  para- 
noia, but  which  provisionally  he  includes  in  this  group  for  purini-ses 
of  gn-ater  definition,  'lliis  group  of  paraphrenia  is  divided  into  four 
subgrcjups,  as  follows; 

Paraphrenia  syiftemafica,  which  is  for  the  most  part  Magnan's 
d^Ilre  chroniquc,  with  the  cxct-ption  that  the  wcll-<(efinei|  precox 
tjTies  with  marked  deterioration  are  excluded. 

Paraphrenia  Expan^ita. — This  form  affects  only  women  and  is 
marked  by  the  devehtpment  (if  ideas  of  grandeur  with  mild  excitement 
and  exaltjktion.     No  dementia  follows. 

Paraphrenia  Cmtfobulanjr. — Here  the  delusions  Ixjth  of  persecution 
and  grandeur  are  spejially  marked  by  their  foundation  upon  and 
reference  to  memory  falsification. ,  as  the  name  indicjites. 

Pamphrniia  phnuUinfirn  is  the  term  ai>plied  to  eases  with  a  certain 
amount  of  exaltation,  with  the  tecounting  of  remarkable  adventures 


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Riitt  iiicolicrciit  (Hiiii^'ing  ili-liisioiis.    This  wuitJitlon  is  cliararteris 
»lly  ac'cnmpttnifcl  by  ImHiicinrttlons  of  licariiig.     This  group  inclii 
the  castw  previously  described  by  Iiim  uiuler    the    term    dcrneu 
purjiiHudcs. 

Interpretation.  Tlie  rather  simplistic  attitude  which  dominat 
shortly  after  the  term  paranoia  came  into  literal  UHe  ami  wliich  !Ui' 
in  every  rombinaTion  of  fairly  well-defined  luxd  fixed  jierseeut 
ideas,  es{K^eiulIy  those  siipporteil  hy  Imllmiiiatioufi  of  henritig'.  the 
disease  ^liiramiia  had  U>  n,\vc  way  in  a  very  few  years  to  a  broader, 
if  somewhat  less  well-de6ned.  attitude.  It  soou  became  evideut  that  a 
fairly  sj-stcmatiacd  and  fixed  deluulonal  system  of  perscciitorj*  eharac' 
ter  mi^ht  occur  ilh  the  expression  of  a  psycliosis  fnim  whidi  recovery 
took  place.  And  so  the  cltnient  of  the  concept  <if  paranoia  which 
etMisidei'e<l  it  as  esseiitial[.y  chroiiif,  pro>,Te-wiive,  an<l  incurable  had  to 
be  readjusted.  These  so-callcil  acute  paranoias  have  been  recently 
stuilied  quite  extensively  by  FViedmanri,'  and  their  origin  traced  to 
ar'tual  situations  in  the  patient's  life,  so  thiit  the  delusions  opp<'ar  as 
logical  outgrowths  of  exix'ricnce.  and  have  as  a  couscqueiwr  fallen 
into  the  group  of  the  psychogenic  psychoses. 

Not  only  was  the  idea  of  chronicity  associated  with  paranoia  serio 
shaken,  hut  from  other  sources  the  idea  of  the  specificity  of  the  per-' 
secutory  delusion  alsn  had  to  ^^ive  way.  for  it  was  soon  found  that 
ideas  of  persecution  of  paranoiac  character  were  not  at  all  iiifrec|Uent 
in  connection  with  other  |»syclioses.  This  was  partirularly  evident  in 
tlic  psychoses  of  chronic  alcoholisni.  It  soon  developed  that  there 
wa:  a  special  form  of  dementia  precox  presenting  paranoid  ideas, 
while  later  studies  showed  luetic  forms  with  paranoid  syniptonialolng\-. 
presenile  fifrms,  paranoid  states  of  mind  of  the  deaf,  and  others  who 
are  ismlated  from  elnsc  contact  with  the  world,  to  say  nothing  of  the 
recent  paraphrenia  group  of  l\rnepcliii  arid  many  other  less  well- 
defined  conditions,  whii;h  have  itieluded  more  reeentJy  not  only  the 
miinic-deprcssive  psychosis,  but  certain  of  the  milder  cycIotJi>iD»c 
nianifeslations  of  this  disorder. 

i'Voni  these  considerations  it  appears  that  here,  as  elsewhere  in  tbe 
field  of  psychiatry,  that  the  important  thing  to  amsidcr  is  not  .so  much 
the  s])ecial  content  of  the  particular  psychosis  in  a  given  individual 
a.s  the  meclmnisms  which  are  involved,  for  liere  are  seen  similar  con- 
tent in  all  sorts  of  mental  disorders,  some  acute,  simie  chmnic,  and 
are  tlK-rcfore  forced  to  look  Ijeneath  and  see  whether  it  is  not  possible 
to  understand  these  manifestations  by  attributing  them  to  a  cummua 
mechanism. 

The  studies  of  Friedniann,  alreuily  mentioned,  went  a  long  way 
toward  showing  tbe  dependence  of  paranoid  trends  upon  actual  situa- 
tions in  the  patient's  life,  and  demonstrated  how  paranoid  delusions 
in  ^ven  eases  might  grow  as  a  ti^uh  from  these  situations.     In  other 

'  Cod tri Initio Ds  U>  tlto  3tudy  vl  Purenuia.  in  Studte*  in  Parnncfu.  Nt>rrou>  aiul  Meiitsl, 
DfaoaM  Motmgniph  Seriea,  No.  2. 


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words,  the.v  are  of  psychogenic  ori^tm  and  are  perfectly  understand- 
able when  all  of  the  circiimstAnocs  have  Ufeu  uiKcivereil. 

Arntmi;  others,  Gierhfh'  hiis  shown  that  paranoid  ideas  often 
aecitniiwoy  Hnrtuations  of  alTect  wliir'h  couhl  only  he  considered  as 
mttiiifestatiuiis  of  a  nianiiMiepressive  psychosis  and  tlmt  many  of  the 
paranoid  conditions  which  were  o-ssociatcd  with  only  slight  affect 
iiiunif rotations  which  bt'lon^'d  to  the  manir-<lepressive  psyrhosis 
mipht  easily  be  overlooke<i  as  cominK  under  tl»at  grtnip  and  l>e  mis- 
takeii  for  true  jMiranoia.  In  this  way  he  accounted  for  a  very  larjje 
nmnU'r  at  lea,*tt  of  tlie  so-railed  acute  paranoias,  as  these  |>atients  uf 
course  got  well  from  the  attacks  as  tlie  manic-depressive  cases  nsunlly  do. 

More  recently  Sijecht*  lias  nt  grwil  len^h  eiideavoretl  to  deuiun- 
strate  that  tlie  underl>ing  con<lition  in  paranoia  was  an  aifect  of 
suspiciouisness  and  therefore  he  hrou^ht  the  paranoid  group  into  close 
alliance  with  the  great  affect  group  of  the  psychoses,  namely,  the 
manicMlcpresaive  group.  This  whole  discussion  has  broadened  out 
in  all  directions  ami  has  become  ver>'  wtmplox  and  extit-mely  involved, 
and  thcn-fure  it  is  nut  a  projter  subject  for  further  ehdioration  in  a 
text-lKiok.  It  might  he  athled,  however,  that  lileulcr,^  wh«i  lias  niude 
n  most  incisive  study  of  the  |)sychologj'  of  paranoia,  denies  absolutely 
that  suspiciousness  is  an  affect  at  all.  and  therefore  departs  radically 
from  S[M*cht's  position,  lie  believes  suspiciousness  is  a  state  of  mind 
ba.'«'d  entirely  uiwin  perceiitions  and  the  resulting  cftnclusioiLs,  and  is 
therefore  of  purely  intellectual  uri^ia,  but  that  it  is  actnanpaiiied  by 
affect,  as  are  all  n»ental  states.  Here,  again,  the  fallaciousness  of  the 
old  faculty  psyehologi,'  that  would  separate  the  mind  into  different 
parts,  sucii  a.s  the  intellect  and  the  emotions.  sJKPuld  be  empliusi/cil. 
The  two  invariably  occur  tog<,'thcr,  anil  suspiciousness,  of  course, 
therefore  is  accompanied  by  its  affect. 

Bleuler  is  of  the  opinion  that  paranoia  takes  its  origin  in  certain 
constellations  of  ideas  or  complexes  and  the  dominant  affect  with 
which  they  are  loadecl,  tluit  these  complexes  are  precisely  of  the  stmie 
nature  as  are  found  in  healthy  individuuts.  and  ihat  the  disease  ele- 
ment which  leads  to  the  eluboratiim  of  a  psychosis  is  the  fixation  upon 
this  complex,  the  inability  to  get  uway  from  it,  nr  as  might  be  said, 
the  inability  to  reach  an  efficient  adjustment  to  it. 

One  here  sees  wliat  is  ever\T\hcre  apparent  in  <lt«ling  with  mental 
disorders,  that  the  delusion  Is  not  the  disease,  the  delusion  is  only 
one  ex]>re3sion  of  tlie  disease.  The  mechanism  involved  has  to  deal 
with  a  certain  content;  this  c-ontent  is  delusional,  but  is  therefore 
only  the  outwarti  expression  of  the  disorder  lieneaih.     Therefore  the 

)  ParMHlie  PftriuiOM  AOtl  Uie  Orixiii  of  Paniuoitl  Uetuaiutm.  in  Studuis  id  Ftaranoin, 
Ken-nu*  knd  Mental  DlBeoae  Monngraph  Kr-ric«.  No.  2. 

*  l/etier  den  padiolOaiMrliva  affect  in  dwr  i-h runiiirb«n  PftraDoia.     Cit«d  b>'  U)eul«r, 
Iq  Affm^tivlty,  Ir^uiuBstiliUio',  PMnDoiii,  N«iv  \'atk  Suto  Hospituls  Bui]<>lin,  vol.  iv. 

*  Affei-tiviiy,  SiuvMtiliiUty,  I'araoote.  N«w  York  Btate  Llu«pit«b  DulLctio,  tvI.  iv. 
Frlmurr  1^.  1012. 


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TffB  PARANOIA   OROltP 


(lelusinii  renlly  expresses  un  ffTort  upon  the  {wrt  nr  the  inifividiiiil  to 

rciirli   iill   t'fTii'lffit   HiljiistiiU'lit.     Tin'  ruii-^tiOIatliou   of   ii|i*:is   uitll    i(s 
(Ininiiiaiit.  piuiiful  atFt'ct  Ims  })Lrn  ime  t<»  wlucli  ih**  )ULtieiit  conM  iiol_ 
cffwtivcly  roliitf  Iiiiiisi'lf,  ilihI  thcn-forf  the  next  Ix'st  thiiig^  UnA 
Ih*  (lane,  and  This  n*!Xt  he.st  thing  wils  x\w-  fivniiiition  <if  <Tertain  dehl 
sioii-s  which  rLMidered  the  t'xi?itence  of  the  pauifully  alTeetive  t-omple 
TdiiW  endurable.    The  delusion,  therefore,  Sfx-aking  in  physical  u-nin 
is  iiinri'  coinparable  tn  si'ur  tissue  than  to  disease  tissue.     It  represent 
the  hieation  of  the  wound  and  the  result  of  the  reparative  pro« 
To  iiuikc  the  matter  more  clear,  uu  individual  who  is  ambitious,  am 
yet  who  lacks  ability,  may  develop  the  delusion  that  his  lack  of  suO"| 
cess  is  due.  not  to  his  lack  of  ability,  which  he  persistently  refuses  to 
see,  hut  to  the  interference  of  enemies  who  are  jealous  (tf  him  and  who 
persecute  him  and  try  t<»  Wlittle  him  in  the  eyes  of  his  superiors,     'ifl 
tliis  way  an  inaci-eptahle  fiiel^iis  iriefiieieney  to  which  he  cannot" 
made  atlequjite  adjustment — is  so  distorted  that  it  would  appear  thai 
the  results  of  this  inefficiency  emanate  rmt  from  within,  but  from 
interferences  from  without  {projection).    Tins  illustration  shows  wtU 
the  simultitneous  presence  of  both  delusions  of  persecution  and  delu- 
sions of  grandeur.     And  so  the  patic'iit  creates  a  situation  in  wliieh 
he,  so  to  speak,  finds  himself  able  to  set  aiouR,  for  as  painful  as  a 
system  of  persecution  of  the  stprt  which  he  ci-eates  for  himself  may 
be  to  hini.  it  is  less  so  than  a  reidization  of  his  own  inlierent  defef,:ts. 
It  will  be  seen,  therefore,  what  is  meant  when  it  is  said  that  the  delu- 
sion, speaking  in  physical  terms,  represi-nts  scar  tissue,  and  it  will 
Ik-  seen  also  how  a  destruction  of  the  delusion  cimld  in  no  way  cure 
tlie  4liseiise.     If  the  delusion  eould  actually  be  desln»ycd  the  patient 
would  be  in  raucli  the  same  positinii  as  a  patient  who  tuid  a  sear 
cut  out;  another  delusion  would  have  to  take  its  plare,  because  the 
patient  would  lie  thrown  back  u]>r»n  the  same  iuac<«ptable  situation 
to  vvliiKib  he  would  flud  himself  again  incjipable  of  making  efficient 
adaplutioii. 

Aniithcr  mechanism  which  is  revealed  in  this  illustration  is  of  grcftt  ^ 
importance  as  being  cliaracteristic  of  the  paranoid  reaction  t>*pe,  ■ 
nantely.  the  mechanism  of  projection,  whereby  the  individual  prt»- 
jcct-t,  as  it  were,  U[hmi  the  outside  w»rld  liis  own  nient-al  difficulties 
which  return  to  him  in  this  instaneo  in  the  form  of  persfcutinn.    This 
Diechanism  of  projection  is  a  very  common  one  and  appear*  to  be    _ 
fundamental  in  paranoid  trends.     It  is  at  the  basis  also  of  the  ideas  H 
of  grandeur.     I  tcrc  the  patient  projects,  not  his  difficulties,  but  his 
ambitions,  and  his  ho[K.'s  <-omc  back  to  him  fnmi  the  outer  world 
realised.    In  fart,  the  mechanism  of  projection  is  not  a  f)atholi)gieHl 
nM'chanlsm  at  all  but  is  constantly  used  hy  healthy  |»er.sons.     This  h 
is  true  of  all  the  meelianisms  fotmd  at  work  in  the  psycliosed,  it  is  not  fl 
the  mechanism  tliat  Is  diseased,  it  is  the  use  to  which  the  mcclmnism 
is  put  in  the  process  of  adjustment  which  may  bring  the  indi\i  " 
to  grief.    Ideas  of  grandeur  are  alwa^'s  present.     Persecutory 


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grandiose  ideas  are  the  oppoeitc  aides  of  the  same  raechanisui.  Either 
may  dominate  the  picture  hnt  both  are  always  present. 

The  moet  elalwrate  attempt  at  interpretation  of  the  paranoia  syn- 
drome was  made  recently  li.\"  Freud'  in  his  analysis  of  the  Schreber 
trase.  Herein  l-'n'nri  v(ii(M*d  tlir  view  that  paranoia  was  dependent 
npon  a  homosexual  Hxatioii  in  the  i»syehosexiial  th-vi-lopnicnt  of  the 
individual.  To  make  this  statement  somewhat  elearcr  it  should  Ik 
recalled  that  the  individual  in  his  psy^hosexual  development  is  first 
nuto-erotic,  that  is,  interested  only  in  his  own  body,  that  his  next 
interest  is  In  those  immwliately  al>ont  liim,  the  memlx-rs  of  his  own 

Ifiiiniiy,  and  particularly  those  of  his  own  sex,  in  other  words,  th(WO 
who  have  bodies  most  like  his  own.  ami  that  these  stage?*  have  to  be 
parsed  thnitigh  l)efon*  the  nonnal  i-nd-n-snlt  in  a  heterosexual  object 
love  is  attained.  The  unconscious  homosexual  interest  in  the  mem- 
Ix-rs  of  his  own  family  is  designated  a^  narcissism,  and  the  jMininoiac 
tiiet-hanism  is  ileijendent  upon  a  iixation  ami  development  at  this 
IK'riod.  In  the  uoniial  develnprnent  of  the  individual  the  unoimseious 
homosexual  tendencies  are  not  entirely  eliminated  by  any  means,  but 
the  homosexual  libido  is  sublimated,  that  is,  its  energies  arc  utili'Ae<l 
in  other  clmnnels,  mon-  imrticularly  il  is  utilizeil  in  all  those  forms 

hof  assiM-iatiiHi  with  the  same  sex  that  one  sees  in  friendships,  s^x'ial 
orjranizutliMis,  clubs,  games,  and  in  the  higher  social  activities.  liut 
with  a  fixation-imint  at  the  nanrissislic  perio*!  of  psyehoscxual  devel- 
opment the  ixitient  is  constantly  in  danRer.  Any  serious  cnnfli<!t  is 
liable  to  e:mse  a  regression  of  the  sublimation  to  the  point  of  fixation, 
and  this  is  considered  by  Kreud  tu  Ix^  the  mechanism  at  the  bnsis  of 
I  paranoia.  "  Persons  who  cannot  rise  completely  out  of  the  stage  of 
^H  narrissi.tm  and  are  thus  prematurely  fixwi  or  arrcitted  in  the  evolution 
^P  of  their  dis])ositions,  arc  exjHwed  to  the  danpcr  that  a  Hood  of  Ubido 
■^  whieh  finds  no  outlet,  sexualizcs  their  s^x'ial  tendcnries  an*l  reverts  the 
|i  sublimations  achieved  in  the  <rourse  of  development."  The  libido  of 
^■the  paranoiac  i.s  then  projected  upon  those  about  him. 
1^  The  whole  process  is  briefly  and  ingeniously  set  forth  by  Kreud  by 
means  of  ringing  the  changes — supjKwing  the  iMininoiae  to  Ix-  a  male 
— uptm  the  Ixtsal  sentence  "1  love  htm,"  thus: 
^^  Pclit.titnt.^  lif  jirrnrcutivn  ctintnnlict  tlie  verb.  "I  love  him"  is 
^■resented  hy  the  imiividuai  who  reacts  to  the  feeling  by  "1  do  not 
^^love — I  rather  hate  him."  Then  this  feeling  of  hat«  is  projected  w^th 
the  result  "  he  hates  (persecut.es)  me,  which  justifies  my  hating  him." 
As  a  result,  tliis  feeling,  apiM'aring  to  wane  frtmi  an  outer  pen.'cption 
bccome-s  "  I  ri'ally  do  not  love  him — 1  hate  him— because  he  persecutes 
e." 


'P«)'rho-ftiu)ytijicbo  JJciucrkuuitcu  fiber  oiaea  autobtocrnphiwben  bonrhreilmiken  FhU 
iron  fVnutrtiii  (Dementk  parnooidce),  Jahrhuch  far  p«i>'i'lKwinitly)iVIic  iititl  py»<-lii>> 
^litliAlf>|Mctu>  rurvrliiing^n.  U<l.  iii.  I'JII.  A  \t<ry  (•xr«Ueut  'lud  full  ui'.'uuut  iu  Ku4e1u1i 
if  Vnud's  niMl>-BUi  nf  lliia  muD  itiD  br  fnund  iu  the  PSjclxiujuilytk-  Rn^iew,  vol.  i. 
So.  I. 


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Krotomania  coiitradJcts  the  object.    "  I  do  not  love  him — I 
her,"  then  "I  notirr  that  she  Invos  me,"  thon  finally,  "I  do  not  U 
him — I  love  Iht— betimsc  she  loves  me." 

Dehmtm/t  of  jralotist/  contradict  tlie  subject.     "Not,  I  love  the 
—she  loves  him." 

Dctuftiutin  of  grandeur  result  from  a  total  cotitradiction,  a  rejeel  _ 
of  the  whole  Retitenre.     "I  do  not  love  at  all,"  and  hence,  "I  lore 
nobody."    As  the  libido  must  be  accounted  for,  this  is  equivalent. 
"1  love  only  myself." 

Diagnosis.—  Attention  lias  already  been  railed,  in  the  body  of 
chapter  to  the  difTereiit  conditions  which  have  to  be  borne  in  roil 
in  makiup  u  dia^:Ilo^<is.  There  are  uuuiy  paranoid  states,  aiul  wherever 
the  paranoid  mechanism  is  present  then  it  is  proper  to  :speak  of  a  pa 
iK>id  state.  These  paranoic!  states  are  found  in  man.v  of  the  psychasi 
They  may  be  nuire  or  less  permanently  associated  with  the  .spoei 
attack,  as  tn  the  nianieHlepres.sive  pjvjchosis,  or  as  in  alcoholic  hullu- 
cinosis,  or  there  may  be  transient  ejiisruies,  as  in  Reneral  paresis.  It 
will  Ik*  seen,  therefon-,  that  ttiere  are  many  and  various  tyin-s  of  sxTni 
tomatic  paranoid  states  and  that  perhaps  the  main  consideration 
the  matter  of  diagnosis  is  that  a  amdition  which  is  sympt()rnati<-ai 
transitory  should  not  be  mistaken  for  a  chronic,  propx-ssive.  hi 
prtthahK  irrecoverable  p.syehosis.  This  dJITerentiation  cannot  alwaj 
he  made  on  the  basis  of  a  erc»ss-section,  hut  the  patient  must  !«■  studic 
carefully  over  a  considerable  period  of  time,  and  a  reasonably  full 
history  antedatitijf  ihe  ])erifid  at  which  he  enrac  under  ()bser\'ation 
must  also  be  liad  in  order  to  .see  what  the  general  pnjffress  indii.ute?. 
A  psychoanalytic  inve.stigation  of  the  sjinbolic  meaninf^  of  the 
delusional  ideas  is  essential. 

Treatment. — For  a  considerable  time  past  the  general  attitude  towani 
the  (jroup  of  cases  included  under  the  designation  of  paranoia  has 
lieeii  that  they  wore  inrnrable.  The  outh>i^k  has  l>een  an  extremeb 
dark  and  pessimistic  one,  and  correspondingly  therapeutic  efforts 
have  >»ecii  |Miraly'/e<l  at  their  ven.-  in«;ption.  .A  sonievNiiat  chant; 
attitude  toward  the  whole  group  was  the  natural  result 
ment  of  a  concept  of  paranoia  which  was  more 
applicable  to  a  more  limited  number  of  patients,  and  wiien  corn-_ 
spondinply  it  was  learned  that  there  were  many  paranoid  stat 
associatwi  with  essentially  recoverable  psychoses;  in  other  words, 
the  jjaranoia  concept  has  become  more  and  more  nmtraeted  it 
Itcen  ealixcd  that  a  great  many  of  the  pnninoid  conditictns,  whic 
fonnerly  were  grouped  under  the  head  of  panuioia,  really  iH-longed 
recoverable  transient  conditions,  and  therefore  the  outlook  for  the 
was  good.  On  the  other  hand,  as  the  paranoia  concept  has  contract* 
it  cannot  l>e  saiil  that  there  has  heen  any  increase,  at  least  until  very 
recently,  in  the  hopefulness  for  this  limited  group  of  cases.' 

'  A.  Meyet!    Trwumpni  (tf  rHTiitKiiB  in  M(idi-m  Tti'ivtincnr,  Net*-,  luirf   Mcrtl. 
WbJto  nnd  Jelli0c,  U-a  &  Fcbietr.  1013:  Bit'frc:  Pfycticuuolj-ais,  PmIou.  1617. 


■ionievNlint  change^ 

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It  could  hardly  be  expected  that  at  a  tbne  n'heii  paranoia  was 
ronsiderwl  to  Iw  an  absolutely  hopeless  and  irreroverable  psychosis, 
flmiiiii*  and  progressive  in  Jt-s  very  imture.  that  therH|>eutic  results 
would  offer  murh,  or  that  then?  would  be  found  many  who  would 
even  )(ive  any  material  effort  in  this  direction,  but  Iwrc  and  there 

lucatteretl  through  tJic  literature  are  reports  of  cases  of  ])aninoid  type 
which  seeinci]  to  have  been  inHuenced  hy  this  or  that  form  of  thi-ra- 
I)eutic  proce<iure,  and  more  recently,  since  the  doors  have  been  o|>ene<i 
end  one  has  been  able  to  enter  more  intimately  into  a  knowledj^  of 
the  meclinnisms  that  are  involvcti  in  the  development  of  the  psychoses 
and  when  it  has  been  seen  that  these  mechauisnis  at  least  iire  quite 
the  same  in  ineutal  disease  as  they  arc  in  Iiealth  even,  and  that  the 
methanisms  of  chronic  psychoses  are  quite  the  same  as  those  found  in 
recoverable  condition:*  and  also  in  health,  and  that  the  dJscaseil 
feature  was  not  so  mucJ»  the  niechanisro  as  the  fixation  of  the  individ- 
ual at  certain  periods  of  development  or  with  reference  to  certain 
(t)nsieHations  of  ideas,  it  became  at  once  an  open  question  whether 
thcNC  (taiditiniis  miglit  nut  l»e  susceptible  of  the  same  sort  of  modifi- 
cation as  they  arc  in  less  serious  conditions.  And  so  within  the  past 
few  years  there  has  Ix-cii  an  awakcninj;  of  interest  in  these  chmnic 
psychoses  ami  efforts  arc  beinp  made  here  and  then*  to  penetrate  their 
mysteries  and  to  modif>'  their  course,  with  the  result  that  already  a 
number  of  cases  of  imranoia  ha\*e  been  reported  as  having  had  a 
favorable  outcome. 

The  jjpiienil  principle  of  treatinetit,  at  the  psychological  Ifvel, 
resolves  it.scif  into  as  mniplcfe  as  [Rissihlc  an  unraveling'  of  tin-  tangled 
skein  (»f  the  patient's  mental  life,  an  uncovering  t>f  the  activating 
circumstances  in  his  carttr  which  liavc  been  the  etiological  factors  in 
the  development  of  the  psychosis,  and  by  so  doing  modifying  his 
mental  trends  by  a  [)rogressive  ijrtx-ess  of  readjust ment-s  and  nvdiu-a- 
tion.  This  Ls  the  work  of  one  skilleil  in  tlie  analysis  of  psychological 
situations  and  is  of  quite  the  same  nature  as  the  psychoanalytic  treat- 
ment of  the  neuroses. 

It  seems  certain,  fnim  the  results  of  dealing  with  thi^se  paranuiil 
conditions,  that  asi<le  from  any  definite  ability  to  mcxlify  the  course 
of  the  psychosis  or  to  pniduee  a  definite  curative  ivsult.  that  tlie 
psy(ihoanal.\"tic  method  of  attack  may.  not  infrequently  at  least,  lead 
to  a  certain  amount  of  transfer,  that  the  physician  may  come  to  be 
highly  respected  and  affectionately  regarded  by  the  patient  to  such 
an  extent  at  least  that  he  may  very  lately  etmtrol  Ihe  patient's 
activities.  This  has  bwn  knowii  to  happen  under  rather  extraordinar>' 
circtuuNtances,  showing  a  very  high  degree  of  personal  influence  by 
the  physician  over  the  patient,  despite  the  fact  of  well-marked  and 
fixed  delusional  Iwlicfs. 

In  dealing  with  paranoiacs  it  nmst  always  Ix-  remend>ered  that  one 
is  dealing  \\tth  a  cla.ss  of  patients  who  are  potetilially  dangerous. 

Ithat  to  this  group  belong  perhajia  the  most  dangerous  of  the  so-called 


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insane,  ami  aside  from  matters  of  psychoanalysis,  or  in  fart  of 
questions  of  therapeutif  endeavor,  it  must  l>e  reiilize<l  tliat  where" 
ia  evident  that  the  welfure  of  the  imiiviHiial  and  the  welfare  of  socictj 
eross,  tliii  welfare  of  tl»e  iiidlvidiml  must  pive  way  in  favtw  of  that  ol 
society.  If  the  pamnoiae  is  netually  dangerous  it  is  neeessarj'  Ji 
inUrnc  him  iij  some  institution  where  he  will  pet  proper  care.         ^ 

The  (luestion  as  to  whether  a  given  paranoiac  is  d»ngcrous  or  not, 
in  thi:  abiJeiice  of  any  overt  aets,  is  often  an  extreniely  difficult  oi 
to  decide.     In  any  ca.se  it  is  a  question  to  be  decided  by  a  study 
the  individual  case  and  it  always  inelude.s  a  consideration  of  nii 
factors.     Among  these  factors  the  following  may  be  nientionetl:      _ 
is  im[Htrtinit  to  find  out  liow  i-onipletely  the  mentality  of  the  pniirnt 
is  iMTmeaterf  hy  the  dehisional  system,  in  other  words,  how  nim-h  or 
liow  little  freedom  he  has  from  delusional  control,  whether  all  of  brs 
meiitfd  forces,  so  to  speak,  go  to  reenforce  the  delusion,  or  whether. 
on  the  other  hand,  he  Is  left  reasomibly  free  for  a  considerable  portion 
nf  the  time,  in  contact  with  reality,  rather  than  plunged  into  the  depths 
of  his  unreal  world.     It  is  important,  to<j,  to  note  how  clearly  detinetl 
may  be  his  belief  in  the  activity  of  any  specific  individual  in  his 
delusional  system,  whether  he  believes  some  person  who  is  living, 
Ix-rhiips  nearby,  someone  whom  he  cjin  easily  come  in  contact  with. 
is  respcmsible.  at  the  bottom  of  his  ])ersec*utions.     It  is  imi>ort;int  to 
see  v^lK■ther  the  patient,  In  the  consideration  of  his  delusional  ideaa^ 
is  at  all  subject  to  the  reality  motive,  whether  he  ha-i  any  critique  leflfl 
or  whether  his  Iwtief  is  shakable  in  any  degree  by  others.  wWther  he 
can  Ik-  influenec<[  iiiiiterially  hy  his  physirian  when  it  conies  to  the 
(|Uc,stion  of  liis  delusional  ln-Iiefs,  or  whether  they  doniiiiate  the  silui 
tion  absolutely.    It  is  important  to  judge  the  general  attitmle  anC 
mood  of  the  individual,  whether  he  is  entirely  shut  out  from  an] 
consideration  of  others,  of  the  world  at  large,  whether  he  consid* 
himself  quite  a  law  unto  himself,  whetlier  he,  for  example.  Is  exalted, 
egoti.'^tic,  beyonil  criticTism,  .self-sufficient,  and  believes  that  an.vthir 
that  be  may  decide  to  do  Ls  justifiable.     It  is  important  to  knoT 
rtliellier  the  patient  in  his  past  career  has  bt-en  Inipnisive,  whether  he 
bus  shown  teniiencies  to  do  unusual,  bl/urre,  or  grotesque  things. 
t(»  fly  into  passions,  or  to  be  uncontrollable  from  slight,  inadc(|uate, 
unexpected  reasons.    Threats  have  to  be  evaluated  and  an  opini 
reached  as  to  whether  the  patient  really  means  t<(  carry  them  oui,  o 
whether  they  are  used  as  a  means  of  emotional  eatharsu.    Tlie  genei 
etlueation,  bringing  up,  and  ideals  of  the  iiulividual  are  ini|>urtant 
indicating  what  he  is  liable  ti>  do.     .\  person  nho  was  brought  u 
originally  with  a  pn)per  n'guni  ft»r  the  proprieties,  who  is  essentiall 
a  gentleman  or  a  gentlewoman,  is  by  that  very  token  not  so  apt 
conmiit  some  vulgar.  n>wil\.  indecent  net. 

And  (inally,  it  may  Ix*  wiid  that  while  the  general  attitude  towai 
paranoia  has  perh»p.s  not  materially  change*!,  while  there  is  sti 
prettj-  gooil  ground  for  believing  that  a  certain  cl»s!*  to  whom  the  t( 


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TREATMENT  785 

paranoia  ts  perhaps  alone  applicable,  are  inaccessible  to  therapeutic 
endeavor  and  are  doomed  to  suffer  from  their  psychosis  throughout 
their  lives,  still  even  if  this  is  so  there  is  no  absolute  way  of  deter- 
mining this  fact  except  by  a  consistent  and  sufficiently  prolonged 
effort  to  modify  the  course  of  the  disease,  and  with  the  several  cases 
already  in  the  literature  which  indicate  that  conditions  that  might 
well  have  been  considered  chronic  and  irrecoverable  if  taken  at  their 
face  value  can  still  be  materially  benefited  and  perhaps  cured,  no  one 
is  in  a  position  to  pass  6nal  sentence  upon  any  patient  after  an 
examination  or  two,  but  on  the  contrary',  has  the  right  to  feel  that 
there  is  some  hope  for  all  of  them,  and  that  at  least  hope  should  not 
be  abandoned  until  consistent  therapeutic  efforts  have  been  applied 
for  a  reasonable  time.* 

'  CoDuult  Critical  Digest  of  the  Paranoia  Prohleui,  by  C.  R.  Payne,  Psychoanalytic 
Review,  voi.  ii. 


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CHAPTER  XVin. 


EPILEPSY  AND  COIvnTLSn  K  'n'PES  OF  KEAtT'lON.l 

Epilkphy,  the  ''falling  sickness,"  has  boeii  known  from  the  earliest 
times,  the  very  wonJ  itself  earr>*ing  in  its  history  {it  is  ileriveil  from  a 
Giwk  verb  niettiiinR  *'to  seize  upon")  t-viik-nces  of  tlie  (ininu:^da 
hyfMjtheses  of  earlier  and  relatively  more  primitive  ways  of  tliinkia^.  fl 

The  won!  epilepsy  is  used  tis  a  syiiibi»l  under  whieh  a.re  jrrouped  a 
gn-ut  variety  of  eonditioiis  whieh  in  Kcncral  are  ehamcten7*(l  by  simK 
den  and  relatively  transient  attach  involving;  fur  the  most  part  dj~ 
turbances  at  Minscioiisncss  ("faints."  "absenees."  "blanks,"  amnesii 
and  convulsive  seizures  involving  the  voluntary  and  involniiti 
miistidrttiire.  Such  attacks  are  the  outwanl  miniifestatlons  i>f  a  wut 
variet,\'  of  conditions  rati>,'inK  ""  the  way  fn>ni  the  si>-<*alleiil  ftiiution 
neuroses  and  psyehoneuroses  (hysteria,  eonipnisioii  neurosis),  tlie  nil 
frank  psyelioscs  {dementia  pnH.'Ox),  toxemic  states  (luvmia,  alcohd 
man\'  orpanie  disciises  ([Jiiresis,  cerebral  syphilis,  abscess,  softenir 
and  tumors)  to  the  jrrosser  defects  of  devc!o])mcnt  (idiixry). 

The  natural  evolution  of  the  conei^pt  sxTnholized  by  epilepsy  in 
recognition  that  simikir  " seizures"  may  result  fnim  su4h  a  multiplieity 
of  oonrjitious  has  resulterl  in  a  tendency  to  speak  of  "the  epilejisies" 
rather  than  of  "an"  epilejjsy  and  makes  it  worth  while  to  consider  tlie 
attn<"k  as  due  to  a  faulty  distribution  i)f  enerjj\'  which  may  be  brou^hB 
about  In  many  ways  and  through  clivers  mechunisms.  The  n'itW 
variety  of  conditions,  as  a  part  of  which  convulsive  reactions  with 
associated  disturbances  of  consciousness  occur,  cannot  be  too  inurti 
emphasized.  The  toxic  states  {endogenous  or  exogenous)  are  usually 
transitory  «n<l  c!ei>en<l  ujmn  the  eimtiuuumre  of  the  toxemia,  but 
defective  ]){i,mthyroid  functioning  with  disttrdered  eideiuni  metabolic 
the  convuJsi>"e  phenomena  eimtintie  because  the  underhing  metabolij 
disorder  cannot  W  permaiK'ntly  relieved.  Marked  organic  chai 
which  are  resiionsible  for  convulsive  attacks  are  usually  t^rebr 
(tumor,  softening,  hemorrha^'.  meningitis),  but  certain  orfrani 
conditions  resident  else\\'here,  notably  the  cardiopathy  of  .Stokt 
Adams  disease  and  the  condition  resulting  in  animaLs  from  th>im 
extirpation,  appear  to  be  sufficient  causes.  While  still  m«»re  ol 
factors  determine  vagal  and  vasovagal,  gastric  and  intestinal  attucl 
which  ap|x;ar  to  l)c  dependent  upim  elements  of  eoiistutional  tnake  up 
at  the  level  of  the  vegetative  nervous  system.  It  is  worth  while,  thei 
fore,  to  attempt  to  get  a  view -point  of  all  these  conditions  d 
upon  their  common  element-  faulty  energ>'  distribution. 


niie.  then^ 


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EPILEPSY  ASD  CONVVhSIVE  TYPES  OF  HBACTIOJI      787 

For  the  piirpcKte  of  comproheiuiiiiK  tlw  epileptic  plirQumtrim  then, 
tlie  nervous  systfin  may  be  viewed  in  a  very  simple  way.  From 
the  stiiiiil-ixiint  of  striKlurc  it  may  be  thought  of  as  tonsisting  of 
receiving  organs,  ilesigncti  either  to  come  in  mntact  witli  llie  external 
world  (exteroceptors)  or  with  other  parts  of  the  boily  (proprioceptors) 
spoken  of  colle«-tively  as  receptors.  The  combined  material  aeeumvi- 
lated  thnmgh  these  reeeptors  forms  the  basis  upfpn  whiL^h  certain 
extensions  of  the  nervons  system  (effectors)  are  devised,  whereby  the 
reactions  of  the  body  are  conditioned  in  a  way  to  bring  about  that 
adaptation  essential  to  life  or  to  the  maintenance  of  the  social  structure. 
In  this  way  the  ner\'ous  sj-stera  is  viewed  aa  a  mass  of  interrelatt'd 
retiexes  redistributing  the  energy  received,  for  the  purposes  of  the 
organism. 


Fiu,  387. — DiSiuo  srlenMia  of  cori«x  wiih  Kimphy  nionit  tti«  Hol.-im^  and  8ylriftu 

.\s  the  incoming  stimuli  are  multitudint»ns,  .so  the  outgtiing  activities 
are  correspondingly  diverse,  and  a  healthy  organism  is  able,  by  reason 
of  its  nervous  nu-chanisma,  to  so  di.slribnte  tlje  energy  rewived  as  to 
bring  idxnit  a  .series  of  liarmoniously  adjusted  activitii's.  !«•  tiicy 
physicorhemical.  sensorimotor,  ur  psychic.  This  view-point,  tiiat 
euerg>''  distribution  takes  place  at  all  of  these  levels,  shoultl  not  Iw 
Io«t  sight  of.  as  there  is  a  tendency  to  think  of  the  problem  solely  in 
tenns  of  nuiscnlar  work.  Atwood's  "man  in  the  box"  broke  up  more 
nttrogi-n  mmiionnds  during  mental  than  (hiring  mrchantL-al  work. 
This  breaking  up  of  nitrogi'n  ctrtnpounds  is,  liowever,  only  one  furui 
of  registeruig  the  energj-  output. 


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'I'lmt  whifh  characterizes  a  well-adjusted  nervnus  meehaniion 
ability  to  pro|.>erly  and  in  an  orderly  niamier  distribute  its  rn^ 
but  that  which  charaftcrizes  the  pictures  of  the  disorders  iiiclud 
ill  this  clmptcr  is  iiiffliripncy  in  this  rej^urd  \v}iirh  may  bo  iiiurt*  e^ 
cially  emphasized  at  the  physieoehciiiical,  the  vital,  or  the  ps£d 
levels.  II 

An  explanation  for  epileptic  attacks  which  finds  its  ultimate  ex^ 
siou  under  such  sjinbols  as  eye-strain.  Hurttinjr  kidney,  gliosis,  or  U 


Fro.  3>4$. — Otote  anatomical  Iwono  nseociated   uilb   i-piU-|H>y.     An  aitynnncl 
{nt«nin]  lg>-dn>ce|]hfkluB  whjili  bLm  ohawcd  «  «intll  tumor  at  the  Utcnl  bordvr  of  |j 

Mfebdluni.  ,^M 


Specific  indictments  fails  to  realize  that  the  nervous  system  eontiui 
rcpresentaticMis  of  all  of  the  or^ns  and  that  the  final  activity  of  tl 
human  body  is  the  result  of  the  balance  which  luis  been  stniek  amoE 
innumerable  tendencies.  The  part  that  any  particular  or^n  pUj 
can  only  be  understoiHl  when  taken  in  (runsideratlon  with  the  orgaiua 
m  its  totality  ami  realizing  the  spec-ific  part  that  the  organ  in  questk 
phiys  in  the  whole  problem. 

Bearing  in  mind  this  view  of  the  nervous  system,  as  a  great  i 
Ci>niplexly  interrelated  reflexes,  and  further,  the  law  of  avi 


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BPtLBPSY  AyD  CONVULSIVE  TYPES  OF  REACTION      789 

(Cnjal)  which  insures  the  continuous  breaking  up  of  the  oriRina! 
sensory  stimulus  into  an  ever-increasing  mimlx^r  of  nvenues  of  dis- 
chnrgft,  it  will  Ije  seen  how  many  ways  are  oiK'n  to  interfm'  with  tlie 
ortlerli,'  procession  of  energy  througli  this  coniplieated  scries  of  reflex 
ares.  Tlie  nature  of  the  epileptic  (liscliarjte,  essentially  a  manifesta- 
tion of  energy  at  greatly  reduceil  a<laptivc  ctfidenry.  and  the  destruc- 
tive character  of  certain  pathological  lesions  which  initiate  it  (impaired 
metabolism,  grosa  destnictions,  psychic  imbalam-es)  indicates  that  the 


F»o.  SiiO. — Gro*i  Kimtomlr'al  IcsionH  a-*>i-iatoil  with  ci>i)*'i»«>'-  Cwrebnil  Hsymmctry 
nnd  vcaUinilnr  <lUat»tiuD  fullQwinii  »ii  curly  mumncitia-  Tlie  dunv  over  tbu  aUoptuc 
heintaptutr*  wM  of  the  cnruulcruw  of  an  cgi;-ahoU.    BecUoo  of  preMdicK  bnin. 

esscutiul  defect  is  not  irritant  but  destrnirtive,  the  blocking  or  closing 
of  many  paths  of  outlet  structurally  or  by  iuliibition,  and  so  accu- 
mulating the  discharge  mthin  relatively  narrow  confines.  Such  a 
conception  would  apply  equally  well  to  the  "idiopathic"  or  "genuine 
epilepsy"  with  Ammo;i'8  horn  gliosis  and  to  the  epilepsy  associated 
with  niarkrd  developmental  defects  (idioi.y}  in  which  it  may  lie  con- 
ceive<l  that  the  wider  paths  for  avalanche  ilisehargr  liave  not  been  laid 
down.  ITiis  vicw-iHiint  is  aW>  ronsistt-nt  witli  tlie  dilferi-nt  levels 
at  whicli  the  discharge  may  take  place    psychic,  physiological,  and 


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790       BPIKEPSY  AND  CONVmsn^  TYPES  OP  REACTIOK 

physiforhemical — the  chururter  of  the  attack  as  limiteil  to  wrtain 
Ifvels,  lilt'   iwyeliif   (liystt'ria,   dfiiiciitia   pnt'ox),   tlir    jiIi>sio]i>>,n)3 
(Jacksonian  types),  the  phyaicwhenucal  (tetany);  the  distribution 
the  discharge,  (feneral  attacks  {"genuine  epilepsy"),  loealizcci  att 
(Jaeksoiiian  tyjjes),  and  as  Iwing  iiiltiatei)  by  s»'ns<(ry,  iiuitor, 
psychic  prodromes.' 

STmptom  Groups. — OmvuIsionM  may  neeur,  aft  already  indicated.  \i 
a  ureat  variety  of  cDnditiuns  while  distinctly  explosive  Jitt«rks  nc 
fonvulsive  in  the  sense  of  miiseulnr  sjuisnis,  oreur  under  still  u-ider 
conditions  In  states  not  definitely  epileptic  but,  with  irfercnee  to  tl 
more  essential  epilepsies,  in  what  may  be  refcrretl  to  us  borderlanc 
conditions. 


I'ju.  a90. — Grow  atuiloniii-*]  leaiouo  Havocjaited  v'wh  tpiltji^y:     Tuiiiur. 


The  essentia)  epilepsies  have  been  divide<l  into  the  late  epilepries 
occurring  relatively  late  in  life  and  dependent  upon  toxemiJis  and 
p'oss  or^nic  changes  and  the  earltf  epilep»inf  which  occur  relatively^ 
early  in  life,  jcencrally  before  or  during  adolescence.  H 

Kj>i}ei>jt\es  oj  Gross  Hrain  Disease.— 'Vhcm;  i>ecur  in  pam*Us.  cerebral 
syphilis,  brain  cysts  (echinrtcocrus,  etc.),  hyihvicephalus,  the  ccrebnil 
meningitides  (syphilitic,  tuliereuloua,  serous,  and  itaehynieniiigitis) 
bony  tumor  of  skull,  traumatisms  (fractures,  insolation,  cuueussions»' 


>  Fur  literature  fnim  190(1  to  1910  see  Hctemte  liy  (Iruhlc. 
N«arol.  u.  ^rb.,  Bftnd  ii,  Boft  I.    BtitAWAn««r:  Epilopnle. 


ZtBTbr.    r.   d.    KRKtBlB 


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SYMPTOAf  OnOVPS^ 


791 


heinorrliapwi),  multipte  sclerosif*.  cerpbr.il  sclerosis  a\v\  gliosis,  cerebral 
nrterioscleriisis,  the  enfeplialilidt-s  and  myot'loiiias. 

Thf  Ej/ilcjKtirjt  trj  Tiu-if  nml  iufvclioun  Origin. — The  toxemias  include 
tliost'  of  t'rulujfi'nous  ciriKiii  (uremia,  fliabetes).  uf  ex<ij,THuiis  oripii 
tiui'lallic— such  as  Ica<I  and  arsenic,  aud  strychnine,  alcohul.  and  carbnji 
monoxide). 


Via.  391. — Gross  aontcmiciU  ktHni^  nw^-iatcd  'nitli  rjiilepsy.    lau-rna)  hydrocvplwluSi 
Marked  fwblc^-niiiidniliicH. 

The  infections  arc  more  especially  the  exanthemata,  influeaja, 
rabies,  malaria,  rheumatism,  syphilis,  etc.,  oi)erating  either  through 
the  mechanLsm  ttf  an  nverwhelniiiig  toxemia  or  by  mcninjcitides  or 
encepiia  11  tides. 

Anoin(thii.t  and  Hordfriand  Conditiom. — Here  are  included  certain 
internal  .secretory  imbalances,  particularly  diseases  of  the  thymus, 
thyrnid.   and   paratliVToitis   an<^l   depMHTatii)-)uliiM>sn->:eiiitaIis. 

Certain  high  level  attacks  <M:t;ur  in  hy.steriti,  compulsion  nn<l  anxiety 
neuroses,  and  in  dementia  precox,  esix-eially  the  eatHtoiiic  fonn. 


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Here  also shouIH  U-  iinhulcd  tiie  vagiil'  and  vjwi>vaRaI  attacks,  siifrhl 
pssHitig  (listurlNim*s  of  (-i>n*ciou9iies3  assocuiteti  with  vertign  ami 
sometunes  scnsi>ry  disorders  as  loss  of  sifiht,  possibly  ferlAJn  sctisijr\' 
disorders  of  fulmiimting  rliarat-ter  such  hs  migraine,  and  some  distwlt- 

aiK-es  of  slwi)  (imroulcpsy)  dLv 


tiirbaiicTS  itf  ct»ns<-ioiisness  of 
syncopal  nature,  and  the  affet't 
epilepsies  of  the  Bratz  type. 

Convulsive  attacks  may  W 
conibintil  witli  a  luunber  uf  con- 
ditions, 'Hie  as.irx:iation  erf 
myoclonia  is  one  of  the  most 
ititiiuate  myorUmxts  rpUrfutf. 
Thb  combination  is  fainilial. 
several  children  of  the  same 
laniiily  suJferiug  anil  sometimes 
sueeessive  generations  bein^  af- 
fected. Here  are  epilcpiifumi 
nttacks.  particularly  at  night, 
find  inyocionici-onlraclioiisiaffeet- 
iritf  especially  tlie  muscles  of  the 
tunpue.  pharynx,  and  diaphragm. 
The  n-Iation  of  the  two  symptom 
gnmps  is  lint  clear. 

Patliologlcal  Groups. — The  pre- 
ce<l ing  clinical  grouping  givesa  fair 
idcji  of  the  pathological  conditions  whicli  nuiy  be  found.  The  Hdlonnng 
(rrouping  is  ^;iven  by  Al/heimer  as  ii  result  of  the  hisiologiciil  examina- 
tions of  0;i  cases.  These  sini|)!y  indicaie  the  reasons  why  and  how  the 
structure  of  the  hrain  is  mutlilietl,  thus  changing  its  functiornil  capacity 
as  an  energy  distributor. 

A.  Cases  with  very  obscure  etiology  (genuine  cpile|wy): 

1.  This  group  comprises  t>0  per  crnt.  of  the  cases: 
(u)  With  sclerotic  changes  in  .Ajnmon's  horn. 
(fr)  With  superficial  gliiwis  of  the  hemispheres, 
(e)  With  signs  of  an  acute  process  (status)   besides 
(uid  h. 

B,  Cases  due  to  exlenial  poisons: 

1.  Alcohol;  Ilifferent  nnatomieal  changes,  as  in  ehronie  aico-' 

holism.     Besides  these  sometimes  acute  changes,  as 
delirium. 

2.  Lead:  Dtft'erent  changes,     Kxperi mentally  lead  ptxxluccs 

a  gi^nuine  eneeplialltis. 


fill.  :r.^L' — Kiiii.-jifi.  ,    -lii>iniii4    s^**'""? 
L>-L'lin*wa  (ruin  fiJls. 


I 


>  Wm.  R.  Gowen:     Tlw  Bonlurlacid  of  Ei>iloiwy,  PhUudelphia,  1007. 
*  AlBheJiuer   an<l    Voxl:     Diu    GruiiiiiGniiiK   dor  KpilviMiir.  JaltrMVeiwoimlnnc    dw 
d«)ilt*rhon  Vfroins  far  INyrhintrie,  lUUT;  fU(.  Allg.  Ztitchr.  f.  Psjreh.,  Bftlld  Ulv.  1V07. 


IV,   iwr.      ^m 


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CLASSICAL  EPILEPSY 


m 


C.  GeiuTal  clLseases: 

1.  S>T>hiIis:  Different  fimns  of  hrain  s\7>hilis.  especially  the 
endarteritis  of  the  finer  VKsels  (NissI,  Alzheimer). 

2.  Arteriost-Ierosia. 

D.  Foeal  diseases:  Most  of  the  cases  in  this  group  are  cases  of 
epilepsy  with  idiocy  after  encephalitis. 

/•',  Arri'sts  of  lievi-lupiiieiit: 

1.  titudimii  venuwKftim  (Ilanckc). 

2.  Sclerosis  tulH-*rosa. 
This  siir\ey  will  suffice  to  show  what  a  wide  variety  of  conditions 

Ihave  \y^ii  iiii-lndi-^j  ucider  the  term  e])i1e}).\v  and  aUo  tii  ]H>iiit  out  the 
pvarioiis  groups  that  are  being  at  present  .split  off  atid  separately  ideii- 


Pki.  393. — Epilvptic.  showioK  1^ 


litllC  CtllU'ulfiiOD. 


tifieil.  Wliat  has  been  said  about  the  distribution  of  energy  applies 
to  the  bnjad  group  of  convulsive  reacliotis.  Tlie  disease  "  geninne  epi- 
lepsy" wilt  now  be  briefly  described,  althouph  it  is  cxtr<'mely  difficult 
to  do  this  at  all  aceuriitely  a.s  it  niu.'it  Im-  borne  in  mimi  thsit  hereto- 
fore all  matters  of  description  and  questions,  such  as  those  of  hertnlity, 
are  with  ])ractical  uniformity  considered  nnth  reference  to  "epilepsy," 
without  effort  jit  dL'icriinination,  much  as  is  the  ca.se  with  the  corre- 
sponding conglomerate  "insanity." 

CLASSICAL  EPILEPSY. 

This   roughly   corresponds  to   the   group   "genuine  epilepsy"   of 
Alzheimer  and  includes  those  cases  which  are  found  to  have  .\intnoii*s 


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h3 


horn  and  cortical  sflerosis  ultlumgh  there  arc  c»ses  of  "gcuilfl 
lepsy''  which  ihi  nut  give  these  fiiKlings.  ™ 

Heredity. — The  genuine  epileptic  usually  comes  from  a  I 
tainted  stock.  Epik-psy  may  not  appear  in  the  ancestors  hut 
aiitl  often  the  collaterals  show  evidences  of  il]-<lefine<I  nervous  diao 
(according  to  Oavenport  and  Weeks.'  migraine,  ehorca,  ptiralx'^ 
extreme  nervoitsiiess).  Kpik^psy  and  feeble-mi ndedness  show  fl 
.siiiiiUirity  in  their  hereditary  reactions  and  hoth  oppeap  to  Ik*  ih 
a  defect  of  the  germ  plasm,  that  is,  they  are  hoth  recessives. 
should  be  expected,  therefore,  the  two  ainditions  are  U 
found  as3ociatc<l.  This  is  ah»o  of  significance  in  relation 
has  already  been  said  about  the  developmental  failure  to  lay 
paths  for  the  higher  avenues  of  sensor>'  avalanche. 

The  Epileptic  Constitution. ^'hi-  classical  epileptic  is  apt  to  be  inar 
irritaltle,  sus])ici«iu\,  mid  hyinK'hondrineal.  He  is  quite  charac 
istinilly  unrelialilc  am)  with  it  ail  frequently  presents  a  very  a^gres! 
forni  of  seiitiuicntal,  slmliow  religiosity.  This  tj-pe  of  epileptic, 
general  then,  is  very  sensitive,  irritable  and  insincere.  lie  is  e 
centric  to  a  very  considerable  degree,  jiaying  great  attention  to  hi 
self,  his  own  feelings,  his  state  of  health,  his  physical  comforts,  and 
nnmediate  surroundings.  Itis  interests  are  variable  and  be  preae 
light  variations  nf  mood  with  f>crhaijs  headache  and  a  tendei 
generally  to  In-pochondriacal  fixations.  His  interests  all  tend  to 
wiiiccntrated  in  this  egocentric  constellation.  His  reactions  of  ii 
tability  and  unreasonableness  present  infantile  cliaracterislics.  Mi 
epileptics  arc  feeble-minded  or  more  profoundly  defective,  and  rati 
in  conformity  with  this  frequent  finding  the  won!  associations  fn 
epileptics  have  close  analogies  to  the  word  associations  of  the  imbetr 
III  additio[i  tn  tlicst'  tnilts  of  character  these  epileptics  are  usiM 
lazy,  fretpieiitly  they  lie  openly,  present  an  attitmlc  based  on  hi 
moral  standanls  of  great  respect  and  consideration  to  one's  face  a 
quite  the  opposite  when  one's  back  is  turned.  Their  general  hea 
is  apt  to  be  g(W)d  and  they  often  have  enormous  api>etite,s.  and  i 
especially  fond  of  pmteids.  While  good-natured,  even-lemi>er 
well-disposed  epileptics  exist  they  are  more  apt  to  be  most  diflie 
problems  to  gt-t  along  with,  ami  as  a  class  in  the  hospital  they  . 
extremely  difficult  to  care  for.  Passhig  attacks  of  mental  disturlwj 
occur  in  the  iuterparoxysnial  ixriod  without  nppjirent  relation 
seizures.  Attacks  of  transitory  ili-hiimor,  according  to  Ascbatfenbc 
occur  in  78  per  cent,  of  cases.  This  is  a  condition  of  irritabili 
unreas(nmb!encss,  sumetimes  as-sociated  with  delusions  am)  halhiri 
tions,  The  patient  is  in  a  "touch-mc-not"  state  and  very  apt  to 
into  quarrels  or  make  attacks.  Rarely  the  disturbance  is  expana 
in  type  and  in  these  cases  may  be  associate*!  with  rtOigious  fervor. 


■  A  Firat  BtiLfly  of  lahirritanec  in  Epilepsy,  Journal  of  N«rvoua  nud 
Vill.  vol.  xxxviii,  Nn.  11. 


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ClASfirCAL  EPILEPSY 


796 


study  of  tlie  sexttal  cImrHCtfristics  of  epileptics  has  nwi'iitl.v  Itcen 
miitle  by  ^^^^e«l<'^.'  As  a  a'siilt,  Ik'  fitwls  tht*  sexuality  of  tliu  c|ii!('plii_' 
still  larj;t'ly  uiidevelo]H.Hl.  still  only  link'  n-uioved  from  tht  itil'antilc 
;  stage.  The  sexual  feellnfjs  are  very  prominent  ami  are  aroused  in 
[many  ways:  autoyenieally.  eoiistitutinR  auU'-en)ti.vri,  and  pviiijj  rise 
to  such  phenomena  a.s  masturbation,  and  by  stimuli  from  wiiliout, 
constituting  allo-enttijtm,  which  givL>s  rise  to  a  normal  libido  (bptt-ro- 
sexuality),  homosexuality,  exhibitionisnt,  etc.  MaeHer  uses  the  tenn 
p:iilfmh-ni  to  describe  this  characteristic  of  the  epileptic  sexuality  which 
pennits  It  to  be  arouse<l  by  niuuy  kinds  of  excitants. 

The  epileptic  state  leads  tn  a  certain  proportion  of  cases,  if  it  has 
begun  in  early  life,  to  conditions  of  feeble-mindedness,  hnbecility.  and 
idiocy,  or,  dependiujr  upon  the  same  causes,  is  associated  with  these 
conditions.  Kpilepsy  tends,  in  many  ca.'^es,  to  produce  a  general  nienlul 
deterioration  {epileptir  dfmentia]  which  may  become  ver\*  profouml. 

A  recent  study  of  the  personality  of  epileptics  by  Clark'  has  led  hiin 
to  the  conclusion  llmt  tliis  j^encral  type  of  character  as  descrilM'<i  above 
is  a  result  of  the  disease  and  not  ii  precedent  condition. 

Scripture  and  Clark'  have  descritH-d  the  epileptic  voice  sign  and  ff)imd 
it  in  75  ]Kr  cent,  of  cases.  The  voice  has  been  studied  by  the  "air 
puff"  method  of  recording  on  tlie  kymograph.  A  measurt*  of  the  wave 
gives  the  rales  of  vibration.  .\  line  connecting  tlic  tops  of  the  ordinates 
produces  the  "melody  plot."  Nonnally  each  vowel  has  a  rising  and 
falling  melody.  In  epileiwy  the  vowels  run  along  on  an  even  tone — 
"plateau  speech."    This  is  very  characteristic  antl  easily  recognized. 

Muskens,  in  hi.'?  study  of  the  muscular  phenomena,  has  foumi 
fatigability  and  weakness  of  single  iiuiscles  or  muscle  groups,  startings, 
slioeks  and  eranip-like  contractions  esiM-cially  just  before  or  after  going 
to  sleep.  All  sorts  of  phy^^ical  distiu-bances  may  be  associated  with 
the  epileptic  state  which,  like  the  character,  show  infantile  chanicter- 
istics.  Epileptic-s  get  along  best  under  very  cari'fully  protected 
cin-unistances  and  they  are  especially  prone  to  suffer  from  a  change  in 
tlie  accustomed  routine,  a  change  of  diet  bt-ing  accompanied  by  excesses 
and  a  subsequent  gastro-intestinal  upset.'  As  the  disease  progresses 
and  l>ecomes  chronic  and  confirmed  one  will  note  many  evidences  of 
disturbance  at  the  vegetative  nervous  level. 

The  Seisure.— The  cla.isicnl  nvajor  epileptic  attack  (grand  mal)  is 
sudden  in  otLset.  often  i>receded  by  a  warning — aura.  The  patient 
falls  and  the  atta<-k  immediately  develops  into  a  tonic  spa.sni  witli 
uncoiisciousnes-s.  The  tonicity  is  repla<.'ed  in  a  few  moments  by  clonic 
spasms  which  gradually  subside.    There  is  then  often  a  short  pcrio<l 

I  SexuiiliUll  uiid  Kiiilcpdu*,  Jnhrb.  f.  [wyvhosiulyturlio  u.  jisyrhopatliolrtgisrbe  Fon- 
cfaiinacD.  1600. 

*  A  Pcrwm&litr  Htudy  at  Ihe  Einloptic  ConsUtution,  Am.  Jcnir.  Med.  6c.,  Novomber, 
1014. 

■  RmmkJiosod  Uie  Etnlvptji-  V»ifr.  Vtvc.  Now  York  NoumE.  Soc..  Novcmbvr  I'i.  1007. 

*  MiwCurdy,  John  T.:  A  Clinical  Sturly  o(  Epil«[>tEr^  tlotcrtoraiiofi,  PiQ-chiiiirio 
BuUvtin,  Apnl,   l«10,  \x.  No.  2. 


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796      BPILBPSY  ASD  COSWISITB  TYPES  OF  ttEACTIOS 

of  automatic  ftctivity  followed  by  a  gT'i'ltial  return  to  full  conxia 
ncss.  nr  tlif  putlcnt  sinks  fit  onrc  Into  a  Ht^ii  sleep  fr«»m   u'hieh  he 
au'akes  (iHiifiiiiiiiinp  of  latiK-iit'ss  and  wwikni-jw  in  the  niiisc-jcs  thai 
were  convulsed,  and  perha]»s  headache. 

Tin.'  attack  lias  been  descrilxnl  by  authors  in  (frcat  fletnil.  but  is 
really  (lilFerent  in  pim-tically  each  case,  altliough  the  tyjK'  tends  to 
remain  the  same  in  each  pjitient. 

The  omn  may  l>e  sensory,  motor,  or  psyrfiic.  The  sensory  wamioj^s 
may  iK-cur  in  any  of  the  sensor>'  fields:  the  visual  (flashes  of  light, 
hallucinHtioiLs).  the  olfartory  (wlors,  usually  \im\ — uncinate  fits),  ihr* 
auditory  (sunpie  sounds  or  hallucinatory  voiees).  etc.  The  epigustrir 
auru  i-i  most  comuioii  and  consists  of  a  wide  variety  of  dtsaj^rfCttUr 
sensations  in  the  epigastrium. 

The  muscles  first  involvetj  vary  (rrcatiy,  as  diycA  also  the  orcicr  in 
which  they  ait*  in^■olved — marcii  of  the  convulsion.    The  patient  falU 
at  the  beginninE  of  the  spasm,  the  direction  of  the  fall  brin^  dei)eruiont 
upon  the  muscles  (irst  aHVctinl.    In  a  few  moments  all  of  the  voluntaiy 
muscles  an'  convulsed,  including  the  innsi'les  iif  respiration,  jinMluciii^ 
cyanosis,  and  the  jaw  musicles,  resulting  in  biting  the  to?igue.     With 
tJie  iM-jiiiinitij:  of  the  clonic  s  a^f  Trothy,  bliMwly  saliva  issues  fn»ra  the 
mouth  and  the  cyanosis  gradually  disapix'ars  with  the  resumption  of 
respiration.    IViiK'  and  feces  may  Im-  pussetl  durin^t  the  attiiek — usually 
oidy  the  former.    In  the  partial  or  incomplete  .'Seizures -petit  mal — tlw 
convulsive  phenomena  are  mucli  milder  and  may  even  escajie  obs»*rv8- 
tiiiTi  BituKi'tlicr.  while  the  disturbuntf  of  consciousness  is  shorter  in 
(hinitifMi  and  less  profound.    The  patient  may  hiancli.  lte<*ome  etinfuse»l 
for  a  few  moments,  perhaps  falter  in  what  he  is  doing,  or  fumble  for  a 
few  moments  about  his  clothing  ia  a  du'/ed  fashion  and  then  gu  on 
about  his  affairs  as  if  nothing  had  happened.    These  attacks  are  also 
often  preceded  by  an  aura. 

The  psychic  disturl>antrs  associated  with  the  attack,  before  nnd 
after,  or  replacing  it  are  many  and  varied.  fl 

In  a  greiit  uiaiiy  epileptics  there  is  a  marked  dLstmbaiuv  pretttling-™ 
tlic  convulsion,  sometimes  of  several  days'  fluralion,  and  tluis*'  who  arc 
Bwmstonied  to  the  patient  can  tell  that  a  fit  is  irn[K'nding.   This  clmu 
miinifest-s  itself  in  increased  irritability,  complaining,  si»ii)etinies  b; 
depression  or  dulness,  and  there  may  be  as.sociate4l  disturbances  of  th 
sensorium,  hypcK'hondriacal  complaints  and  halluoinatiotis.    All  t 
conditions  arc  commonly  promptly  relieved  by  the  fit. 

Immwiiately  after  the  a)ii\"utsion  there  is  often  a  teniponiry  condi- 
tion of  confusion.    The  patient  rises  clumsily,  looks  abciut  him  in  a 
bewildered  manner  and  often  does  some  semi -automatic  acts,  sue 
as  taking  off  his  clothes.     Also  following  the  attack  a  traiuitor} 
exhaustion  paralysis  in  the  overacting  mii-scles  makes  itself  appurcnr 

Jyist  befnn*,  or  nmrt^  commiHily  after,  the  convulsion  a  cotidition  of 
active  excitement  may  uctur  which  may  rear-h  the  stage  of  frenzy. 
In  this  state  the  patient  is  a  veritable  wild  man— fpilrpiic  furor.    He 


I 


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CLAHftTCAL  EPILEPSY 


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is  liable  to  kill  anyone  wlio  approaches  or  even  himself.  Fortunately 
his  effurts  are  diffuse  ami  not  eolierently  ilirifted.  During  this  attack, 
which  is  usually  hrief,  he  has  to  be  restraint'tl  and  at  tlic  end  i.s  ijuite 
eompletely  exhausted. 

An  attack  of  mental  di.stnrl>ance  may  take  the  plaee  of  the  convulsion 
and  thus  Iiecome  an  rpileptic  equitaleitt.  These  attaeks  nf  jiitifrhir 
f-pUrimf  frHjuently  take  the  form  of  so-tidted  pjtHfjiiie  nnUniintittu  or 
epileptic  dream  statct.  In  these  conditions  the  patient  may  do  ahnost 
anything  and  when  he  eumes  to  himself  lie  has  absolutely  no  recollec- 
tion of  what  has  happened.  Usually  the  attacks  are  of  short  duration 
and  the  acts  rather  simple— more  simple  than  in  the  dream  states  of 
alcohol  or  hysteria.  However,  they  may  last  for  days,  all  sorts  of 
thinj^s  may  be  done,  crimes  may  even  be  eommitteil,  so  that  the  con- 
dition often  becomes  of  great  meilicolegal  importnoLV.  llie  crimes  of 
violence  are  often  noted  for  their  ferocity  and  brutality. 

It  must  not  be  forifotten  that  these  states  may  be  associated  with  a 
seizure  that  was  so  slight  as  not  to  have  Ik-cu  nntienl.  Kvldencc^s  of 
such  a  seizure,  especially  in  medicolegal  cases,  should  always  be 
looked  for. 

Transitory  condltioas  of  deprcMion,  erritement.  nuifum'm,  (Mirivm, 
and  ntujmr  may  develop  and  quite  characteristically  n  <i>Mdition  of 
tr.itasri  with  hallnciiiiitiutis.  'J'hc  patient  sees  the  fjatcs  nf  Heaven  o|x.'U 
atui  us  the  heavenly  hosts  upi>ear  he  licars  himself  addressed  by  the 
voice  of  God. 

The  tran-siforj'  states  of  ill-humor,  as  described  by  A.^haf?enberR 
in  tile  iiiterpantxj-smal  state,  miftht  also  be  considered  as  psychic 
equivalents;  these  are  frefjnently  associated  with  drinking;. 

Besides  these  conditions,  jiarattnid  pitt/rhic  xUiU\h  are  cpiilc  common, 
while  of  the  more  transitory  psychic  manifestations /»^»f*  arc  fri'qucnt 
and  cvrlaiu  types  of  /lifunmniniii  a[)|K-ar. 

In  atldition  to  the  symptoms  thus  far  indicated  various  observers 
have  fouiui  evi<lences  of  ati  altered  bloml  picture  such  ;is  lenkoc.vtosi.s 
and  h^po-eosinophilia,  while  disorders  of  melflholism  with  hv-per- 
trtxicity  of  the  secTctioiLs,  has  long  been  adduced  a.s  proof  that  the 
iiiunifestatioiis  were  dependent  upon  chemical  poisons  due  to  faulty 
metabolism. 

}fmTiijig  of  Iki'  AttaH;. — Hcnring  in  mind  what  lias  u]r(,'ady  been  said 
alnrnt  the  distribution  of  encrgj' ,  it  will  be  of  advantage  to  pursue  this 
line  of  thought  somewhat  further. 

Kncrgj-  flow  may  be  blocked,  dammed  up,  and  break  ihntugli  in 
ditfuse  discharge  at  any  level — psychic,  sensorimotor,  or  physico- 
chemical.  This  Wing  so  it  would  be  expected,  as  is  the  cjise,  as  already 
itKlicateil.  to  find  di.sturl>Hnccs  at  each  of  these  levels.  In  the  classinil 
epileptic  attack  all  these  levels  arc  involved,  but  what  is  of  equal  or 
greater  signitiamce  to  the  gt'oeml  hypothet^is  is  tlml  there  are  atta<'ks 
^^  practically  limited  to  one  level,  and  u  study  of  the  s*;veral  tyi)es  of 
^B  con^nilsive  reaction  will  show  a  series  of  cases  reaching  through  all 


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of  the  intermediate  stages  from  tiie  higliest  to  the  lowiest  instil 
levels. 

The  hysterical  convulsion  oflfers  an  example  of  a  high  level 
aive  tv^M!  of  rcactinn.  This  seizure  is  odmittwHy  psychojceiiic  ill  or 
and  pre^wnts  tlie  picture  of  a  conversion  of  psychological  into  phy 
logical  .symbols.  In  other  wools,  the  patient  escapes  from  hi-s  paii 
ideas  by  converting:  them  into  pliysical  s\nnptoms.    (See  Hysteria, 

The  disturbance  of  consciousne.ss  in  these  hysterical  attacks 
relatively  slight,  much  less  than  it  outwardly  appears  to  he,  while  1 
whole  situation  is  quite  near  the  surface  and  with  very  little  dk 
can  Ije  brought  to  coascious  control.  V 

Next  lower  in  the  scale  of  levels  arc  the  psych  asthenic  convubn: 
of  Oppcnheim  (compulsion  neurosis  tj^w)  which  arc  expressions  oj 
more  se>'cre  Rradc  of  neurosis  but  still  within  strictly  psycho!ogi( 
levels. 

Then  come  the  ver>'  interesting  alTeel  epilepsies  of  Drata  and  Le 
busrher.  These  are  distinctly  epileptoid  types  of  reaction  condition 
by  purely  psychological  situations.  Here  the  outwanl  seniblance 
B  deeper  level  epilepsy  is  much  greater  but  the  situation  is  still 
psydiological  one.  The  reaction  ()f  the  |>utieiit  lierc  is  to  conditio 
that  are  absoUitely  intolerable  and  to  which  no  adjustment  is  possibi 
such  a  KJtuntinn.  for  example,  as  a  yomig  man  has  to  4'onfront  when  tl 
key  is  tiirnetl  \\\nin  hiui  and  he  Is  called  upon  to  realize  that  he  is 
prison  with  a  life  sentence  to  face.  I'nder  these  circumstances  tj 
patfent  nia\'  bectvmc  a  veritable  "wiKI  man,"  l>eat  his  clcni'he*!  fis 
against  the  bars,  rush  aimlessly  uImhiI  destroying  clothes  ami  be<Miii 
and  beat  his  hea<l  against  the  walls  io  ineffectual  attempts  at  >cl 
riestnirtion.  Hallucinatory  disturbances  nm>"  accompany  these  attacl 
and  amnesia  follow  them,  though  conscioatness  dunng  the  attack 
not  entirely  Inst.  That  these  patients  are  much  more  seriously  bu 
denwl  coiistitutiunally  and  mure  nearly  allie«l  to  "genuine  epilepsj 
than  the  psychasthenic  types  of  Ojipenheim  is  indicated  by  the  fa 
that  ihey  give  a  history  of  "'fits"  in  childliuoti  while  the  psychast 
tj-pes  show  tics,  phobias,  and  conipuIsioTts,' 

In  the  ciassiral  epileptic  sciziur  the  greater  severity  and  seriousne 
of  the  attack  is  indicated  by  the  complete  loss  of  consciousness  and  tl 
still  further  rerluction  in  the  purposeful  and  coordinated  adjustmej 
of  the  muscular  reaetions.  Thcw"  have  now  Ix^eome  utterly  rlisorgai 
ized.  The  attack  has  involvt-rl  far  more  than  the  psychological  levc 
and  included  the  scnsoriniolor  and,  as  indicated  by  the  toxicity  < 
the  excretions,  the  biocbeinicid. 

The  low  instinctive  level  to  which  the  epileptic  is  reduced  by  h 
seizure  can  l>e  appreciated  by  observing  his  activities  as  he  is  "comii 
out"  of  the  attack.  His  respiration  is  at  first  <listinctly  lUtdomia 
(infantile  type),  he  makes  chnraeteristic  sucking  movements 

■  See  Gnlsworthy's  drama.  Justice. 


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lips,  and  his  movements,  from  the  complete  dis(»rganiztition  into  which 

huvt'  Iktii  thrown,  assume  at  first  an  nimk-ss  fmiiblhi^  with  his 

lothcs,  a  tentative  feeHng  about  as  lie  nistinetively  tries  to  readjust 

limsclf  to  rcfllity.  to  "find  himself"  a^iii.    In  this  tentative  "feeling 

'about"  he  rei>eats  in  a  few  minutes  the  process  of  relating  himself  to 

reality  which  is  a  normal  period  of  development  in  the  child. 

ft      Kcri'iiczi'  has  endfavored  to  clas-sify  the  neun)Bes  with  reference  to 

Ktlie  stage  of  development  they  represent  and  in  accordance  witli  thw 

Hscheme  suggests  that  epilepsy  belongs  to  the  period  of  wlsh-fulfilnient 

by  means  of  incoonlinatc  movements.    It  is  known  how  stHiic  children 

when  thwarted  will  cry  <nit.  thructh  al««it  and  sometimes  stndphtfn 

out  rigidly,  "  lose  their  breath"  and  be«)mc  blue.    Attacks  of  "  temiM.'r'* 

»thc  mother  calls  them.  Later  on  the  child  will  kick  the  chairs  and  tear 
up  its  books  under  similar  circumstances  while  regres.'iion  to  approxi- 
mately the  same  level  is  shown  when  an  adult  stamps  his  foot,  clenches 
his  fists,  grinds  his  teeth,  and  otherwise  shows  reactions  of  anger  which 

tan-  (|uitc  iiietTci-tnal  to  ellect  any  change  whatever  in  conditions.  The 
meaning  of  it  all  is  an  absolute  inability  to  accept  or  to  adjust  and  an 
equally  determined  attitude  that  it  is  iwt  so  because  it  just  cantwl  be 
so.  An  effort  lo  fonr  I'ircLiuistanees  to  Ik-  different  by  a  supreme  effort 
of  thinking  them  different  which  when  it  fails  results  In  a,  flight  from 
the  whole  thing  into  the  rigidity  and  unconsciousness  of  the  epileptic 
scizun*. 

The  extreme  egoeentricitj'  of  the  epileptic,  his  great  failure  to  project 
his  interests  into  the  outer  world,  his  tendency,  therefore,  tc>  retreat 
further  and  further  from  reality  and  to  revive  earlier  way^  uf  finding 
pleasure  result  in  &  profouml  regression,  which,  in  the  unc<iiiSfioustM?ss 
of  the  fit.  repHMJows  the  helplessness  of  the  child  in  niero  and  deniaiids 
the  same  degree  of  ahsohitely  <-omplete  care.  Clark,  who  calls  thiti  a 
state  of  metn>-criitisni,  has  brought  for^vjinl  an  abnndiuur  of  material' 
to  demonstrate  that  ihe  fit  has  a  psyelndogical  setting. 

As  bearing  upon  the  importance  of  tlie  psychic  element  it  is  surprising 
to  note  how,  as  a  result  of  acute  questioning  in  intelligent  subjects, 
it  may  very  frequently  be  demonstrated  that  a  particular  fit  served 
the  i»nrpnse  of  the  patient  in  some  way,  by  enabling  him  to  escaije 
from  sonte  respniusibility,  avoid  some  nece,ssity  /or  adaptation.  The 
way  in  which  this  is  done,  by  a  return  to  a  condition  demanding  the 
sort  of  care  which  a  mother  gives  her  I>aby,  and  the  assuuiptiun  of  the 
characteristics  of  infancy,  Tlark*  illustrates  by  abundant  nuiterial,  as 
for  example:  talking  baby  talk,  assumption  of  the  fetal  positicm, 
covering  the  head  with  the  bedclothes,  passing  of  urine  during  the 
attnek,  are  infantile  types  of  conduct. 

■  EiitwifkltinsMluhii  dm  WirklichkciUMiinnoii,  IntrnuiUonalo  Zlerlir.  f.  Aentliche 
p!>yrho.itMl}-«(>,  |DI3,  i. 

'  ( 'lurk,  L..  P.:  CUoicitl  SiutUm  in  £yil«v"T>  I^chiaUio  BuUotin,  Jnniutry  RDd  AprQ, 
101&.  is.  Nus.  I  and  2. 

*  Loo.  dt. 


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In  tlie  cimr»e  of  the  introversion  of  the  libido,  until  the  fit  occurs, 
Clark,  ill  a  nxriit  chiirt  for  uraphie  rcwrtiiiiK  of  tlie  epileptic  reactioiis 
sugjfcsts  ttint  the  degrees  of  rejjre.ssion  are  indieatc<l  as  foUows:  spon- 
tai»eous  interest,  directed  interest,  letharuj-,  irritation,  anger,  elation, 
psychic  phenomena,  petit  mal,  grand  mal. 

ITiis  way  of  viewing  the  epileptic  attack  is  warranted  because  il 
fnlliiws  along  a  (Mith  that  pnteoeds  from  the  known  t)>  the  unknown, 
The  inechanisni  at  the  higher  psyehtilogieal  levels  can  be  worked  out, 
anil  altlumgh  those  at  lower  levels  cannot,  it  would  apjx-ar  that  the  two 
extremes  are  connecte<I  by  ii  regular  series  of  intermediate  stages  as 
represented  in  types  of  cases.  It  con  only  be  assumed  that  the  ilisonln- 
in  "genuine  epilepsy"  has  to  do  with  adjustments  at  deep  instinetivc 
levels,  adjustments  that  are  profoundly  biological  in  character,  and 
that  the  coufiitd  may  almost  threaten  life  itself  in  onler  to  under- 
stand the  severity  and  seriousness  of  the  attack  as  a  rt^action  to  failuie- 
A  study  of  the  aura  as  a  clue  to  the  point  at  which  blocking  of  energj- 
c(>tnnicin!es,  anil  a  detailed  analysis  of  idl  the  elements  of  the  attack 
plus  an  analysis  of  the  niake-up  of  the  individual  in  llic  interparox>'sina]  ^ 
perio«i  would  seem  to  offer  The  mode  of  approach  to  a  further  under-  ■ 
standing  of  tlie  mechanisms  in  individual  cast's.  The  depth  to  which 
sin-ii  liii  analysis  would  have  to  go  and  the  severity  of  the  constitii- 
tionu!  burden  in  the  classical  tyjies  of  the  dlsejtsc  is  indicated,  fw 
example,  by  the  prevuleiice  of  the  epigastric  aura  tlic  cliarscteriAtic* 
of  which  indicate  the  possibility,  at  least,  that  the  disorder  reached 
as  deep  as  the  vegi^tative  nervous  system  level, 

Jt  can  Ir"  seen  from  this  <liscussioii  why  the  epileptic,  burtlemnl  by 
deeply  instinctive  defects  of  biological  adjustment,  should  deteriomlr. 
It  is  also  consistent  with  this  view  that,  in  general,  this  should  not  be 
true  of  symptomatic  epilepsy.  .\  localized  lesion  of  the  ixirtex.  for 
example,  may  produce  convulsive  reactions  in  welUlefiiied  prouixs  of 
nuist^Ies  only  without  loss  of  consciousness  (Jaeksouian  tyi>e).  Here 
there  is  no  defect  of  biological  adjustment  involving  the  individual  as 
such.  A  group  of  muscles  only  has  been  cut  ofT  from  effective  WASix;ia- 
tional  relationship  willi  higher  levels  and  so  bi"ut>mes  re«hnv*i  in  its 
possibilities  of  reaction  to  relatively  incoordinate,  automatic  ami 
purijoscless  types.  A  portion  only  of  the  machinery  has  Ijcen  damnged. 
the  individual  remains  othcr^^ise  intact.  The  disorder  is  coa6De<l  to 
the  sensorimotor  level.' 

I''rom  this  point  of  view  it  seems  that  the  toxicity  of  tl»e  blood  and 
urine  is  only  an  outward  evidence  of  the  depth  of  the  ilisorrler  nitlwr 
than  an  indication  of  its  cause.  It  is  tnie  that  certain  toxic  snl)stanee» 
do  produce  convulsions,  but  they  do  it  by  damaging  the  machinery 
like  the  cortical  lesions  just  referred  to  and  the  seizures  cease  with 

*  See  <'laTk,  L.  I'.:  Nature  iiiul  PnthDeeQetU!!  of  Kjiiluiny,  New  York  Mixl.  J<Nir., 
Fvbnuo'.  1015.  rtttq.,  (orn  oompleMsUttcmetit  of  tbiaview^potntwithiiiuneroiuHuural 
pioofa  ol  iU  valur. 


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tin*  n-nioval  of  tht*  [wison.    Tliis  is  seen  in  severe  forms  of  infection, 
febrile  states  in  children,,  air'thol.  uremia,  etc. 

It  is  inlerestinjc  and  .si^Tiificant  to  note,  in  this  cunneetioii,  that  the 
form  of  dementia  precox  in  which  convulsive  seizures  are  most  prone 
to  occur  is  the  cntatonic.  In  the  other  forms  types  of  c(mii)romise 
fornmtioii  take  place  wliile  the  eiilatunic  endeavors  to  cut  out,  to 
enucleate,  so  to  speak,  n  certain  portion  of  his  psyche,  a  condition  nmch 
more  favtiriildc  In  liliH-kiiis. 

Varieties  of  Convulaive  Attack. — Tlie  Jackstminn  type  Ims  ain-ady 
been  referred  to  as  has  also  the  distinction  between  tlie  (jraml  and 
petit  lual  attiteksand  various equivalent-H  (larvuted  or  masked  ejiilepsy). 

In  addition  to  myiniai  seizures,  then*  an?  jirridt  uifark.f  in  which 
several  seizures  follow  each  other  at  relatively  short  intervals  and 
finally  utaffui  epUepticus  in  which  larRe  numliers  of  attaokH  accumulate, 
following  each  other  at  short  intervals  until  unconscious nftts  liecomes 
continuiiiis,  the  attacks  then  nter^dnj;  into  otic  another- i>\'erlappinp. 
'J'hc  tcn)|RTaturc  rises  in  this  ciindition,  life  is  tlireatciied  and  indiH'^tl  it 
is  the  typical  hukIc  of  death  of  the  ejtiiepticand  Ins  ever-present  danger. 
Serial  attacks  are  usually  prnnd  mal,  but  niny  be  |jetit  mal,  while 
status.  e\  en  if  it  iK-^frins  as  petit  mal.  soon  takL*s  on  tlie  seriousness  of 
the  major  variety.  Psychic  8ei2ures  may  also  U'  wrial  an(l  status 
attacks  are  possible  without  or  with  very  minor  <T)nvu!sive  nmnifesta- 
tions.  Status  may,  ami  frequently  does,  develop  in  the  syinptomalie 
epilepsies  due  to  gross  lesions  of  the  brain  as  well  as  forming  a  fretpient 
termination  of  the  partial  or  iiictimpletesi'izuresiif  the  Jacksiinian  type. 

Miifirhiiirii<  rjii/rfit^y  apiM'ars  tn  lie  an  nsso(;iatii»n  t>f  myoclonia  and 
epilepsy.  It  would  sittu  that  the  myoclonic  shocks,  however,  gratlualh' 
eventuated  by  a  prnccss  of  summation  Into  an  epileptic  seizure.  Some 
ejiilepties  have  myoclonic  shocks  between  their  attack?  which  ap|«.'ar 
U\  be  fon'runners  of  the  seizure  rather  than  true  form.s  of  myoclonia. 

('imtittiiom  KpHrfKip. — Similar  to  the  mym-Ioni<-  varieties  are  the 
polydonia  epileptoides  continua  of  ('hon)schko  and  the  epilepsia 
corticalis  contiinia  of  Koshewniknw.  This  is  a  ccinditi(ui  of  continuous 
myo<'lc)nifcirm  shocks  iu  single  muscle  groups,  usually  unilateral  and 
withont  loss  of  cunsclousuess. 

Course  and  Prognosis.— E]>ilepsy  is  not  a  unitary  concept.  Numerous 
CI)n^lrtiurl^  ;ire  ct>vered  under  the  name,  anatoniiciil.  etiological,  and 
sjTnptomati<'.  It  is  Ix-tlcr.  therefure,  here  also,  tu  speak  of  the  reaction 
type  as  manifested  clinically.  The  epileptic  type  of  reaction  tends  to 
cripple  the  indivi«iu!d  more  and  more.  One  can  only  Ixvomc  efficient 
in  dealing  with  reality  by  ctmstantly  keeping  in  ]>ractiti\  a.s  it  were. 
To  withdraw  front  difficult  situations  means  les.s  ability  to  meet  the 
next  problem  that  arises.  The  attacks  then-fore  tend  to  become 
more  fr«|ue[il  aial,  in  a  considerable  ninulHT  of  cases  to  end  in  that 
IMTitmiiciit  reininciutinti  tt>  ffficient  a<!ju-siincnl  t»  reality  -dementia. 
Diagnosis.^Krciiu  what  lias  been  .suid  it  can  l>e  seen  that  epilepsy 
is  not  an  entity,  that  the  tenu  includes  a  great  nmltitude  oi  widely 
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different  conditions  and  that  th^  problem  of  diagnosis  is  there 
the  problem  of  difTerentiatinf;  the  particular  one  of  these  sev 
p().s.^ihilities  in  an  imlivirlLml  L-jise.  Dlanmisis,  however,  does  not  is 
Kivirig  a  name  Ut  a  thioK.  but  iimlerstamling  it.  Every  individ 
epileptie  should  be  aeeepted  as  an  individual  problem,  ami  althoug 
may  often  Ix;  quite  im]>ossible  to  fathom  the  mechanisnLS  involveii 
\s  only  by  stieh  a  metho*l  (tf  approach  that  anything;  worth  wl 
can  Ix;  hoped  for  wht-'n  the  question  of  treatment  comes  to 
con.sidereil.  M 

Ulie  possibility  of  exclusively  nocturaul  attacks— nw/)irf«i/  c/wf 
— shoiilil  l)e  Iwrne  in  mind.  It  is  suspicious  if  the  patient  awn 
tired  and  lame,  us  if  his  muscles  hwl  Ix-en  beaten,  particularly  if 
shows  conjunctival  eccbymoses.  a  wounded  tuuRue.  and  llw;ks  of  blc 
on  the  pillow.  A  localized  muscular  weakness  that  passes  ofT  promp 
would  at!']  certainty  to  the  diagnosis. 

Treatment. — The  only  efficient  prophylaxis  is  not  to  transm: 
defective  f^enn  plasm.  It  would  seem  that  in  the  purely  symptoi 
epilepsies,  Eueh  as  those  due  to  oortic-al  iniumatism,  that  tl»e 
l>lasm  might  escape  iiulietnient,  but  this  does  not  iHrcessarily  foOc 
A  certain  proportion  of  these  cases  will  be  found  to  have  had  c( 
vubions  in  infancy  so  that  they  mi^jlit  have  been  considered  as  potent 
epileptics  predisposed  to  react  by  r<m\ndsion-pro«HucinK  mecliarusn 
This  [Missihility  is  eniphasizeil  by  the  frequency  with  which  the  s. 
tomatic  epilepsies  develop  status  attaeks. 

Treatment  of  the.  Aiiack. — Onoe  the  attack  has  started  it  is 
to  so  care  for  the  patient  during  his  period  of  helplessness  that  lie  in 
not  Ix"  injured  in  any  way.  If  he  has  fallen  in  a  safe  place  lie  may 
allowed  to  remain  there,  perhaps  only  removing  him  from  proximity 
furniture  or  the  wall  against  which  his  limbs  might  be  injured  as  tti 
are  in  the  throes  of  the  mnvulsive  .seizure.  The  clothing  should 
loosened  nboiit  the  neck  to  permit  free  breathing,  and  if  possible 
towel  end  roHcil  up  and  pressed  lictwwn  the  teeth  to  prevent  injii 
to  the  tongue.  As  a  rule  he  shoultl  be  pennitted  to  remain  on  his  ba 
or  side,  ac^-ording  to  the  position  the  contracted  muscles  force  up 
him.  A  wound  rcL-eived  in  falling  may  need  care  and  a  broken  lu 
needs  protection  from  the  severity  of  the  conxiilsive  contractions 
prevent  additional  injury  by  the  broken  ends.  Kpileplics,  in  gener 
should  not  be  permitted  to  sleep  unobserved  or  alone  for  fear  they  m 
roll  over  and  smother  during  an  attAck.  If  vomiting  occurs  the  patie 
shoidtl  Im*  rolled  on  his  side  and  rare  should  l)e  e\ereise<l  to  preve 
aspiration  of  the  vomitus.  In  the  automatic  period  following,  watchi 
care  is  needed,  but  dini-t  efforts  at  control  should  l>c  avoi<led  if  pos^h 
as  they  are  not  umlerstood  and  may  only  excite  antagonism, 
patient  should  not  be  permitted  to  get  up  until  it  is  seen  that  no 
are  broken.  In  this  automatic  stjite  an  attempt  to  walk  on  a  bi 
leg  might  ejiaily  compound  the  fracture  for  coiuscioasness  is  so  r«duG 
that  pain  would  not  be  felt  or  reactwl  t<». 


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Treaimeni  of  Rtalua. — Serial  attacks   indicate  pc>s.4ible  danger   of 

^drtatiu  and  sedatives  sliould  be  used  to  eoiitrtil  their  frequeuoy.  while 

sudden  withdrawal  nf  hromides  should  lie  avoided  as  tending  to 

ppceipitate  a  riumfier  of  seizorcs.    Clark'  recommends  the  following 

as  an  eraergenej-  prescription  when  status  is  threatened: 


B— Tr.  oi.ii  (irrtd 

Potas.  bromid 

Chlor.  hyd 

Liq.  mon>h.  sultili.  t^U.  8.J      .     .     . 
B.~Ouc  duw:  ropiiat  io  two  houn  if  nwc 


Ullv 
nr,  jntv 

KT.  X» 

3i-M. 


try. 


This  pn-scription  may  be  given  after  the  first  four  or  five  seizures. 
after  that  sedation  niunt  lie  pushed  to  coutrnl  the  attueks  as  they  are 
themselves  a  souree  of  serious  danger  to  life.  C'hlorofonn  may  be 
given  in  emergeney  t>y  inhalatit)n,  but  the  most  valuable  of  tlie  ilrugs 
are  chloral  and  the  bromides.  While  It  w  iieeesaary  to  push  them,  it 
must  be  constantly  kept  in  mind  that  these  very  drugs  are  contrain- 
dirut(!<l  in  the  next,  the  stuporons  stage,  and  then^fnre  no  mort^  should 
he  used  than  is  actually  netressary  to  eontrul  the  situation  as  the  fol- 
lowing ennui  will  be  deepened  thereby,  ("hloral  and  bromides,  are, 
as  a  rule,  best  given  by  reiaum.  Tlie  heart  needs  watehing  and  may 
need  stimulutlng.  esperially  if  larj^*  doses  of  ehloral  an*  admiiustered. 

In  the  stuiMjrous  stage  the  treatment  is  sttnnilating  ami  supporting. 
Cjireful  nursing  and  feeding  and  protection  during  the  great  exiiauslion. 

Treatment  hfturfu  .IWacA**.— .As  there  is  no  disease  entity  (epilepsy) 
there  is  no  treatment  that  applies  to  all  of  the  eases  included  under 
I  that  term.  Kaeh  of  the  various  conditions  rwjuires  treatment  suited 
to  it  as  does  eac-h  individual  require  individual  consideration. 

The  various  surgical  conditions,  tumor,  cyst,  ahs<fss.  trauma,  etc., 
require  appropriate  surgical  intervention.  In  tumor,  for  example,  as  in 
otliep  organic,  conditions,  when  the  locjition  of  the  trouble  is  not 
evident,  a  study  of  the  attack  together  with  the  aura  may  give  vaUiable 
evidence  to  guide  the  surgeon.  It  is  desirable  to  have  all  such  cases 
reside  in  a  hospital  long  enough  for  their  attacks  io  be  accurately 
obscr\eii  before  operating. 

Conditions  of  infection  and  toxemia  require  no  special  mention  here. 
Ill  arteriosclentsis  witli  softening  the  general  condition  overshadows 
the  special  manifestation  as  is  also  generally  the  ease  following  hemor- 
rhage. Conditions  of  niarketl  jirrest  of  development,  either  tTongcnitJil, 
as  due  to  serious  birth  injuries,  or  early  inflammations  naturally  offer 
little  prospect  for  improvement. 

Internal  secretion  unbulant-es  should  be  eorrcited  as  far  as  possible, 
but  for  the  most  part  tittle  uu*iv  than  palliation  can  he  expected, 
attiiougli  the  near  future  may  well  have  something  to  offer  in  this  realm. 

Middle-ear  disease  should  Ix.'  arlequately  treated  before  meningeal 
symptoms  and  lateral  stnws  thrombosis  tjike  place. 


L 


1  Wm.  P.  BpraUiuK!     KpUupAy  uimI  Iu  Trtmunont.  PhUnde^phin.  1904. 


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804       EPILEPSY  ASD  CONVUISIYK   TYPSS  OP  ItKACTJ^^ 


The  s>T>hilitic  meniiigitiHfS,  wIk-iIrt  iicqiiirc<l  or    i  ' 
promUiiif;  (icld   for  relief  hy  appropriato    atiti!%y|H 
whitrh  should   be  intensive  und  include   intra\-enou.H  ntjefXiB 
salvarsan. 

p  As  io  the  pharmafothcrapy  of  "genuine  epilepsy"  it  cmn  br  iirfrr* 
from  whiit  Ims  already  been  said  that  there  is  m»iR*  except  sw-h  pt- 
be  ciillerl  upon  to  meet  or  prevent  einerjcencies  siieli  iis  stsnt  i-'- 
niiik-s  lm\e  Ixrii  so  cxinslantly  used,  however,  that  they  need** 
briefly  discussed. 

Bromide  arts  as  a  motor  depressant— it  raises  the  thiedKiU^ 
motor  discharge  and  does  tlierefore  inhibit  the  ctrnvulsivr  riqircM 
That  it  docs  this  is  sufficient  explanation  for  its  extenf-ive  use.  N» 
popular  medicines  have  much  less  to  recommeiKl  them.    Whm  f 
realize,  however,  that  the  convulsion  Is  not  the  dis<.-a,*te.  that  ii  ba* 
the  cause  nor  a  first  expression  even  of  the  disease,  but  only  it-s  iwtwif* 
expression  and  the  cud-n-sult  at  thai,  it  may  be  well  questioned 
bromide  mcdit-atlon  is  rational.     KxjX'Henoe  seems  to  show  t 
fit  jKMitponcd  by  bromides  crimes  to  pass  ultimately  any  way  aodtbt 
the  bromide  may,  in  fart,  tii)erate  unfavorably  by  tendin);  ti»  [itwfao 
a  sunmmtion  of  attacks  and  thus  increase  the  lianfcer  f>f  status.  AdW 
to  this  is  the  potentiality  for  distxu-binff  digestion  whieh  tlK*  l^nmib 
possess  so  prominently,  so  it  may  Ih'  said  tliat  they  ha*!  best  iwtbl 
given  at  ail  unless  under  most  carefully  regidated  conditions.   Tlr 
funt-tlon  of  the  bromides  is  to  control  the  convulsive  numifrstfttiitf 
when  they,  as  sucli.  Ix^comc  a  source  of  danger  as  in  serial  attada 
threatened  status. 

Hearing  lu  mind  tlie  theorj'  of  tlie  essential  epileptic  attacks 
has  been  elaborated,  the  rational  treatment  in  all  cases  wherr  tlr 
underlying  mechanism  cannot  be  uneartlied  (as  in  the  sj-mptomanr 
e])ilepsiesj,  is  to  assist  in  the  ortlerly  dischai^  of  energy,  to  lielp  tir 
process  of  sublimation.  This  is  best  elTcc-ted  by  manual  traiiiina 
steady  occupdtion  graded  to  suit  the  intellectual  level  and  otJier  rtijuin^ 
ments  of  the  patient,  and  preferably  conducted  under  institulioi 
(colony)  supervision.  In  many  individuals  much  is  to  be  ex|X'ete<i  fn 
psychoanalysis.  No  results  will  follow  from  short  treatment,  Iiowtmt. 
The  most  favorable  cases  necfl  from  twelve  to  eighteen  months.  TV 
treatment  by  tins  method  is  reeducational  and  coiwists  in  caRfuOr 
regulating  the  entire  lite  and  the  living  conditions  so  as  to  sJuwh 
lead  the  patient  into  reality  by  arou.-iing  his  interests  in  tilings  iiutsiik 
himself,  a  gradual  leading  away  fn.m  the  egi>cenlric  fixation. 

Surgery  of  the  colon   is  inefTcrtive,  unintelligent,    and    in    tanst 
ins  ana-s  is  a  criminal  procedure  largely  actuated  by  Bnanciai  coi 
siderations. 

The  social  positinii  of  tlie  epileptic  is  most  pitiable,  often  so  inii 
menTatly  that  his  Ud>or  is  at  a  discount,  he  loses  his  job  on  the  otTssmo 
of  the  first  fit,  even  though  he  may  have  snccee<h-d  in  getting-  ooe 
that  is  free  from  tlie  dangers  to  wliicb  he  is  particularly*  expoticd  on 


nuksi 
msina^ 


u 


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CLASSICAL  EPILEPSY 


805 


ouoount  of  his  iiiBmiity.  He  is  thus  smously  handicapped  in  the 
struRrlc  f(ir  existence  ninl  baa-ly  gets  !»  earning  liia  livelihuiKl  in  une 
position  before  he  fintls  hiinst;if  jobless  again,  without  recommenda- 
tion, antl  forcHx)  tc»  begin  all  over  apiin.  He  is  thus  apt  to  be  poorly 
nourlsbmi,  ixwrly  <-totbed,  and  the  subject  of  intense  social  repression 
operating  from  without  that  drives  him  buck  upon  himself  ami  aggra- 
vates greatly  his  tmuble.  He  Iieeonies  diseouraged  ainl  ileprps-^pd 
and  only  tmj  often  takes  to  aleobol.  the  very  worst  ixjssiljle  thing  he 
could  lio. 

In  the  ailony  all  these  soeial  handieaps  are  ramovefl.  Here  he  may 
have  ft  tit  in  peace  and  comfort  without  feeling  that  be  is  disgraced  or 
in  imminent  danger  of  losing  his  means  of  livelihooti.  This  relief  alone 
got:-s  H  long  way  tuwanl  [>erniitting  him  the  use  of  his  avenues  of  expres- 
sion and  in  bringing  about  a  Relative  peace  aiul  quiet,  so  essential  as 
a  therapcutie  mljuvant.  U  in  addition  to  tbis  he  is  trained  lu  some 
form  of  healUiy  occupation,  preferably  outcjoor.  that  is  interesting 
and  affords  an  a<lded  mcaius  of  expression  the  bt-st  possible  has  lK;en 
done  for  him.  In  the  colony,  too.  he  is  providefl  a  home.  <;ongenial 
surroiuidings,  a  regulateil  diet,  and  is  under  that  <aireful  and  con- 
tinuiHis  skilleil  suiJervision  for  a  prolonged  lime  wliieb  is  so  essi'ntiiil 
to  tlie  best  results.  Under  colony  ejire  ^pratling  thinks  5  [X'r  eent. 
of  cases  as  they  go  can  be  cured  and  timt  this  pertviitage  could  be 
doubled  or  perhaps  trebled  if  all  the  cases  eould  Ije  gotten  under 
treatment  early. 


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CHAPTER  XIX. 


DEMENTIA  PRECOX  (SCfUZOPIUlEMA)  GR< 

The  term  dementia  precox  has  been  the  occasion  of  a  great  denl 
of  (liwiissinn.  Coming  into  gencni!  use  as  it  did  as  the  result  of  the 
studies  of  the  Kraepelinian  st-hool  it  whs  eoiu-eiveil  to  apply  to  a  group 
of  psychoses  Ix'loiigiiig  to  the  jxTiod  of  adolescence  and  presenting 
dementia  as  a  fundamental  element  in  the  s>inptom  picture.  When, 
huwever,  it  wua  »een  that  what  appeared  to  be  Uie  ftame  disease  might 
occur  later  in  life,  even  after  thirty  years  of  age,  it  seemed  hardly 
projier  to  use  the  term  precox  as  applied  to  psychoses  of  early  life. 
It  waa  therefore  propnsetl  tlmt  tin-  term  precox  should  ii-fer  not  to 
tlu'  agt^  of  tlie  palieiit,  hut  to  tlie  relatively  early  apiR'aranee  of  demen- 
tia in  the  course  of  the  disease.  The  term  dementia  was  here  used 
to  mcEin  H  pcniiaiteiit  nieiital  inipainneut,  and  when  it  uus  realized 
that  nuuiy  cases  made  rckkI  recoveries  without  any  appart^nt  or  at 
least  material  defect  remaining,  another  reason  •mw  evident  for  the 
inapplicahility  of  the  term.  The  concept,  then,  might  be  formulated 
that  it  was  a  disease  in  which  dementia  was  a  relatively  early  sj-mp* 
toni,  and  that  the  recoveries  occurred  only  when  the  disease  had  not 
prt>gressed  to  any  extent.  This  also,  unfortunately,  <!oes  not  meet 
the  facts,  because  many  eases  get  well  after  prolonged  ami  apparently 
chronic  courses.  In  the  abaenct;  of  any  well-defined  criteria  of  dementia 
it  was  impossible  to  predict  when  it  was  or  was  not  present,  and 
therefore  the  term  presents  very  many  untlesirable  features,  Althontrh 
it  is  souifwlml  of  a  bootless  task  to  discuss  names,  and  allhungli 
it  is  much  more  important  to  kimw  what  the  names  stand  for  than  to 
quibble  about  tlieir  applicability,  still  it  is  of  course  desind>le  to  have 
a  name  that  fairly  represents  the  thing  nnmed.  To  meet  thus  demand 
Bleuler  has  sujigested  the  name  schizophrenia,  implyinj;  u  splitting 
of  the  personality,  which  he  thinks  is  the  fumlamcntal  33'mptom. 
Although  this  term  as  used  by  Uleuler  includes  a  number  of  conditions 
tlmt  uiany  psyehiatrist.s  wouhl  object  to  as  being  includcxl  in  the 
dementia  precox  concept,  still  it  is  genendly  concedeil  that  the  splittiag 
of  the  persojialily,  as  indicated  by  the  name,  is  fundamental  In  tilts 
group,  and  the  name  is  coming  into  gradually  uiore  and  more  general 
use. 

rVmentia  precox  must  undoubtedly  have  always  existed  and 
have  been  observed  by  ph>'sicians.  and  in  particular  the  grotesque 
cases  of  catatonic  rigidity  and  jieculiar  mannerisms  must  Imve  always 
Bttmcted  attention.     In  the  early  history  of  psychiatry,   hnwrver. 


I 


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ETIOLOGY 


807 


few  descriptions  of  cases  exist  that  could  be  unequivocaily  said  to  be 
rast's  of  premx,  as  the  pmiip  had  not  Ik-cii  dofiiK-il  from  other  Rfoup!* 
suixTfiriulIy  n-seriibliiij<  it,  as  f(ir  fxainplr,  iinliecility.  Willi.s,  llie 
KiikMmIi  anatomist,  rciToj.'ni'/,ed  as  early  as  Hi72  that  iiuiiiy  younj; 
people  umierweiit  deteriorntion.  and  Sydenham,  a  hxnidrecl  years 
later,  \a  1772  descrilK's  similar  conditions  uiuler  the  description  of 
stupidity,  while  later  on,  after  mania  and  melancholia  had  t>een 
more  or  less  defined,  many  of  the  excitements  and  depressions  that 
are  incident  to  the  cinirse  of  dementia  precox  were  imdoulitedly 
grouped  under  these  headings,  while  at  one  period,  only  a  few  years 
ORO,  there  was  a  ilistinet  group  supposedly  representing  a  special 
disease  desmlx-d  by  the  name  of  catalepsy,  where  also  uiidoubteiily 
a  certain  number  of  precox  cashes  were  arranged. 

At  the  present  lime  three  pretty  wclMefined  groups  of  cases  are 
included  in  the  general  concept  of  dementia  precox,  namely,  the  hebe- 
phrenic, the  catatonic,  and  the  paranoid.  Kahlbaum  was  the  first 
to  desiTilw  hebephrenia  as  a  ilisease  entity  in  ISOli,  and  in  187!  !iis 
pupil,  Hecker,  ]iublislR'tI  some  exeellent  dcscriplions  of  this  disease. 
Ill  I8('>9  Kahllwum  desiTiln-d  catatonia  under  tlie  term  Spanuungsir- 
resein  or  vesania  eatatoniea.  of  which  he  gave  an  admirable  mono- 
graphic description  in  1S7-1.  In  189(>  Kraejx'lin.  in  the  fifth  edition 
of  his  T^'hrbuch.  arrange*!  dementia  precox,  catAtonia,  and  dementia 
paranoides  as  disonlers  of  metal>olism.  Clouston.  tlie  Scotch  psychiat- 
rist, had  already  described  what  he  termed  adolescent  lasanity  anil 
objected  to  the  term  dementia  preci>x  as  being  too  inclusive.  Kraepe- 
lin,  however,  worke<l  over  his  material  with  great  thonnighnei«  and 
arrivciJ  at  llie  concept  that  includes  the  three  forms,  hebephrenic, 
catatonic,  and  [Miraiuiid  by  tracing  the  life  histories  of  his  patients 
and  grouping  all  these  cases,  hun'ever  dissiuiilar  they  might  ajijiear 
on  tlie  surface,  from  the  stand-point  of  prognosis.  They  were  cases 
that  had  a  fairly  definite  course  and  outcome,  eventuating  always 
in  a  certain  degre**  of  dementia,' 

Etiology. — The  question  of  IteredUy  in  precox  has  been  studied, 
particularly  by  Wolfac^n,*  who  carefully  analyzed  the  material  fn»m 
this  stand-point  at  the  Bergholzi  asylum  in  Zurich.  The  study  of 
2215  admissions  disclosed  C-17  cases  of  dementia  precox  of  whom  90 
p<'r  cent,  showed  beretlitary  taint.  Of  four  factors,  mental  disea.se 
was  the  most  frequent — about  tX  per  cent  .^followed  by  ner\ous 
diseases,  alcoholism,  and  other  fonns  of  hereditary  taint.  Heredity 
was  combined  in  .'H  per  cerit.  The  most  freriuent  combinations  were 
those  of  psychoses  and  alcoholism,  and  jisycliose^  and  nervous  (liscase. 
She  concluded  that  a  distinct  influence  of  heredity  could  not  lie  proved 
in  the  cases  in  which  the  tauit  wa:^  alcoholism,  nenous  disease,  or 
other  forms.    The  catatonic  was  tlic  most  and  paranoid  the  least 

'  JcUilTr;  OcmoDm  Frorox.  n  HuHunitnl  Hiiminiir>',  New  York  Mod.  Jour,.  1012. 
'  Die  JK-riKlitftt  >wi  UBnH>r.ii»  Pr-vx,  Alltc  ZUclir.  f.  r'>y<^li..  IWJ7.  Bwid  Uiv,  tiefl 
2  and  .-i. 


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DBMBSTrA   PRSCOX  QBOUP 


jiiTci-teii  by  tlie  iiuMital  taint,  wliitt*  the  iiifliieiioe  of  X\\v  taint  had 
strikiii};  effect  on  the  charnctcr  of  the  first  symptoms  of  the  ilisojus* 

It  would  swtu  that  there  is  ii  CTfiiiiii  element  of  direct  hertxl 
inastiuH-h  as  families  are  fuunii  in  which  Hpveral  cases  of  preL-^jx  o« 
just  as  there  are  families  fourut  in  which  several  cases  of  the  mw 
(lepn^ssive  psychosis  occur.  ^| 

CM"  tile  exeitiiiR  causes  severe  shocks,  l>oth  mental  ami  phy,-aOffln 
not  iiifrcijiieiilly  fouml,  as  for  exauipK".  severe  hciiioirliam-s  and  infi 
tions  following  jHirturitiyn.  In  the  latter  cases  precox  brcak-do« 
cHxrur  as  a  re:^ull  of  chut  tniin  uf  emotional  dtsturbaiiecs  which  ft 
upon  seduction  and  desertion. 

For  a.  nuiiilKT  of  yc;irs  there  has  been  a  teiuiency  to  ascnl 
disease  tu  ilisiurlianccs  of  metAhoIism  with  i»4>ssihle  toxic  factors  al 
to  suppose  thiit  its  origin  might  be  traced  to  disorders  of  the  glandul 
secrt'tions,  more  [mrticularly  of  late,  of  the  internal  secretions  of  tl 
ductless  glands,  and  inasmuch  as  the  disease  tends  to  focalize  abo 
the  period  of  puberty  ami  arlolesccnce,  it  has  been  siip[Hise<i  th 
IHrhaps  the  testicles  and  tlie  ovaries  mipht  lie  the  offending  orgai) 
This  theory  has  received  confirmation  recently  more  especially  I 
Fauser,  who,  working  with  the  Abilerhnlilen  technic  hjus  Ls*»lat( 
defensive  ferments  aKainst  the  xunatls  and  the  i-ortex.  More  will  I 
said  of  this  matter  Inter  when  the  discussion  of  the  nature  of  the  diaei 
is  taken  up.  but  it  may  Ix-  mentioned  liert-  that  whatever  its  ultiBia 
nature  may  Ix*  the  existence  of  toxic  factors,  or  internal  secreto 
dtsturbamres  is  largely  h>-potbctieal  so  that  at  the  present  time  it 
more  useful  to  formulate  the  up&ettinfi  factors  as  well  as  the  gt^nei 
s^Tuptoinatology  in  psychological  terms  rather  tlian  in  terms  dead 
tive  of  ilislurbanccs  at  physiroi-henili-al  levels.  fl 

The  formulation  of  the  disease  In  terms  of  the  nffects  or  of  complex 
or,  in  aasmhincc  with  Meyer,'  continued  unhealthy  biological  rei 
tions,  or  as  an  outp^wth  of  a  "shut  in"  character  is  after  all  mc 
of  an  effort  of  <lcsmpti<ni  of  what  is  found.  Kvcr>'one  Ims  cumpIeJQ 
but  it  is  nut  clear  why  in  certain  cases  they  lead  to  the  devehjjiine 
of  a  precox  psychosis,  while  a  "shut  in"  character  mif^ht  itself 
certain  cases  at  least  be  considered  to  be  an  early  expression  uf^ 
disease  proa'ss,  a  latent  precox  perhaps,  in  the  sense  of  Uh-iiler.*    f 

Symptoms. ^J/rnffi^ — A  patient  from  time  to  time  writes  lette 
appealing  for  h"s  dis<;hargc  ami  h  s  Hbcrty  and  signing  himself  "Tl 
Emperor."  It  is  this  incongruity,  this  lack  of  oneness  of  the  indtvjdu 
that  for  a  long  time  has  attracted  attention  in  the  s\-mptoniatalof 
of  this  dis*;ase.  How  is  it  jKissible  for  a  person  so  exalted  as  to  thii 
huiisclf  an  emperor  to  plead  \x\  quite  a  natural  way  for  his  dJscJiar] 
from  an  asylum?  The  two  positions  winch  the  man  takes,  acV 
edging  himself  as  a  patient  and  pleading  for  his  discharge  while 

'  Fundftiiifnial  Conwiptionji  of  Dcmvntm  I'ri'niK.  BriL  Mi-d.  Jutir..  SutiU-mbnr  29,  IW 
■  Bloulcr:  Dio  Schiiopbieaio,  1011 ;  nlvo  B«e  Bloiiler:  tfebtbuch  der  PqrchiaUicwi 
Erftcpclin:  Lclirhudi  dn-  Psj-chiatno  8  Bdit. 


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SYAfPTOJdS 


809 


I 


prociaiininf;  hinusolf  nn  einpcror,  Hhim*  the  iMissihility  nF  niaiiitniiiing 
two  tlistinct  aini  inutimllj'  opiMisiil  Irt-mls  of  thimj;lit  at  tin-  same 
time  ftithoiit  the  one  apparently  interfering  or  serving  nt  all  to  correct 
or  modify  the  other. 

This  possibiUty  is  dependent  upon  a  fundamental  flsvfociational  HIs- 
turhance  which  has  eau^Ki]  Bleiiler  to  »c€  b  spf'tttitig  uj' the  jHrsniHtHty 
as  the  foundation  sj-mptoni  of  the  disease  and  to  pive  it  the  imnie, 
therefore,  of  sehizophrenia.  This  splitting  of  the  i>ersonality  has  l>een 
expressed  li'ss  elearly  in  many  of  tlie  theories  that  Iia\p  been  advanced 
to  account  for  the  symptoms.  The  symptoms  have  I»een  said  to  be 
depetulcnt  upon  a  diy integration  of  the  personality,  a  di^^inlegration 
of  cnn.sciousne.ss  with  the  consequent  iwipainnent  of  the  function 
of  the  real.  Hcality  is  unable  to  correct  or  adequately  niiKJify  the 
deliLstonal  ideas,  with  the  result  that  such  bizarre,  strange,  ami  ai>- 
parently  un psychological  miKlification.s  of  conduct  are  seen. 

Tbe^  unpsychologicid  ap|>earHiices  are  de[KMideiit  upon  what 
HleuJcr  calls  utilixtir  thinking,  that  is,  a  form  of  tliiriking  to  wliich  .lung 
would  apply  tlie  term  introverU-d,  in  which  the  individual's  interests 
are  withdrawn  from  reality,  aiid  he  occupies  himself  with  himself 
to  the  more  or  less  complete  exclusion  of  the  outside  world.  This  is 
the  field  of  dream  formation,  of  phantasies,  wherein  tilings  come 
true.  An  analysis  of  eases  of  dementia  precox  shows  that  the  (k'lusion 
format)  >ns  are  based  upon  wish-fulfilling  uiecIianismM  which  n-sult 
oftentimes  iu  highly  symbolic,  and  to  the  ob^Tvcr,  non-understandable 
expressions  which  are  fnnnulati'd  in  accordance  with  the  particular 
complexes  which  may  be  oijerative.  These  mechanisms  are  the  same 
a.s  those  observed  in  normal  TH"ople.  in  hysterics,  and  those  sutfcring 
from  the  various  neuroses,  but  it  is  impossible  for  these  individuals 
to  ailequately  utili?.e  them;  they  therefore  result  to  imjMiimieut  of 
cfKcicncy  and  withdrawal  from  the  world  of  reality.  It  would  sei-m, 
too.  (hat  iu  pretax  the  regression  is  very  much  more  profound  than  in 
the  neuroses  and  the  psychfuieurnses,  and  for  some  unknoisii  reas(Mi 
involves  a  serious  dUintegration  of  the  personality  which  tends  (n 
become  chronic  and  crippling.  Trom  the  stand-point  of  this  schizo- 
phrenic splitting  of  the  psyche,  based  upon  autistic  thinking,  many 
I>oints  in  the  s\Tnptomatolog.v  of  the  disease  liee<ime  understandable, 

Tl»e  peculiar  emntUmai  duitie-^g  and  uneertjiinty  of  emotional  response 
of  the  prec«>x  has  long  been  noticed,  and  Stransky'  has  particularly 
designated  it  by  the  terra  of  intrapgychic  alania,  by  which  term  he 
means  a  disturbance  <ti  the  coordination  between  the  intellectual 
and  the  affective  attributes  of  the  psyche,  which  are  respectively 
known  as  the  noopayche  an<l  the  thyniopayche.  This  noothymo- 
psychie  ataxia  gives  the  api^earance  at  times  of  emotional  dulling  and 
at  other  times  of  a  senseles.%  emotinuul  reaction.    Thus  a  patient  who 

>  Vtltnr  tUs  DaitMifiUa  Ptmox.  StrvifiOirc  duroh  Klinik  unil  PsyrbniuthnloRk'.  Vcrinjr. 
[vuv  T.  F.  Uortmuo:  WioitxuiHn.  1W». 


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receives  iieu's  <if  the  ilejith  uf  a  near  relati\'e  uninoved,  may  a  6i 
later  on  latigh  heartily  at  apparently  imttiiiig.  He  h  happy  when 
sIhiiiIiI  Ije  .sail,  siul  when  he  shoulil  lie  Imppy,  aii)^'  withtntt  I'aii 
ex|XTieiieiiig  fear  wtthtiiit  reason,  fur  the  must  jiart  ixAd  anil  imp 
sive,  but  uccasioiuUly  showing  uutbursts  uf  iiuirked  and  oceeocual 
emuttunalism.  Tliis  is  the  "April  weather"  behavior  of  the  affce 
in  the  luiii^iiage  of  StraiLsky.  m 

This  citmlitioii  of  atTair^  is  understandable  upon  the  basis  ofl 
splitting  of  tlie  psyehe.  The  emntiuiml  reaetioiis  occur  when  t 
complexes  have  been  touched,  which  the  individual  is  eoitstJintly 
an  attitude  of  trying  to  prevent.  This  inethnd  of  ilt*nling  with  t 
emotions  is  well  known,  particularly  in  tlie  fnnnatiitn  of  the  dreai 
in  which  the  mechanmn  oj  dixplacemcnt,  by  reuK»virig  llie  alfeei  fn 
the  constellation  of  ideas  to  which  it  belongs  and  attaching  it  to  i 
in<Jitl'erent  set  of  ideas  serves  to  hide  from  the  patient  the  realizatii 
of  the  nr.tual  cMffinilty.  I'or  example,  a  patient  identifies  Iterself  wi 
a  whoi>linHte  of  her's  ami  then  aitnises  the  schijolniale  of  bring  ''  ha< 
and  jm'gnaiit.  It  will  l>e  easily  seen  that  in  such  a  ease  the  jwitie 
is  protecting  herself  from  the  realixatioit  tliat  she  has  thoiigli|fl 
which  the  term  "bad"  might  he  applied,  and  that  the  pregiuincj-  wflj 
might  result  from  l>eing  bad  is  transferred  to  her  schof>tmatc.  L*nd 
such  cireumstanars,  she,  so  to  speak,  unloads  her  emotion  \x\xm  tli 
schoolmate  and  very  easily  may  pnKluce  the  impression  of  indifferen 
towani  herself  with  an  unmotived  affective  attitude  toftanl  ll 
schocjlmate.  m 

This  u-ithdrawal  front  reality,  this  looking  within,  oecupjing  t^ 
selves  with  thcinsi-lves.  no  longer  subject  to  the  wirrcctive  inffuenfi 
of  the  outside  world,  produces  many  surface  indications,  among  whi< 
are  Jiulurejt  of  to} itntani  utfention,  lack  of  intervxt,  dinturbancex  of  orier^ 
tioti,  diAordfru  nf  memory.  'IV  disorders  of  attention,  lack  of  intera! 
failur*  of  voluntary  attention  can  easily  be  seen  to  be  due  to  tl 
turning  of  the  interests  within.  'I'he  caiwrity  for  attention  may  I 
as  keen  as  ever,  but  the  patients  are  not  attending  to  the  tilings  goii 
on  about  tliem,  but  rather  t4)  the  things  going  on  within,  and  so  tfai 
apparently  take  no  interest  iu  the  people  or  the  events  of  their  eiiviroi 
mcnt.  They  may  even  express  themselves  as  perfectly  satisfied  wit 
their  amfinement  in  a  hospital,  ami  be  so  manifestly  hee*lless  i 
those  al^out  them  that  it  is  practically  impossible  to  draw  them  inl 
conversation.  This  lack  of  interest  and  attention  naturally  prodw 
what  api»ear  to  Ix"  disturbance?!  of  memor\'  and  orientation.  'H 
j>atient,  who  is  heedless  of  his  surroundings,  may  easily  not  know  tl 
day  uf  the  week  or  may  have  forgotten  the  events  tliat  oidy  ret^ntl 
took  place  alwut  him,  because  tliey  were  not  sufliciently  attended  t 
to  make  any  profound  impression,  while  a  patient  who  identilics  hin 
si'lf  with  some  great  public  funetioiiar>"  might  easily  not  gi\e  tli 
wrrect  date  iif  liis  own  birth.  Such  considerations  as  those  show  Iw 
necessary  it  is  to  penetrate  beneath  tlie  surface  indicatioiu 


^ 


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SYMPTOMS 


811 


the  patient  mnnifestH  ami  fimt  <>iit  tlieir  true  mciiiiing'.  They  nbw) 
K  iiulk-:ite  iiiicqiiivffcally  thnt  what  may  apjieur  quite  u tipsy chologieal 
H  is  really  |jerffctly  iiii<1etstaiutiililo. 

^M      'I'he  suuie  type  of  exfilanntion  seires  to  n-ndiT  fleiir  the  uiejiiiiiig 
^  of  such  Hurface  indictttiniis  as  the  fihalUnnurmt  nf  thinking  and  the 

|tipi>arent  iliiapithiivu  of  (fioufjhl.    Tlif  interests  and  thf  eiRTgies  lire 
<»cciipi«l  witli  tiiinjis  which  arc  not  accessible  to  casuiil  questioning. 
In  fact,  as  will  later  un  lx>  seen,  the  jmtient  may  lie  w  holly  iiiaccesaihle 
to  any  form  of  approach,  and  when  there  is  considerable  speech  produc- 
tivity what  is  said  may  Ik*  so  Incoherent  upon  the  surface  as  to  be 
quite   n4)n-niiderstaiidabk'   and    (xiii-stltutc   what   basS   lH*en    called    a 
"won!  salad." 
The  drUtifiimal  formation  of  precox  is  notoriously  grotesque  and 
partakes  of  this  characteristic  to  such  an  extent  in  harmony  with 
the  grotes(|UciK*ss  of  the  thou^rhts  In  dreams  that  the  similarity  has 
not  been  ovprhH>kwl.    The  mechanisms.  t<«>,  are  prol>ably  tinite  the 
same,  altliough  much  more  diHicult  to  fulhom  Ijeeaiise  of  the  inace&si- 
^  bility  and  lack  of  cwperation  of  the  patient.     If  the  eye  is  pn>perly 
^m  trained,   however,  to  see  meaning  in  the  apparently  meaningless, 
^B  there  will  be  little  difficulty  m  seeing  huw  certalu  expressions  may 
^P  lie  interpreted,  even  though  in  an  individual  case  it  may  W  impossible 
to  verify  such  an  inter] 'retntion.       Kor  example,  an  old  pri.'C4)x  who 
talked  in  a  thoroughly  dilapidated  manner  but  was  able  with  some 
iwtiem*  to  give  a  fairly  good  account  of  himself,  injected  into  his 
aeries  of  replies  to  questions  that  the  ('resident  was  confine*!  in  an 
ahnshotisi^  and  that  he  hail  eonif  to  Wasliiiigtt^i  to  \h-   I'lvsiileiit. 

I  Me  also  stated  that  he  had  had  something  to  do  with  his  sister  when 
he  was  a  young  boy,  that  he  did  nut  tell  the  priest  and  that  his  shadow 
was  ver>'  heavy,  that  it  was  black,  and  that  he  saw  the  TKn-il  in  it. 
Here  an  expression  of  grandiose  ideas  which.  siK-aking  generally,  may 
be  considercil  as  comjjensatory  are  seen.  In  his  autistic  thinking  lie 
wishes  to  be  the  great  man  that  in  his  real  life  he  is  not.    Then  one 

■  sees  the  po«.sibility  of  a  serious  moral  conflict,  the  residt  of  incestuous 
relatious  with,  or  jxThaps  only  incestuous  thoughts  about,  his  sister, 
'  while  his  dark,  and  lieiivy  shadow  in  which  lie  sees  the  Devil  can  be 
easily  seen  U*  in-  a  s.^nll^olic  rcpR-sentation  of  the  destructive  elfecta 
which  his  moral  delinquencies  have  had  upon  him.  Here  one  also 
sees  that  the  halhicinatory  exp€ri£ncefi,  the  disorders  of  the  sensvrium 
express  thenLselves  as  symbolisms  of  the  mnfiid  anti  receive  their 
inter]>rft!ition  with  a  knowledge  of  the  nature  of  that  conflict. 

The  ilelusioiis  are  essentially  endogenous  in  ori^u,  that  is,  ulti- 
iimtcly  dejiendent  upon  factors  that  are  within  the  individual,  and 
they  tend  to  be  colored  and  determined  by  etimplexes  wliich  Me  at  the 
very  foundation  of  the  iiersonality,  wliidi  have  to  tlo  witli  the  region 
of  the  psyche  which  has  long  since  been  forgotten  an<l  to  which  Freud 
gives  the  nan>e  "unconscious."  It  Is  largely  beeanse  of  their  pro- 
foundly unconscious  origin  that  they  are  inacessible  and  it  is  largely 


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^3 
est 

i 

oem 
...ive 
irtipoi 

or  irt 


owing  t^)  this  alto  that  tliey  produce  such  serious  disturl 
Riicli  markc*)  dcjmrtiires  fmm  tronduut  that  is  at  all  flliriont. 

It  is.  ttH),  l)e(ausc  the  motivation  of  the  lutivitici*  of  the  p 
and  the  origin  of  his  dehisions  are  in  the  iincoiistions  that  his  OJ 
and  prudiictions  strike  us  us  uiipsyctu>Iuf;ica).  Tltut  wfiich  orig 
in  tilt'  iinct^iiM-ioiis,  because  its  origin  is  unknown,  seems  straitg 
invsteriuiis.  m 

Just  as  tlte  hull  urinations  are  syml>olisnis  of  the  element^ 
conrtitt  so  arc  tlK*  various  mannerism;/,  alereofyj/if^,  and  twoh^ 
All  uf  the^  motor  disturbances  are  in  effect  symjtiom  actimties, 
indicators,  and  ser\T  in  some  way  to  portray  the  nature  of  the 
In  a  rproontly  reiwrt«l  case,  for  example,  an  old  pn^-ox  was  i>l!l 
to  keep  [^M»un<ling  one  hand  with  her  clenL-hed  fist  in  a  rh\i:hinie  st 
tj-jied  fashion.  It  was  dis(;overed  that  in  her  earlier  (lav's 
IxTii  jilted  by  a  shoemaker.  This  peoiliar  actiun  foulcl  be 
the  li^ht  of  this  kiiowlctlge,  as  but  the  movements  of  tlK*  ahoem 
pounding  at  his  last.  Many  of  the  old  cases  of  precox  have 
stereot.NTied  activities  which  it  is  often,  in  fact  u.sually.  quite  irtij 
to  fathiint,  but  in  the  light  of  such  a  case  as  this  it  will  be 
they  must  nil  be  lodkinj  u|h>il  as  having  meaning  and  that  for 
plete  reconstruction  of  the  psychosis  it  is  necessary  to  detenninc  v 
that  meaning  is.  M 

As  an  example  of  what  painstaking  anal>'sis  may  disclose  o^ 
mentioned  a  (Xitient  of  Jung's.  She  expressed  hers+'lf  in  stensDt,^ 
and  apparently  meaningless  phrases  interspersed  with  neologisms. 
of  her  statements  was:  "I  atHnn  a  million  Hufeland  to  the  left 
tlie  last  frngincrit  of  earth  on  the  liill  above."  A  detjiiktl  anal 
di.sc|osed  this  sentence  t*»  mean,  approximately:  "For  the  bad  li 
meiit  of  the  pliysieiaiis  which  I  have  to  emlure  here  and  with  wl 
1  am  tortured  to  death  I  claim  a  high  indemnity." 

Xegaiitism,  one  of  the  characteristic  symptoms  of  pre<?ux,  maj 
exprcsse<l  pus-iivcly  by  the  patient's  nnt  doiuR  what  is  expecto 
hiin,  or  what  he  should  do,  or  by  actively  doing  the  exact  oppc 
of  what  Is  requested.  The  passive  negativism  may  show-  it»el\ 
refusal  to  attend  to  the  promptings  of  normal  desires,  s^i  tliai 
hiadder  and  the  rectum  arc  |K'rmitted  to  become  overloaded  and 
saliva  to  collect  in  large  quantities  in  the  mouth,  or.  on  the  o 
liand.  active  negativism  may  show  itself  in  the  patient  doing 
exact  opposite  of  wliat  he  is  asked  to  do;  for  example,  if  he  is  u 
to  shut  his  eyes  he  opens  them  wider  and  if  he  is  asked  to  o(>en  tl 
he  will  shut  them  tightly,  and  if  he  is  asked  to  put  out  the  tongw 
shuts  his  lips  tightly,  and  if  he  is  asked  to  shut  his  mouth  he  o( 
it,  etc.  Tliis  peculiar  symptom  is  dependent  upon  what  HleiUer  te 
the  ambitafencj/  of  ideast  by  which  he  means  that  ever>'  itlea  has  % 
uectwl  with  it  by  association  Its  exact  opptislte  more  intimatcli 
otlier  i<lea.s,  and  so  the  patient  who  is  withdrawn  from  re«li( 
objects  to  being  inva<led  by  the  world  of  real  things,  who 


L'lyiii-' 


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SYMPTOMS 


813 


^ 
» 


M: 


words,  live  within  hiinsolf,  finds  that  In  refusing  to  ncoord  nith 
A  siiXResTinn  friini  the  out^r  world  tiie  path  of  the  diametrically  iippo- 
site  rfUftion.  is  more  jKitent.  more  aceessible  than  any  other.  Tins 
is  a  type  of  reaction  wliich  one  sees  bIm  in  other  conditions,  as  in 
hysteria,  and  ali^n  quite  naturally  in  ehililrtMi. 

The  fuggfxtihility  of  the  precox  receives  a  similar  explanation. 
Some  pntient-s  find  it  easier  to  follow  blindly  any  suggestion  which 
comes  tn  them  fniin  any  source  than  to  actively  initiate  contiirt  with 
reality.  One  pn'oix  patient,  for  example,  had  to  be  fed  by  placing  his 
food  before  liiin  and  a  spoon  in  his  hand  and  reiK-atitig  eacli  time  the 
command  to  take  another  mouthful.  After  having  re«poiidc4!  to  the 
command  he  remaineil  inert  until  it  was  repeated.  This  form  of 
activity  re<|uires  no  initiative  on  the  part,  of  the  patient,  no  a(;tiial 
effective  cimtact  with  reality  nf  his  own  devising  ami  permits  him  to 
remain  witlnn  himself,  much  as  <loes  the  uegativistle  tenth'ncy. 

Tlie  cafatotiir  ngiditi/  of  the  precox  is  a  still  more  active  .shutting 
of  the  world  to  the  point  of  absolute  inattention  to  the  en\iron- 
t,  but  an  inattention  which  i.**  positive  and  active  rather  than 
passive,  as  in  catalepsy  and  command  automatism,  while  stupor  still 
more  effectively  shuts  out  the  world  of  real  thing.^. 

There  is  a  rejection  t,\^je  in  dementia  precox  wliich  is  important  for 
an  niiderstanding  of  the  nature  of  the  disease.  It  is  the  archaic  tifpe 
of  reaction.  In  the  illustrations  that  have  been  given  it  is  seen  that 
when  the  individual  under  the  influence  of  mental  di^asc  regresses  he 
not  only  reaches  lower  levels,  but  frequently  reaches  levels  corre- 
sponding Vkith  his  early  infancy,  and  so  it  is  frequently  found  that  the 
delusions  and  other  morbid  manifestations  only  find  their  explanation 
when  traced  Iwck  to  the  infantile  peri<Kl.  In  the  same  way  regressions 
may  lead  I>ack  to  lower  cultural  levels  so  tliat  patients  show  .s\-mpfom.s 
that  are  only  understandable  in  terms  of  the  psychoUigy  of  more 
primitive  peoples.  The  materials  of  experience  are  used  by  the 
patient  in  an  archaic  way.  One  such  patient  with  a  ver>'  coniplitated 
delusional  system  states  tliat  he  is  the  father  of  Adam,  that  he  ha.s 
livcil  in  hi.s  present  human  Uidy  thirty-five  years,  hut  in  other  bodies 
thirty  million  yc«rs,  and  that  during  this  time  he  has  occupied  six 
million  different  bodies.  He  has  been  the  great  men  in  the  history 
of  llie  devi'lopnient  of  the  lunuan  race:  he  himself  created  the  hmnan 
race:  it  t»H»k  him  three  hundred  million  years  to  perfect  the  first 
fully  <levelopi'd  hmnan  being:  he  is  both  male  and  female,  and  identi- 
fies all  the  different  pairts  of  the  universe  with  his  own  iMniy;  Heaven, 
Hell  and  Purgatory  are  h>cate<]  in  his  lind>s,  the  stars  are  pieces  of 
Ills  biMly  which  luive  been  torn  apart  by  t«rture  and  persecution  in 
various  ages  of  past  history;  he  Is  the  father  and  creator  of  the  various 

CCS  and  elements  of  the  humau  urgauizatitm.  etc.    Here  is  a  very 

primitive  type  of  thinking  in  which  the  patient  identifies  himself  witli 

the  whole  universe  somewhat  as  the  biiby  does  ami  somewhat  as 

irimitive  man  iloes.    He  Is  quite  in  the  ]>ositiou  of  the  chief  of  some 


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IrpO- 

I 


primitive  tribes  in  wlioin  all  the  forres  of  the  iiiiivcrse  cpntrrl 
fmni  wliom  rnHintc  nil  of  these  forces  for  gci«»d  or  for  ill.  Thb  isi 
archaic  tj-pc  of  reaction  wliirh  sliows  how  deep  the  split  of  the  pcrsou 
ality  may  he.  ht»w  fuiidamentul  it  may  l>e,  and  g:ives  an  insight  inti 
the  seriousness  of  the  disease  process. 

This  archaic  type  of  reaction  results  from  represLsion,  or  in  dd 
wortis  nn  iututteritloii  of  the  libido  which  is  the  exact  o}>]Ni.site  of  ini 
is  found  to  be  the  case  in  the  niauic-depressive  psychosis.  Dtinenlii 
precox  is  an  iitirorcr^wn  /wj/rAfwrw.' 

Physical. — A  cousidcrable  number  of  precox  patients,  particular^ 
the  catati>nic  and  the  hebephrenic,  show  marked  physical  symptoim 
and  nnt  infrp<|uently  have  all  the  outward  appearances  of  lieinj;  qiihf 
ill.  They  often  emaciate  during  the  early  period  of  their  illiu'ss,  snlf« 
from  anorexia  and  insomnia,  circulatory  disturbances,  dLsturl)r<l  car- 
diac action,  cyanosis  of  the  extrenuties,  vasomotor  disorders  of  whififc 
dermographia  is  not  an  infrequent  manifestation.  Tlie  deep  reflefl 
arc  commonly  exapgerat«i,  while  the  pupila  in  thLs  class  of  cases  arv 
eliamcteristirally  widely  dilated.  Conrul^rf  seiztirrs  of  an  epilep^ 
furm.  but  more  often  of  an  hyateriform,  variety  may  occur. 

In  the  very  early  stages  of  the  disease  physical  s>7nptonis  whi| 
do  not  lead  to  the  suspicion  of  mental  disturbance  are  not  infrequ< 
Such  symptoms  as  headache  may  be  in  evidence  for  n  consideral 
time  as  may  also  vertigo,  and  Urstcin*  has  calleil  es|>ccial  attentic 
to  the  occurrence  of  gastric  disturbances.  Other  physical  <Iisturhancis 
may  also  of  cotu^e  occur,  and  if  no  adequate  foundation  can  be  fnuml 
for  them  a  mental  nripin  should  be  thought  of. 

It  is  this  t\'p4'  of  physical  illness  that  has  led  to  and  maintAitml  the 
belief  in  eliologicid  factors  at  the  hicMlierniral  level. 

The  -Vltderlialden  method  of  research,  especially  as  applied  by 
Fauscr.  lias  irulioted  the  adrenal,  the  th>Toid,  and  the  gonads.    A  nt 
ber  of  investigators  have  also  found  a  reaction  to  bmin  tissue  (cortr 

Symptonjs  of  <lisor<ler  of  the  various  vistTra  not  infrequently 
noted  in  the  prfKlromal  period  of  the  disease  and  are  treated  for  sow 
time  before  the  psychosis  is  siiffieiently  in  evidence  to  force  reeogTiiti4ii 
Kppinger  ami  Hess  find  a  tendency  to  instability  of  both  parts  of  tl 
vegetative  nervous  system  arnl  many  tif  the  gaslro-iritestiiuj.  cnnlii 
circulatory  and  cutaneous  conditions  are  ilependcnt  ui>on  disturbanc 
at  this  level.    Vagotonic  symptoms  are  not  infrequently  in  c\*id«« 
Laignel-I^vastine  records  pathological  changes  in  the  sympati 
ganglia,  notes  the  commonly  observed  fact  i)f  the  frequency  uf  deal 
from  pulnmnary  lubcn-ulnsis,  and  observes  that  the  pn'i">»x  often  hasi 
small  heart.     Many  other  abnormal  cttnditions  have  been  foinid  but 
their  ivrrelation  to  the  larger  concept  of  precox  is  not  yet  clcat^ 

'■htnit:  pHynbolfisy  of  Dvnicaiiii  Precox,  Norronu  untl  Manul  Dimamm,  Mooofnjn 
S«rii»  No.  3 

■  Die  DfnictilJn  Pn>o<ti  timl  Ihn*  Ri«llung  luru  manURti-<l«prMdvM  IrraMJn, 
u.  vrvm,  lOOU. 


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[n  tviiiicf-tioii  with  this  wliole  mattrr  uF  dcfeetive  organs  Acllors* 
ronecpt  of  the  part  they  play  at  the  psychological  level  is  lielpful.  The 
psyche  b*  the  region  where  the  final  correlations  and  integmtions  of  all 
the  reacting  levels  find  final  expression  so  that  a  badly  constructed  Uwly 
must  express  itwlf  at  the  psychological  level  in  defects  of  adjustment. 
The  correlation  of  the  ps>'cholog]'cal  syTnptoms  vrith  the  several  organ 
ilefects  is  not  always  possihle  in  the  present  state  of  our  knowledge. 

Mode  of  Onset.  Tlie  early  niaiiifi.'stations  of  precox  vary  greatly. 
As  already  indicatc<l  the  disease  may  remain  latent  for  a  considcrahle 
pcriotl.  manifesting  itself  oiJy  in  slight  dLsturbauecs,  predominantly 
of  a  physical  nature,  such  as  headaches  and  gastro-intestinal  disorders. 
In  quite  a  large  percentofje  of  cases  a  "shul-iu"  tyjw  of  character  has 
been  found  to  havr  cxiste<l  for  a  consirlerahle  period  before  the  out- 
break of  the  sjTnptoms,  xn  fact  to  have  Ijeen  a  chnract eristic  nf  tlie 
individual  before  the  break-down.  Whether  this  is  to  be  considcrcfl 
as  a  sjinptom  of  the  disorder  or  an  expression  of  the  type  of  individual 
ill  whom  the  disorder  is  possible  cannot  be  ans\vere<l  at  this  time. 

In  shari>  i;ontra.st  to  these  latent  |)eri(»<ls  the  <li.^)rder  develo|>s 
not  infrequently  with  great  suddenness.  After  some  emotional  shock 
the  patient  l)eeomes  almost  immediately  greatly  I'onfused  or  catatonic. 

It  is  quite  frequent  to  have  the  break-down  \ytr  a  slowly  progressive, 
developing  condition.  During  the  early  [»enod  the  H>-mptonis  may 
take  nil  starts  of  forms  and  may  easily  U-  mistaken  for  tyjH's  of  manic- 
depressive  psychosis,  compulsion  neuroses,  neurasthenia,  hysteria, 
hypochondria,  acute  confusion  ami  paranoid  states.  An^-thing 
atj-pical  in  these  psj'choses  should  make  one  think  of  the  possibility 
of  (lementiu  precox. 

Tlie  \  iirii'tics  of  dementia  precox  will  be  described  under  five  heads: 
L  IVmentiu  Simplex;  II.  Hebephrenia;  III.  Catatonia;  IV.  Para- 
noid Forms;  V.  Mixed  and  Atj-pical  Konns. 

I,  Danenii'a  Simpiex.  -  In  this  group  of  cases  the  origin  is  usually 
insidious,  perhaps  manifesting  it.-^'lf  only  by  slight  physical  di.'^turl)- 
ances,  such  as  headache,  gastro-intestinal  atta<rks,  by  some  irritability, 
and  perhaps  a  tendency  to  withdraw  from  the  association  of  othiTs. 
The  patient  may  .suiter  from  insonmia,  perhaps  rlisagrt-eablc  dreams, 
and  there  may  Ix^  |>assing  evidences  of  lialhicinations  and  ilrliisions. 
Tlu'si-  an.'  apt  to  U'  cx]>ressed  only  at  times,  iHTliajw  under  the  inthienoe 
of  a  little  excitement,  and  sJiow  little  tendency-  to  organization  or 
progressitm. 

The  patient  emotionally  is  more  apt  to  be  somewhat  depressed,  or 
at  lea.st  inditrerrnl,  lacking  in  i[iiiiati\e,  and  presenting  outwardly  an 
appearance  that  frequently  leads  to  tite  diagnosis  of  a  "nervous  break- 
down," ''raTVous  prostration,"  or  neunustlienia. 

Such  mild  attacks  as  this  may  be  pretty  nrll  reC(»vered  from  but 
may  re<nir,  and  one  not  infrwineiitly  finds  a  histr-ry  of  one  <ir  more 
such  iittncks  having  pn<rdcd  a  more  severe  brcakHiown. 

>  Adicr:  Orswi  Iiidniimty,  Nnv.  «&d  Meal,  Da.  Monticr«j>b,  Str.  24. 


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It  is  this  jrroiip  nf  cases  of  mild  abortive  forms.  ** former  ft 
of  the  French,  which  after  recovcr>*  from  a  "flun-\-"  or  "exo 
episoile,"  jnvfs  one  the  impression  of  "peculiar  characters."  Mb 
such  cases  are  fomui  in  the  ranks  of  the  criminals,  hoboc-s,  prostitut 
]isetnliJfieiiiiises,  cranks,  aii<]  eccentrics,  and  accurate  nmiKjies 
the  histories  in  these  cases  would  not  iiifreriuently  show  a  prveoi 
episode  which  sepnrated  a  perioti  of  relative  ertiuien,^'  In  their  lives 
from  the  period  following  of  relative  inefficiency,  in  which  latter  it 
miplit  he  jHissible  to  detect  certain  precox  residuals. 

An  analysis  of  the  life  histories  of  this  class  of  cases  shows  quite 
regularly  a  constant  tendency  to  slip  from  under  all  forms  of  responsi 
hility,  and  a  lack  of  capacity  for  any  kind  of  continuous  applieatioq 
and  inidjiilty  to  de\eliip  the  liubit  of  work.    They  characterlsticali 
re'Hort  to  (he  holm  tyije  of  existence,  are  unahte  t!>  a<lapt,  with  any 
degree  of  efTitiency  at  all.  to  complex  conditions  of  life,  and  wonder 
from  place  to  place,  occupjing  one  position  after  another  from  which 
they  are  either  dismissed  because  of  inefficiency  or  Icax-e  voluntarily, 
givinp  reasons  for  so  doing  which  are  totally  inadequate.    Such  r^Lse^ 
as  these,  sometimes  by  a  steady  prugress  l)eeome  very  greatly  dilapi- 
dated, anil  it  is  quite  snrprising  at  times  to  find  the  amount  of  deteriora- 
tion in  such  cases  after  their  admission  to  au  institution  and  to  reaU» 
how  long  they  have  gotten  on  in  the  outer  world  in  a  serious  mentally 
cri]>p!cd  c<m<lition.    Of  course  their  continuance  in  the  outer  world 
was  made  possible  only  by  their  having  sunk  to  low  and  relatively 
simple  .social  levels  that  made  little  or  no  demands  upon  thera. 

When  such  patients  as  these  get  into  situations  which  require 
ctnitlniiity  of  effort  and  constant  adjustment  and  from  which  tiiej- 
cannot  escap".'  they  not  Infn'quently  suiter  from  5C\'cre  and  more 
atnite  breaks.  This  is  seen  in  the  military  service.  Tlie  army  aia! 
the  wfixy  naturally  attract  this  wanderiag  horde  of  incffieients  who 
see  in  the  military  servit*  only  the  glitter  of  brass  buttons  and  tlie 
opportunity  to  see  tl»e  world.  After  enlistment,  however,  when  they 
are  reqnii-ecl  to  take  uji  the  grind  of  daily  work,  their  defects  soon 
(■oiiK-  into  the  foregnmnd  and  manifest  thenwelves  either  by  distinrt 
psychotic  episodes  or  by  minor  infractions  of  military  discipline, 
such  as  staying  away  fn>in  the  post  Iteyond  the  leave  granted,  or  per- 
haps more  serious  ollenws,  such  as  desertion.  Such  c^ses  when  they 
finally  come  under  observation  in  a  hospital  easily  show  lln-ir  defect. 

Many  women  of  this  t\T>e  marry,  have  children  and  alth<mgh 
looked  \\\tm\  as  "unique,"  or  *' queer,"  nevertheless  get  along  if  therr 
is  no  serious  economic  strain. 

II.  Ihbii^hrrtiiit. — This  form  of  dementia  precox  is  more  severe 
than  the  preeeding.  It.  however,  is  not  essentially  different.  Iieing 
practically  the  same  condition  occurring  with  greater  severity,  mor* 
apt  to  Ix-'  somewhat  more  acute  in  its  onset,  and  niauifesting-itadf 
ntore   jinimineiilly    by    liallni-inatiitus   and   delusions. 

TI»e  onset  of  hel»ephrenia  not  infrequently  presents  the  outw-ard 


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Bppfurances  of  a  depression  and  so  resembles  the  depresave  phase  of 
a  rnanic-ck'prcssive  psychosis,  or  perhaps  some  other  form  of  <U'pres- 
sion.  It  not  infrequently  hai)|>ens  on  the  other  hand,  thjit  the  Hrst 
appearances  of  the  disorder  are  those  rather  of  mental  (■oufusion  than 
of  ft  marked  depression.  These  early  manifestations  an'  the  methtMl 
of  reaetiiui  nf  the  imiividnal  tci  the  first  outItn*ak  of  the  CDuriiet.  He 
may  become  either  prently  deprt-ssed  or  may  be  quite  unable  to  react 
along  any  well-defined  line  and  Ijecome  quite  confused.  From  this 
Bcute  condition,  after  a  longer  or  shorter  duration,  he  settles  down 
into  a  more  stcrccttyiicd  expression  of  jisyehotic  sjinptoms. 

Durinp  these  early  stages  the  productivity  is  not  infrequently 
delirioid  in  character,  accusing  voiires  are  heard  and  rather  ilWIefined 
and  not  well-formulated  delusions  are  expressed  which  are  characteris- 
tically of  a  self-accusator>*  t.v'pe  and  in  harmony  with  the  depreasion. 
Attempts  at  suicide  not  infrequently  oeeur  during  this  jieriod. 

After  the  active  symptoms  of  the  onset  have  subsided  there  is  a 
settling  down  into  n  more  s*ereotyped  delusional  expression,  but  not 
infrequently  wtlli  a  more  or  less  incoherent  productivity  and  with 
expressions  that  sound  fantastic*  and  silly.  One  patient  complains 
that  the  sheets  stick  to  his  feet,  another  that  he  ls  the  "wandering 
planet."  Such  ideas  ap]X'ar  to  have  no  adequate  reason  and  are 
expressed  quite  disconnecteilly  frotn  the  general  train  of  thought  and 
little  or  no  attempt  is  made  to  support  them  by  logic.  One  patient, 
for  example,  says  that  his  enemies  are  following  him.  and  that  he  has 
been  killed  a  number  of  times.  Another  complains  that  other  patients 
are  tj.ving  txi  injure  him.  .\ll  of  these  statements  are  made  n-ithout 
show  of  emotion  in  a  tleeidedly  matter-of-fact  way.  Such  appear- 
ances as  these  have  1«1  to  such  descriptive  phrases  as  loo9ene.i>t  of  tba 
train  of  thowjhU  i>orerty  of  ideojf,  rtnotivna!  deterioration.  Frt)m  the 
previous  discussion,  however,  of  the  meaning  of  symptoms  it  is  known 
that  the  hallucinations  are  expre.ssions  of  the  conHiit,  that  the  delu- 
sions arc  compromise  formations,  and  that  the  apparent  incoherency 
of  the  speech  (Iws  not  nCL'cssarily  imply  an  incoherency  in  the  thought 
content.  It  is  usually  not  es[»etially  dilHciiIt  to  find  some  fairly  direct 
connection  between  the  accusations  of  the  voices  and  actual  occur- 
rences in  the  patient's  lift?.  Similarly  with  other  disonlers  of  tlK' 
sensorium.  One  jmtient,  for  example,  who  had  seduced  a  girl,  who 
bore  him  an  illegitimate  child,  saw  visions  of  his  mother  and  heard 
the  young  woman's  voice  telling  him  to  come  home,  to  go  to  work,  and 
lead  a  decent  life. 

The  jK'culiar  emotional  reaction,  the  lack  of  interest,  and  apparent 
emotional  dilapidation,  as  note<l.  is  due  to  displacement,  and  so 
it  is  perfectly  understandable  that  when  an  effort  is  mmie  to  gain 
access  to  such  individuals  that  they  show  little  interest  and  eharacter- 
istirnlly  reply  to  questions  addres.sed  tn  (]i>ieiivcring  the  reastms  for 
their  actions  by  "I  don't  know."  It  is  really  ([uite  true  that  they 
do  not  know  tiic  reasons  for  their  actions  any  more  tlian  anv  person 


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understands  thi*  roasons  for  0»c  dtffcreut  appearances  that  liavp 
to  him  in  a  dreiim.      And  thicn  ngain  these  patients  arc  so  octi 
with  thcmseK-cs  that  tliey  do  not  care  often  to  be  interfered  wit 
the  "  I  don't  know"  is  as  much  as  to  say  "  leave  me  alone." 

The  Kfii^ral  conduct  of  the  i)atient  may  als<»  be  Iistlesf>,  njMtbeti 
And  disinterested  in  cliaraeter  and  in  harmony  with  his  enM>ticim 
condition,  whtm-iis  mild  alternations  of  depression  and  of  excitenieni 
with  the  devehipmetit  of  little  |>eenliarities  of  conduct  and  sptX'ch 
show  the  nlliaiiw  Ix-twecn  this  ^^""1'  "f  fases  and  the  eatatonics. 
One  patient,  for  example,  who  thought  that  he  was  ordaimvi  t«i  pr 
and  that  bread  was  impure,  would  be  quiet  for  montJis,  and 
exhibit  a  certain  degree  of  restlessness  by  foliowinp  the  doctors 
nurses  about  the  wards  telling  them  his  troubles  for  it  few  days.  The 
alternation  may  \n-  nnieh  tmire  uuirked  as  lietwet-n  a  state  of  stupor 
and  n  stJite  of  excitement  in  which  the  patient  eats  pai^er.  strii^ 
and  tK-deek.s  himself  with  all  manner  of  trash  and  shows  outbreaks  of 
violent  an^T.    This  condition  appniafhes  much  closer  to  catatonia. 

Many  of  ihc  cases,  however,  do  not  show  that  amount  of  dilapida- 
tion which  the  previiiUft  descriptimi  woulil  imply,  wliik-  any  dc 
of  ineoherent-c  nui>'  be  seen  up  to  the  prcnluction  of  a  veritable  "  woi 
salad."    On  the  other  hand,  the  patients  may  be  found  well  oriented, 
making  outwardly  a  natural  appearanee,  being  able  to  give  a  voBB 
good  accouiit  of  themselves,  but  pre>ienting  u  grotesque  <]rlusioi^ 
system,  supported  by  Iwdhici nations  the  expression  of  which  stands 
in  rather  striking  contrast   to  the  outwanl  appearant^es.       Thi 
delusional  systems  represent  all  degrees  of  coherence  ami  it  wot 
seem  lluit  the  ability  un  the  |)urt  of  the  patient  to  formulate  a  cohf 
anri  cunsisteut  delusional  world  was  one  expression  at  least  of 
caimcity  to  react  to  the  destructive  influences  of  tlie  conflict. 

One  such  patient  complained  of  illness  on  a  train  and  told  the 
conductor  that  she  ha<l  had  a  hemorrhage.  No  sign  of  any  hemor- 
rhage was  in  evidence,  however,  and  when  she  reached  the  sanititrit 
to  which  she  wnsrenmved  nothing  abnnmuil  was  found  on  exaiair 
tion.  When  her  mother  arrivetl  shortly  after\rard  she  was  fou 
delirious.  Later,  upon  her  admission  to  a  hospital  she  was  vi 
hypochondriacal,  talked  at  length,  complained  of  attacks  of  hemor- 
rhage from  the  vagina,  which  hemorrhage  she  said  was  due  to 
assault  white  she  slept  either  by  a  man  or  some  sharp  insirumei 
l<ater  on  she  claimed  to  be  married  to  a  Mr.  O.  and  wTote  long  let! 
giving  an  acmunt  of  her  troubles  and  giving  an  account  of  tlie  hentf 
rhages  and  the  supjwsed  operation,  showing  an  extensive  deltLsiimal 
system.  She  clainiei!  to  have  been  the  victim  of  a  eriminal  o[)craUon 
perfomii-d  by  a  doctor.  She  later  said  that  she  had  been  engaged 
a  Hebrew  before  she  was  bom  and  that  at  twenty  she  broke 
engagement,  that  at  three  years  of  age  a  Catliolic  priest  requested 
of  her  oHspring  \te  given  to  that  ehtireh  for  a  elerg,\Tnan  ami 
the  Hebrew  family  consented.    In  the  midst  of  a  great  mass  of  inc 


tnor- 

ten 
tt«fl 

itoi^ 


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hcreiit  jiuuliled  deliUiioiiEl  expressions  e\'i(ien<'cs  of  a  conipensatory 
wisli-fnlfi!ii)p  <lcltLsional  system  are  found.  WJMhing  for  a  child  she 
beriiine  iniprc^imtei).  Bcinp  a  virtuous  woman  this  has  to  be  acrounlt-d 
fi>r.  She  therefore  has  the  delusion  that  she  is  niarrieil  to  Mr.  O. 
inasmurh  as  no  child  apt>ears,  a  delusion  that  she  has  had  an  nliortioii 
perforniei!  ji(iiiimt.s  for  its  ahs<Mice,  ami  as  this  is  a  friiuiiuil  oiwration 
it  was  iM'rfoniic*!  without  her  knowledge  while  she  slept.  These  delu- 
sions are  mixed  up  «ith  all  sorts  of  ideas  alxnit  the  dislocation  of  her 
variuii:,  \istTra.  numerous  lieuiorrhages  from  the  vagina,  and  a  frac- 
Inreil  skull,  etc.  It  Is  luosely  organized  and  interrupted  by  violent 
outbreaks,  reslle&iness  aiul  irritability. 

She  has  been  unable  to  adjust  to  reality,  the  effort  at  ooniiM-nsatiou 
by  delusionjil  formation  has  also  failed,  with  the  resulting  pMgressixx' 
dilapidation  of  cohei-ence  in  the  stream  of  thought. 

IIL  Cdfafmiia. — Tlds  variety  of  precox.  like  the  hebephrenic,  may 
Come  on  sndtlenly  with  symptoms  of  cnnfusinn  or  depri-^sion,  ur  may 


FiiJ.  ;iftl- — Apiwwrfiiiirf'  (if  [i.Tiii-fii  iij  r.ii ni.iiiic  6tu()-jr, 

be  of  somewhat  slower  onset.  It  is  more  ii])t  than  the  other  forms  tw 
be  of  relatively  acute  onset,  in  which  case  it  si)metimps  follows  a  suil- 
den  shock  of  a  Inghly  emotional  character.  It  is  (:liaracterize<i  more 
especially  by  a  pre(ioniinanee  of  motility  disturbances  and  tends  tu 
express  it,self  in  alleniating  conditions  of  raUitonic  stupor  and  cataionic 
rrntemrtit. 

In  the  conditions  of  ratdUmic  ttitpur  negativism  rvaclies  u  very  high 
degree.  The  p^itients  are  perfectly  initnobile,  sitting  off  in  comers  by 
themselves  or  I.Wng  in  bed  wiihnut  paying  any  apparent  attention  to 
what  goes  on  aWit  them,  are  qnite  inaccessible,  fail  to  an.swer  ques- 
tions, uufl  do  n<)l  react  at  all  to  stimuli  from  the  outer  world.  They 
characteristically  often  refuse  to  speak  at  all.  This  mutism  is  a 
manifestation  of  the  iiegati\Lsm.  He-sidcs  tliis  the  patients  often  refuse 
food,  pay  no  attention  to  the  promptings  of  tlie  hiaflder  and  the 
pectmii  which  become  overloaded  with  urine  and  fecal  mutter,  often 
to  a  serious  extent.  .Sidiva  may  lie  pennittcd  to  acennnilate  in  the 
mouth  where,  if  attention  is  not  paid  to  it,  it  may  undergo  putre- 


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fartivp  chaiipcs.  Tlir  iwtifuts  quitf  cluiniftfristicajly  show  {roifir 
theatTical  attitudiiiiziitg,  make  griiim<fs,  (m-cu|\v  {lei-ulutr  ptwti*- 
and  if  they  sj)eak  the  imKiurtivity  is  often  irifoheront  hdH  opimrr 
senseless,  with  a  tendency  to  constant  repetition  of  the  saoie  jiKny 
—/M'rifrzv*rn(mM-  which  may  also  manifest  itself  iii  the  inov«DeiU*<^ 
the  ImkIv.  burh  as  a  eimstaiit  swaying  inovenieiit  or  the  like, 

The  muscular  systeiri  may  Iw  in  a  eoniiition  of  wazy  fiti\iihti 
pennittiufi  of  tlie  molding  of  the  limbs  into  any  pot^ition  wJicti'  thf? 


->  .'t  ili-|-.-<>  .  HojuUlitA^ 


remain  indefinitely— cat/i/e;^*!/.     When  this  is  present    the  n«tM 
tend  to  show  a  nmre  or  less  hi^h  degree  of  snpgestiSjIity  aiKl  r»M»ii 
automaimn ,  diuiiK  meelianically  and  in  a  perfectly  automatic  n 
tlwit  which  they  are  coinmamlcfl  to  do.       This  Mif^j^catiliilitv 
it-self  further  in  rrfiiiluUii,  tlic  it-jietititHi  of  words,    or   phrHM 
are  addressed  tn  theni  or  that  they  hear  others  speak,  and  rrht 
the  repetition  of  movements  which  arc  made  in  their  f>rps**nf:v. 
the  other  hand,  there  may  Ix-  a  marked  .degree  of  mttjtctitar 


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I 


It  |»atipi»t  maintftining  f\\pf\  attitudes  with  thp  muscles  thrnwii  into 

(•^mriitiim  I'f  nj,'i<l  nititnictidn.  Tlie  hinlis  ami  \mi\y  jin*  stUY  ami 
ii]iinnl>ilf  and  resist  any  rlfiirt  iit  hciKtin^'.  t'atients  in  this  coixlilioii 
positively  aegativistie,  withdntwiug  from  itll  Hppruaelics,  n^fusing 
ny  co6p<'ratit)ii  with  the  nurse  in  uttem|)ting  to  dress  or  undrens  or 
'eeti  them,  and  sfiow  a  tendency  to  react  by  doiiijf  the  oppiwite  of 

hat  h  expected  of  them,  lu  thU  eondition  of  stupc>r  the  patients 
may  appear  to  be  quite  disoriented  and  have  no  knowledge  of  what 
is  guinK  on  aiwut  tliem.  If  they  are  watched,  however,  they  may  be 
seen  at  times  to  show  evidences  of  paying  attention  to  their  envimn- 
nieiit.  and  not  infn^quently  whrii  the  stii[Mii'  passes  they  an'  able  to 
give  a  fairly  giHxl  aceount  of  the  things  that  happened  during  it,  but 
show  nil  ea[w<'ity  fur  explaining  their  strange  conduct. 

In  the  opposite  condition  of  vaintvnic  excitrmnit  there  are  marked 
degrees  of  activity,  constant  talkativeness  and  noisiness,  ^nnetimes 
<k'strueti\e  and  impulsive  tendencies  manifested  by  breaking  windows 
or  attacking  those  about  them,  but  in  general  showing,  as  docs  the 
speech,  a  markeil  lack  of  coherence.  lioth  the  pri)duetivity  and  the 
actiWties  of  tlie  patient  fail  to  show  any  clear  goal,  Jillhnugh  .simie 
patients  show  what  very  closely  approaches  to  the  flight  of  ideas  of 
the  niatiic.  Catatonic  excitrnicnt  may  reach  a  ven,"  high  gnidc,  mani- 
festing itself  by  wildly  delirinid  reactions,  constant  motor  unrest  and 
sleeplessness,  a  rapid  failure  in  nutrition,  a  veritable  vUitus  catatonias. 
Some  of  these  eutatnnie  cases  show  liysteriform  or  epileptiform  seizures, 
ami  <ieath  (wcasionally  results  in  these  higher  grades  of  excitement. 

The  chronic  conditions  tend  to  show  wclUletincd  maimcrisms,  such 
as  the  jH-ndiar  attitudes  of  the  IxMly.  esperially  clumsy  ways  of  hniditig 
the  sjKion  or  the  fork  in  eating,  meaningless  grimaces,  odd  ways  of 
walking,  such  as  sliding  the  foot  back  and  forth  two  iir  three  times 
before  stiirting  tiif.  and  other  ceremonials  fur  initiating  movements. 
They  are  chararteristicully  stitf,  awkward,  dunisy,  and  inan-essible, 
ami  usually  indilTereiit  to  their  surroundings,  and  apparently  eniotion- 
atly  dull,  though  given  at  times  to  euiotional  outbreaks  without 
apparent  cause.  All  of  theae  psyeliieal  s.Mnptnms  of  course  must 
be  considered  as  having  some  psychological  meaning.  In  harmony 
with  what  has  been  said  l)efore  both  the  types  of  increased  suggesti- 
bility ami  catJitouic  rigidity  are  ways  of  shutting  out  the  world  of 
reality,  whereas  the  peculiar  automatisms  can  sometimes  be  traced 
to  their  meanings,  as  in  the  case  before  mentionetl  of  the  young  woman 
whfi  kept  constantly  jwutrding  her  hand  with  her  rlenchcfl  fist. 

I'hifttical  Sifmp1o7>is.~T\\t'  general  apiH-amnce  of  the  catatonic  forms 
of  precox  indicate  raorethan  tn  the  other  varieties  thepreseuceof  definite 
somatic  accompaniments.  Kxnggeratton  of  the  tendon  reflexes,  lower- 
ing of  cutaneous  sensibility,  vasomotor  disturbances,  eohl  and  cyonoscd 
extremities,  xvidely  dilated  pupils  disturbances  of  secretion,  and  loss 
of  weight  are  frequently  obsen'cd.  it  is  this  gn>up  of  cases  that 
have  led  most  distinctly  to  a  toxic  theory  of  etiology  and  caused  the 


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precox  cases  to  be  thought  uf  in  uumection   with  diaturlarKts  J 
metabolism  dm:  to  dmiiges  in  the  iiiUTiuiI  .secn-tHiriA,' 

l\'.  Paratiuid  fonn.i.—  \n  tlir  (laraiioi*!  cases  tlierc  ia  a  mufii  »w 
efficient  effort  al  creating  a  aihcreiit  an<\  JiifOfJiHy  f*>riiie<1rtl  ^r^ 
of  ilehisimis  Hiici  Hssoeiatetl  hallminations.  In  tlic^if  i-a-«->  tlt^n  - 
much  less  nutwjtnl  eviileitce  of  the  (lilaptdation  utuj  trinntiiHial  luU- 
fcrcnce  tliat  huve  le<i  t«i  the  Iielief  in  the  prcstMitf  c»f  »  prnniwtii 
mental  impairment,  a  tlementiH. 

These  rnitieiits,  origiiuUly,  many  of  them  ut  le»^t,  were  pruupni 
with  tlie  ()ariim)ia>.  but  umlcr  the  infiuenee  of  Kraepc'lin  tJifll  zp**? 
of  paranoid  conditions  tt'liich  sliowx-d  a  trmlency  toward  proprw^ 
deterioration  were  included  in   the  dementia    precox    o(iLssi6iatiia. 


Fill.  3iHi  — Dctni'tiliii  iiienjx:  iniiiirK'riMii. 


Fta.  307. — Dftt»«nUa  pn«as: 
mniiiiprwn. 


All  degrees  of  intervening  possibilities,  however,  m-cur.  s»>  tluit  one] 
get  a  fairly  wetl-knit  di-hi:f>ioiml  system  in  a  patient  who  detent 
quite   rapidly,    whereas   other  patients   maintain    their    intdl 
integrity  over  a  ixriod  of  years.      The  dflirc  chron;(|iie  of  Miienan 
generally  considered  to  be  dementia  paranoides,  and   this 
ca.ses  in  general  have  (hh-ii  retrntly  inrhided  by  KruepelJD  ti 
designation  of  itamphrnim.     Some  authors  tinlay,   more   imrtici 
Bleulcr,  are  ine!ine<l  to  think  that  ]H'rhaps  the  so-callc'd  tnie 
are  only  attenuate^l  forms  uf  dementia  prectix. 

The  delusional  system  in  these  cases  must  lie  concv^ived  ns,  « 
promise  fonnation  and  as  essentially  wish-fulfiling,  and  is  rburati 
tically  sexually  c-oloretl.      One  such  patient,  a  uiiddle-n^^]  wi 


■  MtilTp:  Dr-mentia  Precwx  wad  the  VacMatlvo  Nervou»  SyHtom. 
May.  IVt7. 


N.  Y.  MkU. 


'^■^V>' 


Mdt>B  Of  6NSSr 


m 


I 


was  persisU'iitly  pyrserutcd  by  a  man  who  awiised  her  of  leading  an 
iininnrni  life  to  siu-h  nn  extent  thiit  t^he  filially  went  to  n  physieian  to 
Ik-  rxuiniiuul  to  prove  her  \'irjtiniiy.  .Ml  surl-s  uf  vulj;ar  remarks  were 
constantly  made  about  her,  sbe  was  referred  to  by  the  voices  as  the 
widow  of  this  man.  The  patient  was  a  devout  Catholic  and  the  man 
was  a  I'rotestantf  a  perfectly  understandable  rea-son  for  n  severe 
emotional  coiiHict,  which  in  her  delusional  system  unloads  itself  upon 
the  man  rather  than  acknowledging  its  true  origin.  This  whole  ci>n- 
Ifllct  arose  at  the  time  of  the  death  of  her  brother,  and  it  is  signHit-ant 
that  in  her  delusions  she  l>elieve<i  that  she  had  received  letters  accusing 
her  of  ince?^tu()iis  relatiiuis  with  her  brothers,  of  having  l>ecoTne  preg- 
nant by  them,  and  of  Jestrojing  the  pregnancy.  These  letters  were 
addrcsse*!  to  her  as  tlie  wife  of  her  scvcrjil  brothers.  Here  one  sees 
an  infantile  determiner  for  the  delusional  system  In  the  love  which 
she  entertained  for  her  brothers  and  which  later  was  transformed, 
under  the  iufiuence  of  the  conlliet,  int<i  delu-sions  of  an  incestuous 
nature.  Finally,  there  was  a  whole  crowd  of  people  who  were  conspir- 
ing against  her  and  whose  object  it  wa.s  to  kill  her.  Such  dehksiimal 
sj'stejns  can  without  much  ilifliciilty  Ijc  seen  to  lie  expre-ssions  in 
distortetl  form  of  the  eonfliet.  She  has  never  been  able  to  get  away 
from  her  infantile  attachment  to  the  members  of  her  family  and 
estflblish  herself  upon  her  own  feet,  and  these  attachments  hold  her 
bock,  protiuce  a  withdrawal  fn>m  the  outer  world,  n  regression  into 
the  wurld  of  phantasy,  with  a  tendency  towanl  what  nmy  be  termed 
psychic  death,  or  an  absolute  lack  of  efficient  reaction  to  reality,  and 
this  is  sjTnlMjlized  by  the  gang  of  persecutors  who  are  bent  uiwn  her 
destruction. 

V.  yfixed  and  Atypical  Stateg. — .Ml  of  the.se  forms  of  dementia 
precox  so  far  de-scrilied  are  stmply  variants,  in  accordance  with  the 
prestMit  view-point,  of  one  disease  trenil.  and  so  it  is  not  strange  that 
it  should  be  found  that  there  are  no  hard-and-fast  lines  si*[>amtiiig 
one  frtMii  the  iither.  In  couset^uence  it  is  not  infrecpient  to  see  transi- 
tory or  mild  motility  disturlMinces  in  cases  that  are  essentially  hebe- 
phrenic, or  to  see  fairly  welKleiiiied  paranoid  delnsioiial  Formations 
In  either  the  helwphrenic  or  the  catatonic  varieties. 

As  to  the  atypical  forms,  there  has  been  mentioned  and  described 
under  dementia  simpkx  the  larvatwl  and  abortive  types,  the  "formes 
frustes."  These  are  probably  much  more  freciuent  than  onlinarily 
supposerl.  Tor  example,  Wilmanns,  in  a  study  of  127  vagalxjnds, 
found  (ill  ca>es  of  dementia  precox,  while  undoubtedly  it  Is  not  Infre- 
quent for  these  alxirtive  forms  to  be  considered  as  cases  of  constitu- 
tional defect.  This  ilitficidty  Ix-comes  very  much  more  aggravated 
when  it  is  remembered  that  attacks  of  dementia  precox  may  occur 
in  childhood,  according  to  V'ogt  as  early  as  five  years  of  age,  while  a 
little  later,  nearer  to  the  period  of  puberty,  they  are  not  so  uncommon. 
In  these  cases  of  course  mental  development  is  interfered  with  ami 
remaining  upon  a  lower  level  gives  the  impression  of  imbecility.    The 


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DEMBSTIA    PHSroX   OUtH'F 


1 


»aim'  rlifBciilty  urises  in  »  wtncwliiit  Hggrnvatcl  form  when  dcniel 
pretox  dcvfiops  in  jouiip  persons  already  of  <Jtfe<;tivc  iQskc> 
Herp,  of  counw,  the  differentiation  is  no  longer  poAsible,  be<vii9 
must  l>o  realized  that  both  conditions  of  defect  and  precox  are  pfl 
in  the  ■fn.uw  individim].  ■ 

Pathology.— Thertr  is  a  eonsi<lenihle  [Mithologj'  of  precox  wt 
however,  is  not  always  clearly  airrellateil  with  the  clinical  pictl 
It  is  pn.)lwhle  tliat  during;  the  life  of  the  inthvidual  disturbances  t 
are  .shown  in  the  general  phytiieal  inanife:>tation^  of  the  (li.s(*aso  oc 
at  the  hiiH'heniieal  level.  HcjciniiiiiK  degenerative  ehunge^  in  ' 
veftAeU  are  .sometimes  found,  and  tuberculosis  is  quite  frequent,  bui 
easily  understandable  as  lieing  dependent  upon  the  general  loirei 
physictil  roiwlition  and  iiiaetivity  of  these  patients,  (tiuple«i  with  th 
Itad  habits  and  the  necessity  of  their  rather  close  confinement.  Si 
changes  as  are  found  in  the  iierxe  cells  are  of  a  degenerative  cbaract 
with  evidences  of  neuronophagia  and  with  perliai>s  amcliuid  glia  ce 
The  acute  cas*rs  of  catatonic  excitement  which  end  futally,  the  so-oUl 
<'atatDnit-  "Iliriit<Kl."  show  a  certain  atnount  of  evi{lencf  of  degenei 
tifni,  more  particularly,  however,  evidences  of  a  chemical  imti 
the  form  of  certain  lipoid  elements  in  the  eoncx,  which  seem 
products  of  disintegration. 

Southard  has  found  certain  anomalies  in  precox  brains 
ap|>ear  to  he  of  the  nature  uf  aplasias  or  ageneses.  These  agene 
or  aplasic  areas  appt-ar  to  Ix-  gronpeil  more  or  less  in  corresiwnden 
with  the  three  main  types  of  the  disease.  The  frontal  region  is  clmn 
teristically  involved,  while  he  ha.^  described  a  cerebellar  group  con 
sponding  to  the  catatonic  variety,  while  the  profouml  emotion 
disturbanL'Cs  he  thinks  are  due  to  le^iions  in  the  deep  layers  of  t 
cortex  which  have  no  direct  motor,  sensory,  or  perhaps  associatioi 
relations. 

Kature  of  Dementia  Precox.— Kroni  the  description  of  demenl 
precox  up  to  this  point  it  will  Ix*  seen  that  it  presents  corTelidions  i 
the  one  hand  to  the  more  distinctly  so-called  p.sychogcnic  types 
disonlcrs,  such  as  the  jisychoneuro-scs,  and  on  the  other  hand  to  tJ 
more  <listinctly  somatic  disca.s*-s.  It  has  lK*n  seen  that  it  wits  |hkeu1: 
to  fonnulate  all  of  the  mentid  sMnptoms  in  the  same  way  that  tb 
arc  formulated  in  the  psych onenri>si'S.  In  other  wonis,  the  meiit 
symptoms  are  capable  of  hiterpretation  solely  at  the  i>sychologic 
level.  On  the  other  hand,  for  an  understanding  of  the  whole  disea 
process  it  must  not  he  lost  sight  of  that  recent  investigations  are  tendii 
to  show  more  and  more  that  there  are  distinct  biochemical  disturbanc 
during  life  and  pathological  changes  are  being  found  after  <Ieath. 
any  case  the  acute  cases  that  lead  to  death  must  he  conceiveil  a.s  littjn 
profound  bodily  changes  correlated  with  psyeliic  sj-mptoms.'  M 

>  Jnos:  PayntiUaKy  of  IMmratia  Precox;  S|>icti<;)n:  Aaatyais  of  s  Cm«  uf  Deiufo 
PtMrnx;  BinRwnngor:  Domeatiii  Precox.  Bee  AbwtrftcU  in  Riychooi)iil>Uc  Ho%'ipw,  << 
ii,  iti,  iv. 


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Occosioimlly,  however,  they  are  very  pruiHJUiK-etlly  eniphasi 
r!in)nic  patient  who  had  heen  for  many  years  ia  a  hu.spital,  ' 
(iuily  at  out<UH)r  hiUtr,  was  smMeiily  seiv-ed  nith  a  violent  im 
which  he  attaeked  all  about  him.  lie  seized  a  In-avy  irini  ba 
two  people  and  injured  another,  and  ran  head-long  and  wildj 
direction  into  the  wiwds.  He  was  finally  cornere*!.  aiul  in 
of  securing  him  he  was  shot  by  a  farmer  with  a  hiaiJ  of  bucks 
of  whieli,  however,  pi'uetratetl  farther  than  through  the  sh 
prodneed  no  serious  woundts.  He  was  brought  baek  to  the  b 
iiieolierent,  mumbling  and  trembliug,  showing  all  the  e\it]cnc 
tremendous  emotional  upset.  Ths  shot  were  picked  out  of  hi 
the  wounds  were  dressed,  and  he  was  put  in  bed.  Vp  to  ihat  i 
had  bfcn  a  stronp,  physically  healthy  negro.  He  never  left  I 
again,  ami  approximately  a  jfar  afterward  he  died,  huviug  de\ 
an  acute  tuberculosis.  Such  cases  as  these  denu>n.^trate  tlte  ne 
of  considering  the  human  N'ing  as  a  unit  aud  not  endeavoring  t) 
Iijird-ancl-fast  lines  of  distinction  between  the  mind  on  the  ^ 
and  the  Ixnly  on  the  other.  ™ 

In  the  present  state  of  knowledge,  however,  one  is  often 
to  make  any  specific  correlation  Ijctween  the  ph>'sical  findiuj 
the  mental  symptoms,  while  on  the  other  hand  it  is  quit*  p 
to  express  the  s\mptomatoli>g\-  of  the  di»i^Hse,  to  desctribt'  it.  to 
speak,  reconstruct  the  psychosis  purely  in  psychological  terms 
the  present,  therefuiT,  tlie  disea.se  must  be  described  psycholog 
luml  the  ex])lanation  of  the  mental  symptoms  must  be  sought  p 
genetically,  without,  however,  forgetting  that  there  are  certain  at 
changes  which  are  pretty  generally  attached  to  the  s\'inptoma 
of  tiie  disease  process  aud  which  must  ultimately  be  made  to  fi 
the  general  nibric  before  a  complete  understanding  of  the 
situation  is  )ia<l. 

On  the  psych<>logieat  side,  then,  dementia  precox  is  seen  to 
certain  tyjK*  of  n-action  to  a  mental  cuufliet.  resulting  iu  o  spl 
of  the  psyche  and  the  outcrop  of  niietMi:?<'ious  mental  trends  ( 
surface  t>f  the  mental  life.  The  patient  is  confronted  with  a  siti 
tn  which  he  cannot  adetpmtely  adjust,  which  is  absolutely  ina< 
able  and  hupossiblc,  and  he  is  therefore  driven  away  by  his  inca] 
to  assimilate  it  and  t^st  hack  upon  himself.  The  battle  of  tlie  op| 
forces  produces  the  disea.se  picture  which  is  the  outward  evidei 
tlie  effort  on  the  port  of  the  Individual  to  reach  a  solution  c 
difficulty.  The  symptoms  are  the  result  of  the  appearance  of  the  u 
scions  trends  distorted  and  disguised  as  they  are  iu  dream  formft 
Jung  has  es|)ceially  notc<l  this  similarity  to  the  dream  stale  and  i 
consider  precox  as  a  sort  of  waking  dream  or  dre-am  from  nhuj 
patient  does  not  awake,  the  dream  picture  being  fixed,  as  fl 
by  another  element  in  the  situation,  the  toxin  for  the  sake  of  H 
solely  may  be  said  to  act  like  the  fixing  agent  in  the  photogr 
process.    It  is  seen  that  the  eoneeption  of  the  discuse  as 


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lie  hepiiiiiii};  and  rututamfti tally  a  dementia  must  be  inoctifte<l.  if 
by  ilenieiitiu  is  nwaiil  a  permanent  mental  impairment,  a  mental  loss, 
vvltidris  thought  of  in  tlie  same  trrnis  as  a  h»s.s  of  tissue  from  a  wound. 
It  would  apiK'iir  from  the  ilescriptioii  of  the  niifrlianisms  ttiat  have 
\M,'vn  (jjiven  that  at  least  In  the  early  stajjes  of  tlieilisease  there  is  nothing 
at  all  wjrix-siJimtling  to  such  a  pennauent  l(*ss;  that  what  lias  liap^K-neil 
has  l»een  a  (Ushitegration.  a  falling  apart  of  the  component  |Hirts  of  the 
sydie  and  a  sliifting  of  relative  positioits,  mure  piirticuhirly  a.  sUihUig. 

for  to  use  the  technical  term,  a  (lisplacemcnt  of  the  emotional  euntent 
)f  C'ertain  idea  constellations.     The  dementia,  therefore,  which  has 
?n  descrilied  as  such,  is  at  least  to  this  extent  a  misnomer.     From 

[the  point  of  view,  however,  that  this  d  Is  integration  and  resuliinj; 

[Impairment  h  either  permanent  or  tends  to  be,  it  has  a  meaning. 

The  psycholoj;J3al  side  of  the 
situation,  however,  as  may  be  seen 
is  not  all.    There  are  certain  physi- 

[cul  changes  hi  the  course  of  the 
disease,  and  ct*rtain  pathological 
findings.  So  far  as  the  obser\a- 
tion  goes,  however,  tlie  etiological 
factors  lie  almost,  if  not  cpiite  en- 
tirely, in  the  mental  sphere,  and 
one  must  therefore  coneeive  of  the 
physical  oliaiijp's  as  suiHTathleil. 
This  is  a  ]W)ssihi]ity  whieh  was  well 
illustrated  hy  the  ease  alrendy 
quoted  of  the  man  who  dieil  after 
u  tremendous  emotionid  expj«su^n 
during  which  he  killed  two  jieople. 
When  the  psychic  splitting  is  pro- 
fcmnd  and  when  it  is  of  considerable 
duration  it  is  quite  understandable 
that  it  should  unloose  bits  of  physio- 

Krgicitl  mechanism  and  thus  jmnliKV  the  physleal  changes  found.  From 
the  descriptions  of  the  meehanisins  in  the  psyehoiieiu"«scs,  taken  in  con- 
nection with  the  discussion  of  the  vegetative  nervous  system,  it  may  be 
seen  that  constantly  operative  ps>'cliic  disturlMinees  are  capable  of  pro- 
ducing the  physical  changes.  Compare  ( 'rile 'a  study  of  the  emotions  and 
f 'annon's  work  on  the  relation  of  anger  and  fear  to  the  gastro-intestiiial 
functions  where  it  may  Ixr  seen  that  both  surgeon  an<l  physiologist 
ar<?  forced  to  put  the  psychic  factor  in  the  foregroumi. 

Ways  of  Oetting  Well.  —With  the  concept  of  tlie  disease  pr<»cess  which 
has  been  pre\iously  elaborated,  what  is  the  significance  of  the  three 
main  t>Tjes  of  precox  winch  are  found  cHnicidly?    IJertsi-htnger'  has 


1'.^ 


Vi...    '.'.>'' 
in  fii-v.;.    .1  I 

foe  j'ftirrt.  till 
comer  of  tli«>  ward. 


111  til  n-Rrfs-ititi.  Thi*  iit- 
liiii^iueJ  iinMt  of  tliB  lim« 
jiaiii^dt  ftcpkins  lliP  (Inrkesl 


'  HHImiiiN^-nrtc^nirL'  hri  Srliitr)phreTU.'n,  Alin.  Ztschr.  Psj-rbiat.,  Band  Uviii,  H«ft  2. 
TniiLxUlod  in  l'»)-'-tii>auiUytio  R«viow.  April,  191(3,  iii.  No.  2. 


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recently  nimk:  an  adiiiirnble  study  of  the  prtx-i-ss  of  rvctyvcry  in  | 
Hiid  )iis  ili>i-iisslnii  (if  tilt-  imtiin*  (>f  ttie  uciiiflitrt  ami  the  way:iof'nfljusti 
is  piLTtlculurly  itluttiltiatinK. 

The  three  dniieal  types  i>f  the  disease  are  the  expression  of  tlw 
interpl;iy  of  the  two  fuetf^rs,  the  cimtlict  and  the  reaetion,  the  seve 
of  the  former  and  the  efficicitcy  of  the  latter  determining  the  outcoi 
in  the  individual  ease.  The  depree  of  confu>iion  in  tho  niTute 
would  then  lie  an  exjiression  of  the  ooinpleteness  with  wliicli 
patient  was  driven  hack  from  reality  and  the  <lomimincc  of  tlif  uncnn- 
scious  trends.  ('iin<liti()ii*  of  iinxlerate  etm/iision  with  rapacity  for 
adequate  n-aetiun  to  reality  at  times,  or  wuler  the  :^pe<:ial  stimuli  of, 
for  example,  questions,  show  that  the  patient  still  has  a  certain  gri 
iilMJUthe  real  world  and  is  making  an  effort  at  least  to  retain  it.  C'crlat 
other  cases  of  (|uite  clear  coiis<:iousness  with  amiplete  orientntiun  &ltu 
a  very  adeipuile  jijrasji  upon  reality,  and  these  pitticnts,  to  the  c 
observer,  often  seeiri  quite  natural.  In  such  patients,  however,  on 
will  notice  interferenw  of  tlunight,  hesitatiaiL"*  in  the  course  of  cimve 
sations,  stutterings  and  staninierint^s  over  certain  points,  the  evidencni', 
in  otlier  words,  of  complex  interferences,  and  the  patients  will  conipluJni 
that  from  time  to  linie  their  minds  seem  to  be  absolutely  blank. 
'I'hi'si'  nahatftrij  associntumx  an^l  thimght  (leprimtioiiA  iivv  the  eKjjressions 
of  reactions  to  buried  complexes,  so  that  in  these  patient-s  there  is 
fairly  adeqtiate  griLsp  iijmmi  reality  for  urdiimr;*'  jmrpiises  at  least,  v\ 
only  spasnuKlic  infhiemvs  from  relatively  restricted  areas. 

In  pfiierul,  then,  the  hebephrenic  t>*pe  may  be  seen  to  be  a  reaction 
to  the  a)nriict  wliich  ts  es.senttnUy  inadequate  an<l  litt'fficient.  In  the 
acute  stages  the  patient  may  be  al>solutely  overwhelmed  hy  the 
conHict,  disoriented,  and  confused.  I^tcr  on  the  proj^rrssive  disiuUr- 
jiH'ation  and  dilapidation  of  thought  indicates  the  slowly  pro^jevsivc 
conqnerlu);  of  the  wipaeity  for  adjustment  to  reality  by  the  inva^rm 
iiitit  consciousness  of  the  untsmscious  tnmds. 

The  catatonic  tyiie  rejiresents  a  somewhat  different  fonn  of  pcaction. 
Hen;  tin"  patient  is  oftentimes  suddenly  overwhelmed  by  tlie  contlict. 
as  un<ler  circumstances  of  accident  or  su<iden  and  severe  shock.  No 
attempt  at  adjustnient  is  made  at  first,  but  the  whole  situation  is 
actively  and  definitely  shut  out.  Here  there  Is  an  active  effort  on 
the  part  of  tin-  individual  to  exclude  the  offending  tendencies,  and 
when  this  sutHveds  rccuverj'  takes  place  as  tlie  result,  so  to  speak,  of 
the  encapsulation  of  the  objectionable  material,  and  its  exclusion  tnan 
con.sciousness.  This  form  of  the  disorder  is  the  most  acute,  and  the 
recovery  is  equally  nmst  apt  to  be  prompt,  ami  it  will  be  seen  from  this 
exp[aitat)4>n  why  this  is  so. 

In  the  paranoid  form  of  the  disorder  the  reaction  is  much  marc 
efficient  than  in  the  heliephrenic  variety,  and  in  some  respects  less 
eflicient  than  iu  the  catatonic.  Here  the  individual  takes  n  flight 
into  a  psycliosis,  and  the  delusions  are  the  expression  of  a  coDipmniisc 
between  the  opposing  psychic  trends.    Unable  to  live  in  tlie  peal  world, 


IIIS 

1 


I 


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thf  pHtieni  suecpetJs  in  inventing  n  worM  in  which  lie  win  live,  and 
haviiifT  invented  it  he  suiTeeds  in  getting  along  fairly  well  without 
nntireable  deter ionil ion.  The  eonlliet  in  these  rases  temU  ti»  In-conie 
trtalkniary  iiFter  the  tIe\elopment  of  the  delusional  world. 

Bertschinger  has  more  espt^cially  define<i  the  ways  of  pelting  well 
by  pointing  out  that  the  patient  in  recovering  may,  as  the  result  of 
his  cunfliet  to  whieh  he  oannot  adjust,  find  a  compromise  by  changing 
himself  and  interpreting  the  world  of  reality  in  terms  of  bis  niorliid 
phantasy,  or  by  tronshiting  the  world  of  his  phantasy  into  tenns  of 
external  experience.  And  so  one  would  find  on  the  one  hand  delusions 
of  grandeur  which  ar*^  u  eonipromisc  formation  and  serve  to  change 
tlie  individual  s<»  that  he  may  l>e  better  satisfied  with  life,  and  on 
the  other  hand  one  finds  delusions  of  persecution,  the  delusions  of 
influence  from  the  outer  world,  that  serve  to  change  the  outer  world 
in  conformity  with  the  jMitient's  complexes.  These  outside  iiJlnctn^es 
arc  but  the  reflections  l>ack  upon  the  iwtient  of  his  failures  to  get  friwn 
the  world  what  he  wants,  and  they  are  con.sequently  felt  as  malign 
and  destructive  inHuences.  Another  methwl  of  getting  well  is  that 
already  described  of  the  catatonic,  the  shutting  out  and  encapsulation 
of  the  conflict  in  a  circnmscriljed  amnesia. 

In  many  cases  conversions  into  bodily  symptoms,  such  aa  are  found 
in  hysteria,  are  found.  Another  Tnethu^l  of  getting  well  is  by  living 
through  a  series  of  imaginorj'  experiences  which  brings  the  complex 
to  a  logical  conclusion.  For  examjile:  A  young  Japanese  woman 
was  overwheluned  by  tlie  aad  news  that  five  members  of  her  family 
had  been  killed  in  battle.  She  passed  instantly  into  a  dreamy  state  of 
consciousness,  went  on  with  tlie  work  of  the  household  just  as  if  all 
five  were  members  of  it,  made  their  beds,  set  their  places  at  table  and 
acted  in  every  way  as  if  they  were  alive  ami  present.  Fimdiy  .she, 
so  to  si)eak,  let  one  nf  them  die  ami  tlwn  another  and  amrther  until 
finally  she  had  cumiNissed  the  death  of  all  five,  after  which  she  awoke 
from  her  dream-like  state  and  was  well.  .She  had  snceeedeil  in  an 
efficient  reaction  to  the  .situation  by  its  attenuation,  extending  it  over 
a  considerable  period  of  time.  I-'inally,  a  certain  numU^r  of  patients 
get  well  by  the  final  domination  of  the  reality  motive,  with  a  resulting 
correction  of  their  delusional  phantasies. 

Course  and  Progress.— As  will  be  «'cn  from  the  description  of  the 
tliseasc  the  catiitonJe  form  is  more  apt  to  be  acute  in  onset  and  it  has 
the  best  prognosis,  while  the  hebephrenic  form  and  the  simple  dement- 
ing varieties  tend  to  prof^'s-*ive  deterionition.  and  the  paranoid  form 
tend.s  to  remain  stationary  without  material  ileterionitiim.  A  few 
of  the  heliephrenics  get  well,  more  of  IIk:;  eatatonics  recover,  but  all 
of  thi'se  cases  are  liable  to  recurrent  atta''k3.  According  to  a  rei-ent 
Istudy  of  ZaWocka'  of  olo  eases,  (iO  per  cent,  proceeded  to  light,  18  per 
I  cent,  tti  medium,  anil  22  per  cent,  to  severe  deterioration. 

'  S£ur  ProjtniM(<»tcIlun4[  bei  tier  UemmUa  Pr?Doi,  AOk-  Zun-lir.  f.  PiijThial.,  Bvod  liv. 


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DEMENTIA  PRECOX   GRfiVP 


In  the  catatonic  cases  that  recMver  thepp  is  usually  an  ap[>mirit 
ulmnjce  in  tlio  iodi vidua !.  Tlie  encapsulation  of  the  conflict  moB 
that  the  recx)very  has  taken  place  hy  a  sacrifice  of  n  c^rtnin  ptftka^ 
the-  |K'rsonaIity.  The  portion  of  tlie  i^ersoiiality  in  whirh  the  owfc 
is  resident,  so  to  speak,  has  had  to  be  cut  out  or  wulleO  otf,  uk)^ 
energies  from  this  region  are  no  longer  available  Ijy  the  intfinW 
This  loss  is  quite  characteristically  shown  in  certain  elianpTv  <i  ^ 
aeter.  indicating  that  the  individuRl  has  gotten  well,  but  ha*i»iil« 
certain  prii^e  for  that  result. 

The  eases  tliat  do  not  get  well  tend  to  regress  to  Iowtt  fc\*rk  w 
quite  characteristicailly.  in  institutions  at  least,  they  finally  rp»fk  i 
level  on  whifli  tliey  {!an  inaiiitaiu  themselves  without  sinking  furtM 
In  this  condition  they  ifnialn  stationary  for  long  periods  trf  tiit? 
Quite  often  patients  brought  to  an  institution  in  a  ver>'  much  d'wlurir; 
condition  settle  (h>wn  quite  promptly  under  the  simpler  eonditini 
of  institution  life,  whik  in  the  outer  world  the  precox  cas<  -  ■ 
gravitate  inti)  the  ranks  of  the  hobo,  the  prostitute,  and  ii 
criminal.     Here  they  finally  find  their  level  and  get  along  after  a  in-^hKic. 

Acute  and  severe  grades  of  regression,  in  which  the  splitting  ggr*io 
the  \'er>'  foundation  of  the  |iersanali^,  often  cx|ires5es  thenr*!"^ 
by  suicidal  attempts  and  stmietimes  by  homicidal  attempts.  ~ 
preparation  for  .siieh  attempts  may  sometimes  l»e  foreseen  in 
dreams. 

liemissioQS  are  quite  the  rule  and  come  about  under  cinniin.si 
which  reanimate  the  conflict.  Often  patients  get  along  ver>-  wdLi 
an  institution,  but  become  upset  shortly  after  going  luc-k 
conditions  under  which  the  coiiHiet  developed.  This  is  e8{Kfinll 
Ilertschinger  has  shown,  if  the  conditions  to  which  tlie  pat 
returneii  have  materially  changed  during  his  internment.  The 
does  better  if  returned  to  a  home  that  has  reniained  roniiw 
unchanged.  If.  on  the  eontrary,  the  family  has  n)o\>^I  into  ii 
neiglilmrhood.  acrjuired  new  associations,  ur  if  a  parent  ha.s  dieij  mraa 
time,  conditions  rcrpiiring  new  adjustments  on  the  part  of  the  p«tin4 
he  may  not  be  able  to  meet  the  demands  and  so  rcUpses. 

The  ways  of  getting  well  show  that,  for  the  most  part,  the  metb(4 
(if  Healing  with  the  wmflict  is  the  opposite  of  that  in  ihe  cxtm\Tr90« 
tyiK  of  psychosis.  It  is  the  methiHl  of  introversion  that  demamU  tt»t 
the  individual  change  in  conformity  with  the  demamls  of  the  eom|)lei. 
the  delusional  system.  Tliis  methtxl,  because  It  involves  u  (light  ami.*" 
from  rather  tlian  into  reality  is  a  iletemiiuing  factor  in  the  nialignuKy 
I'f  the  pre^-ox  tyiie  of  reaction. 

The  com^'  of  the  disease  is  irregular  and  pre«lic"tion  is  quite  impo*- 

•'il'lr.     In  a  gr'ueral  way.  hnwever.  one  gets  clui*s  fntni   kerpioi;  in 

,,.;.. .1  tit-  fiit-t  that  the  c(mfli(-t  is  Ix-tH'een  tlie  reality  raotivf  and  the 

formiitiou,  and  by  \«-atching  the  interplay  nf  titese  t*o 

iiu  idea  as  to  whether  the  mility  motive  is  gaininc 

iMmtion  uf  a  retoverj*  is  a  mooted  one,  but  in  ^nera^  it  is 


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831 


^■conceded  that  thp  patients  that  recover  di>  present  to  careful  analysis 
certain  reslihtals*.  Of  wmrsc,  however,  these  residuiils  tnny  he  (»f  any 
rlejrree  and  may  be  so  slight  as  not  to  necessarily  iuip:iir  tlic  individuals 
in  the  position  in  life  whieh  they  naay  occupy.  It  is  possible  that  true 
'  recovery-  may  take  plaw  with  a  resohition  of  alt  the  symptoms,  but  if 
this  i.s  so  it  is  probably  the  exception. 

■  Diagnosis.— Tlif  dijipriosis  of  dementia  precox,  while  comparatively 
easy  in  the  well-defined  and  the  udvjimrd  cHses,  Iwcomes  a  matter  of 
great  difficulty  during  the  early  histon,-  of  the  illness  or  in  eases  in  which 

I  the  svTiiptoms  are  mild. 
'I'he  manic-deprrssi\c  psychosis  presents  one  of  the  characteristic 
difficutties.  In  this  psychosis  there  is  usually  a  historj'  of  repeated 
attaclcs  without  rtelerioration.  It  miLst  not  be  forgotten,  however. 
that  precox  itself  frequently  presents  ft  similar  history  and  that  if 
deterioration  is  pn'sent  it  niuy  rot  l>e  prominently  in  evicjence.  The 
de[nt'ssit)n  which  so  fre<iuently  ushers  in  a  pretiix  attack  nuiy  easily 

I\n.-  mistaken  for  a  depression  of  the  maiiic-ilepressive  psychosis.  The 
muiiiiMleprcssive  retardation  is  similar  in  its  outward  appearances 
to  the  indifference  and  perhajra  lighter  degrees  of  negativism,  |)anicu- 
htrjy  the  inaccessibility  (tf  the  precox.  The  maaic-flepressive  is  more 
apt  to  have  delusions  of  a  sclf-accusatory  tj-pe  than  the  precox,  and 
the  hitter's  dehi.sions  are  more  apt  to  Iw  grotesque.  They  more 
frequently  are  evident  distortions  and  sjinbolisms.  The  pressure  of 
activity  of  the  manic  resembles  the  activity  of  the  catatonic.  In  the 
former,  however,  the  activity,  although  rapiilly  ehantrfng  as  to  its 
object,  is  cluiracteristicaily  addrcsscil  to  .some  purjiose,  while  in  the 
catatonic  the  activity  Is  more  ditfuse  and  has  less  direction.  It  is 
more  incfjherent.  The  distinction  lien*  between  tlie  extroversion  of  the 
manic  ami  the  introversion  of  the  precox  will  aid  in  the  differentiation. 
In  the  early  stages  the  mild  depression  of  tlie  precox  may  simulate 
that  of  a  neura.stheni<-,  or  the  agitated  depression  may  simulate  that 
of  an  anxiety  neurosi.*.  In  lK)th  instances  the  precox  is  more  apt  to 
|Kbow  grotesque  deliLsions  and  conduct  disorders  of  a  bizarre  nature, 
as  tearing  his  clothes,  self-mutilation,  or,  on  the  other  liand. 
' characteristic. negativistic  synipti»ms,  such  as  retaining  the  sidiva  or 
the  urine,  withilrawiiig  fnini  efforts  addn-s^sed  tit  assist  him,  refusing 
ti»  isWipcrate  in  changing  his  clothes,  the  refusal  of  food  and  the  like. 
|*It  nnist  not  lie  forgi>tten,  however,  tliat  the  etiohigical  factors  of  the 
factual  ueuroses  may  operate  in  the  same  person  who  breaks  down  as  a 
)rew>x.  and  that  therefore  neurasthenic  and  anxiety  symptoms  may 
present  as  ex])ressions  of  these  cti()logieaI  factors.  It  is  im|>ortant 
to  keep  such  a  possibility  as  this  in  mind  when  it  comes  to  the  matter 

tof  tn'atn>ent. 
It  is  still  a  mooted  question  whether  there  are  not  citnilitions  inter- 
mediate Ix'tween  precox  and  manicHlepressive  psychtwjs  whicli  partake 
somewhat   freely  of  the  chanoteristics  of  both,     lliere  are  u  con- 

Isitlemhle  nnndier  of  cases  in  which  the  difficulties  of  diagnosis  ore  very 
great.    Flight  of  ideas  may  be  quite  t>'pieal  in  precox,  for  example, 

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DEMENTIA   I'KECOX   GROUP 


wliile  t!ie  (k'prcssinn  of  llw'  pn'cnx  may  resemble  very  cl"-l 
of  the  rnanir-<l<?pressive.  Tlif  difficulties  arc  jcreatfst  with  n.' 
uf  nianic-di'prcssivc  psydiosi's  known  as  the  mixixl  states. 

Epileptiform  and  hysteriforut  epis<jdes  may  lead  to  a  di^toti- 
of  cpilejw.v  or  hysteria.  It  must  not  be  forjsotten.  howe\fr,  liaun* 
possible  to  have  precox  complieated  with  epilepsy  an«l  timt  in  Hciwxi- 
precox  ail  of  the  s,>Tiiptnni;:  and  chanitrU'ristic:  nl^cUamsm^  tli^t  -' 
found  in  hysteria  may  be  found. 

In  the  infection  and  exhaustion  psychoses  the  clifTprentiaiion  ■- 
be  very  diffinill  and  it  is  neeessarj'  in  such  pationts  often  to  w-ait  *  ■■ 
ponrtiderahle  time  until  the  subfiidenee  of  the  infection  and  ihit  • 
whether  the  ease  elears  up.  a.'^  it  usually  does  if  it  is  n  simple  ixilf^'j 
psychosis.  One  has  to  be  verj'  careful  in  making  a  prognosis  in  <■» 
of  this  charueter.  Not  infrequently  cases  of  so-oalleil  purq^ni 
insanity  arc  really  cases  of  precox  which  have  l>een  pn-ripiiRtnl  li>  ti*^ 
cir(inn.'*tan(CH  of  the  jnienMral  iwritKl,  ]<vss  of  blotNi,  pn>Ion)j;nl  Ul'<. 
infection,  or  the  mental  strefw  incident  to  an  illegittniate  pn^gniuif> 

From  paresis  the  differentiation  can  now  be  made  by  the  labtntorj 
methfxls  at  our  disposal.  It  must  not  l>e  overlookerl  that  tk 
precox  may  have  syphilis  and  therefore  a  positive  Wassemmnn  in  tlr 
bloLHi  WTniin.  In  fact,  not  a  few  do  show  this  reaction,  ami  it  is  quilt 
readily  conceivable  that  the  presence  of  an  uncurtni  s\-philis  may  »il 
be  a  preclpitatinp  factor  ht  the  outbreak  of  the  psychosis  in  a  crrtiJii 
proportion  of  cases. 

From  the  toxic  psychoses,  particularly  fnun  alcf>holic  deterioratiMi. 
the  diifen-ntiation  i.s  often  quite  diffimlt.  Ii  iiiiist  In-  borne  in  niiw^ 
in  thiii  connection  that  the  relatively  normal  man  deterioratra  vcr? 
.slowly  from  the  use  of  alcohol,  while  one  finds  in  the  record.s  of  pTrc«\ 
cases  nlio  have  itidulj^^-d  in  ak-olml  that  the  detcriomtion  hai  caoc 
ver>'  much  earlier,  lit  addition  to  this  it  will  be  found  that  tlie  nnirNint 
of  deterioration  iri  t!ic  precox  cji.se  is  vcr\-  much  preater  than  rouW 
reasonably  l>c  explained  by  the  alcoholic  Indul^ncc  of  the  patieai- 
"When  this  discrepancy  in  the  history  is  found  one  is  jtistitied  in  suspctt- 
in^  that  one  is  dealing  with  a  fundamentally  more  serious  ninditioo 
than  mere  alcoholism.  These  two  types  of  cases  .shou-  a  cli«nKi<7- 
istic  t>T5e  of  defence  which  serves  to  sc[>anitc  them,  the  one  from  (be 
other.  In  both  instances  the  jtatients  tend  to  minimize  the  trv 
etiological  factor  and  to  exaggerate  the  unimjiortant  one.  For  esnn-  ' 
the  precox  case  will  always  eva};i;crate  the  amount  of  alcohol  lie  l-a- 
been  taking,  whik-  the  aliiiholic  will  always  mininii£e  it.  This  i->  <^ 
courx-  only  ruiiyhly  true  but  it  may  Ix-  beljtful  in  sizing  up  patirnt-v 

The  whole  cjuestion  of  atcoliolic  dcterionitiou  is  by  no  means  set 
lilculer'  is  inclined  to  include  the  alcoliolic  hallucInose.s  in  the  detuent 


t>»mHi>liA  I*n>r4^x  rvW  Uruppo  dor  Brhuophreiiipn.  Fmni  Deailrkt.  Lnpaic  u.  Wii 

'  I  r  tlif!  niiMi  nint|m*lii*ii!iix<>  Hud  ntiiiplvlp  trvatiiMiit  ol  Uni  ot 
'  (^tJiiit      An  fXi'ollfiil  rvMow  <>(  <W  work  l»y    Atuniat 
...'.  <..  .<..   .^L.K-w  u(  NmmitoKy  nvni  PxychiutO',  Juuc,  lUIS. 


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TREATMENT 


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prtHiix  gnnip  ami  iit  least  it  must  be  acknowledscd  that  many  alcoholic 
patients  after  repeated  attaukii  of  acute  aleohohc  psychoses  unilerso  a 
deterioration  whit-h  is  precox  in  character. 

Tlie  (llfTicuIty  of  (liltercntiatinK  between  <]efect  due  to  precox  ami 
congiMiitul  defect  hjis  already  been  mentioned  in  diseiissinjc  precox 
ill  children,  and  precox  on  a  defefctive  basis.  A  material  help  in  making 
this  differentiation  ts  an  inquity  into  the  school  knowledge.  The  school 
knowledge  will  be  ren.smably  well  rctjuntil  in  tht*  precox,  while  it  will 
not  Imve  Ihtii  actpiinnl  in  the  defective. 

As  was  insisted  upon  in  the  lx-Ki>iiiin(j;,  the  hebeplireuic  and  simplex 
t>T>es  frcfpieiitiy  complain  of  numerou.s  minor  ailments.  These  arc 
uetitly  treated  by  the  general  practitioner  or  the  specialist  on  the 
lis  of  their  physical  nillicr  than  their  psychical  character.  .Such 
patients  repeatedly  go  through  complicated  systems  of  treatment  until 
the  true  character  of  their  illness  haa  become  evident,  when  often 
much  valuable  time  \\ba  l>een  lost. 

Treatment.— Dementia  precox  has  generally  been  considered  to  be  u 
hoiKdcss  conditinn  for  which  little  or  nothing  coulil  Iw  iluiit-.  This  is 
at  lea.st  not  an  attituile  with  which  to  npi)ronch  a  patient,  and  when  we 
bear  in  mind  the  considerable  number  uf  rtxtiveries  tliat  take  place 
in  the  disease  it  is  hanlly  an  attitude  that  is  warranted.  The  treat- 
ment, however,  must  of  necessity  Ije  very  difficult,  because  conditions 
that  have  to  be  met  are  multitudinmis  and  range  all  the  way  from 
disturbances  at  the  lower  physiological  levels  through  distinctly 
pyachoiogical  problems  to  the  relation  of  the  individual  to  his  social 
milieu.    These  matters  may  be  taken  up  in  their  order. 

Trenimeni  of  Physical  (.'imdUion^. — Here  the  treatment  must  be 
practically  entirely  s>-mptomatic.  The  blailder  nrid  n-clmn  must  be 
carefully  watched  where  thertf  is  uegativistie  retention.  The  mouth 
must  be  kept  clean,  swabbed  out  with  listerlue  or  some  other  autise]>tic 
mouth  wash,  if  there  is  retention  of  saliva  or  food  particles,  otherwise 
putrefactive  clianges  may  occur,  infections  of  the  gum  with  ulcerations 
may  result,  with  possible  complications,  such  as  pneumonia  and  death. 
Other  .such  conditions  as  the.se  have  to  he  met  in  a  practical  and 
common  sen.se  way  and  need  little  special  eonimeiit;  for  instance, 
surgical  injuries,  such  as  self-mutitation,  bniises,  and  the  like  have  to 
be  met  in  the  usual  way.  while  it  is  esi>eeially  tinportant  to  get  these 
patients  out  of  doors  and  not  permit  their  seclusivc  tctnicncies  to 
further  the  development  uf  tulH-ri'iilar  diseast*. 

.At  the  present  time  a  good  deal  of  attention  is  I>cing  paid  to  the 
internal  secretioiLs.  These  may  be  investigatcil  in  the  individual  case, 
but  as  yet  their  beneficial  action  is  unproved. 

Tycatinenl  oj  the  Mcritai  ConiHtion. — Tiie  treatment  of  the  mental 
condition  resolves  itself  into  the  treatment  of  disturbances  at  lower 
and  higher  levels.  In  the  disturbances  of  the  lower  levels  we  have 
eharftcteristically  the  excitements  and  the  stupors.  In  general  the 
treutinent  of  tJie  excitements  should  Ije  by  hydrotherapy,  the  con- 
fi3 


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DBMBSTfA   PRECOX  GROUP 


tinuous  l>ath  or  the  pack,  accunling  to  tlie  individual  exper! 
physician  or  the  tonvcnicncf  of  the  hospital.  Uestmint,  cith 
or  chemical  should  he  avoided  if  pnssihie,  resorting  to  dm 
so  far  as  may  be  necessary  to  produce  a  sufficient  amoun 
It  must  he  home  in  mind  that  all  of  the  drugs  that  areusttj  f< 
restraint,  more  es|>ec:'ially  tliose  helonginj;  to  the  helladoiina 
ddirium-pruducing  and  therefore  tend  to  interfere  with  the  i 
of  the  patient  to  reality.  .Small  doses  of  atropine  are  n 
inilieated  to  obtain  vegetative  nervous  system  control 
annoying  Mimatic  symptoms. 

In  conditions  of  stupor  the  general  health  has  to  t>e  carefi 
after.  The  patient  must  often  he  tube  fed,  bowels  and  UhuU 
special  attention,  and  the  position  of  the  bmly  slunihl  b 
Mdficiently  so  as  to  prevent  pressure  ujwn  any  |M>rtion  o 
surfaces  or  a  tendency  to  hypostatic  congestion  of  the  lung 
encd  patients.  Cleanliness  and  regular  and  sufficient  feedii 
essential  things,  and  it  is  ver>*  desirable  in  addition  to 
patient's  bed  out  upon  the  open  porch  where  he  can  have  4 
of  fresh  air,  if  this  is  possible. 

Treatment  at  the  higher  psycholc^'cal  levels  has  the  M 
to  be  said  for  it  as  psychotherapy  has  fur  the  psychoneunn 
it  cannot  be  expected  that  patients  can  be  cured  by  psyc 
treatment  as  they  are  when  sulTering  from  the  jwychoneu 
it  miLst  be  rememl>ered  that  all  of  the  .'(j'mptoms  of  a  precc 
not  necessarily  at  the  same  level,  and  while  the  patient 
susceptible  of  a  cure,  still  many  of  the  s^Tnptoms 
relieved,  if  not  disjjersed  altogether.  Psychoanalysis  th 
be  used  and  even  where  the  therapentic  effect  may  not  be 
great,  still  it  furnishes  that  sort  of  information  about  the  pat 
it  is  essential  to  have  in  order  to  deal  with  him  intelligently, 
know  something  about  the  factors  that  produced  the  break- 
must  know  something  of  the  nature  of  the  complexes,  in  ord< 
the  problem  of  regulating  the  life  of  the  |Hitient,  not  only  uj 
but  with  any  possibility  of  aceomplisliing  anything.  'JM 
the  problem  in  any  other  way  is  to  approach  it  blindly.'  ■ 

In  the  old  wises  of  [irwox  that  have  become  considerably  di 
that  are  relatively  quite  inaccessible,  it  would  seem  that 
method  of  approach  was  through  the  agency  of  industrial 
If  an  effort  be  made  in  this  direction  intelligently  after  a  i 
careful  analysis,  so  far  as  {Hissible,  of  the  particular  eonilitioo 
will  ap|K-ar  what  is  the  best  method  of  approach  in  t>nler  tOi 
interest  and  fix  the  attention  of  the  [Nitient,  a  great  deal  can 
plished  in  making  this  class  of  ]>atients  generally  useful 
hospital  and  in  limiting  their  destructive  and  filthy  tenA 

■  JdlifT!.'?    Tri>i>liticiil.  nt  Di'niptifin  Prmyix,  Intt'nintioniU  Cliiitri,  1017. 
Modem  TrvatiucDl  of  Nervous  aud  Mental  Obi^ave,  While  nsd  JeUUTe, 
1019. 


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^^^^^^^  TREA  TMEJ^r 

aJaiitiiifT  thcni  to  a  muoh  healthier  series  of  ftdj\Lstments  than  if  they 
are  incroly  left  to  themselves. 

7'A(  Treuimt'nt  nf  the  Stirixtl  lUlatwnit. — The  endeavor  to  modify 
the  i-nvininmcnt  of  the  patient  must  be  piided  hy  what  Iia^i  l>een 
found  as  the  result  of  psychoanalysis.  The  precox  :>pHtting  goes  back 
to  the  early  infantile  situations,  the  time  when  tlic  love  of  the  child 
was  piven  out  in  it.s  entirety  to  the  immediate  members  of  the  house- 
hold, father  and  mother,  brothers  and  sisters.  Later  on  if  the  child  is 
to  he<-ome  an  eflicient  adidt  he  miwi  emancipate  himself  fmm  the 
thraMiim  of  this  afTeciinn.  This,  however,  is  what  the  jirecox  Iuls 
not  l)een  able  To  do,  and  the  nfTection  which  hinds  him  to  his  infantile 
loves  is  quite  truly  felt  us  ii  destructive  force  that  prevents  his  onward 
pmnress  in  the  woHil.  There  frequently  results.  then*fore,  all  sorts 
of  antagonisms  addn-sscd  to  tlie  nieml>ers  of  the  imniedinte  household 
which  are  variously  expressed  and  variously  symbolized  and  distorted. 
The  love  of  the  little  child  for  the  parent  or  the  brother  or  the  sister, 
when  it  breaks  thrnuj:h  frctm  the  unc<>nscious  into  the  conscious  life 
of  the  adult,  h  not  understood  at  its  true  value,  but  l)ecomcs  a  hateful 
thinp,  and  so  eharawceristicully  there  arise  all  sorts  of  incest  phan- 
tasies. Recently  one  such  patient  in  the  hospital  struck  and  stunneil 
another  patient  and  when  called  to  task  abovit  it  he  inslanlly  protected 
himself  by  the  stiitemcnl  that  "they"  were  accusing  him  nf  incestuous 
relations  with  his  sister.  These  are  the  ennmionest  of  ideas  among 
precox  cases.  Psychoiuialysis  will  orient  the  physician  with  relation 
to  these  ideas  and  enable  him  to  adjust  the  jMiticnt  intelligently. 
.Such  ideas  fre<picntly  require  the  removal  of  the  patient  to  an 
institution. 

Ahhoufih  a  wholly  pessimistic  attitude  is  not  warranted  in  approaeh- 
inp  the  problem  ttf  precox  in  an  individual  case,  still  it  must  Ije  realized 
that  after  all  one  can  hardly  cx|)ect  a  complete  recovery.  One  can 
only  liojM*  to  n'adjnst  the  siliuitiftri  so  that  tlie  patient  may  get  along 
ironifnrlably  and  {K>rhaps  lca<l  a  useful  life,  prdhably  upon  a  slightly 
lower  level.  The  tendency  of  the  disease  is  essentially  tn  limit  the 
individual  in  the  mental  sphere,  and  this  limitation  means  uf  necessity 
that  life  has  to  be  led  at  a  (.■orrespondingly  lower  and  simpler  plane 
()f  adjustment.  This  is  exactly  what  tlic  institution  provides  for  the 
patient,  but  there  is  no  reason,  in  the  absence  of  dangerous  tendenc-ies 
and  if  it  is  desirable  from  other  stand -[mints,  why  an  attemin  should 
not  l»e  made  in  this  direction  ont-side  of  an  institution.  We  know  this 
can  be  done,  for  we  sec  nut  infrequently  patients  getting  along  verj' 
Well  under  tl>e  scjlicitous  n»re  of  simie  relative,  for  example,  and  when 
(his  relative  dies  and  the  care  is  n-movcd  and  their  world  is  no  longer 
carefully  arranged  for  them,  then  thc\  find  their  way  into  the  hospital. 

A  careful  dealing  with  all  of  the  conditions  surrounding  the  patient, 
more  particularly  dealing  with  them  intelligently  as  the  result  of  such 
psychoanalysis  as  can  be  maile.  will  enable  the  physician,  in  a  very 
considerable  pro|>ortion  of  cases,  if  the  means  are  at  his  disposal, 


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836  DEMENTIA   PRECOX  OBOUP 

which  of  course  they  frequently  are  not,  to  so  adjust  the  siti 
as  to  bring  about  a  state  of  relative  calm  and  quiescence,  wil 
preservation  of  a  considerable  degree  of  eflBciency. 

Prophylaxis. — ^The  prophylaxis  of  dementia  precox  is  a  most  di 
problem,  and  in  the  first  instance  of  course  should  be  met  froi 
eugenic  stand-point.  Marriage  should  be  very  carefully  supei 
where  the  individual  comes  from  badly  tainted  stock.  Such  gc 
principles  may  be  borne  in  mind,  as  for  example,  the  liability  to  m 
disease  in  children  from  tainted  stock  is  greatest  among  the  e 
bom  and  falls  off  rapidly,  as  Heron  has  shown,  particularly  afte 
fourth  child,  while  Mott  in  working  out  his  Law  of  Anticipatio] 
shown  that  if  the  individual  passes  the  twenty-fifth  year  the  lial 
to  a  mental  break-down  is  very  materially  lessened. 

The  possibilities  of  prophylaxis  before  the  outbreak  of  the  psyc 
are  not  known,  yet  it  would  seem  that  it  woiJd  be  rational  to  end< 
to  deal  with  those  character  anomalies  that  we  know  favor  this 
of  disorder.  The  method  of  approach  will  of  course  resolve 
into  an  attempt  to  define  the  lines  along  which  frank,  open  reac 
do  not  seem  possible  to  the  individual,  particularly  along  lin 
definite  sex  conflicts.  In  this  particular  the  whole  matter  of  b 
education  has  to  be  gone  over  and  its  value  as  a  prophylactic  me 
determined.' 

■  Soo  JcllilTc:  Prodemcntia  Pn>oox,  Am.  Jour.  Med.  Sc.,  August,  1907,  for  a  st 
these  early  features  which  antedate  the  appearance  of  the  disease,  also  chapters 
treatment  of  Paranoid  States  and  of  Dementia  Precox,  by  Adolf  Meyer  and  '. 
Campbell,   Modern  Treatment  of  Nervous  and  Mental  DiaeBses,  White  and  J 
Lea  &  Febiser,  1913,  vol.  i. 


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CHAPTER  XX. 
INFECnON-EXIIAUSTION  PSYCHOSES. 

TuiH  group  of  infection-exhaustion  psychoses  is  somewhnt  of  a 
hetproj^neous  proup,  inctudinj;  nil  of  tlie  mental  disturbances  dcijend- 
ent  upon  the  various  infections,  as  well  as  certain  conditions  which  arc 
tentatively  <inpp(^sed  to  be  dependent  upon  exhnustion  and  which 
givi'  similar  clinical  pictures.  For  the  most  part  it  contains  tlw 
psychoses  dependent  upon  all  the  febrile  diseases,  for  uj)  to  the  present 
time  at  least  these  ditt'erent  diseases  cannot  be  diltereutiated  by  means 
of  the  mental  picture  atone. 

In  connection  with  the  similarity  of  the  manifestations  in  this 
group,  although  the  ultimate  etiological  factors  are  widely  ditt'erent, 
it  is  worth  while  to  bear  a  few  <«)ii.siderations  in  mind.     In  the  first 
place  it  has  btvn  suggested  that  after  the  uiaiuier  of  thinking  regarding 
the  s^-philitic  manifestations  and  the  alcoholic  psycluwes,  as  alreatly 
outlined,  that  the  mental  picture  is  not  depi-ndent  upon  the  immediate 
infecting  agent  or  upon  the  toxin  directly  elaborated  by  the  infecting 
micToorganism,  but  on  the  contrary*  is  due  to  a  general  disturbance 
in  the  nietalxdism,  the  result  of  the  infection;  in  other  words,  that 
there  is  an  intermediate  agency  at  work,  a  metato.\in.    On  the  other 
hand,  it  Iia.s  Ijeen  sugKcsted  that  the  gamut  of  s\Tiiptomatologj'  which 
the  neuron  may  produce  in  the  process  of  its  destruction  is  necessarily 
confined  within  ccrtaui  relatively  narrow  limits  and  that  therefore 
inimical  agendes  that  act  at  the  bio<:hemit»d  level  can  only  produce 
relatively  few  groups  of  symptom-complexes.    Tliis  Is  undoubtedly 
frae.    On  the  other  hanil,  while  it  will  be  found  that  if  the  individual 
Cases  are  cart'fully  studied  the  girnerat  course  uf  the  malady  and  the 
mechanisms  involved   are  quite  similar  in  the  difTerent  cases;  in 
other  words,  that  the  patients  fall  into  one  of  verj'  few  groups;  still 
the  ojntent  of  the  delirious  or  delusional  experiences  and  the  minor 
variations  in  tla*  manifestations  in  the  malady  nnLst  have  another 
explanation.    'ITiis  explanation  is  naturally  the  make-up  of  the  indi- 
vidual.   A  destructive  agency  at  work  in  tearing  ilown  can  only  tear 
down  what  has  I)efore  been  built  up.       It  is  t-onstrained.  in  other 
words,  to  ileal  with  the  material  at  hand,  and  therefore  personal 
variations  must  lie  expected;  for  example,  the  delirious  patient  will 
wvave  expressions  into  lus  proiluctions  that  refer  directly  to  his 
0W71  ex|>erience3. 

Prefebrile,  Febrile,  and  Postfebrile  Psychoses. — The  same  thing 
may  )«■  said  regarding  fever  aiid  infcctiun  which  has  already  I»een 
said  regarding  aleohol,  namely,  that  it  is  a  measure  of  the  mental 


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INFECTIOS-EXHAUSTIOS    PYCH08SS 


stability  *>f  the  imiividua!.  ^Mlile  sonip  persons  may  n-v 
cWttr  witli  11  tomjH'ratiire  of  a  100"  K.,  otlirrs  may  becomi'  i 
hanUy  more  than  a  degree  of  temperature.  I'Tiis  diffemjcr  is  i  »* 
known  one,  and  in  a  disease  like  typhoid  fc\-er,  for  example,  the  jjwa 
consensus  of  opinion  is  that  the  i)roj<iu>sis  is  most  serious  in  tbuaroab 
that  t»'e(>nie  delirious  early  and  show  from  the  begriiuiiig;  mukedwl 
exafjgeriited  nervous  symptoms. 

Infection  and  Initial  Delirium. — I'uder  this  head  are  inciuded  t» 
mental  distnrlmntts  whiL-h  develop  early  in  the  infectious  (&«*■ 
iK'fort*  there  lias  been  any  rise  in  temperature.  In  fact,  thr<klifni 
in  these  cases  may  disappear  when  the  fever  is  fully  develoiied.  «ltJM|> 
this  is  not  ihc  rule,  the  usual  course  beinj;  for  the  delirium  iil  tk 
period  to  go  over  into  a  fever  delirium.  Tliis  infeotkm  delinua  ■ 
also  found  in  conditions  which  are  essentially  afebrilr.  as  (i>r  enunpfc. 
nd>ies,  and  is  tlicre  due  of  course  to  an  overwhelininp  of  the  bcrf> 
with  toxins,  or  perhaps  to  a  bairteremia.  This  t \  pc  of  mental  dis- 
turbance occurs  characteristically  with  the  onset  of  tj-phus,  in  tie 
period  previous  to  the  eruption  in  smallpox,  and  has  hwu  titvurc 
in  connection  with  influeuza,  acute  chorea,  especially  the  ebons  o 
piegnaney,  and  in  tnalaria. 

Syvt}Aom.f.—  'Y\\e  syniptonis  of  infection   delirium    are  the  asM 
s>'mptouis  of  delirium,  which  may  present  any  ilegree  of  severitv, 
mild  confusion  to  Mtrium  acutum,  or  eolla|>se   delirium,  ei 
death.    The  diagnosis  of  initial  delirium  previous  t«  the  apj 
of  the  tj-pical  .signs  of  the  disease  of  which  it  i.s  a  Kyrnpttmi  is 
practicjill\-  impossible. 

Fever  Delirium. — I'ever  delirium  is  the  psycho*u.s  which  acrompMM 
fi'lirtle  movement  and  wliich  in  (general  varies  in  severitj'  Imnd  in  ban 
with  the  variation  in  the  severity  of  the  fever. 

It  may  Ix-  di'-seribcd  in  four  sta;ges  according^  to  the  degnx  of  it 
severity:  In  the  first  stage  iieadache,  u-ritabiiity,  flensitivexias  ft 
noises  and  lijjht.  restlessness,  and  disturbing  dreams;  in  the  secon 
stiipe  ballueinatioa'i  appear,  esijeeially  in  the  visual  field:  the  baih» 
nations  arc  of  a  <lream-like  charaiter,  and  the  patient  may  still  be  la^M 
to  react  clearly;  in  the  third  stage  the  motor  disturhun<^  is  j^rafll 
atid  take^  oti  the  chitracter  of  jactitation;  in  tin*  fourth  stikjte  thcfv  H 
])rofninicl  dulling  nf  consciousness,  uncertain  and  ntnxie  movemmt^ 
enilitig  in  roniii  ami  death.  Of  course  this  regular  progress  of  the  drlir~ 
iuni  may  be  interrupted  at  an>'  point  by  an  iinpruvcnient  In  tlie 
symptoms  and  rt-i"ovcr>'. 

The  un.set  and  the  severity  of  the  delirium,  as  alr<*jidy  art  forth, 
shows  to  an  extent  the  mental  stability  of  the  patient.  'ITic  lidiriuni 
develoi>s  or  l>ecomes  severe  much  more  rcjulily  in  the  unstable  awl 
[Niorly  (irgiini/,ed  than  in  the  stable,  llie  M)urse  of  the  deliriuni  may 
Ik:  inU-rmptt'd  by  an  acute  excitement  followed  by  n  stuporvHU  con- 
dition, whic-li  IkmhoefTer'  describes  as  an  epUrfttifonn  rrritrmrnl.  whidi 


the  ooal 

ritv.Ag 
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{»  folliifti?<l  by  a  (ireiiiii  state,  for  which  latttr  he  retains  the  name  of 
Ziehen,  infection.^  dream  ittate.  With  lliese  comlitioiis  confusing 
syinptums  may  arise  whicli  makei^  the  diagnosis  difficult  for  a  time. 
Thus,  along  with  the  disorientation  there  may  be  flexihiUtas  ccrea 
confabulation,  perseveration. 

Ill  certain  eases  the  orientation  is  less  disturbed,  while  the  hallucina- 
tions are  more  prominent,  and  there  is  an  outward  semblance  of  an 
hallucinosis. 

Here,  as  elsewhere  in  psychiatry,  the  various  forms  of  the  jisychosis 
frequently  desij;iiiiteil   by  the  prcvHiting  sjTnptonis.     Thus,  the 
ptoiiis  found  limy  !>e  epileptifonn  excitenieut,  dream  states,  stu- 
porous conditions,  hallucinosis,  catatonic  and  coiifusional  states,  ntid 
the  deliriuiii  may  be  designated  by  using  any  one  of  these  descriptive 
terms. 

Postlebrile  Psychosea.— These  <onditinns  cither  develop  as  a  result  of 
the  passinp  over  of  the  delirium  of  the  febrile  state  into  the  period  of 
convalescence,  or  they  may  take  their  origin  from  the  6rst,  during  the 
postfebrile  period.  In  the  latter  case  they  would  be  considered  as 
belonging  more  properly  to  the  exhaustion  psychoses,  and  yet  it  must 
he  undcrsUKMl  that  the  tenti  exhaustion  is  a  very  vague  one  and  that 
iu  hU  probability  it  implies  at  least  the  ucemnulatioii  of  toxins. 

The  ehanietcristic  picture  of  this  psychosis  is  associated  with  the 
great  physical  <lebility  whicJi  follows  the  subsiitence  of  the  fever  in  an 
infectiou-s  disease.  The  patient  is  weak,  tremulous,  exhausted,  and 
complains  of  being  tired.  The  mental  state  is  fundamentally  one  of 
weakness.  'Hiere  is  no  confusion,  but  the  capacity  for  attention  Is 
ver3'  much  reduced,  and  in  that  way  there  come  about  apjmrent  mem- 
ory (list  urban  CCS.  The  ]iatient  is  uiiol>servant  of  his  snrniundiMgs, 
Usually  scnnewhiit  depresse<l,  and  may  lje  very  much  <»ceupied  with  his 
own  iKMiily  fwlin^s  to  the  extent  of  having  hypochnndriacal  ideas,  and 
fleeting  hallucuiations  are  not  infrequent.  In  more  severe  eases  there 
may  be  more  evidence  of  mild  delirium  or  confusion,  the  mood  may  be 
more  definitely  aiutlous  and  fearful  and  there  may  be  delusions  char- 
acteri.*rtically  of  the  persecutory  t>i>e.  The  patient  is  apt  to  be  irritable, 
cross,  and  complaining.  OcoLsionally  there  may  be  considerable 
motor  exfitetiicut  of  an  epileptiftirm  character,  and  sometimes  actual 
deliriom  dream  states.  Occasionally  the  picture  of  a  miU  expansive- 
ness  is  found.  \  certain  numVwT  of  cases  present  a  well-marked 
Korsakow  syndrome. 

Exhaustion  Psychoses. — Tlie  term  exhaustion  in  this  connection  is 
not  uitcnded  to  be  used  in  other  than  a  tentative  sense.  The  whole 
question  of  fatigue,  except  with  reference  to  ver>'  specific  problems, 
such  for  example  as  mu.sele  fatigue,  is  still  little  under3too<I.  In  general, 
however,  it  may  Iw  .said  that  there  are  two  factors  in  the  problem, 
the  negative  and  the  positive.  The  former  is  the  result  of  the  actual 
_  wearing;  out  of  a  substance  in  the  body,  as  for  example  muscle,  while 
■  the  second  is  the  result  of  the  formation  of  certain  poisonous  substances 

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wliicli  result  from  the  btvakinn  ilnwn  of  tissue.  In  the  romfeiai 
which  ordinarily  are  observed  it  would  seem  evident  that  brti  J 
thetie  factors,  the  positive  and  the  negative,  are  in  evidcnw,  aM 
exhaustion  is  considered  whert^  tliey  appear  to  be  the  predominlac 
fftcturs.  For  example,  exhaustion  is  s(>oken  of  when  coming  on  fcnBiil 
as  the  result  of  a  sudden  loss  of  a  eonsidontble  (lunntity  of  blDolrV 
coming  on  more  slowly  as  n  result  of  the  debilitating;  etfects  of  idmw 
disease  such  im  tarcinoinu.  lu  this  latter  case,  hoi^'ever,  it  viH  W 
easily  seen  that  in  all  probability  the  toxic  clement  must  enlpr.  3»- 
larly  in  <-onva]escence  from  acute  illness  where  the  fi-vrr  ha*  bm 
very  hijili  and  the  illneiw  has  been  |)roIonpe<I,  cun<litions  amaipaa>' 
by  great  physical  prostration  are  seen  in  which  it  seems  fair  to 
that  tlie  element  of  direct  exhaustion  is  responsible  verj' 
the  nientul  pleture.  I'nder  the  head  of  exhaustion  p&y 
iniiin  ty|K's  will  \w  described — collapse  delirium  and  acute  liall 
confusion  (aiueiitJa) — hut  it  must  !«•  understood  that  these  two  _ 
chores  arc  not  necessarily  jx^culiar  but  only  conditions  in  vAiA  tit 
exhaustion  element  appears  to  predominate.  Kither  or  both  of  iltcsj 
may  l>c  found  during  the  ptTlcwl  of  acute  infection  in  the  febrile  d 
and  comHtions  that  In-jjin  with  infection  and  fever  and  give  ibc 
of  an  infection  or  of  a  fever  delirium,  may  go  over  into  the  sev 
as  tiie  patient's  general  condition  becomes  worse  and  the 
overfthelmed  with  the  poisoning. 

Collapse  Delirium.— This  is  the  drlirium  grave,  or  the  acuir  tUHnn 
munin   of  the  older  authors. 

The  disease  may  present  a  pnxlromal  jx'rltMi  of  resllrssnesA,  iiti 
lability,  and  imorania,  after  which  a  condition  of  mihl  confuM 
may  develop  with  only  a  slight  degree  of  perplexit>'  and  perhaps  flert 
hig  liallucinations,  slight  clouding  of  consciousness,  dis4>rienlatinn  aa 
dreamy  delusions;  psychomotor  excitement  is  common  at  thi:*  tiw 
the  patient  being  active  and  perhaps  inclined  to  acttia)  violence  la 
destructiveness.  Often  associated  in  the  early  s>inptoms  are  accoM 
of  anxiety,  amounting  at  times  to  actual  terror.  Tliis  conditia 
gradually  becoini's  Wdrw.  and  finally  the  degree  of  excitement  beof^H 
very  great,  exteeding  anything  that  we  usually  see  tn  tlic  otherpH 
choses.  When  this  extreme  form  of  excitement  is  in  evidencr  thi 
outcome  is  usually  apt  to  he  serious,  ami  the  older  writCTs  hdievei 
it  to  be  uniformly  fatal. 

In  these  severe  cases  the  incoherence  becomes  absolute,  titc  disori' 
entation  cfmiplete,  the  clouding  of  consciousness  profoiinfl,  tl>c  te«i« 
perature  generally  runs  high,  perhaps  as  high  as  106*  F.,  gaatrcwntcsti' 
nal  s.nnptoms  arc  common,  there  is  usually  almost  complete  aoorexi*, 
coatwl  tongue,  offensive  diarrhea,  a  high  grade  of  indicanuria, 
ropi<i  emaciation  which  results  in  a  high  grade  of  exhaustion 
tjTjlioid  s>Tuptoras.  There  may  be  a  certain  amount  of  ca 
with  stereot)!^^!  movements,  grimacing,  and  echolalia,  and  3ta; 
conditions;  cotmi  and  death  not  infrequently  result. 


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This  condition  occurs  with  all  degrees  of  severity,  and  while  the  most 
sevorc  casts  die,  the  milder  ones  make  good  recoveries. 

It  i\my  uften  be  quite  impossible  to  make  a  diafi^osis  of  the  ph>*!iical 
condition  nf  the  patient**  while  in  their  excitement.  It  must  be  remem- 
bered, eHjjecially  if  the  patient  \mA  teiii|>erature,  that  these  coii(lition» 
are  pretty  npt  to  be  dejx'tident  \i\nm  srime  aciite  phy.sacal  iUiiess, 
partictiliirly  an  infection,  and  that  not  infrec[uently  a  deeji-scalecl 
pneumonia,  concealed  from  the  usual  approach  by  percussion,  and 
auitenltation,  is  at  the  basis  of  the  difficulty,  while  an  infection  such  as 
grip,  rheuniatJHm,  or  the  like  may  also  be  etiological  factors. 

That  the  element  of  exhaustion  is  after  all  not  the  only  clement, 
and  perhflps  not  the  most  important  element,  will  be  appreciate<l  if 
one  stops  to  consider  tliat  the  great  majority  of  patients  do  not  react 
in  this  exnpEerated  way  to  acute  toxemias  or  infections.  In  all  proba- 
bility the  fundamental  factor  at  the  iwttom  of  such  a  reactitm  is  the 
individual  make-np,  just  as  an  ounce  of  whisky  will  disorganize  one 
individual  as  much  as  a  pint  will  another.  The  personal  factor  is  the 
important  one. 

Acute  Hallucinatory  Confuaion  (Amentia).— This  psychosis  is  less 
acute  in  its  charaoteristics  than  tlie  former.  The  s>Tnptoms  are  those 
of  a  mild  confusion  with  incoherenre  and  a  mn-siderable  depre  of 
perplexity.  There  are  usually  fleeting  hallucinations  in  the  various 
sensory  areas,  snnietlmes  delusions,  which,  however,  are  nut  char- 
acteristically fixifl.  with  a  more  or  less  changenlile  emotional  attitude 
varying  with  the  content  of  the  delusions.  Tlie  patient  is  character- 
istically in  a  i.*ondition  of  mild  motor  unrest. 

The  duration  of  the  illness  is  relatively  bng.  It  may  be  prolongc<l 
over  several  weeks,  is  usually  from  one  to  three  months  in  duration,  and 
may  be  considerably  longer.  The  course  of  the  disease  is  not  infre- 
quently interrupted  by  lucid  intervals,  during  which  the  patient  is 
quite  clear.  These  may  last  ani.'where  from  a  few  minutes  to  a  day 
or  two,  and  then  tlie  patient  will  lapse  tmck  into  his  pn^vious  condition 
of  confusion.    This  is  an  important  point  to  l)ear  in  mind. 

A  very  markc^l  degree  of  perplexity  is  rather  characteristic  with 
these  patients.  There  is  considerable  disturbance  in  their  jxTception 
of  their  enviromncut  which  they  do  not  seem  to  understand,  things 
aljout  them  apjM^ar  to  be  changed,  they  appear  to  be  in  some  strange 
place,  things  are  not  right,  they  do  not  tmik>rstan<l  the  meanings  of 
things,  they  get  mixed  up.  get  into  the  wrong  Ix-d,  and  act  in  sunilarly 
stupid  ways. 

lioulioelTer' describes  hallucinatory  and  psyeliomotor  catatonic  form.s 
in  the  latter  of  which  flight  of  ideas  and  incoherence  predominate. 

In  addition  to  the  previously  deserll»ed  psychoses,  Honhoefrer^ 
des<TilH*s.  as  occurring  late  in  the  course  of  tlie  infectious  diseases, 
and  therefore  it  sould  seem  dei>endent  to  a  certain  extent  at  least 


>Op.  dt. 


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Upon  exhaustion,  a  hyperc^lhetic  rmotitmal  stats  of  mminl  vnh*. 
associated  willi  pliysk'nl  symptoms,  such  as  severe  hea<!»rhe.  fOr 
tlit'siu.s,  ami  pains  in  the  joints.  grcHt  prostration.  ovcn«ensitmn» 
to  noise  and  lijclit.  easily  frinliteiied.  troublous  tlre-ams.  \\t  il)« 
describi*s  an  amnesic  mrirty  rescinlilinj;  Korsakow'.s  psychosis.  Acat 
driiritiin  may  also  develop  and  one  may  see  a  nif^iiingitie  lorn  vA 
vrry  severe  deliriou.**  reaction. 

The  possibilities  of  l(K-al  injuries  to  the  brain,  such  as  hrmtn  afaaos 
and  1iic-al  nienin};iti»  nnist  U-  lield  in  mind.  Wlicn  tliesv  devrlopii 
chitdrt'ti  they  not  inrn.*iiuetilty  leave  sequela;,  such  as  mental  defci) 
and  epileps.v. 

Treatment.  -Tlie  treatment  <if  all  of  these  comlitions  is,  of  cnunq 
in  the  main  the  treatment  t)f  the  underlying  di.sejise.  In  peDoJI 
however,  it  mrny  be  said  that  for  the  excitcincnt  the  oi>nlinitotis  baii 
the  wet  jMiek,  with  jMThaps  the  occasional  exhibition  of  a  hyptM 
sh(juUl  lie  chosen  rather  than  the  constant  Hrufjging  of  the  pulicat, 
fnfinently  employed. 

AVhen  there  is  marked  lack  of  desire  for  food  and  the  cooditioa 
serious  and  ajiproaehing  one  of  profound  exhaufttion  there  sbnuU  b 
no  delay  in  n«iortin^  to  artiBeial  fwiilng.  The  ivctum,  of  rtiursc. 
be  uswl  if  the  stomach  h  very  irritable,  Init  Khould  be  u  last  iwrt 
It  is  preferable  to  kIvc  small  cpiantitics  by  the  Htomach  freqnenlt] 
and  entleavor  in  that  way  to  deal  with  the  situation,  than  to  give  rrm 
feeding,  with  the  usual  rtynlt  of  being  satisfied  with  the  giving  nf^ 
amount  of  food  which  is  really  ver>"  iitadequate. 

In  the  extreme  exhaustion  of  the  later  stages,  esjjet'ially  when 
lA  marUed  dehydmliou,  h^\iMHlermoelysis  often  gives  most  cxi 
results. 

Typhoid  Fever. ^ — An  initial  deUriimi  in  typhoid  fo\'cr  is  get 
conceded  to  be  of  most  ominous  import,  while  an  early  «lelrrhjni  whi 
is  continuous  and  severe  is  also  of  Imd  progimstic  significane*'.  Ui 
tliis  disease  the  pKxI  effects  of  the  bath  tn.'atincnt.  as  u-**^  by  i 
Brand  method,  is  especially  well  seen.  Cold  Imths  for  the  re<luctiun 
temperature  have  as  one  of  their  most  iin))ortant  results  their  vniati 
anil  calrninii  cITect  iiixin  the  ner\ous  sjTnptoms. 

Thf  possihility.  in  all  hucIi  diseases  as  this,  of  ti»e  loralization  oi 
infection  in  the  iiieiiinp's  slmuld  Ih-  thoui^lit  of,  and  in  cast-s  v{  m 
delirium,  therefore  the  possibility  of  a  meningitis  should  be  borne  in 
inind.  Lumbar  puncture  may  be  valuable  under  these  cireuui<ttaiicrS| 
both  for  diagnastic  purposes  and  for  the  relief  of  pressure. 

In  tlie  late  stages,  during  convalescence,  sjR-eial  efforts  should  bo 
made  to  make  the  dietary  as  full  and  lilx-ral  as  i>ossible. 

Kryxiiwlajt,  the  various  einnthenis,  and  tlie  several  tyi>es  of  malana 
are  also  nut  infrequently  ei>mplicAted  by  mental  ^mptoni*,  idai 
grtpjw  often   prtxluces  profound  depressioua  a.ssiMnated   with 
physical  exiianstlon  Itanging  over  during  a  long  convalescence, 
must  remember  in  all  of  these  ennditious,  iwirtictilarly  in  the  exai 


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the  possibility  of  meningeal  focalization.  Grippe  sometimes  also 
produces  meningeal  inflammation. 

Acute  articular  rheumatism  is  especially  important  in  ths  connec- 
tion because  of  its  relation  to  acute  chorea  and  the  so-called  chorea 
iTisaniens. 

Pneuvionia  is  frequently  associated  with  mental  symptoms.  Very 
many  of  the  cases  of  delirium  tremens  owe  their  severity  to  a  pneu- 
monia, usually  a  masked  form  of  this  disease,  either  a  central  pneu- 
monia or  one  located  in  the  upper  lobes,  and  therefore  not  so  readily 
diagnosed. 

In  connection  with  all  this  class  of  diseases  the  many  complications 
must  be  borne  in  mind  which  may  arise  in  their  course  and  upon 
which  the  mental  sj^mptoms  may  depend  other  than  the  meningitides, 
as  for  example,  the  acute  types  of  nephritis  in  connection  with  scarlet 
fever,  the  middle-ear  complications  of  measles,  and  the  endocardial 
complications  of  rheumatism.  Not  infrequently,  too,  these  various 
complications  may  depend  upon  mixed  infections  in  which  the  more 
recently  isolated  Streptococcus  viridans  play  a  not  unimportant  role. 
In  fact,  Cotton  has  called  attention  to  a  toxic  syndrome,  usually  fatal, 
which  closely  resembles  paresis,  but  which  is  probably  due  to  this 
infecting  organism  whose  chief  site  of  activity  seems  to  be  in  the 
pus  pockets  of  diseased  teeth. 


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CHAPTEU 
TIIK  TOXIC  I^^CHOSES. 

Alcobolism.— It  is  generally  conceded  that  alcohol  is  a  po' 
pciihhjn  and  as  such  if  tnkcn  in  large  qnanlities  or  over  a  Imi^  pov^ 
uf  time  prrMluces  serious  (laniufie  to  the  individual.  Their  i^.  unfti^ 
lunately,  associated  with  this  view  the  opposite  view  tliat  alcohol  t*l 
vnhiahle  medicine  in  certain  conditions,  particularly  thut  it  is  a  valnUl 
stinmlimt,  while  among  certain  in-oples  it  is  gciierally  accepted  « 
essential  article  in  tlic  daily  dietary. 

As  a  matter  of  fact  the  to^iic  properties  of  aleohnl  far  nntmilA 
any  possible  beneficent effwts  that  it  may  have.  In  fact,  it  is  queitk* 
able  whether  alcohol  should  be  consielered  in  tiny  other  sen-**  thauui 
poison.  It  has  no  special  metlicinal  proj>ertiei>  that  are  u(  valu«.  it  a 
not  a  stimnlant,  and  at  most  might  Ik  considered  as  a  h,\7)notii; 
especially  in  old  people  with  some  arteriosclerosis.  Other  drvfl 
can  be  used,  however,  quite  as  well  and  more  safely.  It  is  |in)lMil'f< 
that  the  widL*sprea<l  belief  in  ils  efTirary  for  all  sorts  of  condiriooi  H 
based  upon  an  effort  at  the  justifiration  for  its  use. 

The  part  that  alcohol  plan's  in  thr  priKluction  uf  mental  disordm 
is  extremely  difficult  to  express  in  definite  terms.    It  has  been  domed 
that  12  to  15  per  cent,  of  the  psychoses  are  ilependent  upon  alcoW_ 
as  the  prinri[>al  etiological  factor,  ami  yet  any  such  figrure  as  thijBM 
extremely  misleatiinK,  for  il  is  really  not  known  how  alccAol  hm^ 
about  it.H  H'sultt,  and  especially  it  is  not  known  whetlicr  it  is  pruiiftr^> 
the  alcohol  which  is  to  blame  or  whether  secondarily  the  mctabolKa 
(listnrhaniys  which  are  produced  by  its  continuou.^  use.     It  is  of  tkr 
liighest  signHicance  that  of  the  cases  that  ctmie  to  autopsy  a  vay 
oiiisidcrable  iunnl)cr  of  them  in  the  general  hospitals  and  i)oor  hoiun 
are  found  to  suffer  trom  cirrhosis  of  the  liver,  w-hile  in  the  lutspitalA  far 
the  insane  this  condition  b  of  rare  occurrence.    'ITie  indication  is  wwy 
clear  that  the  psychoses  are  dependent  up<in  some  peculiarity  of  maSv' 
up  of  the  individual  which  is  affected  in  an  exaggerated  way  by  rIodIiqI 
or  of  which  alcoholism  is  the  expres.sion.     If  this  is  tnic,  then  thr 
alcoholism  is  only  a  surface  indication,  and  the  true  etiological  fartai» 
lie  dfc|ifr. 

Psychology. — ^There  are  many  tj*pes  of  persons  vho  drink  and  then 
arc  many  reasons  for  drinking.  The  u.sual  reasons  given  n'frr  to  sodml 
conditions.  One  is  rather  taught  to  believe  that  the  social  ilcmond* 
are  of  sui:li  a  nature  as  to  miuire  a  certain  amount  of  drinking,  and 
that  this  drinking  once  started  tends  to  peqietuatc  itself  and  to  finally 


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become  a  fixed  habit.  This  way  of  lookinR  at  the  situation,  like  the 
ief  ill  the  beneficent  effect  of  aleohol,  is  very  Uirgely  at  lea.-rt  aii  effort 
■t  justifiaition.  The  Siicial  t-onditioiiN  caimot  Ix*  chaiipcil.  Tliey  have 
to  be  subiiiittwl  to,  ai«i  therefore  the  t!riiikinn  is  inevitable  anj  not  the 
fault  of  the  indlviJiia].  This  really  offers  no  adeqimtc  explanation, 
and  in  all  probability  there  is  very  little  trutli  in  tlie  statement.  People 
do  not  drink  simply  and  solely  beeause  they  have  acqiiirwl  a  habit 
of  drinkinf?.  The  habit  element  is  tlie  least  niiportaiit  in  the  whole 
situation,  ami  if  that  were  the  only  thing  to  lie  dealt  with  the  j>roblem 
of  alcohnlisin  and  of  other  habituations  woiilii  be  relatively  siniple. 
IVople  drink  lM>rauae  of  definite  returns  which  they  get  fmm  drinking. 
A  given  murilx.'r  of  |jer>ons  all  plaeeil  under  the  same  conditions,  soeial, 
etc.,  do  not  rill  drink.  It  is  only  some  of  them  who  drink,  and  those 
who  drink  do  so  not  only  because  they  get  definite  desinible  results, 
but  because  those  results  are  practically  neeessary  for  them.  In  other 
words,  far  more  importjtnt  tlian  the  question  of  habit  formation,  is 
the  question  of  the  individual  psychology.  Here,  again,  as  has  been 
seen  already  in  dealing  with  the  psycho.ses,  the  (jucstion  of  mental 
ecinflict,'4  is  most  important.  When  the  individual  is  confronted  by 
situations  to  which  he  cannot  adjust  adequately,  when  the  world  of 
rt-ality  makes  demands  which  are  too  great  for  him  to  mrs't,  one  of  the 
ways  in  which  the  individual  reacts  to  such  a  condition  is  by  narcotizing 
himself  and  so  withdrawing  from  the  whole  situation.  Ah-ohol  then 
becomes  an  agent  which  helps  the  patient  to  get  away  from  the  conlliets 
thrust  upon  him  by  reality,  it  helps  him  to  withdraw  within  himself, 
helps  him  to  live  iu  the  world  of  phantasy  where  things  come  true  as 
ho  wishes  them.  I'nder  tliese  circumstances  it  can  be  seen  why  what 
appears  to  Iw  a  habit  is  formed.  The  moment  the  imlividual,  harassed 
by  the  absolutely  inaeceptable  demands  of  the  world,  fimls  an  averntc 
of  escai>e  in  which  he  can  rest  from  their  harassings,  finds  the  possi- 
bility of  iM-ace,  of  repose,  he  finds  it  equally  impossible  to  n'sist  the 
temptation  to  avail  hintself  of  it  and  of  course  he  usually  continues 
to  avail  himself  of  it.  He  is  rendered  more  and  rnnre  inca|>able 
o{  nieetuig  the  eonflict  efficiently.  Then-fore  a  vicious  circle  is  estab- 
lished and  the  individual  is  hojielessly  involved.' 

Aside  from  the  class  of  individuals  described  above,  it  must  be 
constantly  borne  in  mind  that  indulgence  hi  alcohol  Is  oftentimes 
the  expression  of  a  neurosis  or  a  psychosis.  For  example,  the  recurrent 
attacks  of  manic-^Iepreasive  psychasis  may  be  ushere<l  in  by  alcoholic 
imlulgence,  and  if  one  is  not  keenly  observant  he  may  easily  suspect 
ttiut  he  is  dealing  with  an  akvdiolic  psychosis  rather  than  witli  a  nianiiv 
depressive.  Tlie  same  thing  of  cimrse  may  be  said  of  dementia  jir'cox 
which  is  often  found  as.sotnated  with  alcohol  and  with  paresis,  which  not 
infrequently  has  a  history  of  alcoholism  in  its  early  stages.  Then  it 
must  be  remembered  that  in  certain  j>o.st-traumatic  conditions,  that  is, 

■  S«w  Jdliffa:    The  Mcntiilily  »i  Uie  Alcob'>lic.  N*.  V.  Med.  Jour.   April  7,  I9I7.  for 
dwcuwiioii  of  payohoKoulytic  pnnoiitlt^  ooneendDit  ibvdr<-iii>r  pHych'>lo);tyof  ulcoholiffin. 


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cases  foUowiug.  t^iiewiully,  hfail  injury  aiul  siiiistroke.  iiii>i  in  inm- 
sclerotic  (md  senile  conilitions  the  jjaticiit  may  react  in  an  f\^^ri; . 
way  to  aleohul  and  tlial  very  suiull  d(>ses  may  produce  very  praooomi 
effects.  This  is  true  also  in  connection  with  certain  other 
particularly  imbecility  anil  epilepsy.  Here  pronounceil  mdioM 
ul{i>lii)l  are  foiinil,  and  it  is  important  to  evaluate  the  iin; 
the  ulonhol  in  the  entire  situation. 

Filially,  there  are  certain  psychoses  which  nppear  to  be 
alcoholic;  to  ilepend  upon  prolonged  indulgence  in  alcohc^. 
acute  coiHlitions  due  to  alcohol  dninkenness  is  the  moAt  tj^M 
while  uf  the  chronic  eoiidltious  deix-iitlfnt  uix>n  alooliol.  d^nl 
tremens,  aletthoHc  hallucinosis,  and  Korsakow's  psychosis  an  I 
most  important.  The.se  latter  because  they  appear  to  be  depnih 
upon  something  other  than  simple  alcohol,  as  they  ne^ner  occur  at\ 
result  of  single  large  doses,  but  can  only  occur  in  a  person  chnwiQi 
adilicteil  it  has  l>eeii  prop4>sed  to  call,  after  tlte  luaniier  of  the  psychrt 
due  to  syphilis,  the  nieUi-alcoholic  psychoses.  With  this  intnHlilcti 
a  short  description  of  eai:h  of  the  mental  pitrtures  depetMleut  diied 
or  indirectly  u[K»n  alc*>hul  will  be  given. 

Dnmkenness.— 'Hie  general  phenomena  of  drunkenness  air  M 
well  known  to  require  detailed  dcseriptinn,  except  tliat  perhaps  t 
less  evident  manifestations  arc  not  generally  thought  of.  The  \* 
gressive  disturl>ance  of  coordination  of  the  motor  centers,  the  tijdi 
being  thrown  out  of  adjustment  first,  and  the  progressive  dist  ' 
of  the  sen.sory  apptiratus  in  the  same  way  produce  disturhafii 
latter  of  which  iire  entirely  subjective  and  so  are  not  ^•ncrally 
The  mmtd  of  the  dnniken  man  is  vnriable.  Each  ninn  reacts  to 
in  a  way  peculiar  to  himself,  but  in  a  general  way  there  niav  be 
sidered  to  be  two  classes  into  which  cases  uf  drunkenness  m»y 
divided,  the  exalted  and  the  depressett.  tin?  fonner  c-Iosel>  rt-M-i 
the  manic  phase  of  the  manicnlepressive  in  his  extreme  Ifxjuaci 
and  hyperactivity,  while  in  the  latter  the  p:uient  n-ithdmws 
him.4elf,  being  sullen,  moro<se,  and  disinclined  to  associate  with 

One  of  the  important  considerations  under  this  head  is  the 
eaae  with  which  the  inilividnal  is  st*en  to  react  to  alcohol, 
like  fewr,  may  be  used  to  expr^'ss  the  measuri-  of  cerebral 
unstable  and  defective  iodividuals  reacting  to  both  in  an  cxs, 
way. 

Pathologicai  Drwd-ennfss. —  Drunkenness  that  exhihitn  umi 
fcaturi's,  wliich  leads  the  individual  to  pcrfomi  strange  acts  or  mrti  d 
violent*  or  which  prndutvs  serious  physical  sATnptoms  is  kiKiwn  u 
iHithological  (Iruhkenness.  Tersons  in  this  comlition  may  de^T^> 
welbmarked  hallucinations  or  delusions  to  wluch  they  tend  to  mMTt* 
while  convulsive  attacks  an*  nut  infrffiucnt.  and  the  whole  iMrriod  il 
often  obliterated  from  the  memory  by  an  amnesia. 

Chronic  Alcoholism,     rnctmipllciilcd  lial.iituitl  drunkeniics.s,  ilut  iSf 
imrbrkay  not  dependent  upon  some  deKnite  underlying  coiMlitian.surt 


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s  cum'KMlrpressive  psychosis  or  paresis,  has  the  ear-marks  of  a  psycho- 
neurosis  uikI  is  therefore  clepeiifient  upon  the  ehameter  nwke-up  of 
till*  iudivIduBl  for  its  cause.  Tliese  eur-innrks,  wliieh  thr  nloiholie 
veil  shows,  are  the  feeling  of  ineffieieuoy  as  a  result  of  whi<^h  ihi^  alc-ohol 
\h  takcu  as  an  effort  at  fiudiug  safety— it  is  the  means  of  a  llight  from 
feality. 

It  must  be  recalled  that  many  psychoneurotics  whose  compulsive 
flights  are  alcoholic— and  such  are  usually  the  Hight  from  an  uncon- 
scious homosexual  conflict — are  verj'  superior  types  of  people. 

The  life  lli^tn^y  of  many  an  alcoltolie  shows  him  to  lie  an  InefBeient 
inilivichial.  He  is  incaiwhle  of  meeting  reality  efficiently  every  day. 
I  le  may  \w  able  to  deal  with  the  problem  of  reality  for  a  greater  or  lesser 
length  of  time,  but  continuity  of  elTort.  day  in  au'i  (hiy  out,  is  foreign 
to  the  alcoholic  character.  He  can  stand  the  strain  only  aljout  so 
long,  longer  in  some  4!ases  than  in  others,  but  the  principle  is  the  same. 
This  is  the  inefficiency  Adicr  believes  is  dependent  upon  organ  inferior- 
ity, or  to  use  an  older  and  more  tried  ex]>ression,  it  is  constitutional. 
The  reaction  to  such  a  feeling  of  inferiority  drives  the  inefficient 
iiuiividual  to  find  some  way  of  escape  from  the  horrid  facts,  the  o\Tr- 

§  burdening  oppressions  of  r**ality.  This  he  finds  in  aleoho!  which  dulls 
his  pen-eption  of  reality  and  (wnnits  the  world  of  phantAsy  to  reign 
supreme.  In  this  fool's  paradise  the  alcoholic  finds  temporary  surcease 
from  the  burdens  he  is  but  piiorly  equipped  to  l>caf. 
B  'Hie  efTects  of  alcoliolic:  poison  may  be  exhibite<l  in  any  organ  of  the 
^  body,  more  particularly  the  wntral  nervous  system,  the  stomach,  the 
liver,  the  kidneys,  and  the  bloodvessels.  The  efTects  on  the  nervous 
system  are  shown  in  varitnis  distiirbances  of  sensation,  such  as  the 
paresthesias,  amblyopia,  amaurosis,  dulness  of  hearing,  of  touch,  etc., 
while  in  the  inoti>r  realm  we  find  tremor  and  e])ik'ptifonn  attacks,  with 

•  genera!  motor  enfeeble  men  t  characteristically.     The  mental  changes 
are  grathial  and  pnjgressive,  the  intelligence  is  blunted,  the  judgnumt 
is  impaired,  the  moral  sense  dulled,  while  actual  delusioas  nut  iufre- 
quently  develop. 
■      While  all  of  these  changes  may  occur  in  chn)nic  alcoholism,  it  is 
H  usual  to  see  m  indiWdual  cases  one  organ  more  especially  selected  out 
H  by  the  alcohol  for  its  destructive  effe<rts.     With  the  beer  drinkers 
H  who  absorb  several  liters  of  l>eer  each  day,  cardiac  hytxrtrophy  is 
H  quite  common.    Some  patients  develop  serious  kidney  complications, 
while  others  are  able  to  drink  over  long  periods  of  years  without  any 
material  impairment  of  the  kidneys.    The  same  remark  applies  to  the 
liver,  wliile  (he  eftects  u|>on  the  nervous  system  and  the  bhwRlvessels 

•  are  equally  varied.  It  is  characteristic,  too.  that  the  individual  ns  a 
whole  varies  in  the  destructi\T  ctTect  wluch  alcohol  has  upon  him, 
some  individuals  apparently  being  able  to  use  large  qttantitics  over 
considerable  periods  of  time  without  notiwahle  impairment.  The 
general  outv\'iu'd  appearance  of  health,  however,  which  many  Indulgers 
ill  alcohol  show  b  si>metuues  rudely  dissipated  when  they  are  attacked 


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by  an  anitc  illntfss,  for  however  well  they  may  ha\'e  liwn  aUr  to  o 
on  with  the  routine  clay's  work,  their  weakness  is  shown]  when  ti»7  v* 
stihjeeti-il  t4i  the  special  stress  of,  for  example,  a  pueunxmiA.  iddtt 
(Kiith-rute  in  this  class  of  persons  is  much  higher  tluxn  in  ubsU'tDOV 

Delirium  Tremens. — Delirium  tremens,  vrhilc  an  acute  touifab- 
tiou  of  nltjolutlisin.  win  only  ocour  in  «  person  suffering  from  the  Art* 
of  ehronic  ulcohoUc  poisoning.  It  may  niunifc^t  it.-4t-lf  aomrtinait 
the  result  of  a  prulonge*!  debauch,  sometimes  as  the  result  of  aniibi 
or  injury  in  a  chronic  alcoholic.  It  has  often  bctn  muintAinod.  ad 
still  believed  by  maiky,  that  the  delirium  is  not  iitfn-^uently  ihe  nd 
of  a  sudden  withdrawal  of  alcohol,  as  for  example  when  a  pa' 
tJikeii  to  the  hospital  f<ir  an  injury  nothing;  i^  tlunifrht  of  iii^ 
tendencies  until  he  develops  a  delirium.  In  these  eases  the 
US  jiresunitni  to  be  due  to  the  fact  that  tlie  patient  did  not  Ret  his  _ 
supply  of  alcohol.  There  is  no  ginod  reasojk  for  this  opinion,  iml  I 
must  Ik'  renieinlxred  that  in  the  pnidmnial  ix'riod  of  delirium 
not  iiifivquently  the  patient  has  experienced  a  din^ist  of  iiqu 
number  of  days.  A  pretty  effective  m-Ration  of  the  tlieory  of 
ulwtinenee  delirium  is  derived  from  the  KugUsh  prlsi^n  statistics, 
show  that  in  the  year  191)7  there  \^Trc  GS.OtX)  inebriates  wl 
sutldenly  deprived  of  alcohol  by  confinement,  and  in  this  n 
24ri  develii[M'd  delirium  tremens,  less  tiian  one-half  of  1   |kt 

Sytjiplnms. — ^Thc  sjiiiptoms  of  delirliun  tremen-s  may  come  on  sli 
being  precede*!  by  sevcnd  days  of  general  physical  u|iHet,  with 
sensory  falsifications  and   piTliaps  ilelusional    interpretation, 
show  a  siM-cial  tendency  to  come  on  at  night  or  under  i-ondi 
which  accurate  i>erception  is  interfered  with.     On   the  other 
the  delirium  may  come  on  verj-  rapidly.    A  case  is  reeajled  of  ■ 
shoreman,  a  man  of  perhaps  thirty-five,  a  giant  in  physique,  who 
int(»theh*i«pilftlat  noon  with  a  sprained  ankle;  the  ankle  was 
and  he  was  put  to  betl.    That  night  be  was  in  tlie  wildest  del 
and  the  next  nufrnitig  he  was  dead. 

Following  these  prtKlrumal  symptoms  the  delirium  appears  in  ifl 
complete  manirestations.  It  is  a  typical  toxic  ileliriuni  with  niuhifoni 
disorders  of  tlie  sen3i»rium.  The  lialhici nations  predominate  in  d^ 
visual  sphere,  although  tactile  hallucinations  are  wry  common.  Tfce 
patient  is  manifestly  verj-  sick,  he  is  gn.'atly  tlepressed  physioUly,  I* 
is  tremulous,  the  tremor  being  so  constant  as  to  have  pi\-eu  tlie  moB 
to  the  condition,  and  his  niotnl  is  characteristically  one  of  apprebrnsioo, 
anxiety,  and  fear.  He  is  disoriented,  mistakes  the  peoph*  alwut  him; 
not  infR'qucntly  his  delirium  is  an  occupation  delirium  and  he  lielieviS 
liiuist'lf  back  at  his  awustonied  work,  but  it  is  characteristically  6IW 
with  fearsome  sights,  and  he  is  in  constant  terror  from  the  iovasion  rf 
the  numerous  animals  that  he  may  see  about  hiui. 

In  the  somatic  realm  the  pulse  is  rapid,  the  tremor  constant,  the 
skin  bathed  in  pKjrspiration.  the  tongue  foul,  the  appetite  niV,  an*l  tliefe 
may  perhaps  be  a  marked  grade  of  albuminuria.    The  iem|trniturr  is 


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cimraoterlstifally  either  normal  or  Mow  iicrmal,  but  it  may  be  hijtii, 
in  wliich  cusc  we  have  wliat  is  known  as  the  fchrih  type  of  the  disease, 
whicli  is  generally  fatal.  All  sorts  of  eouiplicutioiis  may  iiaturally 
occur.  Acute  cardiac  dilatation  sometimes  causes  death,  while  one 
of  the  most  frequent  of  the  complications  in  severe  cases  is  "  wet  brain." 
In  this  cnndition  the  patient  sinks  into  a  low  muttering  delirium,  the 
temperature  falls  to  subnormal,  the  face  is  pale  and  bathe<l  In  cold 
perspiration,  the  pupils  dilateil,  there  may  Iw  some  rigidity  of  the  neck 
with  a  tendency  to  a  bending  back  of  the  head;  the  patient  sinks  into 
kB  Comatose  condition  and  dies. 

Tlie  psychosis  runs  an  acute  course  of  about  three  days  and  usually 
terminates  by  a  long  sleep  in  recover\".    Ten  to  15  per  cent.  die. 

Treatmcnf. — ^Thc  treatment  of  delirium  tremens  should  be  suiiporting, 
liquid  concentrated  food,  predigested  if  necessar>'.  Thu  bowels  and 
'tlic  kidneys  should  be  freely  ilushetl,  heart  stimulants  are  necessary 
'  to  prevent  eanliac  failure,  and  hypnotics  often  required  to  produ<^  rest. 
For  the  excitement,  hydrotherapy  in  the  form  of  the  continuous  bath, 
or  if  this  is  not  available,  cold  packs  are  preferable  to  drugs.  The 
constant  thing  to  be  kept  in  mind  is  the  support  uf  the  .strength  of  the 
patient,  ami  the  logical  way  to  acaimplish  this  enil  Is  by  feeding.  If 
the  patient  refuses  food  no  time  should  be  wasted.  He  sbotild  be 
immediately  fed  with  the  tube,  preferably  as  often  as  three  times  a 
day  in  small  amounts,  watching  the  stools  aud  goveniiug  the  quantities 
given  in  each  feeding  by  tlie  amount  the  patient  is  able  to  <ligest.  If 
the  patient  is  unable  to  retain  the  food  owing  to  acute  irritability  of 
the  stomach  and  constant  vomiting,  feetling  by  the  rectiun  should  be 
resorted  to,  while  if  the  prostration  is  extreme  and  there  is  emaciation 
and  the  deprivation  of  fluid  considerable,  hypodermoclysis  is  a  valuable 
adjunct. 

Korsakow's  Psychosis. ^Tliis  psychosis  is  found  typically  in  asso- 
ciation with  iilcohulie  polyneuritis,  although  the  same  mental  state 
may  be  found  with  a  polyneuritis  of  different  origin,  as  for  example  the 
metallic  poisons,  some  of  the  uifectioiis  such  as  tuljerculosis  and 
influenza,  and  some  of  the  endogenous  toxins  as  in  diabetes.  The 
syndrome  occurs  also  in  connection  with  general  organic  changes  of 
the  central  nen'oas  system  as  in  paresis,  arteriosclerosis,  and  senility. 
In  the  latter  case  it  is  a  part  of  the  clinical  picture  of  presbyophrenia. 

While  this  psychosis  occurs  typically  in  connection  with  poI.\*ncuriti9, 
the  evidences  of  a  polyneuritis  may  be  very  slight.  They  should  Ix: 
carefully  examined  for,  especially  by  pressure  over  the  large  nerve 
truidis,  which  will  often  elicit  painful  points,  rather  ty])ically  at  the 
points  of  exit  through  the  bony  foramina.  Tlie  Losegue  sign  should 
be  sought  for. 

Korsakow's  psychosis  is  sometimes  designated  in  c-ontradlstinetion 

to  delirium  tremens,  which  is  spoken  of  as  an  acute  alcoholic  <lelirium, 

as  a  chronic  alcoholic  delirium.    In  fart  the  attack  may  begin  with 

a  typic'al  delirium  tremens  which  merges  into  tlie  chronic  delirium  of 

M 


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KoreakoH-'s  psychosis  instead  of  clearing  up,  although  thb  is  iia(4r 
usual  meth(»d  of  onset.  Not  infrequently,  howwcr,  a  hetni;  rf 
pivvious  attacks  of  liclirium  trcmeius  may  he  cliciteti. 

The  mental  syinptonis  are  the  result  of  a  <.-on)bination  of  attntia 
and  memory  disorders.  The  memoo'  disorder  is  of  the  na 
a  lack  of  impressibility.  The  result  of  this  combination  is  a 
tj'pc  of  amnesia.  There  is  defect  in  the  recordinij  of  ciirirnt  fv 
The  patient  is  usually  disoriented,  to  some  extent  at  least,  and  i 
thinps  that  have  recently  happened  cannot  be  recalled.  The*  dcfi 
of  memory  are  characteristically  supplied  by  fabrications  of  all 
of  degrees  of  prolwbilily  and  grotesqueness,  which  are  usualh 
hy  the  [wtient  with  u  compiisetl  hearing  and  with  ever>' 
apiJcarHnce  of  relatiii^  facts,  or  at  least  ott-urrences  whicii  he 
believes.  These  fahritatinns  do  not  corresjKjnd  if  the  patient  is  a)k 
at  inte^^al3  about  occurrences  covering  a  certain  period,  and  they 
often  be  guided  by  suggestions  from  the  questioner.  Nut  infreqocnl 
the  patient  in  his  fabrications  invents  occurrences  wliit-h  hccouoI  S 
his  symptoms,  for  example,  a  patient  who  is  snfTering  from  a  nftii 
amount  of  pain  in  his  legs  as  a  result  of  his  polyneuritis,  even  thou 
he  may  have  IxH'n  confined  to  his  bed  for  weeks,  will  say  that  he  i 
out  tluit  tnorning  and  climbed  a  long  hill  and  tired  his  Ivga  out,  anl 
that  way  he  accounts  for  their  aching. 

The  experienws  which  these  patients  relate  are  of  a  dtdinous  rh*l 
actcr  ami  not  infrequently  it  is  rather  difficult  to  diatin^iish  til 
fabrications  from  the  dreams,  and  it  would  appear  that  the  two  oftd 
merge  into  one  another. 

riiy.sically  the  patient  usually  presents  the  signs  of  a  polx-ncunti 
aUhuugh  these  [iiay  1^  very  mild.  When  the  neuritis  is  severe,  foa 
drop  and  wTist-drop  are  characteristic  signs,  as  the  ner\-es  of  the  wteil 
sors  of  the  forearm  and  leg  are  most  cliaracteristically  invaJ%'cd 
alcoholic  neuritis. 

The  serious  comjilications  of  the  disease  are  either  dcpeniirnt  upa 
intercurrent  affections  such  as  pneumonia  or  upon  the  involvement 
important  ner\*es  such  as  the  vagus,  vajcus  involvement  of  eourrte  hatu 
pretty  apt  to  he  fatal.    A  serious  complication  is  a  nenritis  of  \ht 
phrenic  nerve  with  paraly.sis  of  the  diaphragm  on  one  or  both  ^de» 
with  resulting  tympanitis  and  serious  embarra.ssment  of  cnnlisc  afx 
respiratory  activity. 

Patboiogy. — The  puthologj'  of  the  disease  shows  that  it  is  by 
means  confined  to  the  pcri])heral  nerves  nor  even  to  the  motor  azfSS 
of  the  central  nervous  system,  but  that  tliere  is  a  very  general  invohr- 
ment  of  the  entire  central  ncr\ous  system,  the  coni,  Iio-saI  gangilia, 
and  the  cortex  all  showing  lesions,  although  there  appears  to  Ik  a 
tendency  to  the  focalization  of  the  pathological  process.  As  a  rsalc 
certain  focal  .s^-mptoms  as  aphasia,  apraxia,  hcmianopia,  etc,  are  found. 
This  wide  distribution  of  the  jmtiiuh^ical  di.sturbunces  and  th«r  trn- 
deacy  to  focalization  is  due  to  the  fact  that  the  dL^ase  itivoK'es  the 


m 


.....^y 


ALCOHOLIC  HALLUCISOaiS 


S51 


I 


bloodvessels.  The  smaller  vessels  pruliferate  and  present  e^"i<lencoa 
of  endo-,  meso-  and  |wrinrtcritis  with  frfqupnt  ruptures.  When  this 
condition  is  foonliztil  in  the  luiil-bruin  himI  ^ww.  rise  to  varions  ocular 
palsies  the  syndrome  of  ticuU'  hrmorrhagr  polUirncfphtilitii!  of  iVernu-ke 
is  present.  This  is  not  infnH|Uen(ly  ubserved  in  ehniiiic  aliHiIioHes. 
The  condition  is  typically  uslicrcil  in  by  severe  and  prolonged  vomiting, 
which  is  followed  by  cmrked  confusion  with  delirium,  vertigo,  some- 
times headache,  and  somnolence.  Optic  neuritis  may  be  present. 
Death  usually  occurs  in  from  one  to  two  weeks. 

With  a  disea-se  of  this  character  having  a  pathologj-  so  widely 
distribute^]  throughout  the  nervous  system  and  dependent  upon 
elironio  toxemia  it  can  be  understood  how  very  many  t}/i>es  have  been 
described.  lliese  tyi»es  or  clinical  fcrms  are  nothing  more  than 
desrriptions  of  the  disease  in  which  certain  symptoms  are  cs|x'cially 
proiniiiciit,  anil  so  there  are  autnesic,  confusional.  dehisioiial,  anxious, 
denietitcd,  deliriou-s,  stuporous,  hallucinatory  forms  described  by 
difTerent  authors. 

Treatmeni. — The  treatment  of  the  condition  is  of  course  the  with- 
drawal of  alcoliol  and  the  treatment  of  a  Renenil  toxic  state  along 
supportive  lines.  The  deformities  which  are  due  to  the  paralysis 
should  Ix-  dealt  ^nth  by  recognized  orthopedic  measures.  It  should  be 
n'membered  that  while  the  patient  i^  in  Ufl  and  delirious  the  weakened 
extensors  iif  the  fon-arni  an<l  lejc  should  not  be  strt'tclieci  by  the  weight 
of  the  limb,  but  should  be  supptirtcd.  particularly  the  weight  of  the 
bed  clothes  slioiuUl  l>c  n.'uioved  from  the  feet. 

Alcoholic  Halludnosis. — This  condition  h  also  on  exi>resMon  of 
chrtmic  alci)holism  and  may  be  preceded  by  attacks  of  delirium  tremens. 
It  is  charaetcrizcd  by  hallucinations,  anditorj'  predominating,  in  this 
resi>ect  stronply  contrasted  to  delirium  tremens,  and  delusions  of  a 
persecutory  character  which  harmonize  »nd  are  e^iilanatory  of  the 
ImllucinHtiuiis.  It  is  quite  characteristic  that  (he  hullut-inattons  and 
the  delusions  deal  with  sexual  matters,  the  patient  fn-tjuently  being 
abnsi'd  by  "the  voice"  for  c<iToniilti!ig  some  sexual  erlinc  or  Is  aecuswi 
of  sexual  perversions.  The  delusions  are  practically  invariably  ix-rseeu- 
tory,  although  occasionally  cx])ansive  elements  nwy  enter  the  picture. 
Not  infrequently,  t(Hi.  the  patient  is  very  much  frightenctl.  as  when  Ije 
thinks  he  is  Iwinp  closely  pressed  by  his  pcrsctnitors  who  are  determined 
upon  taking  his  life.  There  are  not  a  few  borderline  mixtures  of  this 
psychosis  and  delirium  tremens. 

The  condition  is  essentially  an  acute  jiaranoid  state  and  as  such 
its  explanation  is  the  same  as  the  cxytlanHtion  of  paranoia,  Tn  othiT 
words,  there  is  an  unconscious  fixation  at  the  liomoseximl  level,  and 
this  accounts  for  tlic  very  great  frequency  of  the  sexual  duiracter  of 
the  haltuneinations  and  the  references  to  sexual  ixnersions.  The 
alcohol  which  is  t»kcn  by  the  individual  because  he  cannot  deal 
efficiently  with  reality  can.ses  him  to  turn  back  ujKin  himself  and 
produces  a  rcaniination  of  this  early  fixation,  and  then  the  mechanism 


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THE  TOXIC  PSrCHOSBS 


of  projfKTtion  romes  in  as  a  distortion   to  make  it  appear  that  tk 
sutTeriiig  lias  its  origin  from  without. 

A  rewnt  analysis  of  cases  by  Schneider  has  brought  out  the  nukMf 
of  the  individual  in  a  type  of  psychosis  which  has  too  often  bern  thov^ 
to  In-  aiifficiently  explained  by  aelohol.  Aside  from  tlvc  fart  drf 
hnllucinosis  occurs  aside  olt<i(fether  from  alcoholic  indulcencr  be  fini 
that  rc|K'uted  debauches  may  terminate  without  halliH-ino«tlsthat.thil 
oiJy  supervenes  as  the  result  of  a  siK'cial  precipitatinjr  factor.  Ill 
precipitating  factor  is  <^  psychogenic  nature,  mental  aliock  fftUovo 
by  worn,'  and  the  content  of  tlic  hallucinosis  is  detemiittet]  by  li 
nature  of  the  experience. 

The  dehisional  system  is  rapidly  sip-stematizwi  so  that  in  certM 
causes  the  patient  mi};lit  give  the  impression  of  a  paranoiac  111 
course  of  the  disease  is  usually  prolonged  over  a  numlier  of  m^ 
and  not  iiifnfpiently  over  a  nuinlter  of  montJis.  It  {^•ncrally  cnb  H 
rerover>'.  but  sometimes  merges  into  elironicity.  The  iliseafCBia 
fatal  and  its  pathology  is  therefore  the  pathology  of  cbrontc  aid 
holism. 

Alcoholic  Pseudopue^. — In    a    few   patients    prolungevl 
intoxication  prixluifs  a  pictun-  closely  resemblinp  ^iicnil 
In  these  cases  we  find  an  expansive  delirium  »)mbiiRNl  with  the 
of  alcoholism,  such  as  ataxia,  speech  defects,  and  tremor.     It  must 
renieinljcred,  too,  that  pupillary  anomalies  quite  reguliirly  occur  i 
severe  grades  of  Intoxication  and  even  an  Arg>Il-Uobcrt-*on  popi 
has  been  observeri.       Thes**  uliservatioits  should    \te   tnkrn   with  i 
certain  amount  of  reser\'Htion  Ini-au-si'  it  is  quite  imposHible  oftni 
to  tell,  without  the  aid  of  instruments,  exactly  what  the  (HipiUuy 
reaction  may  be  and  csix'cially  whether  it  is  entirely  liiwt,  and  ri  i* 
generally  amceded  that  toxic  conditions  will  produtx  a  slntriiij;  of  tbr 
ViiiUt  reflex.    On  the  other  hand,  it  has  been  thought  by  some  xhM 
where  tltese  marked  pupillary  disturbancvs  are  found  tluit  it  tndiratnl 
the   presence   of  s.N'pliilis,     Therefore   these   observations    should  be 
correl«le<i  with  the  serologicid  findings.     A  case  has  \xvn  retmdy 
reported  by  Noiine,^  however,  in  which  the  Argyll-lloljcrtson  iwpil 
was  Llemunstrated  to  Ije  due  to  alcohol:  hies  was  ext-Judeil  bv  nnp>* 
tive   four  rcnctions,   optie  neuritis  was  exclurkil  by  i*arcf»l  ophtfait- 
mulogical  examination,  and    the   light   reflex    returned    ujion    wttb- 
drawal  of  alcohol.    These  cases  clear  up  promptly-  u|>on  the 
of  alcohol. 

Alcoholic  Pseudoparanoia.— In  some  patients  witli  chronic  al 
a  fairly  oircuiiis<Tii)«il  delusional  system  may  develop  which  chara< 
istically  takes  the  form  of  delusions  of  marital  infidelity.    In  enilraniT- 
inK  tu  inter]jret  this  delusion  the  paranoia  mechaulsras  must  \x  lK>mc  in 
mind.    Quite  commonly,  however,  the  delusion  wlien  it  occurs  in  a 
is  a  defense  reaction  to  inipotenoe,  which  lias  been  largely 


mao 


•  Neurol.  Cmtnilhl.,  1415,  NM.7-ft.    Also  ««e  Motion  on  RyoHMAoM  lor  oUmti 


853 


probably,  by  the  aloi)h<ilic  inrinlgcina'.  Iiisteail  of  refiliniiig  his  own 
impotenw,  which  is  an  iimtfeptJible  thnupht.  he  blames  his  wife  for 
being  untrup  to  him.  These  case  are  essentially  chronic  ami  persist 
at  least  as  lung  as  ihe  aleohol  is  indiJp-d  in,  while  even  when  it  is 
removed  they  may  be  a  lonp  time  clearing  up  and  may  perhaps  go 
over  into  a  ejirunic  delusional  state  Urgely  because  of  aii  uoeonscious 
hom(»sexual  fixation. 

Alcoholic  Epilepsy — In  a  chronic  alcoholic  toxemia  it  is  not  strange 
that  epileptifonn  cmivulsions  should  onrasionally  develop  and  recur 
from  time  to  time.  The  outward  charucteristics  of  the  convulsion 
ape  in  everj'  way  the  cliarae;ten.stirs  of  an  epileptic  nttAck.  If  the 
IxTson  is  not  esstMitially  epileptogenic  the  convulsions  will  subside 
on  the  removal  of  the  alcohol. 

Dream  States. — In  coiiditiotis  of  pathological  ilriMihemiess  it  is  not 
infrecpient  for  the  patient  to  have  no  recollertion  of  the  ijerimj 
during  which  he  was  intoxicated.  If,  during  this  period,  he  has  been 
engaged  in  some  .sort  of  occnipation.  business  transaction,  travel,  or 
what  not,  or  |)erhaps  engaged  in  the  jierfomiance  of  criminal  acts, 
he  may  .still  wake  up  with  no  recotlertion  at  all  of  this  pfTinnt,  although 
during  It  he  outwartlly  appeared  to  be  in  a  nonnal  stiite.  Some  [jcople 
are  especially  liable  to  these  dreum  states.  It  would  seem  that  they 
j>rr3cnt  a  leTiih-nt-y  to  the  doubling  of  their  ]ierscHni]ity  aiul  that  the 
alcohol   bel|>3  to  prmluce  these  soniniirnbiilistic  episiKleg. 

Dipsomania.  -I)ip.s4imunia  is  a  term  npplicd  to  a  ]H'riodi(iiI  iinpnisc 
to  drink.  Oriiiking  is  only  the  outward  manifestation  of  the  trouble. 
It  is  a  recurrent  neuropathic  attack  which  demands  the  narcotizing 
results  of  alcoholic  indulgence  as  is  not  infrwjucntly  a  manifestation  of 
the  manio-depres-sive  psychosis  or  of  a  compulsion  neurosis. 

Opium. — The  habitual  use  of  o])iura  in  some  form  has  be«)me 
common  among  all  chisses  in  societ\'.  The  same  thing  may  be  said 
with  referent*  to  the  reasons  for  taking  opium  as  has  been  said 
with  referenet*  to  alcohol.  The  opium  luxbltue  is  a  person  prinmrily 
of  neuropathic  tiiint.  the  nu'R^  opium  tiiking  or  the  symptoms  it 
prwluces  being  but  surface  indications  of  the  real  trouble. 

Symptoms.— The  general  symptoms  of  its  use  are  wtU  known.  In 
small  doses  it  h,  mildly  stimulating  and  produces  a  pleasant  euphoria, 
while  if  it  h  taken  in  large  doses  and  continuously  it  leads  to  a  mental 
blunting,  a  general  feeling  of  malaise,  inability  to  make  effort,  with 
nuirked  physical  disturbances  such  as  tremor,  muscular  weakness, 
coiLStipation,  paresthesia.^,  etc.  It  is  not  infrequent  for  opium  in  some 
of  its  fonns  to  be  combined  with  addiction  to  alcohol  or  cocain.  Con- 
tinuous use  may  simply  produce  a  thoroughly  crippled  individual  who 
is  alterniitcly  in  ii  mildly  euphorie  state  or  in  a  condition  of  slupirlity, 
malaise,  and  iiulolence.  When  a  psyeluwis  develojis,  it  is  chanicter- 
istically  an  hallucinated  stitte  usuully  with  paranoid  coloring,  or  it 
may  he  distinctly  delirious.  The  prognosis  is  of  ci^urse  not  gotxl  unless 
the  underlying  neuropathic  taint  can  be  dealt  with. 


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THE  rOXiC  PSYCHOSES 


'Hif  use  of  opium  has  much  less  tendency  tlian  tbat  of  aJcobii  W 
prodmr  tissm^  degeuerntioii. 

Treatment — The  treutineut  is  usually  the  prompt  removjil  o(  tb 
lui'ti'  (loses.  Tliesc  can  be  readily  wJth'Jmwn  until  th:»  patient  b 
rcduwd  to  the  actual  newssar\'  amount  of  drug  to  gt-t  throujH}  li)* 
<lay  HiiiifortiiMy  ■with,  wliicli  is  aljout  two  j^ains.  From  llu?i  p«itW  wi 
withdrawal  should  be  gradual,  carefully  lookinj;  after  the  »,\-rnpu«a 
of  abstinence  as  they  apjiear.  These  s^inptonis  refer  partiinilvly  ta 
the  heart,  the  ner\'()us  system,  and  the  pistro-iiitt*stiiia!  j;yst«-m.  "stvof 
times  pmfouiid  collapse  may  iH-ciir  with  the  withdrawal  t>f  the 
Cardiae  conditions  should  lie  watched  and  stimulants  admiui 
if  there  is  any  sign  of  weakness.  For  llif  diarrheji  opiurii  sb 
avoided  if  possible.  Acute  withdrawal  and  treatment  by  atropine  tiM 
the  synipatiictic  collapse,  and  pilocarpine  or  e.serine,  for  autooMBi 
stimulation,  may  be  practised  to  advantage. 

Cocain.  — Cocain  is  taken  for  the  same  reasons  that  niojhol,  mrir 
phin  and  other  drugs  are  taken,  but  it  \b  much  more  donnnatin| 
in  its  inHuence  and  more  difficult  to  escape  from  (ban  cither  of  tk 
others,  while  it  i.s  more  disintegrating  than  morphin  or  opiura. 

Symptoms. — Tliesj-mptomsofeooain  intoxination  are  those  of  mtrfccifl 
stimulation.     The  jjatient  is  extr^-raely  active  and    very  talkaUhr, 
full  of  all  sorts  of  schemes,  ambitions,  tells  what  he  is  K<*'n;K  W  <^'^ 
unfolds  plans,   and  in  general  is  in  u  manic  condition    of  mimt. 
Following  this  hyperstimulation  there  is  of  crmrse  profound  m»lai« 
and  exhaustitm.    Asst)ciatud  with  the  habitual  use  of  cocain  iberr  i* 
more  apt  to  be  m.arked  and  persistent  sensory  disturbances  in  llr 
form  of  paresthesias,  while  in  the  mental  sphere  the  disinte^rmtion 
of  the  individual  is  much  more  marked  tlian  with  opium,  as  a  nilr 
'I'lie  moral  sense  is  blunted,  he  lies  readily,  the  jialginctil  is  imiMtrnJ. 
ami   not  inrn'<iiient]y   they  develop  distinct  delusions  of   which  iJr 
delusion  of  marital  infidelity  is  not  infrequent.     Clironic  ponnoid 
conditions,  halhurinatory  states,  and  delina  are  seen  in  cases  f>f  loo^ 
continued  habituation.     The  drug  may  be  withdrawn  much  nuat 
rapidly  than  moqihin  since  it  does  not  contribute  so  hirgeJy  Co  pro- 
duce an  infantile  ri'gresHion  as  does  muqihin. 

Miscellaneous  Intoxicants. — A  large  number  of  dnigs  ore  ukcn 
fiabitualiy,  particuhirly  the  whole  group  of  pain-reliennK  and  ^-lerp- 
produciiig  firugs.  In  general  the  mental  condition  due  to  these  ilrup 
varies  uli  the  way  from  delirium  as  the  result  of  an  acute  intoxication 
to  chronic  paranoid  conditions.  The  main  feature  of  the  drug  tieiiria 
13  their  dream-like  character.  The  patients  have  all  sorts  of  grutrsque 
cxixrriences  which  they  weave  into  a  more  or  less  cousistcnt  descrip- 
tion, elalwjrating  the  details  here  and  there  as  may  be  Dcoeasary.  TV 
dilirions  experiences  pass  like  moving  pictun's  before  the  tmtirut'ii 
mind,  and  they  not  infrecpiently  are  perfectly  i-omptxietl  iis  thrV 
recount  them,  no  matter  how  grotesque  f>r  unusual  or  evf  n  tcrrif.Wnit 
some  of  tlK>m  may  be.    The  chief  uiMkrlying  motive  for  the  taking  of 


GENERAL  CONSIDERATIONS 


855 


these  drugs  is  to  escape  from  rcalit}'  as  much  &s  possible  and  to  get 
into  a  world  of  phantasy. 

Bromides. — TI»e  iiossibility  of  bromide  delirium  from  the  taking 
of  large  doses  nf  bromides  for  a  long  perio<l  of  time  sbould  l»e  borne 
in  mind.  Patients  are  not  infre<|uciiTly  mlinitted  to  hospitals  siip- 
postnlly  sufTering  from  some  psychosis  but  with  a  bromide  delirium, 
the  bromide  having  been  adminLstercd  to  quiet  tlic  ner.'ousncss  of 
tt  neurosis,  or  perhaps  given  in  the  treatment  of  an  epilepsy.  The 
avernge  practitioner  does  not  nppcar  to  reidizc  the  possibility  of  chronic 
poisKriirig  that  presmptiiins  of  tliis  sort  i)reseut. 

Carbon  Monoxide.— i'arbon  monoxide  delirium  is  of  special  impor- 
tance in  connection  with  the  frefpient  attempts  at  suicide  with  illumi- 
nating gaj<  that  one  meets  with  in  our  large  cities.  The  principal  thing 
to  be  thought  {(f  in  cniinecirtion  with  earb(tn  inomixide  poisoning  is  that 
after  the  initial  cITinHs  of  the  poisoning  have  suhsldeil  and  the  patient 
comes  out  of  the  coma  there  may  l>e  tjuite  a  rapid  retiu-n  to  normal 
and  the  patient  be  in  an  apparently  normal  condition  fur  a  week  or 
ten  dnys  and  then  a  relapse  occur  with  marked  mental  disturbance. 
The  patient  should  never  be  dischargc{l  from  the  hospital  until  after 
this  i>ericid  nf  danger  has  been  i>asaed.  Delirium  is  characteristic  of 
this  form  of  poisoning,  and  an  amnesia  for  the  period  usually  follows, 
often  lussociated  with  fabrications  ami  pseudoreminiscences,  producing 
a  Konyikiiw  syndrome.  Disturbances  of  speeeh  are  also  common,  as 
lire  disturbimccs  in  the  eniotinnnl  field,  such  as,  for  example,  causeless 
KuiglitLT.  I'uthologiLidly  there  appear  tu  Ijc  thromlmtie  occlusions  aiwl 
hemorrliages  which  characteristicjilly  are  found  in  the  Iwisal  ganglia, 
and  in  this  region  may  account  for  the  dlsturl>ance5  of  mimic. 

Lead. — In  chronic  lead  poisoning  we  may  finfl  a  eotidition  of  pseudo- 
general  paresis  or  Knrsakow's  syndrome  in  atldltlon  to  the  ordinary 
hallucinatorj-  and  delirious  episodes. 

Mercury.— This  poison  producer  characteristically  a  condition  of 
great  irritability  associated  with  insomnia  and  anxiety.  This  cimiii- 
tton  may  beeimie  more  pronounced  and  develop  into  a  well-marked 
delirium.  .Subacute  mercurial  [Hiisoning  may  bring  on  a  typical 
vagotonic  condition  with  the  physical  symjitoms  of  general  or  local 
vagotonia,  the  somatic  symptoms  of  visceral  vagus  alterations  or  the 
psychical  analogies  of  an  anxiety  hjirteria,  or  a  manicKleprcssive 
I)sycli03is. 

There  are,  of  course,  other  poisons,  but  these  are  the  principal  ones. 

General  Conalderfttloiu.— With   regard  to  all  of  the  habit-forming 
particularly  alcohol,  opium,  cocaine,  and  the  analgesics  and 
)notles,  it  umy  be  said,  as  already  indicated  in  discussing  them 

jarately,  that  the  true  cause  of  addiction  lie-s  in  the  make-up  of  the 

lividual.  This  cause  would  apjiear  to  be  a  narcissistic  or  homo- 
sexual fixation.  This  fixation  and  its  results  are  by  no  means  simple 
matters  psfyehologtcally  and  differ  very  materially  in  different  individ- 
uals.  The  only  hope  for  the  treatment  of  this  group  of  cases,  however, 


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THE  TOXIC  PSYCUOSBS 

is  ail  ability  to  modify  tliis  character  anomaly.  The 
course,  therefore  can  only  be  tentative  and  sj^iiiptomatic 
perifxls  of  acute  dii^ttirbiince,  and  it  is  iu  the  iQter%*ftl,  vhen  tkt 
patient  is  free  from  the  psychosis,  that  the  treatment  shotiM  br  npfiliBi 
This  is,  of  course,  the  psychoanaljiic  treatment  aiu!  shuuU  h 
addressed  to  discovering  the  underlyiiiR  ctiohigical  factors.  Vnlrt 
somcthuig  can  be  acctiniphshc*]  in  this  direotioii  very  little  is  to  b 
hoped  for.  The  mere  palliative  treatment  by  drugs  is  Urgely  a  mniia 
illusion,  somctimc»,  as  in  specially  vaunted  s>':stezns  of  cure,  a  deluni 
or  quackery. 

As  regards  the  metallic  poisons  associated  with  dangerous  tradet, 
course,  tlie  treatment  here  is  purely  s.NTiiptoniatic,   eliininativc,  t 
expectant,  while  the  real  effort  that  is  to  be  of  niatcrial  help  should  b 
exiJemled  in  prophylaxis. 

Uremia. — In  acute  uremia  the  convulsdoa  is  one  of  the  most 
sij^n?^,  and  cannot  be  di^tinguislied  in  its  outwanJ  nianifestJii 
the  orditiary  epileptic  attack.  Similarly  with  epilepay,  too, 
be  quite  well-defined  delirioid  experiences  or  dream  Htac«.s  in 
there  is  ilisorit-ntatloii  and  noticeable  disturbiitice  of  the 
usually  assocUitcd  with  mua*  or  less  constant  activity.  There 
an  anxious  affect,  or  the  patient  may,  as  is  quite  u^iial  in  de 
merely  be  interested  in  halluciimtory  ex|»ericnrt\s.  Acute  uremM 
s>inptoms,  in  the  mental  sphere,  of  this  clmracter  may  Hca>mi«ii} 
exacerbations  of  the  physical  condition  in  a  patient  suffering  fn«8 
chmiiic  nephritis. 

In  chrtiuic  uremia  one  finds  not  infrequently  markeil  mcntjU  syiajf 
toins.  The  mental  symptom.^  arc  usually  of  tlie  character  trf  ddcrt.  i 
general  stupidity  with  a  feeling  of  physical  weakness,  destine  to  fllwp, 
with  perhaps  complaints  of  headache,  associatetl  with  irrttability. 
Along  with  the  mental  symptoms  may  go  trt-mor.  speech  disturbaaas. 
eye  muscle  pabics.  pupillary  ditfercnces.  slug:gish  or  failirift  light  reac- 
tion, which  point  to  au  organic  disease  of  the  brain.  If  alon^  with 
crtruiition  there  are  .lack.sonian  attack.s  folIowTd  by  mono-  or 
plegia  witli  perhaps  aphasia  and  disturbances  of  vision,  the  similan 
general  pjire^ls  on  the  one  hand  and  to  brain  tumor  on  the  dtiicr 
be  very  great.  Sometimes  along  with  these  s.N'mpliifns  the  tmiod  ts 
distitictly  euphoric,  which  .still  further  suggests  the  possibility  ti 
paresis.  \  certain  imniber  uf  the  cases  of  uremic  ps^'choaea  show  dntc 
rclatiun:^hips  to  dementia  precox  showing  negativism,  tnoobereiKV. 
catatonia.    Probably  this  group  is  more  serious  i[i  its  progooeis. 

Diabetes  Mellitus.^Tlie  mental  disorder  wliich  is  associated  wilk 
diabetes  is  u.sually  of  a  mild  depressive  t^pc,  often  with  ide«a  of  rain 
and  sir.  .Anxiety  states  have  aLw  l»een  descril>ed.  Occa«ionally  ih* 
picture  gives  somewhat  of  the  impre.^ion  of  general  parois.  WitJh 
the  chronic  dcpn's^fl  condition  paranoid  ideas  sometimes  dfvrloft. 

In  gcnend  the  severity  of  the  mental  symptoms  may  alternate  with 
the  severity  of  the  physicid  disease,  a,s  indicated  by  the  sugar  eUu»- 


t  reac* 


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857 


natetl.  )Mien  the  intoxication  is  v(*rj'  great  tlie  pntieiat  may  be 
irritaWe,  sleei>y,  stupitl,  complain  of  uvakiiess,  hikI  hcsulBfhe. 

The  diabetic  atate  itself  is  an  etiological  factor  in  the  production  of 
arteriosclerosis,  and  evidences  of  arteriosclerosis  may  be  found  asso- 
ciated with  the  condition.  It  shnnl<l  he  reniembennl,  however,  that 
both  the  arteriosclerotic  condition  and  the  senile  state  interfere  willi 
the  metaboli:sra  of  tlie  sugars  and,  therefore,  may  tlwmseives  be 
associated  with  glycosuria. 

Gaatro-intestiEal  Diseases. — In  general  it  is  well  known  that  with 
diseases  hclnw  the  diaphragm  there  is  as.siwiated  on  the  menial  side  a 
depressive  mimd.  The  relation  between  diseases  of  the  gnatro-iiitestinal 
tract  and  associated  glands  to  mental  states  is  extremely  difficult  to 
interpret.  Many  of  the  gastro-intestinal  disturbances,  rattier  than 
being  causes  of  mental  disease,  are  effects.  This  is  particularly  six^n 
in  tlie  realm  of  the  neuroses  and  the  psyehoneunises,  and  is  discussed 
in  the  chapter  dealing  with  these  conditions. 

Certain  <'ases  of  acute  <-onfusion  develoi)  associatefl  with  profuse 
and  offensive  diarrhea,  a  high  grade  of  indicanuria.  vomiting,  low  fever, 
and  perhaps  mild  albuminuria,  ."^onic  of  these  easels  go  (m  to  acute 
deliriiun,  with  typhoid  state,  profound  exhaustion,  coimt,  and  death. 
Just  exactly  where  these  cases  belong  and  what  they  mean  is  not 
altogether  known. 

Pellagra.^ Tliere  has  l>een  ver>"  little  stu<Iy  of  the  mental  symptoms 
of  pellagra  of  late  years.  From  the  few  cases  observed  and  from 
stud>'  with  those  who  have  had  it  under  observation  then;  secios  to 
be  a  variety  of  sjinptom  pictures. 

Many  cases  present  no  ner\'ous  or  mental  symjitoras  at  all.  In 
those  who  do  there  seems  to  be  a  tendency  toward  a  variable  localiza- 
tion of  the  disca.se  process.  There  seem  to  lie  patients  in  whom  the 
spinal  con!  suffers  most  and  others  in  whom  the  brain  suffers  most.  In 
this  latter  group  a  condition  of  verj*  acute  dflirium  may  be  developed 
rmining  a  rapid  course  to  fatal  termination  and  reminding  one  of  the 
acute  fonns  of  paresis.  The  more  fre((uent  condition,  of  which  we 
have  seen  a  numl>cr  of  cases,  seems  to  be  more  in  the  nature  of  a 
gimpie  ntartiatioji .  Tlie  patient  moves  slowly,  or  not  at  all,  and 
answers  questions  after  a  long  <leUiy  in  a  low  lone  of  voice  and  in 
monosyllables.  There  does  not  go  with  this  retartlation,  however, 
a  corresponding  emotional  depression  as  in  melancholia.  I'rliagra^ 
phobia  has  been  observe<l  in  an  infected  territorj*. 

With  this  disease,  as  with  many  others,  it  mu.st  not  be  forotten  tliat 
it  may  be  associated  with  various  psychoses  withcMit  having  any  specific 
relation  to  them.  This  is  peculiarly  so  in  this  country',  as  the  large 
groups  of  cases  winch  have  iK-cnrred  ha\'e  iRt-n  in  Iiospitals  for  the 
insane. 

Perhaps  Gregor'  lias  niiide  the  most  can'ful  recent  clinii-al  study 

■  BcitHUte  Aur  Keiiluiiw  der  iivllnur&aen  OvislesntOruugen,  Jalirb.  I.  Pnyoh.  u. 
NauToL,  IM7. 


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THE  TOXIC  PSYCHOSES 


of  tW  mrntfl!  sj-mptonis.    lie  considers  his  caries  uiwlrr  the 
seven  ciileyories;     0)   IVUagroiis  neitrti>lhi>iiia,    (2)   slti[Mmiii> 
(3)  menial  alH-rnition,  (4)  acute  (lelirium,  (o)  katatoiits,  (6) 


IH\' 


^>^■lli   Ic-imi-   (.'I   ■••'UaBTa. 


psychosis,  (7)  nianicwieprfssive  gruiiji.    It  tloea  not  seem  clcarj 
ever,  just  wlmt  is  the  <'orincetion  in  all  of  these  c'u.sea  betwi 
pellagra,  and  the  psychosis. 


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CHAPTER  XXII. 
PSYCHOSKS  ASS(X_'IATED  WITH  ORGANIC  DISEASES. 

Apoplexy.— I minetliately  following  the  apoplctic  insult  the  patient 
is  qiiiU'  fotiiitioiily  uiu'oiisimihis.  As  thft  sjTnptoms  subside  ami  the 
patifiit  begins  to  "(XHHc  tt>"  there  nmy  be  tnarkeil  iliMirii^ntution  to 
the  extent  of  a  mild  deliriuiti.  especially  if  fever  be  present.  This 
symptora  of  a  slight  rise  in  temperature  with  onset  of  mild  delirium 
sometiim-s  occurs  a  few  days  after  the  original  insult  and  is  then  of 
Iwd  propTiostic  omen.  In  severe  uttacks  the  uiicou3ciousne:ss  may 
pass  on  into  profound  eoina  an<l  death. 

Onlitiarily  f<»llowiiig  an  apoplectic  insult  after  recovery  from  the 
acute  symptoms  a  <x>ndition  of  more  or  less  impnirment  is  left,  ami 
when  it  is  Ixvriie  in  niitid  that  the  patients  who  siilTer  from  apoplexy 
are  in  the  tiiain  in  the  senile  or  iirterioscrlerotic  periml  it  will  be  under- 
stood that  the  symptoms  of  the  defect  take  on  characteristically  symp- 
toms of  these  two  conditions,  which  perliaps  become  ag^rravated 
materially  following  the  iiuult.  Tlie  defect,  however,  may  ap|>eur  to 
\)c  very  much  greater  than  it  realty  is,  because  of  the  imd*ility  of  the 
patient  to  express  himself  owing  to  incident  aptiasia  or  apraxia.  The 
emotional  attitude  of  the  }>atieiits  is  usually  one  of  irritability,  although 
indifferonre  also  enters  into  the  picture.  Such  patients  often  lie 
<|uiet!y  and  apparently  indilferenl  Lmtil  an  attempt  is  made  to  coni- 
muni<uite  with  them.  Under  these  circumstances  if  they  have  serious 
aphasic  or  apmxic  disturbaiKtrs  and  know,  for  example,  what  they  wish 
to  say,  they  may  become  ver>'  umch  excited  and  quickly  fatigued  ami 
emotional  as  a  result  of  tlieir  repeated  efforts  and  failures  to  enter 
into  communication.  This  i.s  also  quite  characteristic  in  the  younger 
patients  with  apractic  disturbances  antt  relatively  clear  intelligence. 
It  is.  so  to  s[>eak.  "  maddening*'  not  to  Ik:  able  to  control  any  longer 
the  |)Ower  of  expression.  Some  of  these  patients,  especially  tho.*4c  who 
sulTer  from  sensory  foniis  of  aphasia,  l>eing  out  4>f  comuumieiitiiHi  with 
their  fellows,  ami  nr>t  Ih-Ihr  able  to  understand  wliat  goes  on  about 
them,  may  acquire  a  suspicious  attitude  which  gives  n  pantnoiil  cotor- 
ijig  to  their  mental  condition.  It  can  be  tuidersto«Nl  that  the  u|xiplexy 
which  j>roduces  dis«>rders  of  expression  and  Interfcn-s  with  the  patient's 
keen  contact  with  his  fellows  will  not  only  prccipitau*  the  deteriora- 
tion of  the  senium,  but  will  make  that  deterioration  umeh  more  rapid. 

The  neurol(^caI  signs  of  hemiplegia  are  present,  al.so  often  the 
signs  of  senility,  and  not  infrequently  of  arteriosclerosi.'i,  while  a  certain 
few  of  tliese  patients  develop  epileptic  attacks.    (See  Chapter  XII.) 


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800    psYcnosfss  As^cTArnn  with  oroasjc  diseasb» 


Trannutisxn.  -Tlic  effects  of  trauma    may    be   divided  i"' 
imintiiiuut  ur  Hcute  eiTtK-Ls  and  the  mare  remote  or  clironit'  - 
into  which  the  former  may  or  may  not  metKe.     The  ultinifttr  ■ 
are  divisihlo  into  changes  in  constitution  and  drfecrt  rotidiriftu 
a  certiiin  proiK>rtiou  of  cases  develop  psj'choses  following  an  l,  . 
without  there  lieing  an>'  special  connection  between  ibe  tira  or  % 
w]iit;h  the  injury  can  only  be  ct>necive<l  as  a  precipitating  or  c«ntril»- 
torj-  factor.    Oftentimes  the  injury  is  the  result  rather  than  ibrciipr. 
as  is  so  frequently  seen  iu  paresis,  the  injury  serving  to  ™I1  nttoiu* 
to  the  presence  of  a  disease  up  to  that  lime  not  recognizetl.    Mic} 
shell  sliock  cases  have  to  be  interpreted  tn  this  broad  manner. 

The  usual  immediate  result  of  a  head  injury,  either  direct  nr  imliirrt. 
is  a  certain  degree  of  unconsciousness  which  may  vary  hII  llic  nr 
fntiri  II  light  stu]mr  to  profouwl  coma.  When  the  unconsetiHisicrs^  r 
not  profound  tlie  patients  are  ciiiiet,  but  if  diatnrbetl  they  beeonie  ***; 
irntable  and  resistive.  Quite  topically,  associated  with  the  jittiptf. 
is  II  inilil  iletirium  of  Imiluelnatory  character  which  is  ei*pe<'ially  pr* 
nouna'tl  an<l  apt  to  be  more  violent  in  patients  who  arc  the  subjrrt 
of  aU-oholbmi.  Associated  with  this  may  be  a  slight  rist*  of  lernpetatoR, 
but  if  the  rise  is  pronounced  meningitis  should  be  thoUf;ht  of,  .AltrrMi- 
ing  conditions  of  apparent  clcarnc^  and  marketl  cx>nfu5uon  may  ocrar 
I'sually  the  stupor  is  of  only  short  duration,  but  may  Inst  scvrnil  d*n 
aiui  finally  disappear.  In  severe  cases  the  piitient  heetJiney  cumatajK 
and  dii's  in  that  condition.  In  a  few  cascit  the  ik-liriuus  reactkiD  il 
unu.sua][y  prolonged  and  may  l*e  associated  with  Korbukf>w's  sywImaK 

After  recovery  from  the  immediate  effeots  of  the  injury  rntato 
eonstttutiomil  eliuiiges  nmy  slowly  develop,  the  most  typical  of  wbii 
is  b'rledm'inn's  complex,  which  is  attributed  to  a  vasomfdnr  didtor^ 
ance  in  the  brain.    The  sjinptoms  of  this  complex  arc  heatiaebe,  Sm- 
ncss,  irntahility.  insomnia,  physical  and  mental  fntiptbility,  a  crrtM 
change  of  character,  and  intolerance  of  alcohol,  with  which  iiiii\  1* 
a.ssociated  a  memory  defect  of  the  type  of  retrograde  amnenia,  wfaid^^ 
however,  is  nut  a  part  of  the  con>pl<''X,  although  there  nuiy  tie  a  crrtaa^l 
menior>-  defect  wliich  is  quite  common  to  all  highly  nervous  wnrriwl 
IK'<)plc.    The  ln-Hflache  is  apt  to  Ix?  complained  of  as  a  ftrrling  i*f  pun 
or  a  |)eculiar  fueling  of  constriction  of  the  head  and  is  as.<i()ciatrd  «id> 
feelings  of  fulness,  es(>ccially  on  stooping  over.    The  dizziness  b  abo 
characteristically  intensified  by  stooping  or  by  sudilen  inuvemnitL 
The  irritability  of  temper  may  be  30  marked  as  to  lead  to  cxplooiT 
outt>reaks,  which  sJniulate  psychic  eptleps).    KapUn  has  named  tht< 
condition  the  expiofive  diathesis.    'I'hey  an*  nuich  aggravated  b> 
alcohol.    Sleep  is  liable  to  lie  disturbed,  phyidcal  and  mental  eiKhirar^r 
is  very  niucli  les»nied,  uihI  the  iwitieut  may  become  dcpre.ssr^I,  m<"'  t». 
and  in  various  otlier  ways  show  a  subtle  change  in  character  whirh  r 
appreciated  by  all  uf  his  close  ussooiates.    Tlje  intolerance  to  aic<>b>'' 
is  very  ehantcterlstic  of  this  post-traumatic  eoiustitution.    Sometimr^ 
associateil  with  the  explosive  diathesis,  but  also  occurring  HkmCr  art 


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trnipt>niry  dpeiim  states.    Various  other  hysteriform  and  epileptiform 
luauifestatunis  may  also  occur. 

Finully.  certain  defects  are  left  as  a  result  of  the  traumatism,  depend- 
ing, of  course,  upon  the  nature,  the  extent,  and  the  location  of  the 
injury.  As  repanU  the  more  eliaracteristic  result'?  of  head  injury  uf  a 
<listitK-tly  psychotic  nature,  it  shoulil  t>e  borne  in  mimi  that  the  ehan^ 
in  character,  transformatiim  of  the  perstmality,  as  it  rniglit  lie  called, 
is  often  a  very  subtle  prowss  iind  onu  extending  over  a  very  consider- 
able perioi]  of  time.  It  Tnight  be  prartieally  imposdble  to  evaluate 
the  situation  at  all  if  one  wen*  deix-ndvnt  iiijon  a  eruss-aectioii  of  the 
|*atient's  mental  life.  When  a  longitudinal  settion,  however,  is  avail- 
itble  one  finds  in  typical  cases  an  individual  who  up  to  a  certain  point 
in  life  has  gotten  along  well,  showing  efficient  reactions  and  developing 
by  steady  pn>gress  in  some  chosen  line  of  work.  Such  an  individual 
receives  a  head  injury  and  from  The  time  of  this  injury  on  there  will 
be  noted  in  the  history  n  gradual  falling  olf  in  efficiency.  It  may  be 
quite  uniHJssible  to  put  one's  finger  upon  any  six-i-ifie  thing  In  the 
situation  and  set  it  down  as  a  jMitliolt^ind  ty(»e  «f  n-action,  but  the 
inrlividuul  reaction  lias  changed  in  character,  and  from  efficiency  there 
is  evolved  inefficiency.  Naturalh',  it  is  a  long  time  Ix'fore  the  true 
explanation  of  such  u  change  is  n^arlu'd.  In  fact,  it  Ls  a  long  time  before 
it  is  realiwd  tliat  any  change  at  all  has  taken  place,  and  it  is  because 
of  this  fact  that  the  ohler  psychiatrists  used  to  spe^ik  of  traiunatic 
insanity  as  sometimes  eventuating  many  years  after  the  injury.  Not 
infrcciueutly  t]m  falling  off  in  eflieieney  lias  going  with  it  a  gradual 
deteriomtion  in  morale,  and  with  the  lK*ighteinHl  suscei)ttbility  of  the 
patient  to  alcohol,  which  trauma  produces,  it  is  natural  tluit  alcohol 
shfHild  enter  into  tin*  jiieture  very  largely  and  often  be  rcgardi-d  as  the 
cause  of  (he  whole  trouble. 

Mcver's'  clas-siflcation  of  the  effects  of  traumatism  in  the  nervous 
system  is  as  follows: 

1.  The  direct  f<x?al  and  the  more  diffu.sc  destruction  of  the  nerve 
tissue  or  of  parts  of  it;  and  the  reacticm  of  the  tissues. 

(fl)  'ITie  immediate  effects— edema. 
(6)  The  RCiir  formation. 

2.  The  distinctly  diffuse  cc>mmotioiis  in  whieh  the  general  reaction 
and  the  psychic  element"*  preponderate,  including  the  remote  reactive 
results  of  exaggerations  of  vasomotor  and  emotional  resiwiisiveiicss. 

He  classifies  the  psychoses  developing  as  follows: 

1.  The  direct  posl-lraiintatic  dfHriii  with  the  folhicing  rubdirmotts: 

(a)  Pret'mlneatly  febrile  reactions. 

(b)  The  delirium  nervosum  of  Dupuytrcn,  not  differing  from  deliria 
after  operations,  injuries,  etc. 

(c)  The  delirium  of  slow  solution  of  coma  with  or  without  alcoholic 
basis. 

>  Tho  Aotttotnicftl  FacU  «ik]  CUoical  VarioUe*  <4  Tnuimalio  Iiutnoit}',  Am.  Jour. 
IHMDit]'.  jAuuary,  1904. 


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Bum 


(i/)  Forms  of  j>rotracte<l  deliria  usually  vni\\  numerous  fabul 
etc.  (with  or  without  nlfoliolic  or  senile  basis). 

2.  The  pait-traumatic  ronstUufion. 

(a)  T>'[H.*s  with  mere  facilitatiou  of  reaction  to  alcoliol,  gnp| 
(6)  T>-pes  with  vasomotor  neurosis, 

(c)  Types  with  explosive  tliiithesis. 

(d)  Tyi)es  with  hysteroid  or  epileptoid  episodes  with  or  wi 
convulsions  (sueh  as  most  reflex  psychosesj. 

(e)  ^Yypcs  of  paratioiae  development. 

3.  The  traunmiir  tfi'frff  ptmditums. 
(a)  Primary  defects  allie<l  to  aphasia. 
(h)  SiToridary  <le!trriorarion  in  conne<-tion  with  epilepsy. 
(r)  Tormijml  deterioration  due  to  projire.ssive  alterations 

primarily  injured  part.s,  with  or  without  arteriosclersis. 

4.  l\t}frhw('s  in  whirh  trtiitrmi  w  merflu  n  nmlrthutiiig  fatittr. 
(a)  (jriieral  panilysi^  with  or  without  traumotie  stigmata. 
ill)  Maiiic'-flepressivc    and    other    Inmsitory    psyehoses,    eatntb 

deteriorntion  and  paranoiac  conditions,  uith  or  without  trai 
stijtmata. 

5.  Trauvmiip  i>.vjrho.trjt  from  wjurj/  luU  dirrrily  affecting  the 
This  ^oup  of  tniuniatir  jisyehoses  ineliides  also  a  eertaiii  tiunibei 

the  ]K)atii}>f^ratiFr  psychoses,  psychoses  foDowinp  oixrationa  u|Km  i 
eye  and  residence  in  a  dark  room,  the  so-odled  irphthatmir  psjxho 
the  psychoses  of  iristthfion  and  many  shell  shock  cases  scon  imder  \ 
conditions.  Of  course  tliis  titatenient  applies  in  general  oidy  to  s\ 
acute  ])sychoscs  as  do  not  belong;  in  other  groups,  as  the  shock 
suTKical  operations,  etc..  may  well  be  a  precipitating  faetitr  in  the  on 
of  such  psychoses.  When,  however,  they  are  essentially  psycho 
the  re-sult  of  shock  they  have  a  symptomatology  ami  histi»r>'  f\\ 
the  satne  iis  the  tniumutic  i)sychosfs.  They  can  Ix*  undcrstiMMl  if  ' 
hj'pothesis  of  Friedmann  is  borne  in  mind  that  the  complex  named  aJ 
hhn  is  due  to  vasomotor  (listurl>ani:x'.  If  this  lie  true  it  can  be  und 
stood  how  severe  emotional  tniumas,  as  well  as  physical  traumas  n 
produce  a  va.soraotnr  imbalance,  although,  of  course,  it  must  nev« 
forgotten  tlmt  whatever  may  in  the  last  analysis  be  the  lu-tual  cai 
the  cause  operates  upon  a  certain  kind  of  iiulivi^hml,  and  the  syi 
picture  is  necessarily  modified  accurrlingly.  In  many  shell  sliockl 
concnssion  and  actual  tiestructiori  of  tissue  takes  ptiice. 

Acute  Chorea  (Syderiham'.s). — Quite  usually  a  patient  with 
chorea  is  irritable,  somewhat  emotionally  unstable,  fretful,  anr 
patient,  a  .state  of  mind  one  would  exjiect  fnan  the  nature  of 
illness.  While  this  condition  is  quite  iLwal  it  may  become  soniew 
more  aggravated,  the  restlessness  and  emotional  in.stability  be  m 
proiioniiifd,  with  e^'idcnccs  of  transitory  disturbances  in  the  senscirii 
and  perhiips  slight  apprehensivcness  and  suspiciousness.  The  bn 
ciuatory  disturbances  may  become  very  much  aggrnvnteil,  togct 
with  cloiuling  of  consciousness  and  marked  delirium  In  conned 


I  cni 

'I 

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CHRONIC  CliORBA 


863 


fwith  the  febrile  movement.  Uiuler  these  eircumstnnces.  of  course. 
we  are  dealing  essentially  with  a  fever  dfliriuni.  Alon^  with  these 
milder  manifestatioDs  of  mental  disorder  one  occasionally  finds 
►s>Tnptoms  of  a  hysteriform  eharaeter. 

Chmea  insaniena  is  f^-nerally  considered  as  a  distinct  form  of  acute 
chorea.  It  is  associated  with  high  temperature  and  markeii  mental 
disturbances,  usually  l>cgiiming  early  in  the  disease.  The  mental 
disorder  is  esseulially  of  a  delirious  charwcter,  witli  halhirinatlons  and 
clouding  of  eonseiousness.  The  halhtci nations  are  quite  apt  to  he 
terrif\'iMK,  and  the  patient  eoiiseipiently  apprehensive  and  fearful, 
altliough  the  opiwsite  condition  of  elation  has  Wen  descrihed.  The 
disease  is  quite  frequently  associated  with  pregnancy,  and  is  not 
infrequently  fatal. 

Korsakoft's  psychosis  is  sometimes  seen  in  patients  suffering  from 
acute  chorea  as  a  result  of  pol>*neuritis  resulting  from  overtreatment 
with  arsenic.     fScc  section  on  Chorea.) 

Chronic  Chorea  (Huntington's). — It  lias  always  been  recognixed 
tlijit  this  disease  was  associntwl  with  mental  sjinptonis,  and  it  has 
generally  been  considered  that  there  was  a  tendency  to  progressive 
deterioration  ending  in  well-ni»rketl  dementia.  While  in  a  general 
way  this  may  l>e  true,  it  is  well  to  be  cautious  in  estimating  the  mental 
condition  of  chronic  choreics.  They  are  extremely  inaccessible  in  many 
instances,  especially  tho.se  patients  whose  spweh  apjwratus  is  affected 
by  the  disorder,  and  it  rec|uire.s  great  ]>atienee  to  make  a  satisfactorj"^ 
examination  of  their  mentalitj'.  Chi  the  other  hand,  the  patients  them- 
selves find  extensive  explanations  so  diflieiilt  to  communicate  that 
they  are  content  with  tJie  shortest  possible  responses,  so  that  they 
frequently  mislead  (he  examiner  into  the  belief  in  an  intellectual 
poverty  which  does  not  really  exist. 

With  these  warnings  it  may  he  conceded  that  in  general  the  chronic 
choreic  is  of  somewhat  enfeebled  mentality  with  a  tendency  to  emo- 
tional depression  and  to  a  mood  of  suspiciousness.  The  emotional 
depression  tan  be  readily  nnderstoTKl,  as  the  patient  realizes  quite 
well  his  plight,  namely,  that  he  is  affected  with  a  chronic  disease 
which  practically  isolates  him  from  his  fellows.  Not  infn-qucnlly 
there  b  a  mjuked  emotional  instability  and  irritability,  and  such 
choreic  patients  may  have  great  difficulty  in  getting  along  in  wards 
where  they  come  in  contact  with  other  patient-s.  Finally,  with  the 
increasing  deterioration  there  is  a  tendency  to  indifference,  to  emo- 
tional tieterioration.  The  suspicious  m(Mi<i,  which  so  many  of  these 
patient'}  have,  we  believe  has  at  least  in  part  its  explanation  in  the 
patient's  isolation  as  a  result  of  the  nature  of  the  disease.  We  find 
suspicious  niood.s  in  all  jktsoiis  who  are  cut  off  from  active  contact 
with  their  fellows,  more  esiH'cially  in  ptxiplc  who  are  closely  confined. 
either  voluntarily  or  otlierwis*',  th<ise  who  .suffer  fmm  pronounced 
varieties  of  aphasia,  which  make  it  imiHjssible  for  them  to  eummunicate 
their  thoughts  or  to  receive  communications  from  others,  and  pre- 


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864       PSYCHOSES  ASSOCIATED  WITft   ORGANIC   DfSB 


dumimintly  among  tlie  deaf.  To  a  certain  extent,  too,  the  dcoirtil 
is  pRilmlily  due  to  tins  eultitijj:  ofT  of  nctive  contact  with  life  by  m^ 
iiig  the  means  of  communication.  The  choreic  finds  it  citron 
difficult  to  talk  to  other;.  He  may  find  it  equally  diBiruIt  to 
perhaps  because  of  defect  of  vwion  which  is  liable  to  be  prcscnl, 
it  must  be  remembered  tliat  this  is  a  disease  of  later  life,  nnd  tn 
ways  he  loses  touch  with  what  is  going  on  about  hirn.  Kinally,  irt 
he  has  loDg  passeil  any  ability  to  pick  tip  the  thread  nf  events 
becomes  indifferent,  and  when  it  is  realised  that  he  is  frttiucotl^ 
the  arteriuc^-lerutie  ]>eriud,  often  appritaching  the  seniunt,  it  can 
Seen  that  this  removal  from  acute  contact  with  reality  tcntls  to  pndl 
inactivity,  as  it  were,  and  the  apiiearanei's  of  clcrneiitia,  if  not 
dementia,  ami  so  the  chronic  choreic  show's  eu3oti<>nal  def«»ct^,  ntteati 
disorder,  lack  of  impressibility,  defect  of  recall,  ami  in  other 
demonstrates  that  he  lias  lost  interest,  as  it  were,  in  life. 

A  certain  few  eases  show  distinctly  more  pn^nounceii  p^tln 
symptoms,  ooeosionally  showing  well-marked  persectitor>'  ideas. 
Chaiitcr  X.) 

Paralysis  Allans. — It  is  probable  that  the  majority  of  caaes 
paralysis  aj;itaii:>  show  a  certain  amount  of  uieiital  disttifbail 
although  in  a  great  nuinlier  of  cuifies  this  disturbance  Is  so  di 
ci«upan-il  wilii  the  pliysical  and  so  easily  seen  to  Ije  rlcpt-iident  iq 
it  that  it  is  quite  overiookc<l.  This  sunple  dist»irl>ancr  is  tn 
emotional  s])hcrc  and  for  the  most  part  is  one  of  slif^ht  dep: 
but  rarely  one  of  euphoria.  Occasionally  deUrioid  episodes  siipcn* 
with  marked  confusion,  but  in  general  cortseiousness  is  clear  and 
patient  remains  well  oriented,  except,  of  course,  in  (lie  termiaaj 
ilition  when  arterJoselemtie  changes  and  the  deterioration  of 
seniiun  have  set  in.  Occasionally  there  is  a  well-marked  pay 
ill  which  instance  it  is  most  ajit  to  be  of  a  depressive  h\-pocho 
character,  often  with  paranoid  coloring.  The  ileprcsaion  niay 
sufliciently  great  to  n*sult  in  efTorts  at  suicide.  In  these  cases  diaotd 
of  the  sen.wrium  may  also  be  present. 

As  intimated  above  it  must  be  remembered  that  we  are  deaB 
with  a  disease  of  later  life  and  that  not  infrequently  arterioadeia 
and  senile  changes  show  themselves  by  changes  in  the  mental  splia 

Multiple  Sclerosis. — The  outwanl  manifestations  of  the  oiea 
disorder  associated  with  this  disease  are  mainly  in  the  emotioa 
sphere.  It  has  been  stated  Iwth  that  the  majority  of  patients  we 
depressed  and  that  the  majority  were  exalted.  Both  these  stateakM 
are  Imse^I  upon  the  observation  of  very  few  iwtients.  .-Mtbougfa  cxsfe 
tion  and  depression  may  be  manifest  and  there  may  also  be  8)muM^H 
laughing  and  crying,  due  probably  to  lesions  of  the  haaaj  ga^l^ 
which  are  unaccompanied  by  onotion,  there  b  a  certain  amotuit 
deterioration  which  Is  progressive  and  which  dcpcnfls  of  ootirse  Opt 
the  dcstnictive  changes.  When  the  distribution  of  the  adcral 
patches  is  (|uite  similar  to  tl»e  distribution  of  the  lesions  in  gencn 


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tlEART  DISEASE 

pappsis  the  outward  symptoms  of  the  two  conditions  may  be  very 
much  alike  and  lead  to  confii-sinn  in  ilinKruwis.  The  iliagriostio 
problpinis,  Imu'cver,  ran  be  clearnl  up  by  tin.-  iMlmratory  fnnlEiins. 

Polyneuritis. — .See  Korsiikow's  Psychosis. 

Heart  Disease. — Oepre-ssive  states  arv  uutst  in  evidince  here. 
Mental  symptoms,  howtver,  are  most  apt  to  lie  associated  wfth 
failure  of  eoinpeiisatiun.  With  prec-onlial  distress  goes  typically 
a  mental  stiitc  of  aiixiousness.  Transitory  amfusitins  with  dreamy 
hallucinations  occur  with  compensation  disturbances  and  edema. 

Various  other  diseases  have  from  time  to  time  mental  sjTnptoms 
a.ss()(;iate(!  with  them.  The  great  majority  of  such  diseases,  if  not  ail 
of  them,  have  clement-s  of  iiifeetion,  or  toxemia  arul  exhanstii»n  nini- 
Iiined,  with  all  or  |»art  of  them.  Tlie  mental  symptom- a^mplex  of 
confusion  arises  mitst  t\'pically.  In  some  cases,  especially  tJie  less 
acute,  paranoid  couditions  occur  aud  Iiallucinosis  is  of  occasional 
occurrence. 

Head  luis  shown  that  certain  visceral  diseases,  esijcciully  of  cardiu- 
\'a.'*cular  and  pulmonary  oripn,  often  have  associated  mental  symp- 
toms, although  they  may  nitt  appear  except  on  the  most  careful 
examinatliin.  The  sjnnptonis  found  are:  (I)  Hallucinations  of  vi.sion, 
hearini^  and  smell;  (2)  moods,  either  of  deppeAsion  or  exaltation,  and 
(3)  suspicions  u.sually  occurring  when  a  depression  has  ptTsistwl  for 
some  time. 

These  conditions  take  their  origin  in  part  as  a  result  of  reflected 
visceral  pains.  Each  spinal  segment  has  both  a  visirral  and  a  cutane- 
ous representation.  Disease  occurring  In  the  visccml  urea  is  referred 
to  the  cutaneous  surface  supplied  by  the  same  segment.  The  cutaneous 
distribution  of  the  fiftli  nerve  correspomis  to  the  vLsceral  dLstribution  of 
the  vagus,  so  pain  occurring  in  the  vagus  territory  will  be  referreii  to  the 
scalp  and  thiLs  occur  points  of  tenderness  in  this  region  with  which  the 
hallucinations  arc  associated.  The  mnod  of  exaltation  is  essentially 
transitory  ami  arises  as  a  contrast  phen<nuenon  of  the  depression  and 
as  a  result  of  the  disappt«rance  or  lessening  of  the  reHectx'ni  .somatic 
pain. 


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CHAPTER  XXIII. 


PRESKMI.E,  SENILE,  AND  ARTKniaSCIjLlwmC 
PSYCHOSES. 

The  grouping  of  the  presenile,  senile,  anri  artrriosclf  mtk-  ifc>Thi*o 
togetlitT  ill  one  eliapter  is  a  matter  not  only  of  <."onvcniftHT.  h 
obviously  one  would  expect  all  sorts  uf  admixturcH,  partiiniUri}'  u 
between  the  senile  and  arteriosclerotic  group,  but  tliere  are  nunj 
pictures  here  which  are  not  distnictive,  especially  in  the  prcstnik 
periixi,  wliich  KracpcUn  begins  his  discussion  of  by  saj'inK  it  is  the 
darkest  region  of  all  psydiiatry  tiniay. 

The  Presenile  Psychoses.-  In  the  presenile  |M*riu(J  therv  srr  t 
ntnnlwT  of  psychotic  pictures  the  exact  significant*e  and  nosnlngial 
placement  of  which  is  not  at  all  imderstood.  There  is  no  doubt,  hriw^ 
ever,  but  in  this  perio<l  that  depressioiu;  are  much  more  in  evidesa 
tlian  exciteuicnls.  llie  tlepressions  scfmiinj;  to  luount  up  in  frcqumc? 
during  the  period  of  involution.  Iltibner  found,  for  example,  21  cam 
of  single  attacks  of  melancholia  after  the  fiftieth  year,  but  ouly  2  ctcs 
of  single  attacks  of  excitement. 

Involution  Melancholia. — Symptoms. — The  Kraeiielin  s<*ho<»l  f(«r  • 
con^ideniibie  time  ci)nsidered  that  certain  tlepressious  of  later  lifc. 
characterized  by  an  anxious  apprehensive  agitation,  »-ith  prottmai 
cmotioTifll  depression,  composed  a  nosological  unit  to  which  was  frivni 
the  name  involution  melancholia,  or  mttre  hrielly  muLincholia,  iht 
term  melancholia  being  limited  in  its  application  to  this  partirulir 
ty]Mr  of  depression. 

The  symptoms  of  this  psychosis  are  generally  preceded  by  ■  con- 
siderable perio<l  during  which  there  are  vague  head  sjiTiiptoiu*,  weh 
as  pressure,  pain,  vertigti,  together  with  anorexia,  irritability,  insonuM* 
mental  instijficicncy,  ami  a  mild  neurasthenifonn  stuto  with  perh^l 
some  emaciation.    This  condition  bccomi-s  progressively   wume  nP 
the  patients  develop  an  agitated  depres.sit>n,  with  anxiety,  apprdMo- 
sion,  fear  of  impending  danger,  with  quite  usually  delusions  ol  an. 
The  depression  is  characteristically  ver>'  prtifound.   and  the  motor 
agitation  may  be  quite  con-siflcrablc.       The  imlient    may   go  ahofit 
wringing  his  hands,  moaning  anil  gnianing,  perhaps  repcatin^c  over  twf 
over  again  such  phrases  as  "Oh.  my  GodI    Oh,  my  God!"     "It  iia 
fearful  thing.     Good  I-*ni  help  mc!"    One  i>atient  con.stantJy  rr|>mU 
"Uuctor.  will  1  be  done  away  with  tonight?"  and  "Then  will  I  hf 
here  tonight  jast  the  .'*ame  as  last  night,  and  «iU  I  be  hen*  toinom»« 
juat  the  same  as  today?"    Another  patient  believca  hers«-lf  very  ^infuJ, 


— ,V 


THK  PRESEMLE  PSYCHOSES 


867 


refuses  to  e«t  iK-aiifit*  the  Uxk\  sIiduUI  hv  u.sed  for  ntlicrs,  wulk»  about 
in  an  aptatpil  iimniuT  jiicking  Iut  fiiiffera  iind  nttcmptctl  stiicidc 
because  ^he  was  afraid  she  v;as  to  he  put  to  di'utli. 

Even  in  these  cases  of  quite  extreme  aptatiun  and  ]>r*>foun(l  depres- 
sion consciousness  remidns  unclouded,  orientaticm  is  little  if  at  all 
impaired,  and  the  form  of  thought  is  well  maintained. 

Another  tjpe  of  case  i>re.scnts  symptoms  of  rctflrdation.  Many 
of  these  cases  may  be  so  retanled  as  to  U-  almttst  stuponius  and  sonic 
of  them  present  an  nniouiit  of  resistance  which  rt^duds  one  of  the 
clmnicteriatic  negativism  of  dementia  precox.  This  latter  group  was 
originally  di-^-ribud  by  Knic|X'Uri  as  "late  catHdmia."  Its  nosological 
status  is  at  present  in  doubt. 

Certain  cases  of  anxious  depression  may  l>e  h^hly  agitatcil  with 
iiLsoniiiia,  refusal  of  f(MHl,  rapid  emaciation,  chniding  of  consciousness, 
hallucinations,  self-inrticte<i  injuries,  attempts  at  suicide,  a  rapid 
course  ending  in  death. 


Flo.  401. — Fiioi««ot  Involution  melnuL-holla. 

In  the  marked  cases  of  apprehensive  and  agitate*!  depression  there 
is  fretpiciitly  a  <tinsirhTnblc  degree  of  precoitlial  distress  with  fM'rhups 
tachycardia  and  often  a  scnsi.'  uf  oppression  over  Uic  chest  willi  a 
feeling  of  difficulty  of  breatlung.  These  s>-mptoms  are  apt  to  appear 
in  attacks,  at  which  times  the  dcpressiiui  is  mure  pronouncL-d. 

The  <langer  inan  suicide  is  vcrj*  great  in  tliis  psychosis,  particularly 
In^-ause  the  patient  js  not  so  frequently  rendered  inactive  by  marked 
retanliition. 

The  delusional  c<mtent  of  consciousness  varies  widely,  but  hypo- 
elumdriacal  delusions,  nildlistic  delusions,  ami  the  feeling  of  unreality 
are  common.  Otx-a.slonatly  the  delusions  take  on  birArre,  absurd  and 
fantastic  forms,  and  there  may  be  delusions  of  grandenr  kite  in  the 
course  of  the  disease.  There  may  be  a  strangt^  mixtim>  of  <lepre!isive 
ond  grnndiose  ideas,  as  in  the  patient  ()f  Weygandt,  who  Wlieved  she 
was  going  to  l)e  boiled  in  a  silver  kettle. 

The  stati-stics  of  tliis  disease  show  that  about  40  [wr  cent,  got  well, 
the  remaining  tiU  per  cent,  terminattng  in  various  wa.\'s:  some  by 


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868     PltESEyiLE,  SE!^rLS  AffD  ARTE/irOSCLBlVtrW  PSYCBOfti 

siiioide,  some  by  death  from  intercurrent  tll'^'ftsc,  which  thn  wp 
ilt  adapted  to  withstand;  some  by  denlh  from  ff«nenil  mansmmot 
the  development  of  tuberculosis;  some  la|>sc<]  into  clironicity;  aaJ 
finally,  a  few  improved  sufficiently  to  leuve  the  hfjspititl  and  \yl  *l'a: 
at  homej  thmiEh  still  somewhat  depressed.  A  certain  iniinlieT  irf'Ju- 
cliiss  may  get  worse  under  home  surroundings  an<t  luive  Ut  \te  rttunri 
to  the  Imspital. 

This  gnmp  of  involution  nielancholia,  so-4L'alle<l.  was  studied  rti 
greiit  care  hy  Drej^iis.'    He  studied  the  life  liisturtes  of  SI  aue<.  ^ 
of  wliieh  were  perstnmlly  in\e.stigate«l     Eight   were  not  perwnaDj 
Investiftated,  and  ;i9  were  deceased.    As  a  result  of  his  study  he  o«i- 
eluded  that  with  the  exception  of  2  cases  undia^no.stfl,  2  caiie?*  ii; 
a  mistake  in  «lia^iosis  had  In'en  made,  and  possildy  2  more  <l>  . 
cases,  all  were  cases  of  manic-depressive  ps>'chosis.      This  ctjudusift 
was  reached  by  finding  the  fundamental  s>Tiiptoms  of  this  dixKat 
pnrsent.    Of  these  eases  (j(>ijer  cent,  were  reooventi  »»r  were  recuvmBg 
at  the  time  nt  death.  S  per  cent.  develope«l  nrteriosc^rosis.  25  pe 
cent,  died  unrecovered  nf  intercurrent  disease  c»r  suicride. 

Tlie  eont-Iusion  reiicheil  hy  Dreyfus  that  tJic  lavolution  nielanrhi^ 
of  KmeiK-lin  is  really  a  form  of  mauic-depressive  psychosis  hiw  wiw 
been  accepted  by  KrBcpcIln  himself.  A  study  of  tin's  gn>iip  of  eK« 
shows  quite  characteristically  the  presence  in  the  history  uf  peri(«i* 
of  alfet;t  fluctuation;  and  c|uite  usually  periods  of  slight  dcprcjiii* 
which  were  not  severe  enough  to  attract  atte-ntion  Sfriously  to  the 
mental  condltiun.  or  perhaps  were  not  at  all  understood  at  the  time, 
being  accounted  for  in  various  other  ways. 

Kven  adniitting  that  this  group  of  involutinn  melancholias  iwlly 
belouR  to  the  manic-<lepressive  psychosis,  still  the  problem  is  not 
wholly  solved  and  it  must  he  admitte<l  that  in  all  probability  ihc  inviiJo- 
tion  perio*!  has  certain  modifying  ettects  uptMi  the  psyohnsis. 

In  the  first  place  the  depressions  as  noted  heretofore  are  v<t>'  mvA 
more  frequent  than  the  excitements  and  they  are  Yer>-  much  lonjEcrin 
duration  tlmn  during  earlier  life.  This  of  c*>urse  can  \>v  cosily  under* 
stood  by  the  falling  resistance  of  the  involution  period.  A  [tsyclioeu 
that  has  manifested  itself  only  by  mild  and  hardly  appreciahic  evwleiKZi 
tlinnigliont  the  youth  of  the  individiml  may  well  get  a  firm  hobl  wIkii 
the  powers  of  efficient  reaction  are  failing. 

With  tiie  recent  work  that  has  been  done  on  the  <]uctl«!!i9  gknb 
and  with  the  somewhat  cliaractcrtstic  Dieotal  pictures  that  gn  ulaoi 
with  disturbance.s  of  the  internal  secretions  one  must  Ik^it  in  miwl 
that  perhaps  many  of  the  changes  of  the  involution  ptrifMl  are.  io 
part  at  least,  detennined  by  changes  in  these  glands,  pnrtii-uhiriy  v 
the  result  of  atropjij'  of  tlie  uterus,  the  ovaries,  the  prv^ttate,  the 
testicles,  and  the  adreiwls,  untb  the  possible  result  of  an  imbmiance 


'  Dio  Melntti^bolin,  cin  SStwtaiubbUd  dr*  ntAuUcb-depraniveo  ImMiiM,  J^na.  G 
Ptecbcr,  1907. 


L'lyiii^i.-i..  u_v 


oogi 


THE   PRESENILE   PSYCHOSES 


I 


ang  brouglit  about  in  the  relatiuiiship  bt^tweeii  them.  This  of  course, 
if  it  is  so,  would  only  I»c  one  of  the  iniHlifyiiig  factors  of  the  iuvuhition 
period  whic'li  one  mjyht  expect  to  see  rcGeeted  In  the  diseases  at  this 
time  of  life. 

The  following  case  illustrates  this  t>-pe  of  psychosis:  The  patient, 
a  woman,  was  admitted  to  the  hospital  at  the  age  of  fifty.  She  was 
very  much  depressed,  said  that  she  was  ver>*  unworthy  and  sliould 
he  hung,  that  she  had  ennuiiitteti  the  uni>art3onable  sin  and  would 
burn  forever  in  the  flames  of  Hell.  A  little  later,  in  addition  to  these 
ideas  tliat  she  had  eommittcd  the  unpardonable  sin  and  tlwt  her 
soul  was  lost,  she  said  tliul  she  was  dewd,  what  existed  of  her  now  was 
her  spirit,  that  her  body  ha<l  passe*!  away,  and  l»ecau5e  she  was  dead 
it  was  useless  to  attempt  suicide.  This  condition  had  its  origin  s^mie 
two  years  before,  following  an  operation,  when  she  had  cleared  up, 
and  as  a  result,  so  stateil,  from  overwork,  had  broken  down  again  and 
develoj)e<l  these  ideas,  and  subsequently  was  admitted  to  the  hospital 
after  having  made  a  sulcliial  attempt.  In  a<ldition  to  the  (Jelllnions 
she  had  visual  hallncimitions,  saw  spirits  and  heard  them  talking  to  her. 

This  patient  gave  the  general  impression  on  her  admission  to  the 
hospital  of  a  patient  suffering  from  hivolution  melaneholia.  A  further 
inquiry,  however,  develojx'd  the  history  of  numerous  previous  attacks 
of  <lcpressioii,  which  suggested  a  itianie-<Iepressive  reaction  type. 
Just  before  her  discharge  from  the  hospital,  however,  when  she  had 
liecome  much  more  accessible,  we  learne<l  that  in  her  early  hfe,  before 
she  was  twenty,  she  liail  had  a  love  affair.  This  love  affair  had  been 
a  very  prtifound  enintintial  exi»erience,  |>artieularly  because  she  had 
found  it  necessary  to  give  up  the  young  man  because  of  his  drinking 
haliits.  That  this  was  not  willingly  dont,  however,  was  showni  by  her 
subsequent  life,  which  was  taken  up  by  uinstant  activities,  largely 
of  a  social  nature,  and  apparently  for  the  purpose  of  side-tracking  her 
disap|M>int[nent.  She  was  an  attractive  young  woman  and  had  many 
a<lmirers.  but  did  not  permit  herself  to  l>e<'ome  attached  to  any  one 
of  them.  She  led  a  very  active  life  aixl  whs  able  to  sublimate  the 
energy  of  her  suppressed  emotions  until  the  iieriod  of  the  menopause, 
when  she  broke  dfiwri  with  self-accnsatory  delusions  anil  suicidal 
tendencies.  .She  belicvcil  she  had  conmiitte<l  the  ujipardmiuible  sin; 
this  sin  was  having  committed  adultery  in  her  mind  with  the  young 
mati  witii  whom  slie  had  been  in  love  iu  her  youth.  The  psychosis 
lasted  somewhat  over  five  years,  at  the  end  of  which  she  finally  suc- 
ceeded in  reachuig  a  a)mpromisc  hj-  developing  tendencies  dianictri- 
eally  op))ose<l  to  her  delusional  system.  She  became  tjilkative, 
humorous,  and  particidarly  facetious,  and  just  before  her  discharge 
she  made  the  remark  that  she  was  Ixirri  dead,  but  made  it  with  a  smile, 
and  with  the  added  conunent  that  she  had  gotten  along  pretty  well 
all  her  life  fur  a  dead  person.  This  (vndition  of  relative  cquilihriun\ 
enabled  her  to  go  Iwck  to  her  family,  an<i  in  the  absence  of  disturbing 
factors  she  will  probably  get  along  all  right,  at  least  for  a  considerable 


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870     PRESENILE.  SENILE  AND  ARTERIOSCLBROTIC   f'SYH 

time.    Nothing  has  been  heard  of  ht-r  for  some  years.    The  vttuii* :  .. 
don,  tlie  lalancc  struck,  was  a  foirly  cHident  oiie. 

Such  a  casi^  as  this  illustrates  a  common  type  of  flrprmsioa  irtiA 
occurs  in  the  involution  period.       It  18  a  t^ixa  whirli  if  dralt  wA 
golely  fpiini  the  dcsiTiptive  stand-point  wuuM   Imvr  lun-n  t-imsiimj 
au  involution  nielanchnlia.  while  a  little  mure  cMrvful  hislnr*  iiifiirato 
that  it  h  a  nianicwlcpressivc  reuction  tyj»e,  while  h  still  more  pnJimai 
pn)l>ing  inti)  the  facts  of  the  life  make  the  whole  thiiif;  quite  uwie- 
standuhlc  in  psycliologind  terms.     It  is  inaiiifcstly  a  psych iiptDrtir 
(lepres-sion,  hut  wljethcr  it  should  be  called  inanir-<lepr»'S.'iivc  of  w 
is  a  question.       Now  that  psychoanalytic  methfxls  are  slinwing  tit 
presem*  of  endojKychic  conflicts  in  the  manie-dc^pn^ssivr  psjt^wi*, 
such  a  rjisc  as  this  shows  the  dose  connection  between  a  puiv  pp- 
chogcnctio  psychosis  and  the  manie-^lcpressive  rfaction  tyix*.  bdiI  tlir 
furtlicr  rdatitin  uf  these  conditions  to  the  depressions  occumng  dniiu 
the  involution  perio<i. 

VaOwlugy. — An  increase<l  neuroglia,  formation  in  the  depper  Ujm 
of  the  cortex  has  been  descnlx-d,  and  in  tliis  cli.sea.se  wr  find  maS. 
often  a  termination  in  the  condition  ilesiTibpii  hy  Meyer  as  cmti^ 
nfuritis.  Tliis  is  essenlially  a  parenchymatous  ilegeneratiun  iriUi 
swelling  of  the  cell  body,  a  disaiiiKriTance  of  the  chnnnophile  Mib- 
stance,  and  eccentricity  of  the  nucleuii.  In  rapiilly  fatal  cases  liwf 
are  evidences  of  extensive  destructive  changes  in  the  e^irtex.  Thereuc 
also  found  a  certain  amount  of  disintegration  prrMlurts. 

TrrnUncnt. — One  of  the  very  imintrtjint  eonsitlerations  in  t^ 
^oup  of  deitressions,  as  shown  by  the  symplomatolojfy,  is  the  prT!\'«>- 
tion  of  suicide.  It  is  therefore  ver>"  mudi  more  fre<|ueiitly  noceAair 
to  interne  these  ]>atienls  so  that  they  can  l>e  pro|MTl\'  ivaldiaL 
In.somniji,  ajntation.  failure  of  nutrition  with  suiculal  Cemlenries 
the  conditions  that  have  to  be  met.  For  ihe  agitation  and  the  ir 
hydrotherapy  i.s  the  best  means  of  treatment.  As  few  ilru^  as 
shouhl  be  used.  For  the  suicidal  tendencies  con.stant  watchful 
which  should  have  as  it^  ideal  an  unnhstrusivene.s<i  wfiieh  di>r^ 
sugpest  the  suicidal  idea  constantly  to  the  [wilient's  mind.  Fj 
nutrition  ninst  Ih-  met  hy  tube  feeding  if  necessary. 

Au  analysis  of  the  patient's  mental  s.Mnptom.s  with  a  view  of  unricr- 
standitij;  tliein  is  of  course  highly  desirahle,  but  this  cU»s  of  r 
do  not  lend  themselves  easily  to  analyuc  teclmic.  at  lea.st  until  iJi 
have  hegnii  to  quiet  downi.  oftentimes  not  until  they  are  ctfiivalcscmt 

Other  PsychoMS  of  this  Peiiod.  -Various  other  t>'pes  of  |iA>TiiuaK3 
have  licen  descrilKHl  as  iM-longing  in  this  period.  Types  of  ileprrsointi 
Wahnsinn,  siinie  of  them  associated  with  anxiety  ami  pnKixxling  lo 
deterioration,  while  KnicjH'lin  has  dcscrihed  a  verj'  small  cla-^^  nf 
so-called  presenile  delusinnal  i>sychoses,  afTcrting  e.sp*'fiBlly  women, 
in  which  delusions  of  infidelity  arc  usually  pwmiiient,  together  with 
luilliicituttiuns.  The  delusions  ftre  variable  and  do  not  seem  to  at 
all  logically  control  the  conduct.      Farrar  has  descriiied  three  l\-pc* 


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pSQrchoses  hdonginn:  to  this  pcriwl:  melanrholia  vera,  anxirtair 
presenilis,  and  depressio  apathetica. 

In  mciatwhiifia  vera  there  is  in  the  main  an  autnpsychosis.  The 
delu.si»HiA  are  auto-accusatory,  with  ideas  of  sin  hut  with  dear  con- 
sciousness; there  is  no  defect  of  orientation.  The  patient  believes 
his  soul  is  lost,  tluit  he  is  tii  suffer  ettTiml  torment  hereafter,  and 
about  these  beliefs  there  is  no  lioubt,  but  on  the  contrary  a  marked 
** auhject'ttf  ctrttiinty."  There  may  be  some  slight  tendency  to  soma- 
topsychic delusiuos,  insight  is  defective,  and  slight  aiLxiety  may  be 
present. 

la  anririwi  priejtfnilis  there  is,  on  the  contrary,  in  the  main  an 
allopsychosia.  There  is  very  marked  ''suhjedite  uncfrlaintij"  which 
gives  an  unreal  tinge  to  the  outer  world,  and  out  of  which  grows  the 
fear  of  thinjjs  unknomi,  culminating  in  the  marked  anxiety  which  is 
characteristic  of  this  form  of  the  psychosis.  Uemttrse  or  dreafi  of  the 
future  are  not  elements  in  the  depression;  on  the  contrary,  it  is  the 
great  uriknuwn  and  overwhelming  present  that  seems  about  tu  destroy 
them.  These  cases  occur  later  in  life  than  the  former,  show  more 
evidences  of  senile  decay,  such  as  arteriosclerosis,  and  present  such 
svmptoms  as  verbigeration.  rh>thmical  movements,  suggestibility;  the 
prognosis  is  less  favorable. 

In  firpressio  apatbrtica  there  Is  simply  a  let-<lowTi,  a  stopping  (m  the 
part  (jf  one  wh<i  hiis  been  leading  an  active  life.  Interest  abates,  the 
struggle  ifl  drawn  away  from  and  we  have  a  picture  of  mild  depression 
with  clear  consciousness  and  no  disturbance  of  orientation.  There  is 
some  "subjective  unwrtatnty"  delusions  and  senstiry  fabrications 
play  little  (mrt.  The  symptoms  are  negative  rather  than  |)ositive;  the 
prognosis  is  relatively  gooil. 

Finally  one  must  remember  that  a  true  anxiety  neurons  may  develop, 
and  it  not  infrequently  does,  at  this  periml  of  life. 

In  conclusion  then  it  will  be  seen  that  we  have  during  this  period 
of  life  a  group  of  psychoses  of  widely  ditTerent  forms,  although  tending 
towanl  a  certain  amount  of  uniformity  in  their  outward  expression 
in  that  depressions  are  so  much  more  frequent  at  this  period.  In  the 
first  place  there  are  frank  attacks  of  manic-depreswive  psychosis  with 
here  as  elsewhere  markol  differences,  depending  upon  the  severity 
of  the  constitutional  taitit  upon  the  one  hand,  (ir  its  absence  and  the 
presence  of  a  reactive  type  upon  the  other.  Apprehension  and  aiLxiety 
appear  frwiueutly  at  this  period  of  life,  and  a  true  anxiety  psychosis 
is  not  uncommon.  Paranoid  conditions  occasionally  occur  and 
disonicrs  of  the  sensorium  arc  not  infrequent.  In  a  certain  gn)Up  of 
cases  negati\istic  tendencies  are  sufficiently  marked  to  make  the  out- 
ward semblance  to  catatonia  quite  pronounced. 

Certain  of  the  psychoses  of  this  periml  tend  toward  more  or  less 
phy.sical  clmnges.  In  other  words,  the  physical  side  of  the  disease 
has  to  be  kept  constantly  in  mind  and  must  he  considereil  to  l»e  the 
most  iniiMirtant  pmgnustie  feature.    The  changes  incident  to  vascular 


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872    PRESEMIE,  SESILS  AND  ARTERIOSCLSROTfC  PSTCB' 


■<r- 


(lepcticratinn,  while  of  course  nol  usually  prominent  in  the  filth  »iii 
sixth  (li'c-adfs,  may  well  be  in  e\-iHenre,  while  the  chaiij^  in  iht-  dufl- 
less  glands  are  tn  lie  buriie  in  mind.  Other  chauges  uiiduuhtedly  ixvar. 
but  tlieir  nature  and  ttieir  Ix-ariiig  uiwin  the  psychosis  are  noi  at  tH 
understood.  Tlie  iwycliosis  niui^l,  nevertlieless,  be  exprewed  iii  ^>- 
chologieal  terms  and  the  explanation  of  the  mental  s\Tupt»juis  nui"* 
be  ifought  by  psychaanalytie  study.  \Ye  have  here,  then,  dist**? 
whieh  have  a  marke<l  physical  side  ajiart  from  the  mental  manifrfi^ 
tion.s,  the  physiral  side  being  tnore  prominent  than  in  dementia  prnw 
and  les:*  prominent  than  in  genemi  iwresi.s. 

The  Senile  Psychoses. — ^The  normal  course  of  life  leads  to  a  ccrtia 
amount  of  ^railnnt  iiR-ntal  and  physical  deterioration  during  ii« 
lutter  years.  Whether  this  occurs  or  not  probably  depends  upon  mwy 
factors,  for  we  see  some  men  Mt  sixty  as  old  as  tliej-  ;^hoidd  be  at  so'aiiy- 
fivc,  and  other  people  at  eighty  preseutiiig  a  won<ierful  degnr  J 
elasticity  and  enthusiasm  without  an.v  apparent  falling  off  in  mental 
powers  nr  interests.  This  variation  was  wont  to  be  exprnwd  by 
saying  that  "a  man  is  as  old  as  his  arteries,''  but  it  is  certain  that  theft 
are  many  other  fat-tors  besides  the  condition  of  the  hhioilvejncl-s  thil 
lead  to  senile  deterioration.  In  fact  senile  deterioration  may  take 
place  and  lead  to  very  profound  dementia  nithotit  material  (EmbK 
of  the  bloodvessels  at  all. 

Intermediate  Conditiom. — A  certain  number  of  the  involutioii  p^ 
thoses  continue  over  into  the  senile  [K-riod  when  the  patients  und«^ 
the  mental  and  physical  changes  of  senile  involution.     This  is  in  put. 
at  least,  the  reason  for  the  termination  in  dementia  of  a  certain  gn»p 
of  involution  eases,  aside  from  the  addwl  obvious  fact  that  voscultf 
degeneration  is  also  un  ini]N>rtant  etiolof^ical  moment.     The  caja 
that  show  this  outcome  in  dementia  are  more  especially  the  ponniiid 
tyiH-s.     This  group  of  cases  shows,  therefore,  that  there  is  a  f^vdud 
transltitm  from  the  psychoses  of  the  distinctly  involution  fierio<l  to 
those  of  the  senile  perio<l,  a  ixTfectly  understandable  condition  if  «t 
cciaccivc  of  the  psychotic  manifestations  as  being  expressions  of  mrntal 
eonflicls  thai  are  at  tlie  Imsis  of  the  iiidividual  cluiracter  and  »'hirii 
express  themselves  in  the  later  years  of  life  wh«i  efficient  reaction  b 
becoming  prftgressively  less  possible,  and  which  later  on  become  fixrd, 
ehrontc.  hikI  disintegrating  at  a  time  when  the  ph>'s)cal  changes  of  the 
senium  cooperate  to  this  end. 

Normal  Senile  Involution,— The  more  usual  sjiuptoms  iif 
involution  occurring  after  sixty  are  in  the  main  a  lo-v*  of  ineiuory 
recent  events,  due  to  lack  of  impressibility  to  tiie  extent  evei»  that 
events  of  only  an  hour  before  are  comiJetely  forgotten,  lack  of  abUitj 
to  rec(^?ni*!e  faces,  marki-<l  egotism,  so  that  others'  wants  and  comfv: 
are  not  ronsidere<I.  which  may  be  associated  with  some  irritability 
on  interference.  There  is  <leveloi>ed  more  and  more  as  the  year?  jpt 
on  a  true  misoneism,  so  that  the  patient  will  positi\*ely  not  tiJerati: 
any  change  in  the  usual  order  of  things,  everjthing  must  be  done  the 


L'lyiii-i.  I'  Oy 


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THE  SEKILR  rSTCfinSES 


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[same  from  day  to  day,  the  same  seat  Is  preeiiiptetl,  a  particular  kind 

of  fiHw!  drniaii(l»il.  ami  t}it'  liki'  with  othtT  wimforts.    With  this  mis- 

loneisni  ami  the  hick  of  memory  for  recent  events  goes  u   murked 

Iteiidcricy  to  rcmiinMcenct'.      The  events  of  yontli  and  the  years  long 

jst,  uiUike  those  i)f  recent  oceurrence,  are  vivi4ily  recaUeti  and  tlie 

[pnticiit  thus  really  Hvcs  in  a  worki  of  former  days,  constantly  recalling 

'and  reiterating  thingn  that  ncrurred  kinp  apo.    This  eonihtioii  liei-oraes 

progressively  worse,  ihe  patient  leiidiiiK  a  vegetative  existeiu*  almost 

[wholly,  no  mental  initiative,  failure  of  jufJKment  and  a  pro^p-essive 

of  eompR'bcnsion  of  the  environment,  so  that  there  is  no  adequate 

sp  of  the  present  at  all. 

Wilh  tliis  mental  failure  jfoes  a  e<)r responding  chiingc  on  tlie  physical 

jekle.    The  signs  of  age  are  evident  in  the  wasted  muscles,  the  wrinkled, 

[inelastic  skin,  gray  hair,  the  raucous  voice,  arcus  senilis,  sejiilc  cuta- 

fneous  affections,  and  signs  of  arteriosclerosis  in  the  superficial  arteries. 

I  In  this  eonditk)n  it  should  be  rememhiTed  that  the  condition  of  the 

Ipable  arteries  may  nut  indiejite  at  all  the  eniidit»in  of  the  cerebral 

;ls.       The  superficial  vessels  may  show  marked  arteriosclerotic 

changes,  while  the  cerel>rftl  vessels  are  in  relatively  good  condition, 

or,  on  the  contrary,  the  cerelmil  vessels  may  he  seriously  affected  in 

a  person  whose  rndials  are  comparatively  stift  and  whose  temporals 

are  not  noticeably  tortuous. 

Upon  this  backKroiuid  of  dementia  there  may  a[)pear  the  usual 
pictures— excitements,  depressions,  paranoid  .states,  stuporous  states 
and  confusions.  All  of  these  conditions,  however,  must  be  recon- 
structed in  i>sychological  terms  to  receive  any  ex]Jantttion  at  all,  and 
it  is  not  difficult  oftentimes  to  make  out  some  logical  reason  for  the 
particular  type  of  delusional  formation. 

In  the  senile  dement  and  in  the  delusions  of  this  perio*)  there  is 
notice*]  an  apparent  indifference  in  the  emotional  spherv,  an  emotional 
[M)verty.  Persecutory  delusions,  delusions  of  infidelity.  hy]KK-hoii- 
driacul  delusions  take  on  grotesque  forms,  and  their  expression  is 
not  accompanied  by  an  adequate  affect.  A  i>atient  tells  of  .severe 
injuries.  v(  having  been  slint,  while  perhaps  smiling;  another  patient 
tells  a  long  and  pitiful  story  about  her  allrnrs  and  alwut  a  claim  she 
has  against  the  government,  but  tells  it  in  a  sterentyiie*!,  matter-of- 
fact  way  without  the  expression  of  any  feeling.  This  rnndition  is 
usually  descril)ed  as  one  of  emotional  blunting,  emotional  ilcteriom- 
tion.  IJIenler.'  httwever,  lays  great  stress  upon  what  he  Ix'lieves  to  be 
tin-  Fui't,  namely,  that  there  is  no  lack  of  cajMicity  for  feeling,  but  that 
the  affeetivity  is  only  disturbed  secondarily,  that  patients  with  organic 
brain  disease  fail  to  get  a  sufficiently  clear  idea  and  therefore  do  not 
react  wiequateiy  in  the  emotional  sphere.  Wherever  it  is  possible  to 
get  a  sufficient  comprehension  of  the  situation  the  emotion  of  the  proi)er 
quality  is  manifested  and  with  commensurate  intensity. 

'  AffecU\ily.  ftuKftMtihility,  Pjinuioift.   TrajDilalorl  hj-  Chiut.  Rivluthpr,  Now  York  RUU 
Hoapital  liullotiD,  February  IS,  llfl2. 


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874    PRESESILE,  SENILE  AKD  ARTERIOSCLEROTIC    PSTCBOSXii 


Simple  Senile  Deterioration. — This  coiwiition  of  jfradimlly  p 
(Ipineiitia  witliuiit  marked  ps.vcholic  disturbances  is  de±sigiia' 
simple  JteiiUe  ileterutrntion. 

TTie  senile  dement  is  iipt  to  be  restless  and  suffer  from  iiiscHnmii 
revtTsitig  tlie  timi'  of  day  and  sleeping  jjerimps  in  the  da>'tiMie  ui 
lying  awake  iit  niffld.  perhaps  waiulmtig  ubuut  tlie  hmisc  ut  ni^ 
in  a  more  or  less  disuriciitcd  condition.  This  tendency  to  disttrtOH 
tutinn,  ^ntlmut  the  ilevelopment  of  <lelusiou9  occurs  in  the  counr  d 
the  projcressive  deterioration,  and  it  is  where  distiirbaiiccis  ot  llw 
scn.sorium  are  markeci  and  eonfusion  hwfjmori  very  niiioh  more  in 
evidentv  that  we  have  the  citndition  of  senile  deliriunt.  Tliis  co» 
fusion,  however,  may  be  only  transitory  and  is  quite 
isticftlly  in  evidence  In  the  intervals  lictwctni  waking  and  sleeping.        J 

Senile  Delirium. — This  is  merely  a  form  of  senile  fleterioratic^iJ 
whii  ii  c-oiifnsinii  doiniTiates  the  picture  and  in  which  nstially  disor^l 
of  llie  sensorium  are  also  markedly  in  evidence.  Patients  are  hifthly 
disoriented,  they  do  not  know  where  they  are,  or  what  time  of  day 
it  i-s,  do  not  know  whether  they  have  just  liad  their  liinner.  or  whcthrr 
it  is  time  to  go  to  be<l  or  fjet  up,  are  frequently  quite  active  and  irn- 
talile,  and  arc  apt  to  die  from  exhaustion.  The  <leliriuin  may  ukf 
the  form  fif  an  oecujjfttion  delirium. 

Presbyophrenia.— A  certain  proportion  of  these  patients  resemble 
very  flosely  tlic  Korsakow's  psychosis,  being  disorieiitetl  as  to  time 
and  place  and  supplying  memory  defects  by  fabricutinris.  Our  old 
man,  fcr  example,  who  was  90  ft-cble  he  TOuld  hanit.\  >itan<l,  reiaUs 
that  he  had  been  working  for  a  man,  makiug  some  sort  of  a  wire  a&ir 
fijr  the  i>ast  .seven  months. 

Course. — The  course  of  senile  dementia  in  its  various  forma  is  a 
progressive  one.  The  patients  tend  to  become  profoundly  deniniwd, 
wholly  disoriented,  ami  die  naturally  of  marasmus.  Where  the  rhanxe 
is  somewhat  more  acute,  delirious  or  confusiona!  episodes  may  be  in 
evidence  fn»m  time  to  time,  and  of  ixnu-se  if  the  excitement  is  «c  afl 
prolonged  exhaustion  is  the  result.  The  patients  are  naturally  sniict^ 
tible  to  intercurrent  aiTeedons.  partiiidarly  pneumonia,  nepluicis  and 
cystitis,  and  uiany  of  them  die  in  delirium,  tlie  roult  of  a  tcmunU 
infection. 

Diagnosis. —Paranoid  conditions  may  resemble  |>aranoid  stalest  of 
earlier  life,  but  occurring  in  the  senium,  usually  show  endencts  of 
organic  brain  diswise  and  marked  mental  iletcriorati<Hi. 

.'^ume  of  the  patients  alsi*  show  .smilarities   to   dementia 
espceifllly  those  ihal  develop  negativistic  reactions.    Just  wliat  rtU- 
tion  these  caises  have  to  the  preoix  of  earlier  life  is  not  fully  known. 
The  nuirke<l  mentjil  dilapidation  and  the  period  of  life  at  which  thry 
develop  usually  give  the  clue  to  tlie  diagnosis. 

A  few  cases  show  a  mixed  svTnptomatologj*.  presenting  the  picture 
of  senile  deterioration  on  the  one  liaiul,  together  with  the  ^'ariom 
s.N'roptoms  of  arteriosclerotic  disease  uith  focal  lesions  on  the  othrr 


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TIfS  SEKriB  PSYCnOSS.'i 


875 


ind.    Here  are  found  all  aorta  of  mixtures  of  pupillary  disturbances, 
[dislurliaiKTs  of  speecti,  and  various  furms  <»f  paralysis. 

(VrtJiiti  l«mlorIarn:l  ttiiiditioii*)  show  iiiarkeil  einotiimal  states  nf 
I  either  depression  or  cxcitomeut  which  dnmimile  the  picture  fur  the 
I  time  Ix'injt.  These  ch-si'S  slmw  l>c'nrHth  the  emotional  slJite  (he  prcsenee 
!i)f  a  ilefeft  which  shows  the  Uasal  dis«jr(Jer. 

Tlie  siiuilarily  Ix'tween  presbyophrenia  unci  Korsakow's  disease  is 
very  consideruhle.     N'ouet'  lias  recently  made  a  car<.'fu!  stuiJy  of  the 
[two  tx>nciition»  and  has  set  dttwn  the  following  differential  criteria: 

Korsakfjw's  psychosis  aft'ecta  persons  particularly  of  adult  age; 
presbyophrenia,  nn  the  eiintrary,  belongs  to  the  periinl  of  old  age, 
the  age  <»f  predilection  oscilluting  about  seventy  years.  I'resbyo- 
phiT'nia,  it  is  known,  is  quite  uiiir|ncly  an  alfeetion  of  women,  while 
Korsiikow's  psychosis  i-s  far  from  lieing  rare  among  men.  The  Innnor 
of  the  pn.*sbyophrenic  is  always  gay,  euphoric  and  satisfied,  quite 
'different  from  the  jwycbopoly neurit ic,  who  is  onlinarily  depn.'Siied  or 


Flu.  402. — Praatiyophrviiic  rwies. 

apathetic,  and  whose  face  preserves  an  invariable  hnniobility.  TUe 
traits  of  the  preshytiplirenic  are  extreme  nujbiliiy,  they  laugh,  moke 
grimnros  in  which  the  niimie  mu>fcles  participate.  The  facitfs  of  the 
psycbnpniyiieuritic,  however,  are  atwa>'s  dull  ami  without  expression. 
J^Kjuacity  is  a  symptom  scarcely  ever  lacking  iu  presbyophrenia; 
the  patients  talk  without  stopping  alxnit  everything,  with  equal 
volubility.  Tliii*  symptom  is  lacking  In  Knrsakow's  psychosis.  The 
presbyophrenic  is  polite,  luniable  and  cordial,  characteristics  wlucli 
one  seeks  in  vain  among  the  ps\ ■chnj)oly neurit ics.  I)isiir<h'rs  of  con- 
scldu.'inesa  are  much  mi>re  niarkwl  in  the  presbyoplm^nie.  These 
patients  have  no  understanding  of  their  state  of  illness  and  content 
themselves  with  laughing  when  one  asks  a  question  relative  to  their 
jihyslcal  {»r  mental  licallb.  (hi  the  contrary  the  psych opolxiieuritic 
gives  a  Fairly  giMul  account  of  hiniseif  and  of  his  position,  ainl  is  the 
fiRit  tu  lament  his  situation.    The  judgment  of  these  patients,  even  in 

'  rrwil>yo[>hrfnii«  <!**  Wfrnfi-ltp  ct  Im  P.iythopolynJvritcs,  L'Encephalo,  Ksbruarj-  10. 
IDIl. 


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870     PRBSESILE,  SEMLE  AND  AHTETllOSCLEROTfC  PSTcm^ 

the  rhmnic  forms,  is  less  noticeably  afft?cte<l,   and   their  Jfpw  ■* 
iutelleftiml  eiifet'hieim'nt  less  tnarke<).    The  amiiesiQ,  finally,  Unw 
prori)tintl  in  the  preshvejphreiiir,  anil  besides  in  this  alTwtinn  thepaxi* 
dws  not  possess  n,t  all  a  knowledge  of  this  amnesia — the  invew  ^ 
what  one  obsen'es  in  the  chronic  forms  of  Korsakow's  dista'^c  ite» 
the  snhjeets  speak  sp(t[itaiienusly  to  their  interlocutors  of  the  ptntnod 
troubles  of  their  nienutry.    IVesbynph renin  is  rare  in  its  t ypiod  frne. 
hut  ivniinon  In  lUv  formeft  fruntt'.'t.   \\\urv  the  s^inptoms  only  apprt«t 
or  where  certaiji  of  thera  are  lacking,  the  presbyophrenia,  has,  pa^uft. 
the  distinctive  cliaracteristics  of  arteriosclerosis,  n-hieh  an-  aera  waA 
more  nmonp  these  patient-^  than  amonp simple  senile  iteinent!).    IWfliP 
die  nearly  always  of  cerebral  heniorrliage,  and   their  nervous  cwlrts 
pn'seni  at  aulnpsy  pmnounrvd  atheromatous  lesinns. 

Pathologf. — Cinissly  the  brain  shows  si);ns  of  atrophy  and  is  d^trnw^ 
in  tteight,  the  hemes  cif  the  skull  are  thinned,  sotiietlmes  in  w-ell-definp) 
regions,  [wrticularly  the  temporal  reginns.  There  is  a  compcnsat'tr- 
external  hydrocephalus  as  a  result  of  the  atrophy  €>f  tJie  brain.  T» 
(■^involutions  are  shnnikt-n  and  the  fissures  (-"orrespondin^jly  wideoEd. 
nie  atrophy  h  not  uniformly  distributetl  and  amy  l>e  very  niudi  n»tt 
markcfl  in  some  areas  than  others.  Arteriosclerosis  is  a  frrqaeu 
findinji.  but  Is  not  a  niM^essary  part  of  the  pi<'tur(\  In  faet  the  t*^ 
processes  are  quite  tllstlnct  in  every  way,  althouf;h  fnijueritly  »-v— 
cinted.  When  arteriiisclerosis  is  present  there  niay  of  course  be  found 
its  results  iu  such  lesions  as  softenings. 

The  arehitecli tonic  of  the  cortex  is  greatly  disturlM^l.     The  nm* 
<t11s  show  advautrd  flegenerBtiftn  with  largi-  ipiaiitities  of  degr«cr»tivr 
products  of  a  lipnld  luiture  within  them,  amounting  to  a  sevtre  gr»<V 
of  fatty  degeneratiou.    A  very  cliaructeristic  picture  are  the  hm^kti 
formations  alwut  the  nerve  cells.     The  neuroiibriU   appear  to  ht 
thickened  and  produce  whirls  and  loops  almut  the  nen'r  cell,     li  b 
thought  by  some  that  these  basket  formations  are  due  to  inrf 
upi>n  the  neurolit)rils  of  perhaps  neurogliar  origin.    The  eon 
imrticularly  welt  seen   in  ]>r<*shyophn'nia. 

The  miliary  plaques  are  pt-rhaps  the  most  distinctly  itathohiginl 
findings  in  senile  dementia.  In  fact  they  are  distinctive  a.s  much  as 
any  jMitbological  finding  can  be  distinctive  of  any  one  condittrm. 
Their  presence  iu  considerable  numln^rs  prai-tically  makes  the  diijt- 
uosis  of  senile  dementia,  while  tJieir  absence  or  extreme  rarity  would 
negative  such  a  diagnosis.  They  are  small  spots  of  necrosis  whidi 
are  not  dependent  upon  softenings  ami  are  in  no  wiiy  associated  with 
the  hlomlvessels. 

There  is  a  great  deal  of  neurtigHor  prolifomtion  throughout  tlie 
brain  and  marked  c\idences  of  disintegration  and  the  pirscncr  ot 
scavpuger  cells  and  tlie  like. 

Aside  from  these  cluiugcs  the  usual  changes  of  tliis  period  of  life 
are  found,  particularly  in  the  heart,  the  kidneys,  and  other  intemai 
organic. 


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ALZHEIMBR'S  DISEASE 


877 


Treatment.— The  mild  cases,  esppcially  those  that  niiiiiitain  their 
[oriontatkm  fuirly  well,  am  be  cared  for  at  home.  Those  with  marked 
[omfusion,  esiiecially  vnth  n  tendency  to  wanderinK,  need  an  atteudaiit 
be  witli  them.  There  is  danger  of  their  becoming  lost  and  comiiiK 
(H'ief.  or  if  they  minder  about  the  hmise  at  nipht  they  arc  apt  to 
meet  witli  some  accident,  iiion^  often  to  fall  down  stairs  and  sustain 
fractun^s.  Patients  who  an-  very  resistive,  pn*sent  stirj;ical  troubles, 
arc  filthy  "ui  habits,  ur  show  «  tcndeiicj'  to  commit  sexual  offeuces, 
should  be  cared  for  in  an  institution. 

-Vs  rcKiinis  the  more  special  treatment,  littic  is  to  Iw  said,  lly^enic 
surroimdings.  a  .simple  diet,  looking  after  the  cmunctories,  and  if 
irisonmia  is  present  the  occasional  exiiibition  of  a  hypnotic  constitutes 
about  alt  there  is  to  l>e  done.  In  thi.s  class  of  case-s,  more  |>erhaps  than 
in  any  other,  is  the  use  of  alcohol  as  a  hypnotic  indicated.  A  littic 
whisky  and  hot  water,  or  a  filiuss  of  beer  or  ale  acts  very  nicely.  It 
should  be  given,  however,  strictly  under  medical  authority  and  super- 
visiim,  as  thest^  patients  are  apt  tc  be  susceptible  to  its  iiilhicncvs. 
In  tlie  earlier  stages  of  the  disi-ase  i»otassiura  iutlide  is  the  drug  par 
excellence  for  its  general  alterative  properties  and  its  effect  on  the 
arterial  tension. 

.\s  soon  as  evidences  of  mental  deterioration  appear  relief  fnim 
business  worries,  cares,  res[)onsibilities,  and  mental  stresses  of  all  sorts 
is  iiiilicflteii,  with  the  general  hope  of  limiting  disintegration  as  far  as 
possible.  Whether  this  is  of  value  or  not  is  pretty  difficult  to  state, 
ifor  it  iiuist  l)e  remembered  thjit  there  appear  to  l>c  certain  hereditJi-ry 
tendencies  involved  even  in  tliis  ciMidition  anil  that  arterii»sclerotic 
disease  and  senile  dementia  both  appear  to  be  more  prevalent  ill 
certain  families. 

Alzheimer's  Disease.— ^This  disease  was  first  described  by  Alzheimer 
in  IWKi  and  sinc-c  that  thne  a  number  of  cases  have  been  reported. 
The  disease  occurs  usually  in  the  fiftli  decade,  althongii  rases  have 
been  reported  in  the  early  part  of  the  fourth  decade  and  a^  late  as  the 
beginning  of  the  seventh.  The  s.\Tnptomatologj-  is  one  of  a  gradually, 
often  of  a  rather  rapidly  progressing  rlenienlia,  interrupted  |)erliaps 
with  episodes  of  a  certain  aniuunt  of  excitement  ami  anxiety.  A 
rather  rapidly  progressing  ilcKicntia  in  a  niai)  of  aiiout  forty,  or  a 
little  over,  is  in  itself  a  rather  unusual  picture,  and  in  the  absence 
of  signs  of  brain  tumor  ctr  .syphilis,  Alzheimer's  disease  should  be 
thought  of.  The  dementia  is  markeil  by  a  considerable  degree  of 
disorientation.  The  symptoms  otherwise  arc  very  largely  neurological 
and  particularly  f(«-alizcd  al)i)ul  tlie  function  of  speech.  Various 
aphasie  and  apraxic  .«\*mptoms  are  prominently  in  evidence.  Para- 
phasia and  as\'mboIia  arc  cjuite  frequent.  There  may  also  be  spasticity 
and  convulsions,  ftltIu)Ugli  tliere  .in-  never  well-marked  paralyses. 

Tin-  pathi)l4)gy  of  this  condition  ttirows  abnost  the  only  light  up^in 
its  natiux'.  There  Is  marked  and  extensive  degeneration  of  the  nerve 
cells  with  disturbances  of  cortical  architeclitonic  and  tlie  presence  of 


1 


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878    FRSSBSflB.  SBNILB  ASD  AltTERIOSCLEHUTtC  PSJT»iSil 


large  quantities  of  di^ntcf^tiun  products,  while  Ihei 
immbcrs  of  biusket  formations  umi  typical  miliary  pUiijin 
ditiim  of  the  blood ves-^ls  is  quite  normal.  The  pathuIoKiiAl  pirta 
thus  resembles  closely  that  found  in  senile  dementia.  In  genrai 
the  disease  is  considered  as  a  presenile  dctiirntia,  althuugh  some  bcbn 
it  to  be  H  distinctive  disease. 

The  presence  of  this  disease,  if  it  be  conaidered  a  prearnile  di-mntii 
offers  another  one  of  those  warnings  to  us  not  to  l>e  too  ilupUD 
It  wuuUI  appear  that  the  senium  is  by  no  means  a  rlrarly  (Ufa 
period  of  life,  and  that  the  pathological  chan>;es  whiuh  aiv  ofli 
thought  of  as  dependent  upon  old  age.  may  occur  v^-ttliin  wid^[ 
itiid  i>erhaps  represent  failure  of  special  tisMuc  reHisianres.       ^^| 

Arteriosclerotic  Psychoses. —These  psy<lic»sf:s  are  dependent. 
their  physical  side,  upon  arteriosclerotic  cbangi^  in  the  oerebml  Mw 
vessels,  and  this  eonilltion  is  due  in  turn  to  the  ^neral  tsiusrs  via 
prmliKre  iirteriosclerosis.  In  the  main  the  two  fa<tor»  are  chni 
toxemia  and  high  blood-pressure.  It  mu.st  Ix;  iHtrne  in  mind,  hi 
ever,  that  an  julvanced  dcffree  of  arteriosclcrosi.s  may  exist,  |MirtJi 
larly  in  the  ix-ripheral  vessels,  and  the  cerebral  ves,s**l.s  retain  tfa 
elasticity,  while  on  the  contrary  the  cerebral  \-esst*ls  may  be  -xvm 
soiemsed  while  the  peri])heral,  pal|Kd)le  ve.ss<*Is  sliow  little  diui 
,\rterit)sclerosis  is  essentially  a  refjiunat  disease. 

'I"lie  psychoses  of  arteriosclerosis  form  another  onr  of  tlie  connrcti 
links  which  join  the  iieriud  of  involution  and  the  senium.     Maay 
the   involution   psychoses  merge  Into  arterioscJerotic   Heteriipratki 
and  artcrii  isclert)5is  is  frwiuently  combined  with  the  chattg<e:i  inddil 
to  the  senium. 

Aside  fn>ui  the  usual  causes  of  arieriosclerosis  there  n-mikt  s»bi1 
be  (Tftain  hercditan,-  factors  at  play.  Certidn  families  .thim-  a  hig 
ineulenw  of  death  dci)cn(lent  njMin  arteriosclerotic  disease. 

There  are  four  fairly  welI-<IpfiTied  varieties  of  this  dlsniae  ha» 
upon  both  clinical  ami  pathological  findings  as  follows: 

1.  Arteriosclerotic  Brain  Atrophy. — 1  his  oteurs  in  two  forms:  a  vA 
ionn  with  severe  Hrtcrial  sclerosis  but  an  al)sence  of  focal  bratn 
The  symptoms  are  easy  fatigue,  slight  fiiilurc  of  memorj', 
and  headache.    Tlie  seven-  i\  [X-  nniy  rt*sendile  the  mild  at  first  Inil 
progressive,  lends  to  ]m.)f(ninil  dementia  ami  prvsents  in  its  coi 
a|)oplectiform  and  cpiieptiform  attacks  and  focal  symptoms. 

2.  Subcortical  Encephalitis   (Binswanger).     In  this    <'onditioo 
white  matter  is  largely  involved  as  a  result  of  disease  of  llie  lo 
medullary  arteries.       .\popleiTtifrtrm  and  epileptiform  attacks 
and  also  transitory  attacks  of  confusion.  aphiLsia  and  parestN 
turhances  suggesting  focal  Itrsions.    IumtiI  lesiuits  are  not  found  rxtci* 
sively  hut  an-as  of  sitftening  often  occur  in  llie  \i&sa\  ganglia. 

3.  Perivascular  Gliosis.—Iii  this  cunditiun  thert>  is  a  dtsappearana 
of  nervotis  elcuicnts  about  the  diseased  vessels  and  repUecmetit  bg 
neurtiglia. 


A  UTERWSCLEROriC  PSYCHOSES 


879 


I 
I 


4.  Senile  Cortical  Devastation. — 1  Icrc  extensive  destruetiun  of 
cortical  urt-as  in  the  \asfnliir  terrltorit'S  of  t\\v  ilisfastfl  vessels  b 
fouii<l.  Ill  this  ctJnditioii  thf  arteriosclcrusis  is  loeiilizt'il  lurj^ely  in  tlie 
»nmll  curtica]  vcsst-Is  which  coiue  off  fruiu  the  pia.  The  basal  vesseU 
remain  relatively  normal. 

Pick  has  very  thoroughly  (Icstribed  ctTtain  larjfc  atrophies  involving 
wholp  loin's  or  ]M>rtionsof  lohes.  The  ooinpitJil  lobi's  may  !«■  involved, 
producing  blinilness,  or  the  temporal,  producing  tleafacs.s,  for  example. 
The  fttrtiphy,  however,  does  not  always  follow  a  vascular  area,  and  so, 
while  it  is  p^-nerally  supposi*d  to  In*  due  to  arterioscIcn>tiu  disturbances 
in  the  irrigation  of  these  tiTritories,  the  cause  is  not  always  altogether 
clear. 

SijviyUims.—ln  the  main  the  sj-mptoraatologj-  of  cf?rebral  arterio- 
sclerosis is  one  of  gradually  progressive  mental  deterioration,  to 
which  are  added  the  evidences  of  focal  lesions  which  are  the  results 
of  thrombotic  softenings.     (.tSec  Chapter  on  Hemorrhage.) 

The  pnMlmmal  ilisLurbances  of  the  arteriosclerotic  psychoses  are 
very  apt  to  exten<l  over.a  considerable  j>erio<l  of  time,  and  manifest 
tliemst^lves  in  the  main  as  nervousness  and  irritability,  with  hearluchc. 
dizziness,  insomnia,  a.ssociatwl  nf  course  with  the  sjjecial  signs  of 
the  vascular  disease,  more  particidarly.  as  a  rule,  high  blraxl-pressure. 
With  this  series  of  symptoms  there  may  be,  of  course,  associated  a 
certain  amount  of  deafness,  with  sclerosis  of  the  drum  membrane, 
cardiac  attat:ks  with  the  Stokes-Adams  syndrome  and  evidences  of 
interstitial  nephritis.  Quite  frec|uently.  too,  these  patients  show  the 
signs  of  arterio.selerosis  of  the  vessels  of  the  spinal  cord,  with  perhaps 
some  sclerosis  of  the  palpable  vessels.  On  the  mentji!  side  the  patient 
may  have  a  fwling  of  growing  inefhciency.  at  least  his  work  shows  a 
falling  off  in  efficiency,  which  characteristically  manifests  itself  at  first 
in  a  failure  to  do  the  creative  things.  I*ii^k  has  called  psirticiilar 
attention  on  the  emotional  side  to  a  lack  in  the  finer  moilulations  of 
the  emotions.  Blculer's  suggestion  must  Ik'  remembered,  that  patients 
with  organic  bruin  disease  fail  to  show  a  natural  emotional  reaction, 
not  because  of  any  defect  of  emotion,  but  because  of  a  lack  of  grasp 
nf  the  situation,  and  when  the  situation  is  fully  appreciated  an  adequate 
emotional  response  issues. 

These  prodromal  .symptoms  gra<Iually  merge  into  symptoms  of 
greater  severity  and  may  be  piuictuated  from  time  to  time  by  attacks 
of  excitement  or  of  depressiim,  and  delusioiLS  may  develop  which 
are  charB<;tcristieally  of  the  paraiioi4l  tyi>e.  The  following  i»se  illus- 
trates tills  paranoid  treml  very  well:  A  man  who  haii  Ixt-n  a  successful 
business  man  in  his  younger  days  l«'gan  to  fall  niT  in  efficiency  as  he 
entered  the  arteriosclerotic  period  uf  life,  and  finally  entered  uiie  of 
the  Soldiers'  Homes  as  he  was  unable  to  adequately  sui)|>ort  himself. 
Here,  because  of  his  training  as  an  accountant,  he  was  euiploye<l  in 
the  office.  >VhiIe  employc<l  here  the  characteristic  series  of  paranoid 
ideas  developed.    In  the  first  place  he  developed  e.xalted  ideas  of  hia 


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ow'ti  ability  which  were  ilistitiL-tly  Hcfcnstve  in  character,  m^» 
sating  him  for  the  n-nl  fai-t.  his  fiitliiig  abiiity.  Alongwdp  J  tia 
cxaKJ^Tnteil  ideas  he  ha'l  delusions  of  a  persecutory  character, 
was  interfeix'tli  with  by  those  about  liiin  who  w-ore  envious  J 
betrause  he  had  seeiireil  such  a  pood  position  in  the  Gtntimar'i « 
This  is  another  defetise  reatrtion  in  the  opposite  directmn  aod 
to  explain  to  him  how  a  really  efficient  man  after  all  can  turn  oaii 
poor  work.  It  is  not  liis  fault,  but  the  fault  of  those  about  him. 
so  he  is  ajo*i'i  s»ve<l  frum  the  realization  of  his  failing.  Henuivtidbi 
this  situutioii  and  taken  to  a  hospital  where  he  c*ould  no  longer  i 
ill  aleoliol,  wlilch  had  been  a  factor  in  brin^tuK  About  this  c»gifiti 
lie  reeovi-red  fronr  tlnse  distinct  jwychotic  mauifestation^i.  but  iritlH 
however,  a  full  insight  into  what  his  coii<lition  hud  l>eeii.  Timl 
of  insight  probably  had  its  basu  in  the  or^uic  changes.  Tlir  hmb 
no  longer  capable  of  adjustment,  except  witliin  narrtiw  limili. 
while  removal  from  the  painful  conditions  relieved  the  srtuatitdi, 
was  unable  to  hilly  understand  it. 

This  case  shows  \ery  well  how  even  in  a  ysyohosis  dependi 
organic  brain  disease  the  mental  s>inptoms  as  such  must 
psychological  interpretation. 

From  time  to  tune  these  patients  show  periods  of  rdnTusiun  i 
bcwildenneiit.  witli  disorientation.    Tliese  periods  may  U-  of  cotA 
able  duration  auil  some  of  them  at  least  are  <le(H»ndent  upon  thraolx 
attacks  which,  when  they  do  not  occur  in  the  motor  area,  arecK 
overlooke<l.    Even  though  they  do  occur  in  the  motur  area  the  t 
turbance  of  consciousness  may  not  be  ver>'  great,  or  at  Icmsi  Ui 
is  nothing  comparable  to  the  une)>nseiousness  and  coma  of  cenh 
JiemorrhaKe;  there  is,  perhaps,  only  a  slight  crmfusion.  and  the  partiv 
sis,  if  it  exists,  is  only  very  slight  and  is  often  explained  by  the  fanuh 
as  the  ivsiilt  of  some  ineonsetiuenttal  cause.    Then,  again,  the  fMtim 
may  1>e  so  bhinted  mentally  as  not  to  complain  of  a  slight  ini, 
of  funtrtion. 

These  patients  are  especially  susceptible  to  alcohol  anil  I 
easily  very  Iwidly  confused  from  small  quantities. 

One  of  the  characteristie  features  with  n^ganl   to  this 
psychoses  is  that  the  so-called  "nucleus  of  the  per>nnaliiy"  i 
pr«\servetl.      The  patient  preserve's  all  of  the  outward  apjx-uni: 
his  itM  self  until  the  mental  dilapidation  lias  reached   an 
degree.     There  is  not,  as  a  rule,  that  marked  "change"  io 
vidual  that  is  seen  in  some  of  the  psychoses. 

The  areas  of  softening  proiluee  focal  lesions  and  these  focal  It-TUOiD 
are  most  prominent  in  the  motor  areas,  pr(nlucing  various  uppef 
motor  neuron  paralyses,  and  in  the  speech  areas  producing  variuut 
forms  of  aphasia  and  apraxia.  The  marked  focal  lesions,  pnrticuiarly 
those  wliirh  lead  to  wellHlefined  spii-ch  disturl»ances,  hasten  vcrn 
greatly  the  dementia.  An  aphasia  which  puts  the  patient  out  of  actual 
touch  with  his  fellows  hastens  the  teudeno'  to  mental  detMi*)ratii>n 


ARTBRlOSCLEIiOTW  PSYCHOSES 


881 


'tn  this  class  of  patients  who  are  no  lonBcr  fluid,  but  are  well  alo»K 
on  the  (iown-hlH  path  of  life.  They  need  even.'  stimulus  of  mental 
activity  to  even  hold  their  own,  and  as  soon  as  an  important  function 
like  spi-ech  is  destroyed  they  are  quite  apt  to  lapse  promptly  into  a 
serious  deterinration. 

'  It  is  ill  this  class  of  patients  tluit,  as  a  result  of  the  focal  lesions, 
epileptiform  attark»  develop  late  in  life — the  so-called  "late epilepsies." 

.Their  signlfii-auee  in  the  main  is  in  pointing  to  the  foeal  disonler, 
und  as  an  indication  that  the  jMitienl  needs  careful  nvenslplit. 


Fir..  'lO^t.— KxU-iii-ivc  tJiKiiiiUilir  ^ofti-iiina,  ihr  rpftilt  <if  iirii'ri'"il.r'i-i'-      !':irii'iif  atci 
cutfity-ihrci>  years.     Thcrt  wort  «!»•»  i>oftoiiiiiii»  on  the  riidii  awle  iu  tlii;  Iwwcr  twrliim 
LiT  iJiiT  uiinpun  and  uiijirr  piirUdiii'  iif  ilif  liiiituiil  mid  ruitirunii  lubulm.     TtM>n>  is  Keneral 
LkUophy  of  tli«  mnvoluUons. 


Patholitgi/. — ^I'lu'  i>athnlog\'  shows  the  arteriost-lemtte  pnieess  in  the 
ferehraj  vessels  in  various  slages  of  pnisresa.  There  may  he  miliary 
nneurismi*  of  the  smaller  vessels  and  other  vessels  may  Ik-  tiMnpletcly 
oeeludetl  with  resulting  areas  of  softening.  These  ureas  of  softening 
usually  show  entire  disintegration  of  the  nervtni?  elements  with  large 
;Tiumbers  of  seavenger  elements  about.  The  nerve  cells  show  varinuit 
grailes  of  degenerative  change  dependent  upon  deficient  milrilion  as  n 
result  of  decrease  in  size  of  the  lumen  of  the  vessels.  There  is  neurogliar 
overgrowth  tilHitit  the  vwsels  and  in  the  ilenenerati.-d  territories. 

/JiVflPiwfW.- The  fliseases  nuist  apt  to  l>e  mistaken  for  the  arterio- 
sclerotic psychoses  are  paresis  and  the  psychoses  of  cerebral  s\i>hiliii. 


J  IKKt 


B« 


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882     PRESEMLE.  SENILE  ASD  ARTBRiOSCLKftCtTW  PSTCBM 

which  shoulil  In*  consklertKl  together  now  that  the  etioU«s>'  of 
has  been  so  thoroughly  established.  The  reas(»ii  for  tlie  posdtJfit 
of  mistake  is  de]icndent  upon  the  fact  that  lK»th  processes  ore  ronnr 
less  (JilTuse.  pro<hi<-inK  a  progressive  mental  deteriorating.  unA  ti 
both  processes  teiul  to  be  more  severe  at  r<*rtaiii  points  and  thii>  pi 
diiee  foeal  sNTiiptnins.  .Sjiphilitic  and  mt'ta.N\-idiilitic  diAurfau 
otTur.  as  a  rule,  at  a  much  earlier  age  than  the  nrterioi*cIeri>tir,  ^nvn 


r 


S^ 


n 


••-"' 


O 


Scrr- 


^ 


K.'V  ■ 


^     O' 


Fi«.  -i(H. — CiJlulsr  alivtittioun  iti  nrvKi  of  M>rt«uitii(.  Arleriotctettnta,  acuta  lelUv 
ins.  iBounnr  f^ufiruinic,  i<4!iiilp  dctcriaralion,  vie:  K,  kdnc-hra  kUco;  K,  «Ddo(MXl 
edit;  ADV.  AdvvDlitia  cwtU;  V.  new  filtroUaato. 


fl 


iKtt  later  than  the  fourth  dei-jide,  while  the  ortertttsrlerottc  \wtv* 
not  entere<l  until  the  fiftli  <Jecade.  When  an  arteriowlfrviiir  lui-.  luii] 
syphilis  also  the  differentiation  heeome-S  qiore  difficult.  The  \Vas»r- 
manji  of  thr  een-hmspiiial  fhiid,  however,  wouKI  I>e  negative.  vdiOe 
with  larpe  areas  of  softeninj;  on  the  surface  of  the  tx-rehniui  there 
would  Ih'  eoii^iiikrahle  evidemr  of  ihsintejirnitioii  proiiitcts  in  the 
cerebrospinal  Buifl.  0"  the  tnenta!  side  the  prcser\citi«»n  of  ibe 
"  nucleus  of  the  persoiiahty"  b  much  more  in  evideaoc  than  in  psimis. 


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ARTERrOSClBROTIC  PSYCHOSES 


8S3 


Trralment. — In  a  f^eneral  way  the  treatment  i+houW  l>e  prophylactic 
ns  far  as  pirssihle.  Witli  the  first  sjmptoms  i)f  prnlunKi-d  nrHi  irilrart- 
ahlt*  hij;Ii  hliKKl-pre-Msiin'  tlit-  indiviihial  slmiiM  lit-  rt-mitve*!  from  the 
influerKt's  of  ph\'sk-al  iiiiil  mental  stress,  ami  the  usuul  means  hIiouM 
be  emijloycd  tn  k«f|>  the  hloiHl-pressure  down  and  tn  rwiucy  or  (Ut 
away  with  any  toxetnie  condition  present.  A  carefully  ri'^nlated  diet 
from  which  ali.-ohol  ami  tobaectj  arc  exelmleil.  hydrotheraj)y  intelli- 
^'cntly  applitd,  iwssihly  a  visit  to  sonic  wjiieriiij,'  place,  and  in  wjriie 


Fiu.  4('6. — Wi^My  (li»lrilnit«<l  arlcrionc-K'mlic  wtflcninio;  patirn  kiinl.vlwtr 

yeam.      There  wore  aI*/»  niliiterDUs    aurifniiies  in   ihe  iMurnl  |tnm  i  ■  iiii  errally 

Htirunkon.  li  cud  be  Mvo  (rooi  Iha  <lu>lnbutJoii  of  (he^te  Iwione  ttuw  tiiw  vlUuval  piclurs 
tni|[hL  aiTniilitb'  [MircEiiii. 

instances  a  viHit  to  a  somewhat  higher  altitude,  witli  moderate  out- 
door exercUe,  and  the  exhibition  fri>m  time  to  time  of  drups  to  rwince 
the  pn-ssure  and,  especially  where  there  arc  kidney  complications, 
ihc  rlritikiiiK  *»f  considerable  qnantities  of  mildly  alkaline  water  are 
in  general  the  thinpi  to  bo  dcpende<l  upon.  ln.soninia  has  to  be  dealt 
with,  Rnd  in  enscs  where  the  jKitienl  is  umler  absolute  control  a  small 
rtmuunt  of  alcohol  at  ni^ht  will  simietimes  pnKlucc  the  desired  rcsidt. 
Unless  the  patient  is  imder  absolute  eontn>I,  however,  it  is  best  to  give 
hot  milk,  c»r  such  simple  hypnotics  ils  vcitiiial. 


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CHAPTER   XXIV. 


1D10C:Y,  IMBECILrn'.  FKEBLE-MIXnKDXKSS,  AKD 

CH.4RA<:TKnoux;ir.\L  oefect  Gitc Jin's. 

WiTUiN  the  past  few  years  the  defective   classes    Imvc  asisiuu 

enormous  sociological  importance  .so  tliat  this  chapter  has  ea^ly  henn 
pcrhai>s  the  most  important  in  the  whole  Rroup  of  tli»»rdens  at  t 
psyrhnjogicai  level,  considered  from  the  sm-ial  angle.     Of  course  « 
a  brief  outline  of  the  variuiu  types  of  defect  can  l>e  given  id  s  t 
\iaok  sufh  as  this. 

In  ilmwinK  a  distinction  lietween  ilemcntia  hiuI  idiocy  KsKji 
said:  " The  demented  man  is  deprived  of  the  (j^mmJ  thjit  he  fonnn 
enjDVtHl;  he  U  a  rirh  inaii  heeonie  ].HH>r;  tin*  idint  lias  aliAavr'  Ijvnl 
niisfortime  and  poverty."  In  other  wtmls  the  idiut.  the  imbecili'.  i 
tliL-  fwble-minded  lack  s«tmethiiig;  ihi:  psychotics  are  ^ttifferiiig  fnjra 
dist>rder  of  that  wliich  tliey  (xwsess. 

This  definition.  :^  admirably  W(»rded  by  E;K)Uinil.  ndiffuatelv 
pressed  the  distinction  between  the  insane  an<I   the   iijidt  and  tl 
imbecile  acconling  to  the  knowledne  of  his  day,  and  Ims  l»ccn  u-* 
continuously  since  to  express  such  distinction.     It  «in  no  (ou^t  fa 
said  to  Ih'  a  valuable  formula  except  it  be  iwed  witlx  many  resrrvKiioa 
and  explii nations. 

In  the  first  pliice,  from  the  staiMl-|»i>int  of  tliis  liook  there  is  no  m 
thing  lis  insiniity,  at  le«i*t  in  a  mctjical  sen*',  as    Rsquin>l  u?«^i  thu 
term  and  as  other  psychiatrists  in  the  past  and  the  prcsejit  have  it<»f  it. 
insanity  is  purely  a  legal  and  soeiok>gical  amcept,  and  ait  siich  6ttts 
not  inip]>  anything  more  than  the  judgment  of  a  man's  frlluws  on  tfatf 
desirability  of  liaving  him  live  in  the  community.    Defect ivenesB,  under 
which  term  the  various  grades  of  idiocy.  imlHH-ility,  and  feehltMnmdcd- 
iiess  lire  iixrltided,  is  cpiite  as  generic  a  term,  and  while  it  n-fers  to  « 
(xmdillini  the  fundiuiiental  characteristic  of  which  is  lack  of  drvelt^ 
nient,  it  includes  a  great  variety  of  states,  and  in  its  appltratioa  is  ft 
relative  term  only. 

It  is  quite  as  illogical  to  group  alt  defectives  togetlu-r  and  cndeav**- 
to  draw  a  conclusion  from  their  study  as  a  whole,  as  it  is  to  grtjup  aU 
of  the  .so-caUcd  insane  together  and  endeavor  to  draw  a  ctmrlu^nn 
from  the  study  of  all  of  them.  There  is  obviously  very  little  tiniilaritj 
between  the  cretin  and  the  defective  as  a  result  of  cerebnd  hrmorriuifle 
duruig  a  prolonged  and  difficult  lalHir,  and  therefore  any  principle 
or  conclusions  which  are  reached  as  regards  the  whole  defective  clft5a 
without  an  adequate  appreciation  of  the  multitude  of  ditTrrciit  coo- 


! 


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CLASSIFICATIOS 


(litioiis  that  lire  foitml  iimler  this  generic  i^ptlon  must  Ik"  avoidrd. 
It  must  he  remi'iiilK-n-d.  in<».  tluU  with  uiiy  fk'ftTtivc  patient  it  is 
pus^^iblt:  to  liJive  0S3octBte<!  a  psychtisU,  so  that  the  picture  in:iy  be  still 
more  complictited.  Therefore  in  other  partit  of  this  book  various  fonus 
of  what  are  groxiperf  in  this  chapter  are  treate*!  of  from  an  etiological 
stand-imint. 

Ill  ronsideriiin  the  etioloj^-  of  various  defect  states  the  important 
geruTnl  pritidplf  thai  should  be  borne  in  mind  is  the  location  *>(  tJie 
defect;  (1)  as  to  whether  it  is  in  the  germ  plasm  or  acquirc<l,  and 
(2)  as  to  the  lime  of  development  of  tlie  individual  when  it  became 
operative.  It  Is  only  those  defects  which  are  the  result  of  a  lack  of 
some  element  in  the  germ  jilasm  that  are  tnily  of  an  hereditary-  nature. 

The  procesA  of  development  may  bi'  interrupted  at  any  time  from 
the  beginning  of  the  growth  of  the  cliilil  in  the  uterus  to  the  attain- 
ment of  its  ccmipletc  adult  development,  and  as  tliis  interruption  may 
tjike  place  tluring  intnt-uterine  life  it  is  in  such  InstHnecs  that  it  is 
imjiortant  to  make  the  distinction  between  a  truly  inherited  and  an 
Hequire«l  defect.  In  both  instances  the  defect  is  congenital,  that  is, 
exists  from  birth. 

Disease  or  injury  may  nfTect  the  child  during  intra-nterinc  life  or 
tluring  the  pnH'Css  of  birth  or  after  birth  and  during  the  pnMX'sses 
of  extra-uterine  development.  Previous  to  birth,  illness  or  injury  to 
the  mother  are  the  common  etiological  factors;  during  birth  asphs-xia- 
titm  aiul  injury  by  the  fortvps  are  counuon  causes,  while  after  birtli 
the  infectious  diseases  and  direct  injuries  enter  largely  into  the  etiology. 
Finally,  there  are  reUitive  conditions  of  defect  which  are  due  to  lack 
of  the  opportunity  to  develop,  such  defect,  for  example,  as  re-sults  from 
rhe  deprivation  ctf  the  important  sense  organs,  as  the  eyes  and  ears. 
If  the  jtatient  Ik-  I)i>rn  blind  and  deaf,  under  onlinary  eircumstaiiees 
he  will  be  very  ilefective  mentally,  l)ecause  he  has  not  the  opportunities 
for  learning  which  the  ordinary  child  lias.  On  a  still  dilTcrent  plane 
relative  defect  due  to  sordid  and  unsanitary  conditions  and  lack  of 
educational  facilities  is  found.  Children  are  ignorant  who  have  no 
o|)portunity  to  go  to  schoiil  and  learn,  ami  may  even  lack  the  ordinary* 
brightness  that  c-omes  alwmt  spontanet>usly  if  they  have  lived  under 
insanitarj'  conditions  that  impaired  their  gciieral  health  and  energies, 
especially  if  these  conditions  be  ci>mplicatcfl  by  the  presence  in  the 
child  of  some  such  debilitating  factor  as  infectc*!  ton.sils,  adenoids, 
liigh  degree  of  myupin.  otitis  media  with  deafness,  and  such  other  like 
things  which  impair  the  general  health  and  vigor  of  the  child  and 
interfere  with  the  patency  of  the  avenues  through  which  he  gains  his 
information  of  the  outer  world.  This  general  enfeeblement  of  the  chikl 
may  also  be  tlie  result  of  debilitating  habits,  such  as  masturbation 
and  the  use  of  narcotics  and  alcoholic  drinks,  tlic  latter  of  whicli 
e^'clally  are  an  extreme  expression  of  a  vicious  environment. 

Classification. ^The  genenJ  group  of  defectives  is  a  ver>'  wide  one 
and  includes  not  only  the  idiots  and  the  imbeciles  and  the  frankly 


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886 


JDtOCY.  fStllEClUTY,   fBSBlK-MrXhKDXK.^S 


IM 


ft'rbli'-niiiiderl,  hut  the  still  hif^htr  grades  of  backwanl  diUdicn.  ■ 
thi-ri  a  tt-hnlc  borderland  group  uf  neVr-Hin-wrll:*  in  whuni  thri)r(ert 
mufh  less  tirarly  (Jetiiied  than  in  ihe  lower  gradca. 

l_>avid  .Starr  Jortliin  has  t*ai<l  thiit  "A  gf>od  citizen  is  one  iriw  ai 
take  rare  of  himself  and  has  soiuetUliig  left  over  for  ihf  nxm* 
welfare."  This  siiyiiig  represents  in  a  general  wu.v  the  l>asns  on  «1* 
the  eliissificatioii  of  this  /m>up  may  be  base<l.  The  iiefe<-tiv 
class  nmy  \k  said  not  only  not  to  have  anytliing  left  uvrr 
ennimon  welfare,  but  only  in  the  highest  grades,  and  then  uwUf 
most  favorable  ciroumstamres,  can  they  care  for  themselves.  A 
basis  of  classifieation  h«s  l>een  their  ediieability  and  their  ea 
earc  for  themselves,  aecording  to  some  such  scheme  as  fuOaWT^ 
exiiniple: 

Feeble-miitdedness.— A  eondition  of  mental  defectiveness  c«p« 
of  mueh  inipruvcnieiit  by  e^lucational  niethixls.  The  afflictevi  indi* 
nal  may  iiltliiiutely  take  a  place  in  the  world  and  Ik*  :^lf-:iupfiufti 
nruU'f  favorable  eireiitn stances. 

Imbecility. — A  condition  of  mental  deficiency  which  (•an.  howm 
hv  materially  imprcived  by  training,  but  not  sufficiently  for  the  subj« 
to  take  a  i)l:u'<-  in  the  world. 

Moral  Imbecility.— A  roiidition  of  mental  defcxrtiveness  vrhtch 
slunvii  ]>rttlominnntIy  in  the  absence  of  the  hidfhesi  functions,  partic 
larly  the  moral;  cupable  of  training  to  a  considera bit-  degree,  h 
always  a  menace  to  .society. 

Idio-imbecUity.— .X  condition  midway  between  idiocy-  and  imlMTili( 

Idiocy.— A  wndition  of  profound  mental  defceti\-enes3.  The  Uiwt 
grades  are  unteaeluable,  wjiile  the  hijjher  may  be  traine<l  .slightJy  j 
self-help,  I.  r.,  to  attend  to  the  calls  of  nature. 

More  recently  an  attempt  has  iK-en  made  to  define  m'th  gtrmtt 
accuracy  the  different  grades  of  defect,  and  this  efTort  lias  taken  th 
form  of  an  attempt  to  eom-lale  tlie  paychologii'al  ilevelopment  <«f  ili 
defective  with  the  i>sychulojfiea]  (ievelopmcnt  of  the  average  rliiW. 
so  tluit  the  riefwtivc  a,s  a  result  of  this  correlation  ts  sat<(  to  a>rrps|)iit»J 
to  the  development  of  the  average  child  at  such  and  such  an  age.  Iq 
other  Words,  age  has  come  to  have  a  psychological  rather  than  « 
ehronologieal  significance,  and  an  indi\'idual  wht>  may  be  ffirty  year* 
oI<f.  but  who  is  on]\'  developed  mentally  to  the  extent  that  an  avrnif - 
chilli  is  develoix'd  at  the  age  of  seven,  is  spoken  of  as  having  ibi* 
psych* (logical  age  of  seven  years. 

Vntil  the  use  of  this  scheme  of  classification  all  people  were  dassified 
among  other  ways,  in  accordance  with  their  chronuU»gical  age.  Kur 
example,  in  this  eo«ntr>'  a  person  attains  his  ninjority  and  can  east 
his  vote  at  the  age  of  twenty-one.  This  refers  uf  course  entirely  to  the 
chronological  age.  It  can  easily  be  seen  that  if  there  are  a  material 
percentage  of  persons  in  the  community  who  are  defectives,  altbouj;h 
tliey  may  have  acquiretl  the  chronological  age  of  twenty-one  tlwy  lu\c 
not  the  mental  development  and  the  judgment  tliat  it  is 


UiLjiii^t'M  i;y 


is  expretni 

Google 


7wo(?r 


8S7 


giK's  with  Mirli  an  aj!:«*,  nrn)  tlHTcfnn'frnni  t)iPpsychrilo}(if!il  stinii|-i>i»i»t 
arc  iiot  tweiity-tiiii'  aii<)  cniglit  not  on  tluit  basis  hi'  iM'niiittf^l  t<»  vnte. 
Tbe  psycliologit'iil  classifiration  of  the  uge  as  outlined  b.^■  the  Biiiet- 
Simoii  test  is  a  far  more  jircuratf  way  to  staiulanlizo  the  nieiital 
development  of  the  indivkliial  than  the  chronological  age  luclbiMl. 
anil  although  there  are  objections  which  may  Ik*  nrge<l  against  it  aixl 
ultlioiigh  it  is  ctmcedeflly  not  a  perfeet  methiHl  and  is  at  present 
undergoing  gnulual  mcMlificntiona,  still  it  is  sii  much  better  than  the 
chrouologii-al  metln«l  that  it  should  Ix*  usctl  in  its  place,  aurl  is  by 
far  the  Iwst  standard  wiiich  we  have  f6r  deriignaliag  the  development 
of  the  defective.  The  classifi<*ati<tn,  according  to  this  method  which 
has  recently  been  adnpte<l  by  the  American  AssfM-iaiiiHi  for  the  Study 
of  the  Feeble-niiiideil,  is  as  follows; 


Mpuial  mftp 

Ckpabilitun 

Cluri. 

Uudur  iitw  yvar 

yii-iiiWit* 

Low 

I  year 

I'mhIh  xelf.     K.tta  ovpo'thiiis 

Midaie 

Idiot. 

2  yean 

l-^Ls  discniuiimUutfly 

IltKh 

H  yfoin      .     . 

Nn  work.     Plays  litUe 

I^JW 

4  ymn 

Tries  Vf  liirlp 

5  yean 

Ouly  the  ^iimple*!  Uwlu 

Middli7 

Irtilivctltf. 

6yMra 

Tunk8<'(  ahi-'tl  duration.     WwheadwhcA 

7  yean 

IJtili-  FfTDhdH  iri  house-     I>ust« 

lluK     , 

Syean      .     . 

Emintt-.     l.i|(K(  work.     Malwa  bailii 

l>ow 

Oyvun 

Hc-Avinr  wofk.     Scrulxi,  tnondn.  lays  hrirkx. 

mres  for  mom  willi  >iimj>lo  fiimitiirc 

10  ynan 

.     Qo<kI  innliluliiiii  lidiM>Tn.     R/iutiiie  work 

Muidlv 

Mama. 

1 1  yean      .     . 

Fairly  '-ompltrAtfrd  wf>rk  with  f>n!y  fic<Ta(df>nal 

uvrrsiitht 

12  yean      .     . 

Vaea    tnachintry.     Carw    Un    nriimnlK. 
suiwr^'uion.     Ciuinol  plan 

No 

Hiitii    . 

The  classification,  according  to  the  psychological  age,  while  it  is 
praclicaily  useful  for  defining  the  stage  of  development  winch  the 
individual  has  reachefl,  is  also  of  some  value  in  dilTerentiating  hered- 
itary and  acquire<l  eunditions.  Somewhere  from  (w  to  JiU  j>er  cent, 
of  defectives  luive  feebleMninded  parents,  and  therefore  in  most  of 
them  the  condition  is  herwlitary.  In  these  hereditary  cases  it  would 
seem  as  if  thi-  iliild  develnjied  quite  iionnally  up  to  a  certain  point  ami 
then  stoppe<l  rather  suildenly.  and  that  this  .^tnpjnng  was  a  |>retty 
general  one,  so  that  tbe  development  ceases  at  a  certain  level  without 
many  irrcgidarities.  A  patient,  for  example,  will  test  to  seven  years 
of  age,  will  do  practically  all  of  the  tests  for  seven  years,  and  fail 
completely  with  all  of  the  tests  above  that.  In  other  words,  the  age 
is  very  accurately  seven.  The  ilefect  is  a  clean-cut  one.  When  this 
oonditJon  of  affairs  is  found  there  are  reasons  to  suppose  that  the 
trouble  lies  in  the  genu  plasm. 

In  awpiired  conditions  the  stoppage  Is  not  so  abrupt  as  a  rule. 
For  example,  with  the  deterioration  that  goes  along  with  epilej)sy  in 
childhofMl,  the  tests  show  much  greater  irregularity,  u  much  more 
uneven  development,  and  this  might  be  expected  of  any  condition  in 
which  deterioration  was  g*iing  on.    In  nmnerous  deterioruting  con- 


^ 


Digit 


zedbyGoOgle 


SS& 


IDIOCY.  ntBEClUTY,  PEBBI^-SilSDBDSBSS 


ctition»  suL'h  restilts  are  foimtl  and  therefore  it  ctkti  be  mch  tkM 

dealing  not  only  with  a  stoppage  nf  dev"floj>im-iit,  hut  with  ft 
pnK-ess  wiiicli,  while  it  is  in  operation,   if>   producing  synqitau^' 
its  own. 

Tlic  most  useful  elassi Mention  of  tlie  fecblc-uiinded  is  a  dimo) 
It  would  be  quite  as  absuri]  to  enter  into  a  discussion  ul  the 
psychology  or  tlic  general  pathology  of  dffe»*tiv-es  as  it  would  brcl 
scMulIetl  Insane,  and  therefore  in  this  ehapter  tlie  iliffert^nl 
forms  will  Im*  briefly  and  separately  tirscritM'H. 

Clinical  Varieties. —Amaoiotlc  PamilT  Types  (  Tatf-Sach»  DUmm); 
This  is  a  di-sease  which  generally  affects  more  thnit  one  clulil  bi  4 
family  and  apinyirs  to  l»e  confined  in  its  in(>idcn<*e  U>  the  Jewish  tu 
It.s  etiology  is  nuknowii.  Its  pathologA'  is  in  generul  b  d^menii 
of  (vrtain  elenieuts  of  the  brain,  more  particularly  the  cortical  elema 
and  pyramidal  trai-ts,  including  particularly  the  optic  ner\TS.  It  I 
I>een  described  in  tlu'ee  stages: 

First  Stage. — The  infant  is  usually  all  riglit  ut  birth  and  the  dim 
does  not  make  itself  manifest  for  some  few  months  ther<»fteT,  ibv 
ut  about  the  fourth  month.    At  tltis  time  the  first  s\'niptoms  ohwrn 
are  some  weakness  in  the  neck  muscles  and  indt<^tion^  of  dinmrs.< 
vision.     If  the  fundus  is  examine*!  dnrinji  the  fourth  or  fiftli  mini 
there  will  l>e  found  a  whitish-gray  syunnetrical  i>atch.  o\h1  in  «b«{ 
with  a  hon?j;intal  axis  occupying  the  mai-ula  lutea.     In  the  ct'nttr 
this  iwtch  Is  heeu  the  fovea  centralis  which  upfiears  as  a  dark  rhcn 
red  spot.    Oi>tic  atrophy  follows,  and  later  tiital  aiuaurosi-i.     S«wi 
stage:    la  tliis  stage  the  weakness  of  the  neck  muscies  is  niorr  mart< 
and  tbe  head  falls  backward  if  unsupi>orted,  and  while  lying  on  tJi 
back  the  infant  is  unable  to  turn  over  to  either  side,    'i'he  baial  grsu 
is  noted  to  be  feeble,  objects  are  dropped  and  the  infant  is  gi-nrr*!! 
apathetic,    llie  vision  is  materially  reiluced  in  thus  Ktage,  inn  xh 
seiLtes  of  ta.ste  and  hearing  are  preserve*!,  the  sense  of  hearin>r  ap|«»nni 
to  be  unusually  acute.     Thirti  stage:  In  this  stage  the  aif^-ti^I  iniixlr 
are  atnijiliicrl.  imd  later  tlie  atrophy  extends  to  all  of  the  muscles 
the  Itody,  emaciation  becomes  marke<l,  the  refiexe^  exaggrrated.  and 
late  in  the  course  of  the  dist'asc  the  extremities  become  ri|fi<|.  aiKJ  thcr« 
is  retraction  of  tlie  head. 

Spasmodic  contractions  and  convulsions  have  been  noted.  There 
is  at  no  time  any  rise  in  temixratiuv.  and  the  thoracic  and  ■bdnmimi 
Wscera  remain  normal.    Death  usually  oceiu^  in  less  than  two  yraxt. 

Sclerotic  Types. — ('ertaia  types  of  mental  defect  are  seen  aasoeiatrd 
with  a  condition  of  the  brain  which  in  general  may  be  said  lo  be  due 
to  an  overproduction  nf  neurogliar  tissue  and  corre;-]ioiidiiig  Ktp->t)hy 
and  disorientation  of  nerve  elements.  The  exact  nature  of  this  protrss 
is  nffct  definitely  known.  It  is  nut  improlwWe  that  there  are  a  numbcf 
of  different  conditions  comprised  in  tliis  general  picture. 

The  sclerosis  may  be  diffuswl  pretty  generally  or  it  may  be  hn nliM-d 
in  patches  and  the  affected  portions  may  he  atrophic  or  tln\v  ma\  ti< 


CLINIC  At.   VARIRTtRfi 


SSO 


liypcrtropliii'.  When  the  process  is  hypertropliic  mid  involves  a  liirgt' 
lM>rtioii  of  tlic  brain  out  fin<ls  what  has  heeii  c'iille<!  a  hyju'rlrt*!))!!***! 
brain.  The  bruin  i»  luueh  hir^ci'r  and  heavier  than  ihe  nonnal,  and 
is  much  firmer  in  consistenee  after  being  hardened.  It  <loes  not  look 
like  a  normal  brain,  but  the  surface  Ims  a  eauliflower  ap|«?arance. 
The  condition  Is  ii>nally  associated  with  (jrave  di'grpt*  of  mental  ilefeit 
and  with  epih-psy.  The  loealiziil  varieties  are  more  apt  to  Ih-  as,-(o- 
eintwl  with  eonvnisions  than  the  diffuse,  whih'  there  may  also  be  nntcl 
marked  tremors. 

This  di.iease  has  been  recently  correlated  with  oilier  changes  than  the 
local  LTrehral  changes.    Kufs'  in  a  valuable  extensive  article,  imhuling 


I'lO 


.  A(A. — Adenoniii  »<>1iikcuiii.     Tti^tikiri  iilli-' ' <  ■'■■•1  niih  tnl>pnniB»rt««i» 

dli.  a  profoiinri  dcert-c  nl  menial  il(>fi>''i  itml   v;inoufl  Uiincrs  uf  th«  vUccn, 
ihp  ktilix>>'*.     irunrt«w.v  oi  Dr.  Mnrtiit  W,  narr.) 

autopsy  material,  has  aeemnulated  the  evidence  for  a  distinct  disease 
entity  which  crim]mst>s  various  nun lifi^tat inns.  In  the  first  place, 
besides  these  changes  in  the  brain,  which  have  briefly  l»een  referred 
to,  there  liu  distinct  cutaneous  affection  of  the  form  of  iwlenoma 
sebaceum,  which  affects  more  particularly  the  face  and  the  back. 
Ah>ng  with  this  condition  is  frequently  found  associate*!  mixed  tumors 
of  the  kidney — tumors  imule  up  of  various  elements  of  which  the 
smooth  unstripefl  nuwcle  tissue  ia  tlie  most  prominent. 

'  BmtrA)t(>  aur  l>inip>n(M'tilc  unil  )ii>(lM>1n)(U('ltcii  AunKtmio  drr  iiilMVvkitrn  IlinukkroM 
'  uud  dor  mit  ihr  Konil«Qii?rtcii  SltercnitiinrliUiiitoren  uml  Huub>IT«ktKiiH*o  iidiI  Obcr 
I  (ton  Befund  eiticr  nlcuwwrisi'liiMi  N<'>>riuiiori:  in  ciiivu  OvBrium  bci  dcreolbon.  Kurhr. 
\t.  dw  gtmtnte  Nouroloititi  nurl  Piypliiulnv,  Bund  s%-iii,  Hid'l  3. 


DigitizeO  ij'^i 


noogle 


S{)0 


IDIOCY,  niHECIUTY.  FEKBLE-JktfSDBD.SBSS 


TIk'sl'  tiirve  syniiJiouis,  tlifii.   aik*iH>inu    sohiMtMiin.  mi 


)f  the  kiili 


tuberous  sclert 


if  the  hrai 


ttK-  ti 


rosis 
constitute  the  most  important  ei 
adcjition  tA>  this  patholojij'  it  is  to  be  riote<]  first,  about  the  jcfan 
thut  it  involves  sometimes  the  cerebellum,  that  tuumr?*  of  ilu-  vt-otrii 
un*  quite  characteristic,  ami  that  relati\'*'l\'  coiumoiily  ihrrr  it  M 
ciatetl  with  this  triad  of  symptuius  rhabtloniyorau  of  the  )K*art.  Mw 
of  other  organs,  such  as  the  stomoeh  atid  the  uterus  have  abnh 
observed. 

While  on  the  mental  side,  along  with  this  c*onrlitii>n  therr  koi 
is  a.sswiated  u  marked  depec  of  mental   ilefert  with  e\ 
Kirjiifziks  has  rejiorted  a  case  occurring  in  a  xuau  twvnty-*  -e.:.; . 
ulii  without  mental  impairment. 

Cretinism. — This  di.sease  Is  endemic  in   certain    ptirts  of 
but  so  far  as  we  cunie  in  contact  with  it  in  this  <"ouiiiry  is 

The  rlisease  is  due  to  ti  defect  in  the  secrelion  of  the  thyroid 
All  degrees  of  defect  ina\  Im-  present,  from  Bthyroidism  throogli 
various  degrees  of  hypoth>Toidisni.    The  several  decrees  ol 
which  are  described  and  wliich  c<irrcsi>im<l  with  difTerent 
<lefect  are  three,  namely,  tlie  lowest  grade,  in   whit-h  tJu 
greatest,  the  cretins,  the  middle  grades,  the   aemirrrtins,  awl 
highest  grades,  the  (Tetinoids. 

The  disease  usually  begins  quite  early  in  the  life  of  tlic  lAiiUl.  *oi 
times  during  the  first  year,  altlunigh  it  may  be  delayed  for  several  \r» 
The  general  symptoms  are  those,  Jirjif,  of  retjirdeti  lievehipmeDt:  t 
child  apiK'ars  le.ss  bright  than  he  should  be,  walking  is  leanicd  stt«»i 
s(KiTb  is  dela.Mtl  in  development,  the  anterior  foutancUe  c>  Ulr 
closing;  and  wrwH//.  the  characteristic  (Tetinous  appeiurtuire.  T 
body  is  dwarfed,  the  heail  relatively  large,  and  th«'  Icgn  short  a 
bowed,  bands  and  feet  stum)>y.  and  the  ossitication  of  tJie  boaa 
dcl&yc<i.  The  appearance  of  the  face  is  typii'al.  the  nose  U  bmad  ai 
Battened,  the  lips  are  thick,  the  tongue  thick  ami  often  prutniilti 
from  the  partly  opened  mouth.  tl>e  eyes  widely  separated,  die  eydif 
often  heavy  and  swollen,  and  the  hair  M)arse  anil  M-aut  \'.  The  skrn 
caeheitic  in  appenranw  and  dry  and  thick.  reM-niblinj;  tin*  >kin  of  th 
myxedematous  jwtient,  the  neck  is  short,  the  abdomen  |in>tubcrar 
sumetimes  with  umbihcal  henua.  Tlie  ^igns  of  pul>i*rty  nrr  Uf  a 
making  their  api»eurance,  there  is  often  a  failure  in  the  ixanifk-l! 
development  of  tlw  genital  organs,  and  many  of  the^;  paiien 
sterile.  The  pulse  and  respiration  are  slow,  the  teni|>eruturv  m. 
subnormaE.  and  the  movements  of  the  patient  are  usually  ver.*  ileBt 
erate.  Mentally  tlie  cases  show  various  grades  of  defect,  frnni  tfa 
lowest  grades  of  idiuey  through  the  various  degree:*  of  iiubrcihly.  Ii 
general  cretins  are  quite  gond-natured.  pliable  iudividuaU  who  U 
easy  to  get  along  with  and  cart*  for. 

DiitgnmrU.— In  the  matter  of  dbgnosis  the  principal   canditim 
which   have  to  be  dilVerentiuted   are   rickets,   ndiondropUiua^ 
mongolism 


Digitized  ty 


GoogI 


e 


Digitized  ij-'i 


-oogle 


Rft2 


tDiocy,  nrsEnijTY.  /fEESLE-snxnEti\sss 


Uirkcts  am  usually  be  flifTprpiitmtwl  hy  the  eluirRirtcTistH? 
uf  the  ribs,  tin*  symirietrk-al  eiilarfteineut  uf  the  epipliyses,  ai 
iibst'iH't*  of  the  typical  sijjns  nf  crx'tiiiism. 

Achondroplasia  should  not  be  mh  taken  for  cretinism.  There  h 
imperfect  development  of  the  long  bones,  but  none  of  the  signs  of  ere 
ism,  particularly  none  of  the  impairntent  of  mental  developinent. 

Mongolism  is  at  times  extremely  difTieull  to  differfntiate.  I 
very  inijMjrtnnt  that  this  wjiidition  be  nut  mistaken  for  cretinism,  i 
tieularly  with  reference  to  the  matter  of  tn-atmcut,  as  in-«tnien 
capable  of  modifying  the  cretin,  but  not  the  raonffol.  The  folka 
table  of  dillVri'ntia]  sij^is  taken  inan  Shuttlcivorth  and  Pott^^ 
serve  to  point  out  the  detuled  characteristio*  between  these  1 
(xmditions: 


MoJtOOLt9M. 

1.  Cluimrtorwlifs  notideabip  fpnni 
Hnh. 

2.  i^kull  IjT&chyrvphalic :  niotour 
rounded  or  *hort  civai;  \otigiuulio»l  *nd 
tnins\-vnt)  duuuetcnt   nearlj'   currtMpimt). 

S.  Korrhwd  u«iMll/3TniK)th- 

•I.  falpi>bnUCamire9i"ulin»n()-Kbaiied,V 
And  ninro  nr  l<^«  nltliqiui  upward  nnd  out- 
ward. Fnxjui^ut  (^l}iua»thua.  SuuIhs- 
RiUx  uimimin.  Tilinry  l4i>|iharilM  fn>i|uenC. 

5.  Cbevkji  i-buliby.  often  florid.  Coai- 
plraiun   mottled. 

<5.  Lipfl  often  tniMvenely  ftMur«d. 
Luwpr  lip  TiuLy  lw>  purtwd  up  over  upper. 

7.  Tt>nitmt  Urgp  Hnd  ioar»<tly  luiiiiU 
luted  if  iiui  tWurcd.  Tonguo  frcqueiiUy 
protnidnd  uid  drawo  l^ck. 

H.  Slun  Mtntiutli  in  infuiicy,  but  furfur- 
ftf^ofiiie  Utor;  Dot  reiJundnnt  or  "bafoff." 

n.  Hair  "wir)*."  often  ■'mouse  enlor." 
bul  iM>m«Linitai  blaiide.  Uimiiy  ffruiwih 
fcmmun  on  fnreheud  and  checks. 

10.  Th)Toid  ebiid  pulpablc  to  mefttcr 
or  lens  cxtfiut. 

11.  No  fnt'y  tiiniiira  (luondoliponMta) 
in  posterior  triungle  of  tiirck. 

12.  Loti^  liDium  noincwhat  HhortCf  Ihnn 
(l.tunl.  but  slondcr. 

13.  Ilandc  bntad;  tbumb  and  little 
finger  rfiort,  ihe  latter  oft»Mi  curved  toward 
rioK  tinjcor.     Fininw  taper  nt  wiMb). 

14.  Feel  Inrico  and  flat,  tlsnire  be- 
twOvQ  ureal  uiid  neit  toe  olt«o  evtin, 

lo.  Ah)|r>m<!n  ofun  difteiidod;  oern- 
xioii&l  iiiiibilipal  hernia,  ofieii  inauinnl 
horiiiK. 

m.  £xpn>saioi]  more  or  ]«m  \-i\-ai:ioua 
nnd  lIlubil^,  obmrvaiit  nnd  imitativx. 


I 


CNKTnnra. 

1.  MiatTiftrriMirs    nften    n-n 
nblc  until  AxOi  or  Mi^-^otb  inopti 

2.  Skill]  dulirlutecpluJii- :  flat 
(font^tnf^llav   rloae   liitr).   estiAuded   b 
ally;  broad  t>ebiud.  often  nnj-tnntetr 

3.  Fon-hmd  iwii.'Jl)-  wrinkled. 

4.  PnliK-brul   fLwiimr  hurtBonial. 
npprar  ftmall,  nwiiut  l»  |x«udi^>«tlrni 
vyvlida.      Stnibwiuiu  nod   dluiry    Ui 
kriti*  Imh  eomnian. 

5.  OiXea   rircuituirribcd 
romplcxion  ashy  or  waxy. 

Q.  Lower  lip  afleu  «v(>rtod. 
open.     Dfivdliiw  eottimoti, 

7.  Tonsuo   larae.    but    not 
pnitiltntcJ  or   liHeMirml.     Tip   of 
Ihirkennl,   and    roiistantly 

8.  Kkin   dr>-  and  wuly;  farm* 
here   and    there,   boinx  Tedundii 
"bi«>'.'* 

0.  Batr  bonh.   ennrse.   itud 
UdUAUy  oE  darkivJi  tint  (Boumexi 
brown) :  sculp  ufteu  eeaenut 

10.  Thyroid  idand  impitlpabfe  : 
Lhoroueli  exatniniiticui. 

11.  Fatty  lunH>ra  (paeudofipomi 
fn»iuautly  found  in  poamW  uimi 
of  neok.  etc. 

12.  Iions  boDM  nhortenod 
cned.  in  some  cams  bowed. 

13.  Handa  brood,  ibiirk.  nuH  etuw 
wiiii  wrioUed  •Idn.    Finscrt  Miti 
tipa. 

14.  Feet  Miuat;  bUd  ntdundiutil 
aoklea  uid  doreum'of  foot. 

15.  Abdnmeo  vny  bulk>'  knd  pn 
ne»t  with  folds  of  skin;  umbUhal.' 
romninn. 

16.  EipreMon    dull    and    itni 
unobaorvnnt   attd    apathetir. 


wdfl 

etuw 

1 

1  ptt 

I 


Deficient  ctnturc,  flntlcmil  bridge  of  now,  with  expanded  titc,  late  ami  trnagi 
drntitiiin.  defem-d  clnMire  of  fnntAnallra  and  retarded  puberty  ar»  aimilnr  in  ntrh  ruti 

*  Mpntnlly  Deficient  ChildreD,  lAndon.  1010. 


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aONGOUSM  893 

|{e(«nlly  cataract  lias  been  describeil  as  frequently  developing  in 
'these  (Mses — an  iiuiication  i>f  a  i)ossible  fiuiucriiie  dysfuiiction. 

Trnituirnt.    Tliis  lius  been  taken  up  in  ("hiipter  IV  on  Diseast'S  of 
tlie  Internal  Secretions,  or  Endocrinopathics. 

MoDjwlism.—Tlit'  Monj!oliiin  or  KalmiH;  tj^pe  of  Hpfwtiveness  is 

S(walled  becsiuse  of  the  resemblance  of  tho  fNitient  to  the  Mon^>ltan 

jface,  partit-ulftrly  thn  slant  of  the  eyes  and  the  genernl  fneial  expression. 

The  pre.srnt  tx'lief  with  reference  to  this  cijndition  is  that  it  is  uon- 

[genital  and  not  hereditary  in  the  true  sense,  that  is,  not  dependent 


Via.  411. — MuiiK"!''"'  'M""'  :>t'>il  I'u^Hii.Ti  \rvLi-  i[i:uhi'iii'  idiot,  scmimuw,  speaks 
nly  »  Ivvt  w-iirdM.  eiiiui'.'Uli'i]>  iiii(u*rfL-ct.  Leariu'il  tu  fi-cJ  tanikvlf  nml  u  •'Iraiily.  Dwarf- 
ill,  brHi-hyi^ijhaltc,  furvlivad  flat  und  wrinkled  tnmsvvnicly.  l^Lym  ohliquo,  [Jiouitihtihia, 
ehlMmc  *-'-iijutictl\-iii*,     ToDpie  vcr>-  larKV,  fUliriK  month  ofimplotoly;  dwply  fiwiin^J, 

liillip  enlnrgiwj.     lliiude  brotut.     HnnprB  short  mid  thirk.     (CoiirWsy  of  Dr.  MNtiiu 

upon  II  condition  of  the  >rerm  plosm.  The  condition  is  believed  to  be 
the  result  of  some  iibnormal  stati-  of  the  mc»ther  which  may  be  produced 
>y  injurj*  or  shock,  but  wliicli  in  general  is  believed  to  be  the  result  of  a 
rorn-out  reproductive  capacity,  the  mother  bcin(r  nimble  to  brinn  the 
Jcliild  to  comjilete  development  in  the  uterus.  <  nrn'spondint:  witti 
this  assumption  the  Mongol  \^  ^nerally  the  last  child  born  in  tlie 
^family,  and  not  infrequently  c«mes  from  ;;iiod  stitck. 

There  are  thrw  prominent  physical  sif^is  of  this  condition  which 


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axv  sufficient  wlieu  presoiit  to  make  a  dia^usis.     TIir\  .tn  r 
of  iIk'  skull  and  the  peculiarities  of  the  piilfx'bnil  Hssurr-  a:iii 
tongue,    llie  skull  is  brachjcephalie,  diminished  in  its  nmfr-i"' 
diameter,  tlattcned  on  the  face  and  oc-cipiit,  but  ^v-ithout  n-- 
the  frontal  and  supraoecipitai  refcions,  as  in  the  miorocrpli 
tongue  is  large,  the  circumvallate  papillm    ure   h>•lJ<•^'f 
there  are  marked  irregular  transverse  H.-isures.     This  *->'■ 
tongue  is  eharaeteristie  of  this  tJTJe,  and   is   not   fmind  in  anv  .-ur 
variety.    Tlumipson  has  suggested  thnt  the  fiiv^iuratiou  h  lit^r^plr* 
upnn  two  factors:  an  extxeine  vuhierability  of  tlie  muc«>us  meml 
and  the  liahit  uf  sin-king  the  tongiie,   r-iitnnionly   pre?ient  in  '.'' 
children.    The  hands  and  feet  an:  broad,  <  luins>'  and  si>atulatc.  w 
an  incurving  of  the  little  finger  has  also  been  ilewriljed  aa  of  fi 
oecurrentv  in  these  children.    In  addition  to  thcs«r  quite  cl; 
symptoms  the  children  are  clumsy,  joints  ltH>*ie,  the  skin 
abdomen  protuberant  and  there  i^a  tendenej-  to  clironir  infl 
conditions  of  the  niueons  surface-s.    The  eir<rulation  is  genera 
congenital  eardiae  anomalies  may  be  present,  sutdi  u»  inijKTfect  dortl 
of  (lie  foramen  ovale,  vitjil  resistance  is  \-er>-  Icm-,  and  these  paica 
orf!  quite  a])t  to  die  relativx'ly  early  in  life  fn»ni  tuberculanis. 

Mentjilly  these  children  are  usually  at  a  very  low-  ^a*Jr  of  dcNrkf 
ment,  generally  gra\itat.ing  about  four  years  of  aRC.  They  iiuiy  H 
k'ss  or  they  may  possibly  reach  the  seven-year  limit,  but  r«rrb 
beyond  it.  As  u  rule  they  are  good-natured  uinl  ea.sy  Ui  e*r»  for  bj 
tho.se  who  are  understanding  and  symimthetir, 

A  s|M'cial  form  of  cortical  aplasia  has  been  tlcscribed  n»  brionpil 
to  this  Cdiidition. 

Th.\Toid  does  no  gooil  in  these  ronditioni^.  It  is  therefore  iiecir««ff 
to  carefully  separate  them  dtagnosticadly  from  (.Tetinisni.  n  j^iotiiUtKa 
which  resembles  it  very  closi-ly  on  casual  olwervation.  For  difTm-ntiil 
diagnosis  st-e  Cretinism. 

Hydrocephalic  Types. — Various  degtves  of  mental  ilcfetjt  iiuiy  fcr 
associated  with  hydri>cepluJu3.  Hydntoeplmlus  may  of  counc  ocruf 
previous  to  birth,  but  is  rarclj'  congenital,  as  a  child  with  any  marinJ 
degrpc  of  hydrocephalus  could  not  be  born  aliw.  The  condiQun 
may  be  rt^lattvely  acute,  in  which  case  it  leads  rapiilly  to  deuth. 
may  come  to  an  arrest  or  be  extremely  slow  in  progress.  In  thlt 
group  of  cases  we  find  patients  sometimes  who  live  to  a  fniriy  adva 
age,  although  as  a  rule  this  disease  temiiiiates  life  before-  the  patirnl 
1ms  passed  iiiiildle  life  aiwl  generally  mueh  younger.  'I*hp  s\Tnpt< 
ill  the  slowly  progressive  eases  are  the  symptoms  of  gnvlual  nUi 
of  the  mental  faculties,  and  are  undou)ite<lly  deiH-ndeni  u{M)n 
effects.  These  symirtoras  are  in  general  loss  of  intelligeniv.  i^rudnJ 
Io»s  of  vision,  hearing,  the  function  of  language,  and  grjdiiall^-  tlir 
sinking  into  a  st^raistu]H>rous  eomlition,  and  deaith.  The  raiuca  ol 
hydrocephalus  are  probably  mmieroiis.  s^-phills,  tubcreukusU,  bcmiu 
tumor,  and  meningitis  are  among  them. 


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Isize  of  hea<l  should  be  considered  microcephalic.  Irclaml  pves  the 
general  rule  that  heads  l>elow  seventeen  inches  in  circumference 
(4lil  rniilinieters)  may  be  so  considered.    This  rule  is  not  absohite, 

^and  when  it  is  considered  that  these  STnall-headeil  varieties  may  prob- 
ably lie  the  result  of  various  etiolnj;ical  factors  it  will  be  appreeiatetl 
that  the  terui  microcephalic  had  U-tter  Ix-  nseiJ  purely  as  a  iU'.->criptive 
tenn  rather  than  as  a  term  to  apply  to  a  <lefinite  class  of  ilefcctives 
even  thuugh  that  tUiSs  Iw  considered  solely  foiin  a  morphological 
stand-point. 

It  is  prohahle  that  two  sets  of  causes  may  produce  the  extremely 
small  skulls  which  ao'  fuinid  in  tlie  micriK-epfiaiic  twites.  The  old 
thenry  that  the  condition  was  ilue  to  premature  syniwdisis  has  Ions 
since  Ih-cii  discjinicd,  as  has  alsi>  the  operation  of  craniectomy  base*! 
upon  that  theor>\ 


Flo.  41  s — I'Ltrulyiif  type.     Athetold  iaov«mMiUi  of  haiKJUand  arms. 

The  characteristic  condition  of  the  microcephalic  brain  is  its  extreme 
smallness,  more  particularly  pnuifmnciHl  in  tlic  leni[K)ntsphciioidal, 
[wrietal  and  o<'cipitaI  re^jioris.  The  [x»stcrial  lobes  of  the  cerebrum 
do  not  cover  llie  ccrclM-Uuni.  The  cotivcilutions  of  the  cerebrum  arc 
more  simple  in  pattern  than  in  the  normal  brain,  and  in  atldition  tl]ere 
may  be  localize4l  ageneses  nith  resulting  microfji.'ria.  There  may  also 
be  associattii  inorbiil  pmcesses  such  as  entx-phalitis.  The  hypipplu^ia 
usually  also  involves  the  spinal  ctird. 

Tlie  (ceriend  appearance  of  these  patients  is  quite  duiraeteristic. 
The  conformation  of  the  skull  is  "sugar  loaf,"  or  as  it  is  technii-ally 
teraied  "oxycephalic."  This  is  cbapacttrizcd  by  a  rapidly  receding 
forehead  with  a  flat  occi|Hit.  Along  with  the  reeinling  forehead  then;  is 
iLs\mlly  also  a  receding  chin  which  gives  a  [minted  aspect  to  the  face, 
which,  associated  with  a  small  stature  gives  a  quite  charactiTistic 
general  appearance  ti*  these  |Nitients  and  has  led  to  their  luring 
characterized    as    "binl-like"    in    ap[M'iiraiiee. 

The  mentid  development  of  these  patients  varies  between  wide 
limits,  although  the  tendency  is  fur  thcni  to  belong  to  the  lower  gnidcs 
ST 


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of  defect.  They  are  usually  well  disposed,  good-natured,  afTectioi 
and  not  difficult  to  care  for.  They  generally  do  not  live  to  adwM 
yeiirs,  but  riie  at  rather  an  early  age.  f 

Paralytic  Types.—  Tlieif  are  a  large  variety  of  i-ases  iii  this  gr 
Tlic  iMinilj'scs  may  involve  any  portion  of  the  body  or  be  of  ah 
any  extent.  Monoplegias  and  diplegias  arc  common,  but  local 
palsies  and  hemiplegias  arc  also  not  itifrequent.  They  depend  ei 
upon  lack  tif  development  of  certain  jmrtions  of  the  brain  or  i 

frecjuently  upcm  injuries  and  son)eC 
new  growtlis.  Hemorrhage  is  the  i 
frequent  injurj-  that  prtMiuces  the  vai 
palsies.  'J'ltis  may  oceiir  as  the  n 
of  prolonged  labor  or  injury  by  for 
delivery,  or  may  be  the  result  of  in 
during  the  early  months  of  life. 
amount  and  the  character  of  the  mt 
defect  varies  within  wide  limits  aac 
description  which  woultl  apply  to 
whole  class  would  l)e  possible,  princij 
because  the  class  is  not  a  homot 


one. 


3U| 


Porenct'phahs.  — 'Vi'i  th  in  t  h  is  gron] 
paralytic  tjTws  one  of  the  contlicions  w 
is  found  and  which  has  been  frequn 
descril>ed  is  porenceplialus.  This  cc 
tion  is  consequent  upon  gross  cew 
lesions  such  as  a  lack  of  (vrcbral  subst 
resulting  in  a  cyst  connected  with 
ventricIc^ — true  pvreiicepkalus,  or  dtn 
cysts  not  connecting  with  the  vcntr 
and  resulting  from  softening,  hnuorrli 
or  intlanmiation — fnlsr  jHtrencrphulus. 
Traumatic  Types.  —  Arrest  of  mc 
development  may  occur  as  the  resu] 
an  injiu-y  to  the  brain  during  the  devi 
mental  period.  The  most  frequent  i 
of  injury  priKlucing  this  result  is 
longed  labor  nith  instnmiental  deltv 
Where  the  injury  produces  a  lesion  tn 
motor  pathway  with  a  resulting  paralysis  the  patient  is  geiM 
included   vrithin  the  paraKi-ic  group.  f 

Epileptic  Types. — Kpilcpsy  occurring  early  in  life  is  one  of  the  cs 
of  lack  of  mental  development.  Just  how  this  result  is  brought  al 
by  the  epilepsy  is  not  altogether  clear.  In  part  it  is  due  to  the 
tlwt  the  child  has  to  l>e  ditVerently  treated  from  normal  child 
IS  often  deprived  of  the  same  educational  advantages  l>ecause  o| 
disease,  but  apart  from  this  there  seems  to  be  a  direct  relation 


Pia.  410. — H^miplefiir,  nitftd 
ole^-pii  y«irv.  (CourtMyuf  Dr. 
A.  r.  RoBCM.  FarihnuU.  Min- 
neooU.) 


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the  lock  of  development  an<I  mental  deterioration,  ami  the  epilepsy 
itself.  This  is  probably  dependent  upon  the  fact  that  the  epilepsy 
is  a  disease  which  strikes  very  deep,  close  to  the  foundation  of  the 
neurological  mechanisms.  Its  manifestations  are  evidently  In  part, 
at  least,  depemiciit  ii]M>ii  disttirliances  ut  the  pIiysicoeheniicHi  level. 
Disturbances  which  are  as  fundamental  as  this  necessarily  are  diffi- 
cult to  deal  w-ith  and  also  ncix-ssarily  impair  the  superposed  levels. 
(See  Chapter  on  Epilepsy.) 

Kpileptic  attacks  arc  found  in  many  of  the  other  forms  of  defect, 
more  particularly  in  those  defects  associated  with  gross  <-erebral 
lesions  such  as  are  found  in  the  paralj-tic  and  traumatic  t^TJCs.  It  has 
generally  lieea  assumed  tJiat  the  localized  lesion  was  the  cause  of  the 
epileptic  manifestations.  While  this  inav  be  so  in  wrtain  cases,  still 
in  a  general  way  it  must  be  borne  in  miml  thflt  epilepsy  is  presumably 
an  hcrcfiitary  disease  dcp^-ndent  uixni  a  defect  in  the  genu  plasm  and 
that  perhaps  only  those  children  develop  <'onvulsions  as  a  result  of 
injury  ejr  localized  cerehnil  lesions  hi  whom  hereditary  ctmditions  are 
favorable  for  the  outcn>p  of  epilepsy.  At  least  the  henn^litary  factor 
should  not  Im?  neglected  in  the  study  of  the  patient  simply  because  a 
locati/.ed  lesion  has  Ix'en  found.  lVrhai>s  the  hK-jdi'/e)!  lesion  could 
not  havf  produced  such  a  result  wiUiout  the  hereditary  factor — the 
spasmophilic  tendency. 

The  epileptic  tyjK^  of  <lefective,  besides  the  symptoms  of  his  defect, 
characteri.stically  manifest.^t  the  sj-mptoms  of  the  epileptic  character 
mid  is  tlicn-furc  quite  a  difficult  ]>roblem  with  which  to  deal. 

Inflammatory  Types. — This  gniup  inclndes  tli<ise  conilitions  resiillitig 
from  inflammation  of  the  meninges  and  of  the  brain,  found  most 
fret^iicnlly  as  a  residt  of  acute  infections  fevers  such  as  pneumonia, 
typhoid,  and  the  exanthenuita.  Local  areas  of  meningitis  or  meningt*- 
eiKvpIuditis  arc  not  infrequent  in  connection  with  the  specific  fevers, 
and  when  extensive  or  severe  and  wcurring  early  in  life  phmIucc  an 
arrest  of  development,  to  a  certain  degree,  of  the  mental  faculties 
together  not  infrequently  T^-ith  epilepsy.  Struinpell's  polioenceplialitis 
sU)>erior  l>elorigs  in  this  gn)Up. 

Sensorial  Types. ^The  defect  in  this  group  is  the  result  of  deprivation. 
Here  there  is  no  defect  of  the  germ  plasm  or  no  defect  in  the  structure 
of  the  brain,  but  owing  to  Injury  or  disease  which  has  destroyed 
the  patient's  vision  or  hearing  or  both  the  ch'ld  is  cut  off  from  com- 
munication with  the  outside  world  to  such  an  extent  that  mental 
deveIo]Hnent  is  iin|>aireil  then-liy.  Theoretically  these  patients  are 
of  <-ourse  eriucabic,  but  it  is  only  very  rarely  that  one  is  fcnmd  with  the 
capacity,  the  |>atiencc,  and  the  ingenuity  to  develop  such  u  child  by 
educaticiiml  methotls.  The  cases  of  Helen  Keller  and  I>nura  Hridgman 
stand  out  as  illustrative  of  what  can  be  dime. 

Milder  grades  of  defect  due  to  deprivation  of  the  ordinarj'  nlucu- 
tioiuU  advantages  occur  on  the  same  principle. 


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Syphilitic  Types.  S>-]>hilitic  types  t»f  tlcfcct  luivr  jilwin  ^w' 
kniiWM  ill  tliat  group  of  ai.ses  prc-scnting  distitu-t  i-vidi-iicwof  hcwfior 
s>'pliiIiH,  particularly  the  lluu-liiiisdii  teeth,  linear  xan  aboffitti 
mouth  niul  iiust-,  ami  keratitis.  I'ntil,  however,  the  disco^trj*  d  fc 
Treftonema  iKtlluhim  and  the  eIalx)ration  of  tlie  Wasscrmnnn  ntot  I 
tbt-rt.'  was  no  cum  prehension  of  the  frequency  witli  whk4i  fl'jki 
entereil  into  tlie  etiolopy  of  the  vari(m.s  types  of  inentui  (ipfwt  (te 
of  the  bcst-knowTi  authors,  who  just  anteilateif  this  perio*].  aj^lW 
the  niimher  of  cases  nf  defectivrs  due  to  syphili-s  is  quite  insqfnifiaa 


Fio.  iL.       - 
by  dspii 

■nml   leu   \'-.>f.    (!•' .iMrj<iii-,    F«<  ml 
(Courtco-  of  Dr,  Munin  W.  Bwt.| 


l'"]!;.  IJll,  — Si-nviritil  Ij'p*'.  inilTril*'  by 
iLepnvutii»i.  uiiiidlv  nimJo.  Mtik-.  niMnJ 
nbmiC  thirty  yum.  drnf-miKi-.  Titiiahl 
tiiinsclf  to  talk  and  Ui  rmd  axui  wHtr  in 
n  fitshiQii.  Often  rnicl  to  rhIEdrfD  bul 
di^vot^  to  aDimnls.  AnoroprintM  thincs 
mil  liifl  own.  Vbtj*  kwn  sitd  olHomntw 
(CourW«>-  nf  Dr.  Martia  W.  Barr.) 


prohahiy  not  more  than  1  or  2  per  cent.,  and  cotitmeiits  upon  this 
in  the  face  of  the  frequency  of  sj-philltie  diseu.se  in  the  full>*  dc^'dofied 
bniin  and  the  fre(|ueney  of  siwjdled  inherited  sj'philis. 

There  is  (niu  distinct  type  of  disease  which  only  recently  hjis  iimir 
to  Im!  rccognize<i  with  any  degree  of  aeeurucy  which  used  to  be  £-UM«it 
nmon;c  the  defective  states  and  whicii  is  due  to  a>'pbiliii,  namely, 
juvenile  general  pnrt:iis.  It  is  prolwble  tlwt  still  in  nian>'  pbicn  this 
di^a.se  is  not  reeopnizcil.  hut  is  put  down  probably  as  sontr  fitmi  nf 
pntgressive  defwt.  'Ilie  number  of  juvenile  [paretics  is  not  very 
large. 


IDIOT-SAVASTS 


9ni 


The  applinition  of  the  Wassermann  teat  t<j  the  defectives  as  a  elass 
shows  tlmt  Hut  far  fn»ni  20  jht  triit.  of  the  patients  taken  iiulisfrim- 
iiiately  show  a  positive  Wussenuann  peaelion.  Of  course  it  15  titiite 
another  question  as  to  just  what  the  relationship  is  in  the^se  patients 
lietween  the  syphilis  and  the  mental  defect.  In  one  ea-se  it  may  Iw 
that  the  syphilis  has  priKliieed  vascular  fllsease  and  the  defect  is  due  to 
a  vascular  lesiim.  In  another  case  it  is  the  t\*|>ieal  effect  of  a  genend 
|Miresis.  or  perhaps  a  ineningoenivphalitis,  and  still  further  proUdily 
sjijhilis  has  a  deeidi-dly  deleterious  effect  upon  develojiment  in  ways 
that  we  do  not  at  present  understand,  so  that  it  may  well  lie  that 
tx;rtain  of  the  types  of  defect  which  do  not  present  characteristic 
s.\'])hilitic  lesions  may  be  due  to  subtle  nutritional  ehanjtes.  which,  in 
the  last  niuilysis,  have  their  origin  in  H>7)hilis.  The  (.^^at  part  that  this 
disease  plays  in  this  class  of  cases  is  yearly  becoming  more  ami  more 
evident. 

Inllammatory  eonrlitioiis  of  all  sorts  and  their  results  are  dependent 
iiIM)ii  tliis  cause— meningitis,  hemiplegia,  porenceplialus.  hydro- 
cephalus, which  may  be  associated  with  epileptic  convulsions. 

Idiot-savants. — These  are  rare  cascs^  who,  although  often  deeply 
defective,  still  have  some  special  ability  wonderfully  developwl.  It 
may  be  music,  calculation,  or  memory  for  some  special  class  of  facts,  etc. 

The  calculators  can  name  the  answer  to  niatheinatica!  problems 
almu:>t  instantly;  the  musical  prodigies  often  play  well  and  ntay  even 
improvise;  one  patient  under  the  observation  of  one  of  the  authors 
wo\dd  instantly  name  tlie  day  of  the  week  for  any  date  for  years 
back.  Many  of  these  patients  have  a  capacity  for  mimicrj*  and 
bnlhKtnery,  and  from  this  class  undoubtedly  were  recruited  in  the 
ohi  days  many  of  the  court  fools. 

The  psychology  of  these  individuals  is  not  understofKl  and  they 
themselves  are  quite  iniable  to  give  any  explanation  of  iheir  sin-cial 
abilities.  Their  abilities,  however,  are  really  not  so  great  as  they 
apix'ar.  T]»e\  appear  e.\aggeralod  because  they  stand  out  uimn  a 
background  of  prtniounceil  defect,  also  bt-cause  they  are  unusual 
in  the  sen.se  of  not  being  the  common  ixtssession  of  mankind.    The 

Iculators,  for  example,  do  very  wonderful  ralcul.it ions  in  the  way  of 
Iddiiig  up  IfHig  series  of  Hgiin-s  very  nipidty.  Tiiere  are,  however, 
well-known  devices  fur  increasing  the  rapidity  of  the  ordinary  olrl- 
fashioiu.-d  method  of  adding,  and  matiy  of  our  experts  at  figures  today 
could  compete  ^\^th  some  degree  of  success  with  these  calculators. 
The  patient,  for  example,  who  could  name  tlie  day  of  the  wtx-k  for 
years  hack  upon  merely  being  given  the  date,  anil  do  it  instantly. 
spent  most  of  hi.t  time  in  studying  calendars.  It  would  not  lie  surpris- 
ing if  almost  anyone  could  acctimplish  such  a  feat  if  he  sjient  any 
such  ixanmen-sunite  degnre  of  effort  U|wn  it. 

Other  <lescri]Uive  terms  are  useii  to  desf-rilM'  certain  t\'\M'>  of  defci"- 
tives,  htr  inslauee  in  addition  U)  the  so-iiilh-d  Mongol  or  Kalnnic  tyijcs 
there  are  deticribe^l  American  Indian  and  Negn>id  types  because  of  the 


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JDTOCY,  IMBECUJTY,  FBRDLE-MISDEDKKSS 


obvious  resemblances.   Then  again,  for  purposes  of  practical 
tion  the  lowt-r  grades  of  defectives  are  spoken  of  h.-;  either 
or  cxf'itablr.  and  certain  of  these  latter  who  k<%p  up  cnmiD 
and  characteristic  inovemeiits  ahnost  i'<>ntinuously  are  d 
rhythmic  uliotit.    Other  motor  disturbances  of  course  also  otrur. 
from  paralysis  and  epilepsy,  probably  one  of  the  mast 
atlictuHis. 

Mild  Grades  of  Defect.— A  systematic  examination  of  larpe  nunii 
of  children  has  disclosed  the  fad  that  a  jjrfat  numU'r  of  ihe  dwiHl 
of  conduct  and  t>-ix'»  of  inefficiency  which  are  maiiifestcti  amoDe  tb 
are  iipjiendent  upon  some  dcRrec  of  freble-tniniJt-<Jnesy,  Sv-^itaw 
c-XantiTiatioiis  nf  school  ehildrcii,  for  example,  have  n'sultcd  in  sbowi 
a  not  ineonsiiierable  percentage  of  tlw?  genem]  school  population  » 


Kl(i.  l-J.  —  Amriirnti  liiiliiin 
tJTo.  (C-ouru-ay  of  Dr.  Marlin 
W.  BnrrO 

behind  in  their  mental  development  as  only  to  be  descril>eH  by  a  teni 
indicatinpan  inherent  defect.    These  defects  range  all  the  way  fn 
well -mar  kc<l  imbecility  among  tlie  younger  children  up  thn>ugh  thd 
grades  of  the  so-called  backward  childre-n;  for  the  most  |iart.  tM 
ditferent  grades  nf  the  moron,  of  the  feeble-mimled.     Tlie  ine4kdunnd 
hkI    which    hiiS    ijeen    u.s(*d    for    determining    these    eondilioru    hfll 
been  the  H  i  net-Si  mm  t  si'ide  of  intelligence  tests,  on«l  tlie  treatnten 
which  lia-s  lieen  applied  has  l>«'ii  the  segregation  of  tliese  dcfectivi 
ehiKlreri  from  the  general  school  population  into  classes  and  somrtima 
whole  sch<«)ls  devoUil  particularly  to  thcni.  (heri'by  gaining  bi»ih  tK 
adviiiitagi*  of  the  aitplication  of  special  eilucational  efforts  lo  thr-< 
chiUren  and  the  relief  of  the  normal  child  from  llie  drag  Iwck  to  wbie 
ho  was  sul»jccte<l  hy  luning  the  defective  in  tlu;  same  class  with  hint 


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Many  of  the  mental  defects,  it  must  be  borne  in  mind,  arc  only 
relative  affairs  and  are  dejx^ndent  upon  generiil  condition*  of  ill  health, 
and  poor  nutrition,  cardiac  disease,  chronic  poisoning  (alcohol,  lead) 
and  infect  ions  {nmluria,  tuberculosis).  ^Vii  important  jiroup  are 
due  to  adenoiti  vegetations  in  the  posterior  pharynx.  Under  such 
conditions  of  ill  health  development  Is  impaired  and  does  not  proceed 
at  a  normal  rate.  With  anemia,  impaired  digestion,  and  infected  tonsils 
which  produce  a  constant  toxemia,  the  ehild  cannot  be  ctpccted  to 
proceed  in  his  development  with  normal  rapidity. 


Fia.  434. — In  cenur  &  mctron.  acivl  twonty-faur  yrars;  menlnLIy.  ten  ymre.  At  right, 
nuiroo,  aitod  eleven  years;  mouuilly,  eieht  yean.  At  Ml.  imbrcile,  ngcd  ninv  yamn; 
meabiUy.  six  yeem. 


In  addition  to  such  conditions  as  this  it  Is  found  that  the  defect  is 
often  due  to  high  grades  of  myopia  which  make  it  iniptissilile  for  the 
child  to  learn,  because  he  cannot  sec  to  read  or  even  sec  the  blackboard. 
In  the  ifiime  way  deafness  and  other  quite  gross  tesionn  have  been 
found  to  account  for  many  of  these  conditions. 

In  arldition  to  these  types  there  are  the  usually  milder  grades  of 
defect — infani'duim — flependent  upon  the  dysfunction  of  the  various 
endocrine  glands.  Here  are  found  the  th\Tnic  tjpes,  status  thxTnico- 
lymplmt'cus,  hyper-  ami  hj'pothyroidi.sm,  d,\'^genitalism  (hypcr^ 
genituli»m),  dyspituituri.>{ni  (including  dystrophia   adi|Kisogcnitalis), 

.        dysiidnMmli.siu,  ami  pluriglandular  imbalances. 

^B      (-'hoiKlrodystrophy  and  mjcroraelia  may  be  associated  with  mental 

Digitized  'oy 


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^'fty.  fnr     ^"  "^any  of  *u  "^^-Sfi 

y.  lor  vxHniult.  »i  '"eso  fU/,_ 


PSYCHOPATHIC  COS'STITUTWN 

There  are  many  psychogenic  states  tlmt  occur  in  psychopathic 
indivitluals  — (/fwViif*.  The  so-callwl  jirisim  frnfchmm  are  lyiH*s  aii<l 
come  about  as  the  patient's  reattion  to  the  <hfficiiltics  in  which  he 
fimis  himwlf.  They  may  he  liysterieal.  catatonic,  paranoid,  or  manic- 
depressive  in  ty[)e,  acconlinn  to  the  tyfR*  of  individual.  They  clear 
up  when  the  stress  is  removed — panlonj  expiration  or  wmmutation 
of  sentcntr,  etc. 

These  are  the  types  to  which  Siemerling  has  given  the  name  *'*(/««- 
iion  jj9yrhwfti"  mcaiiin};  that  the  psychosis  is  a  result  of  the  .situation 
in  which  tlie  patient  fimis  liimself.  'i"he  imprisonment  or  perliaps 
the  death  sentence  are  intolenihle  facts  which  can  neitlier  be  esr'«|)ed 
nor  permitted  to  enter  consciousness  and  the  various  t\7»es  of  n'action 
— hysterical,  catatonic,  etc..  are  the  inethoils  cni])loyed  to  try  and 
s(|uare  with  reality  according  to  the  make-up  of  tlie  individual. 
Many  "shell  shock'"  neuroses  develop  in  this  ^ronp. 

This  whole  jcroup  of  reactions  arc  found  in  psychopathic  individual.^, 
the  t\pes,  of  course,  from  which  the  criminal  clas.>*s  are  recruited  and 
which  present  to  society  some  of  the  most  difficult  of  its  pniblems. 
The  solution  of  these  prohlems  will  only  l>e  in  sight  when  tlie  make-up 
of  the  indivichial  is  appreciated  as  a  factor. 

The  question  of  amjifitiitinna!  wfrrinriti/  involves  many  live  Issues. 
This  term,  like  other  clinical  designations,  does  not  apply  to  a  well- 
defined  class,  but  in  tlie  main  it  may  be  said  to  cover  two  groups,  those 
that  art*  inferior,  more  esixt-ially  rn>m  the  intellectual  angle  and  those 
that  are  inferior  more  particularly  from  the  emotional  angle.  The 
latter  group  are  naturally  most  important,  at  least  from  a  sociological 
stand-point,  bc<'ausi^  they  include  thi>se  ill-balanced  indivliluitls  who  so 
fn-ijiicntly  run  c*ninler  to  tfie  estjdilislicd  onlcr  of  things  and  llien-forc 
ci>me  within  the  purview  of  the  criminal  law  f()r  more  or  less  serious 
offeiiccs.  A  discussion  of  this  gmup  is  quite  impossible  in  this  place, 
both  because  of  its  great  extent  and  its  present  lack  of  classifi<-ation. 
It  includes  a  considerable  nuinlHT  of  the  juvenile  delinquents,  of  the 
recidivist  tv^pe  of  crimijial,  of  the  i*au(iers  and  ]irostitute-s.  of  the 
ne'er-d(>-wells,  the  black  sheep  of  tite  family,  and  at  the  higher  levels 
of  erratic,  half-genius,  half-cnizy  |»ersons  with  brilliant  sfntts  here  and 
there,  but  without  continuity,  whose  efficiency  is  niateriHily  impaired 
and  who  live  often  a  more  or  less  wandering  existentv.  The  intellec- 
tually inferior  an*  less  driven  by  tlicir  emotions  and  a  great  deal  of  the 
drudgery  of  the  world's  work  is  probably  done  by  these  dull  an<l 
relatively  stupid  ])erson.s. 

Theoretically  these  c-ases  do  not  impnive.  The  intellectually  inferitir 
can  only  be  improved  up  to  the  point  of  their  capacity  to  learn.  The 
emotioimlly  inferior,  however,  tend  s|x>ntanfously  to  ft  certain  degree 
of  clinical  improvement  when  they  have  passed  tlie  fourth  decade 
and  the  drive  of  the  emotion.<;  begins  to  quiet. 


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ANOMALIES  OF  THE  SEXUAL  INSTINCT. 

QuantitatiTe  Anomalies.— These  are  frigidity  or  lack  of  desire 

sexual  nitiirrt'sa— .vc.r»(W  aticMthrsia — or  ervticism — KTual  hyjM'rratbe. 

QualitatiTe  Anomalies. — These  are  inversimu*  and  i>rrrrr*u 
InversioTi  consists  of  a  lack  of  harmony  l»etween  the  physical  aiJ 
psyrhiral  sex  anr!  leads  to  htmnKtrxuaHiy  or  desire  for  persons  oP 
same  sex.  Various  physical  anonudles  are  often  found  in  th 
persons.  For  example,  tJie  gcnentl  eonfonnatioii  of  the  IkmIv,  p  looi 
etc..  may  indicate  one  sex,  while  the  genitalia  are  of  the  other. 

Sex  inlieritanec  is  aUematite.  That  is.  both  male  aial  female-  ch 
ai-ters  are  present  in  the  genn  and  only  one  nomjally  develops.  Soi 
times  there  seems  to  be  an  uncertainty  a.s  to  which  will  develop  i 
the  result  is  a  certain  mixture  which  may  take  place  either 
Kwlily  or  psychic  spliere  alone  or  in  Ijotli. 

The  perversions  nre  many  and  include  the  various  anomalous 
of  ^nitifying  the  sexual  ajJiK'tite. 

With  respect  Ix>th  to  inversion  and  perversion  it  must  Iw  reow 
hercd  that  in  tlic  younft  child  the  sexual  instinct  has  not  developed  & 
Inter  as  it  develoiB  and  comes  into  prominence  it  differentiates  a 
tends  to  s|X'cialize  by  centeruiR  its  aims  in  a  special  direction,  i. 
towani  the  opposite  sex  and  normal  coitus.  The  child,  before  t 
takes  plaw  is,  to  use  a  tenn  of  Kreuil's,  jMjIyiiuirpkaun-jjrrrrntr. 
may  bt*  develoiH^d  in  any  direction  by  a]>propriate  inBuences  or 
may  stay  in  the  undeveloped,  infantile  stage. 

The  most  imj)ortant  of  the  pen*crsiona  are:  ■ 

MMtmbation.— Masturbation  is  vcrj'  frequent  among  psychopB 
and  vcr>-  often  u  result  rather  than  a  cau.se  of  mental  anomalies,  thou 
umloubtedly  an  im)>ortant  factor  in  some  cases  of  acute  psycho5 
A  tran.sient  period  of  onanism  in  infancy  is  probably  normal  a 
ser\'es  to  focalize  the  sexual  sensations  on  the  iionnal  eroKonous  zon 

Active  Algola^a  (Sadljftn).— The  gratification  of  the  sexual  ft«li 
by  the  iiiflictioii  or  si>:ht  of  pain— real  or  simulated.  In  the  latter  a 
the  sadism  is  symhuiic.  As  the  male  is  nomndly  the  more  active  a 
aggressive  in  the  sexual  relation,  a-s  might  be  expected,  tliis  ai 
is  more  frequently  found  in  men. 

FasaiTB  AlgoUsnia  {Masuchism). — The  gratification  of  the 
feeling  by  siill'crliig  pain— real  or  siniultit^i!.  hi  (lie  latter  case  it 
symbvlic.  The  female,  being  the  more  pasj»ive  of  the  two  sexes  in  t 
.sexual  relation.  st>  an  exaggeration  of  this  passivity  is  more  freqi 
found  among  women. 

Homosexuality.  —Sexual  desire  for  the  same  sex. 

Narcissism. — A  forui  uf  auto^rotic  sexuality  in  which  a  person^ 
love  with  himself—  his  own  hofty  or  someoue  like  himself. 

Fetichiam. — Sexual  excitement  and  gratifi<"ation  by  the  sight, 
tact  or  possession  of  some  object  or  [Nirt  of  the  Ixxly. 


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is  usually  some  wearing  apitarcl,  such  ns  shoes,  hamlkcrclilef,  petticoat, 
or  a  part  of  tlie  btxly  other  limn  the  sexual  organs. 

Bestiality. — SeNual  relatiou  with  aninials. 

Bxhibitionism. — Sexual  gratiiieatiori  by  exposing  the  ^nital  organs. 

Necrophilia.— Tlic  desire  to  have  sexual  eouprcss  with  a  dead  body. 

Most  of  these  conditions  stand  for  what  was  nonnal  at  a  certain 
stfiRe  in  development  hut  should  have  lieen  left  behind  in  the  propress; 
or  else  they  ore  the  result  of  aberrant  develo]»inent  from  the^se  lower 
points  when  there  lias  been  a  stagnation  of  tlie  developmental  prooess 
and  so  are  ineludtnl  in  this  chapter.  The  higher  psyehie  riimifieations 
are  fully  diseiisstTJ  in  the  chapters  on  the  neuroses,  psychoneu roses, 
epilepsy,  and  certain  psychoses,  notably  dementia  precox  and  manic- 
depressive  psychosis,  in  all  of  which  disturbances  of  psyclitt^icxual 
development  are  present. 

This  list  of  the  anomalies  of  the  sexual  instinct  as  defined  refers 
to  the  actual  expression  nf  this  instinct  in  outward  activity.  All  of 
these  various  nijiiiifestations,  however,  may  apjM'ar  in  the  phantasies 
of  the  patient,  expressed  sjiwholically  and  without  any  appreciable 
tendency  to  carry  them  intonction.  In  fact,  the  analysis  of  practically 
any  one  would  show  a  majority  at  least  of  these  tendencies  in  symlwlic 
expression  in  the  unconscioiLs.  It  can  easily  be  understtKMl  why  this 
shtnilt]  be  so,  because  such  tendencies  as  homosexual ily,  narcissism, 
exhibitionism,  etc.,  represent  stages  in  normal  development,  the 
records  of  which  are  preserved  in  the  unconscious.  In  their  crude 
manifestations  they  belong  to  the  symptoms  of  mental  defect,  in  their 
higher  symlM)lic  expressions  in  the  neurosea  and  psychoses  they  imlicate 
the  tendencies  of  the  individual  which  have  not  been  adequately 
socialized. 


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^^^^^^^^I N  I)  E^^^^^^^H 

1 

^^^^^ 

Acute  r-irriiinwTil>e(t  ctlemn,  155 
i.lisspiiiiii}iU''l  Pikpwis,  4-lit,  45tt 

1 

pEAriDKniiAiJiKN  n«rti(ifi,  12R 

hallui-irnton,-  c«>nfiiHi<iti,  S-11 

^^^^1 

AUIoiiiitiii)  miim>]«w,  Iwt  of,  611 

p()lii)eiice)>li»tc)n)yelitJ«,  388 

^^^1 

1 AlKlu<x*ri8  nerve,  'i(i5 

Addiwm'H  fiisejiMf,  219 

^^^^1 

^L              paUv. -iri.Ml 

Adductor  [Nilliem,  cxuiiiiiuilion  of,  6-1 

^^^1 

^H           tciti  t>f .  4:t 

Adenoid.*.  H2 

^^^^1 

^BibdiKtoT*  of  tlli^ll,  u-«t  uf,  7;} 

Adi'iioLim  pfbuceura,  888 

^^^1 

^■UwrraDt  fil>i-r>,  Kl 

Adeiioiniiln  of  iimin,  606 

^^^^1 

^H             mcthilliLPi'.  SI 

Adiatlukokinrai^.  79 

^^^H 

^H               iiteiliilli>|Hintine,  SI 

iti  rc^n-lK-llar  riisnHer,  .1211 

^^^^1 

^^m                |Mm!iiip,  81 

Adipone  icemtal  dystrophy,  21G 

^^^1 

^H                 prnjier,  SI 

Adi|HwiH  (loluruMt,  210 ' 

^^^^1 

^H               sulttlubinic,  81 

treiainetit  of.  241 

^^^^1 

^KAImitcmi  ur  hnijii,  .54\7 

Adier,  oriuin  jnfrnority,  2S 

^^^^1 

^B               K'Jvanrf  stam'  of,  50U 

Adreuul    contoiit    increasv^l     in    t-x«>ph- 

^^^M 

^^1                murKtr  o(,  M'.t 

tlialmic  poller,  2(IU 

^^^^M 

^^M                [liHsruiiiis  nf,  .STO 
^H                i>li(^u|0'  of.  M\H 

Adxc-iwli [1,  2IS 

«  '^^^^^^M 

elTect  uf,  U]y 

^^^^U 

^H               forms  of,  5iB9 

of  fenr  Ufwrti,  100 

^^^H 

^H              hiHtory  (if,  5G7 

Affect  autivitic^,  \m 

^^^H 

^H              oritic.  54J'J 

influenee   of,    upon    vegetative 

^^^M 

^H                pritiuiry  Kla|n>  of,  308 

iicrviiuw  aywtiyu,  109 

^^^^M 

^H              ]>n)f:n«t!(i8  of,  HiX 

ARPnitalism.  220,  221 

^^^M 

^H                reniimiuu  ur  Uitvu«y  stAKU  of, 

AKeuKin,  nk'i 

^^^^M 

^1                   5n!l 

Ardo^h,  591 

^^^^M 

^H               rhiiiogcnir,  67(1 

AgoniBtA,  IS 

^^^M 

^H              Rymptonut  <tf,  5tkS 

Agnm  ihfJtiA.  7X2 

^^^^M 

^H               tnttiiiiatic,  Uti',  oti9 

Aicraii  lia,  321 

A  buiiiiiiiirie  retinitis,  252 

^^^^M 

^H                tn-ntnien(  nf,  571 

^^^^M 

^V       ccrelx-Unr.  540 

vUwjhoiic  epile|»y.  853 

^^^^M 

^H                (lilTuMt    iiurutcni    InJtyrinthitia, 

Imlturimwts,  K5I 

^^^^M 

H                  and, 303 

multiple  neurititi,  357 

^^^^M 

^■AnwsMirius,  Inuuns  uf,  'MR 

coiirsi^  of,  358 

^^^M 

^B                clinical,  3W 

treatment  of.  389 

^^^^M 

^H                In-jilriM-'til  uf,  31)7 

|ineiidi*t)ami]oin.  S52 

^^^^M 

^HAchillen-jerk,  76 

PM-udopnn'Mis,  S52 
Aleoholiflnk,  m,  X44 

^^^H 

Ach<)n(lm}>liuiin,  '242 

^^^^1 

mif-roii)o1ia,  241,  242 

duonic,  S16 

^^^^1 

Acoustic   Qwve,    receptor     Uipognipliy, 

GDiiNtitutiiiiiiJ  iiiferiotily,  S47 

^^^1 

293 

delirium  tremens,  SJK 

^^^^1 

^B         oculorotarv  piilbwiiy,  275 

symptom.*)  of,  S4S 

^^^1 

^1        pathK,  retiimi,  2'.):{.  2U4 

trcfllDii-nt  of,  MO 

^^^^1 

^"         rotary  patliway,  27o 

(lipoomania,  853 

^^^H 

AcniiiicRaly, '2(H),  210.     See  Hy|H*Hiitui- 

drcoai  states,  863 

^^^^1 

^^           tarmn. 

drunkennutt,  84fl 

^^^H 

^^ft        rharaeteniilir  iuui'l  of,  21 1 

Koriakaw's  pysehnsu-:,  S49 

^^^H 

^Hftcropar««ttMmB.  353 

acute    hvmorrimKe,    pob'o- 

^^^1 

^^UrtinniiiyowiH  of  hr&in,  (MS 

eni^plmliti^uf  \Veniieke, 

^^^^1 

^Khctunl  iwiiroficx,  72f> 

SSI 

^^^^1 

^^Arute  lU'iH^'udiiiK  forru  of  po)io«uwpbiilu- 

asKMiulcd    Willi    slcobulic 

^^^1 

myclitiit,  397 

polyneurittii,  S49 

3 

Digit 


zedbyGoOgle 


910 


INDEX 


Alcoholism,  Korsakow'a  pyschoeis,  aaao- 
ciated  with  other  disoi^ 
dera,  849 
pathology  of,  850 
eymptoms  of,  850 
treatment  of,  851 
mental  changes  in,  847 
conflicts  in,  845 

exaggerated     reaction     to 
alcohol,  846 
neurotic  or  psychotic  symptom  of, 

845 
psychology  of,  844 
psychoses  due  to  alcohol,  846 
rote  of,  in  nervous  diseases,  33 
somatic  effects  of,  847 
as  a  symptomatic  manifestation,  30, 

845 
unconscious  homosexual  conflict  in, 
847 
Alexia,  320 
Algolagnia,  active,  906 

passive,  906 
Allo-crotiam  in  epileptics,  795 
Alternating  insanity.  See  Manic-depres- 
sive psychosis. 
Alzheimer's  disease,  877 
Amaurosis.     See  Retinitis. 
Amaurotic  family  types  of  defcctivea,  888 
Ambitendcncy,  766 
Ambivalence  or  ambivalency,  18,  766, 

812 
Amblyopia,  crossed,  in  hysteria,  41 
Amentia,  841 
Amnesic  aphasia,  295 
Amsden  and  Hocb,  psychical  examina- 
tion, 94 
Amyotonia  congenita  atrophy  and  hypo- 
tonus,  60 
hypotonus,  61 
coDJuncta,  237 
Amyotrophic  lateral  sclerosis,  413 

course  and  duration  of,  417 
diagnosis  of,  417 
etiology  of,  414 
hiatory  of,  413 
pathology  of,  414 
symptoms  of,  415 
treatment  of,  417 
Anal,  erotic.     See  Psychoanalysis. 

reflex,  significance  of,  122 
Analgesia,  test  of,  86 
Anamnesis  in  mental  examination,  89 
Anarthria,  58 
Ancestors,  23 
Ancestrj',  definite  nervous  disorders  in, 

29 
Anemia,  cerebral,  574 
cord,  133 
pernicious,  and  spinal  cord,  387,  388 
Anesthesia  of  ulnar,  a  tabetic  symptom, 

87 
Aneurism  of  basilar  artery,  607 
Ancurismal  tumors  of  brain,  606 


Angiomata  of  brain,  605 
Angioneurotic  edema,  155 

inheritance  chart,  156 
locahzation  of,  157-159 
mucous  membranes  in,  15i 
occurrence  of,  156 
pathogenesis  of,  160 
prognosis  of,  160 
symptoms  of,  157 
transition  forma  of,  159 
treatment  of,  161 
Ankle-clonus,  76 
Ankle-joint  movements,  74 
Anoci-association,  574 
Anomalies,  endocrinous,  38 
Anosmia,  249 
Antagonistic  actions  of  sympatheti< 

autonomic  systems,  108,  109 
Antagonists,  18 
Anxietas  presenilis,  871 
Anxiety  hysteria,  728 
neurosis,  729,  871 

accompanying  and  subetil 

symptoms  of,  734 
acquired,  734 
anxiety  attack  in,  730 
anxious  expectation  in,  73C 
auditory  hyperesthesia,  73< 
etiology  and  occurrence  of 
non-aexuol,  736 
sexual,  734j  735 
general  irritabihty,  729 
hereditary,  734 
locahzation  of,  157-159 
mucous  membranes  of,  15S 
occurrence  of,  156 
paresthesias,  734 
pathogenesis  of,  160 
pavor  noctumus,  731 
phobias,  732 
prognosis  of,  160 
symptoms  of,  157,  729 
syncope  in,  732 
vertigo  in,  732 
visceral  disturbances  in,  7', 
Aortic  aneurism  and  neuralgic  pains 
Aphasias,  315,  594 
amnesic,  295 
areas,  313 
auditory,  320 
in  brain  tumors,  613,  615 
clinical  forms  of,  319 
history,  316 
in  migraine,  143 
motor,  319 

and  sensory,  315 
cortical,  320 
subcortical  or  pure,  3^ 
productive,  315 
receptor,  315 

regions  in  left  hemisphere,  314 
in  syphilis,  637 
visual.  320 
word-bUndnesB,  320,  321 


Digitized  by 


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lADSX 


911 


AphuisR,  wordnlcafiKSS,  320 
Aphasic  diaturhiuicce,   annis  anil  pnth- 
ways,  315 
Htatiifi.  57 
Aphcmia,  315,  316 
Ai>huiiJu.  204,  205 
I  Aplaoias  of  c«n.'lwllum,  5'i2 

U)J  bratik,  onmliincd,  534 
and  riini,  ulniphiiw  or,  534t 
Apoplectic  uttack,  577 
AfMinln^tifnrm      ntt4U!kfi      in      multiple 

scleroses,  458,  459 
Apoplexies,  859 
aphasa,  604 
apraxia,  591 
atta<;k,  577 
WTt'bral,  572,  576 

syadrome,  anterior,  579 
miilttic,  oSO 
COTTVA  in,  57s 
diupi<«i«  off  594 

nlonhoSiR  coma,  396 

dialielic  coma,  5Uti 

ei^ik-ptic  and  synt-opal  attacks, 

5dG 
hyrtk-rit^l  hcmip]cf;iiui,  595 
ophthalmoscopic    examination, 

S05 
pftrctio  apoplexy,  696 
111  t«Tiiui  uf  rniiHation,  594 
urrniic  coma,  506 
dixtrilHitinn  and  rauKutioD  of,  576 
hrmianpsllieaia,  581 
heiiiiari(>[)Am,  594 
hemiplegia,  580 

Ute  treatment  uf,  5tHI 
irrilnlivB  wiinplexps,  580 
DicuinificaJ,  544 
pnwnutus  (if,  5m{ 
tluuiunic  Byndrome,  5S1 

affwrtivR  ppactivity,  583 
chJt'f  fvaturcH.  581 
low  n(  Mctuibility,  5S3 
treatment  of,  507 
in  attack,  59S 
prnphylaxis.  597 
mjrgii-al,  5!K( 
Toscubir    injitability    of    cerebral 
vtvselB.  574 
Epraxia.  79.  SA,  591 
facial,  287 

liicaliaitian,  591.  593 
.  Aradmoid,  diaeaaea,  540 
lAtnn-Duchenne  atrophy  in  nulicuUtie, 
353 
type  uf  ifrogroHivc  muscular  atro- 
pbiw.  404 
Arehaiu  ty|x.'  uf  reuetiun,  KI3 
Akob  inv»»lvw!  in  lraion»  of  ihe  $piniil 

coni,  3»7 
Argyll-Kol)crtiton  phenomenon  in  tabe«, 
t>75 
pupil,  W.  109.  110 
s)*ndrome  other  than  s^'pbilitic,  631 


ArKvll-ttol»ert90ti  syndrooie  in  sjiihtliB, 

)i:^i 

Arm,  (-xaniination  of,  61 
Arnenicvil  neuritiit,  300 
Art<'ri(Kwlero«i3,  wit'hni!,  575 
Art«rioeti-lcrotic  brain  atrophv,  S7S 
IwycliuMU,  866,  878 
diagnosts  of,  8A1 
late  entlepHfS,  881 
patliolosy  of,  8S1 
perivsHTuiar  uhuHts,  878 
senile  iNirtirAJ  dp%'iL'«tation,  879 
0iit>i'cirt  tcnl  Piiwplialiti*,  K73 
aymptoms  of,  S79 
trettliriwil  of,  H8S 
aofteniiiK,  SKl.KSa,  883 
Arthritic  (tisdiHnutcPK  in  cuic^store,  30 
Arthrititlw,  pavchoKciiic.  244 
Arthrilia,  33 

rheiimaloid,  244 
Arthrupitlhiui.  241 
m'nnijtpnic,  244 
pflych<»geni(r,  244 
Articular  Hieuinatixm,  omil«,  H43 
Aosodatec)  niovem^nta,  79 
Aasonatiun  fnv.  07,  742,  743 
Ast«reognO!ii9,  87 
Aathonta,  531 
Asthma,  128 
AsyinlHrfia,  591 
Asytwrgiii,  cerelwllar.  53,  530 

trait  for,  54 
Ataxia,  Friedreich'!*,  535 

in  l(»w*T  extrediittpn,  tent  far,  79 
ill  Tiiultigilc  Mrleruii)*,  454 
laU-lic,  r>74 
test  for,  79 
Ataxic  form  uf    acute  polioeiicephalo> 
myelitis,  399 
paraplcipa  types  of  comluncti  ado* 
mflRfl,  431 
Atbetuid  movements,  79 
Athetosis,  902 

Atrophica,    neural,    ncurilic    or    spinal 
iiLTiritif,  103.  Mm 
pemncal  forvurm  tyjK),410 
tatxrUc  lyi«e,  413 
primary  progresAive  muticular,  403 
progntHsire  nuclear,  403 
Atmphy  of  innfcue,  310 

m  ocdibdon  of  oei«beltar  artery,  00 
of  upper  extremitiw,  59 
Auditory  disturbiuic^,  295 

liyiM^n.»Lh<%iiu  an  aiixivty  ayiuplom, 

730 
nerve,  203 

toat  of  cochlear  portion,  52 
of  vestibular  portiuii.  53 
pathwa)"*,  diseases  in,  292 
nyiiiptunus  in  multiple  HrteroBes,  454 
Aura  iu  cpilep«y     Srt  Kpilc|wy. 
Atitislic  lluiikitit:.  SOU 
Auto-erotic  iutrtjvor-ion  in  iicitrAithenia, 
737 


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912 


TNDBX 


Aulocroli^in  in  cpilrptics,  796 

in  nmsCiirliutioii,  738 
Autonomic  diviaon  of  veicctative  nerv- 
uiiH  syHtt'in,  KJ6 
nervoiH  syslnm,  09 
and  )s.vm;tn!lii-litf  «ydt«au,  antago- 
niBtrp  nciidtut,  I(W 
Au Union  iQtonii;  druffii,  107 
Avollis.  »yii(lnmn!  of,  468,  470,  471 
AwiO  neuritis.  :iM 
aruif,  '^34 
cbiuuic.  254 
Kti(il(ip>'  ot,  2M 
hereditary  fonns  of,  256 
t)iilh<i1i>)o'  of,  'iiiti 
sontomala,  254.  255 
vjfluat  finlrls  257 


B 


BAfiiNSRt  and  Xngt^otte  nynclrome,  471 

a^ynur^dc  t^t,  53 

ChnrlitiK'k  iiKHlificJitioTi,  77 

dyaiuftrm,  .W 

luiTtii  siitn,  514 

lUT-at-tw  (extension.  515 

plantur  cxtviituun  tihenonmnun,  77 

rctti-x,  7fi 

lliti;li  "it^ii,  515 
Baby,  nicntftl  life  of,  705 
Bamny  (l-kIs,  43,  55,  290 
BflSP()ow'«     diBPJUiP.        See     llypprlhy- 

roidiA-m. 
Keani'M  tliaeasc.     See  Nourasthcnia. 
bell,  nerve  of.  :J7« 
Itoll'H  piilHi4w,  288 
Beneilict  HynJroine,  480,  541 
Bt-ri  hm,  •i5\ 

BerrinrtMIomor  syndrome,  111 
Btatiality,  907 
Bctold's  methods,  52 
HieerpB,  cxamiTiiiitidn  of,  &4 
Binct-friiiiion'a  teats,  31 

eritipi.im  of,  (f3 
UJrth  palsy,  ccrcbriil  types,  546 

Epb'di,  302,  a«4 
BiriTUm  tp«t.  42 
BliuJiler,  iiir^itluuiiKdi  of,  124 

ill  mulliplr  srliTotrin,  457 
BliiKlnt-Nt,  mind,  'HVi 

mini,  :tL»0 
Blood,  cxaminution  of  tropluc  changes 
in,  40 

glitntls,  enilncrinoits  glunda,  99 

Renin)  reaction  in  tttbeit,  077 

syndromes,  ItlO 

IomI.  ill  sypiiiliif,  625 
Bloo<lve«wl8,"  130 
Btmee.  osaitunuliun  of  trupliic  cb»nKra 

In,  40 
Rnnnirnfyndmnii.',  31)0.  ti7(i 
■tony  liyi)erlrophic8,  causing  cHuiiprosBioo 
of"  cord,  425 


Booy  wnsibiliiy,  83 
test  of,  S(( 
svndronK.  166,  24t 
Bourdon  test,  93 
BmchiiU  iitfuralKia,  337 

diapio«i8  of,  339 
jMunful  points  of,  338 
BymiHoms  of,  338 
tnyitincnl,  of,  339 
paSay,  total,  3ti3 
plcxii8  puLiie^.  332 

superior,  365 
plan  uf,  337 
Bradylalia.  «S 
Brain,  akmoem  tif,  563,  567 
ant-miH  of,  574 
nrli'rii»rlt^n>sis  of.  575 
h](Mi<l  supply  <»f,  573-574 
dLtea»«t  of,  HiiS 
hyiHTCiiiiii  i»(,  574 
multiple  tureoQiA  of,  614 
Ktcrn,  Ittiidiis  of,  464 
tuinonn  of,  603 

vascular  cliHturlianmi  of,  S72!| 
insljibthty  of,  574 
Hrrnl.hitiK.  innerviition  of,  12N 
Bromides  pciii^ininit.  S3^ 
Brown-.S<^iliinril  cyiidrome.  42.T 
localisation  and  Hyinpt 
42-t 
Bullmr  Butonomie  iiy8t«ni,  106 
fonn  of  acute  iralioeneefihal 

litifi,  397 
paUiiit,  clmjuic  proKrawivc,  408 
region  r(>f1rx  patlw,  lOl 
symptoms  in  multiple  (ie]pron&  ■ 
ill  iiyrinKOPiitvphainmyelilta 
Byndrouie,  aiiterth-int^mol,  4(K( 

rptrtt-olivary,  470,  471 
types  of   e^Tiugoencephalomyd 
442 
Bullwiwntinu  types  of  progreanve 
ek-ar  ntrophioB,  408 


Caohetia  th^Teopriva,  174 
Cawiii  dim!iun%  387 
Colearint^  iiiuure,  Iiiillol  wnimd, 
Ciitciuin  thi-rapy  in  lolany,  2li8 
CiitUKin,  sludiiw  in  renctioiiH  of  vcg 

xivo    nervous    eygtem    and    me 

Rliimiti,  100 
CarMn  biKulpttide  poisoning,  361 

inonnxiil*'  ixtiNinmg,  301, 
Cnrcinoinatu  of  Itr&to,  604 
Cunliiir  inm'rvutiuti,  129 

nerves,  116 
CanliDViL.'M-utiir     syinjilauu     ia 

thalmic  Roitcr,  i96 
{"'aritw,  425 
Calali'psy.  830,  840 
CatAlept'iR  rigidity,  54 


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-oogle 


fNDBX 


013 


'fatntniiin,  HID 
I  (.'awtoric  ritddity,  813 
Craitml  connectHinfl  v<>itfUitive  systems, 
102 
lesions,  cliart  Tor  iliffi-renliatioQ  of, 

'CephoJogyric  fibrnp,  3)>^ 
Cerebellar  abaccas.  540 

UifTuee    purulent    lubvnathitu 

tuui,  aoa 

astbcnia.  SAX 

asynrrinn,  ftA\ 
oTaxin.  52ti,  527 

fttninliicft,  Mivrio'H  )if>n>ililAr>',  53<» 
ivmdtlions.  trcalmrnt  of,  543 
ilii^WK'.  K.viii)iliiiu-<  of.  52(1 
<liHorH«r,  »<liadokokincflifl,  52t> 
chirf  ;«yii<lroiiM's.  Tui\ 
for«Hl  movements,  .131 
fi|)ocrli  iliKtiirluuimi,  5ill 
vcrtiKO,  sail 
dvNiietria,  52.S 

filH.  Ml 

f'    lila.  5-27 
ytxit'miis,  53fl 
OD'ii  1ii!>yriiithinc  lii^ttirbaOOH,  dlf- 

fi'n'ciliuJ  tliUKiiuaiH  uf,  296,  303 
lucnlixatiou,  .^7 

iHHliincIc,   ofFerent  tracts  Uirotigfa, 
525 
inferior,  522 
lesions,  531 
pnths,  522 
mUI<]l«,  532 
toaiooit,  532 
IMths.  522 
iwstcrior.  .>23 

Bl>cr  tnicta  of,  523 
8Ut>crior,  52v^ 
Ivsiiioa,  532 
patK-*,  52;( 
ntiil  |KiitUii(i  imt-Ls,  fli'MitriiiliiiK,  525 
Kiltit''  Ml  cliorra  niiiiur,  515 
hyiiiittoins,  .Vifi 
pyiiilrmiiCK,  531 

uccliiKimi  (if  lirtcry,  (W 
I«c«tcri>inrcriur,  482 
tnict».  522 

afferent,  525 

of  Initial  roni,  aitcx;nibuK>  524 
'Ii-M-i'M(liiiK,  525 
tremor,  ohnmic  prognissive,  511 
tttmnni,  537,  53H,  539 
(Uagnoflifl  of,  541 
i<yinplou>s  of,  530 
vert j|Coc«,  300 
'f  <:-ri-lK-l)o)K'titirie  «iiRle  tuiuon,  543 
tVrelvlItiin,  521 

offLTent  tmcts  of,  525 
aplaflian  of,  .Vtl! 

^A  (.trrttl^'.-tliuu  aad  bruiu,  ootu- 

iMTiffll.  534 
|Hirc  bilH.f«ral  agcncua,  534 
iiiiilatertU  loss,  532 
5S 


ICembelliiiu  Donnoctiotu  n'ith  forebrain. 
-298 
epinal,  297 
cord  atrophies  or  aplanas  anil,  530 
cysts  of,  637 
function  of,  521,  525 
bemorrhapt  of,  530,  537 
an  important  wtixnrirantor  station, 

525 
lesion>«,  5>'Vi 
bltvu-pimto-oerobeUor   atrophy   uf, 

531 
position  of,  521 
priiimry  psrenohynruitous  dcevneror 

tioii  of.  o3ft 
spinal  cunnwtions  of,  chief,  207 
tumor  with  ittrophy  of,  61S 
unilateral  kiss  uf  lohv.  .'i:j2 
Cercbr&l  apopkoDM,  572,  578 
orteriosclenjiuK,  57.'i 

chief  s>'ndroin«i  of,  576 
symptontf  of,  575 
form  uf  i»<»li«K'ncpphaIoioyrlitin,  398 
pulMy,  infuiilik-.  5C5,  5tJ7 
piilluuf  vcniilnitiir.  :iOl 
peduncles,  SO 

futtUi  L-umplirut  iuuit  of,  541 
synimMRi!)  in  multiplo  sderoida,  458 
BynJruaif.  aiitvrinr,  579 
syptulis,  fMO,  G-t4 

ntmiiliy  of  lonKiK  and,  3II> 
cxtprniil  rectus  paby,  44,  270 
pUisiw,  2ti(\ 
CcrclmNipinnl  tiuid.  ryU>lo|tic»I  (lamina- 
tion, *i25 
in  ilioKnuniH  of  syphilis,  025 
normal.  t>2'J 
in  parrms,  ft52 
parhi'iMKiciil,  (329 
m  pittiiK'iu-uplialoinyE'litiii,  303 
reaction  in  tjilxs,  (177 
iiiriiinBiliilcs,  54'.l 
□leninfpUs,  554 

lilond  curve.  555 
syphilis,  trochleariH  |>alsy,  273 
Corvjml  rib.  37S 

aympathcl  ie.,  114 

ooulopU|iilliLry  filx-rK,  III) 
typo  of  ttyrinK'^nfvp)iiil<>nn>-elis,  442 
Cvrvico-iiccipital  umniliiiu,  :tll5 
('hati<l<H'k  Rffjil-tnc  (<\N<nsnr  J^ipi,  515 
motlificiilioii  Uabinsid,  77 

Tf^P.\,  7S 

Charactcrolo^cai  defect  Kruupit,  884,  904 

Chorctjt- Mane-Tooth  di.'^■{l.w.  410 

Charcot  study  b  hystoria,  712 

CheuKiregulaUwy,  exauuiutiou  uf  tro- 
phic cluQKgs  m,  40 

Ctiia«ni,  discaw  at  or  about  lh«,  2llO 

Childrpu's  diacaaoi  in  patient'A  history, 
32 

ChliiromiUji  of  bnun,  tiO-t 

Chloioeis,  Ilid,  223 

ChuloBt^omata  of  brain,  fi03 


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914 


INDEX 


Chordoma  of  base,  605 
Cbordomata  of  brain,  604,  605 
Chorea,  612 
acute,  843 

psychotic  disturbanceB,  843 
chronic,  513 

psychotic  disturbances,  863 
degenerans  of  Brissaud,  513 
electrica  of  Bergeron  and  Henoch, 

513 
epileptica,  Dubini,  513 
Huntington's,  513,  517 

psychotic  disturbances,  863 
insane,  843 

psychotic  disturbances,  862, 863 
minor,  513 

diagnosis  of,  516 

etiology  and  pathogenesis  of, 

516 
symptoms  of,  514 
treatment  of,  517 
postapoplectica,  513 
Sydenham's,  513 
tabica,  513 
thalamica,  513 
varieties  of,  513 
Choreas  of  cerebellar  origins,  513 

congenital     or     infantile     cerebral 

palsies,  513 
of  general  paresis,  513 
posthemiplegic,  513 
psychogenic,  513 
of  pnychoses,  513 

of  superior  cerebellar  peduncles,  513 
Choreic  movements,  79 
Chronic  poliomyelitis,  405 
Circle  of  Willis,  465,  572,  573 
Circular    insanity.    See    Manic-depres- 
sive psychosis. 
Circumflex  nerve,  379 
ClassiGcation,  principles  underlying,  17 
Claudication,  intermittent,  135,  329 
Clonus,  ankle,  74 
Cocain,  854 

Coccygeal  plexus,  neuralgias  of,  348 
Cochlear  nerve,  test  of,  51 

oculorotary  pathway,  275 
Collapse  delirium,  840 
Colliculus  inferior,  490 

superior,  487 
Color  vision,  test  of,  41 
Combined  degenerations,  430 
scleroses,  430 

in  paresis,  432 
senile  forms,  432 
spastic  ataxic  type,  431 
toxic  anemic  forms,  432 
Complex,  the,  94 
indicators,  812 
interferences,  828 
Complexes,  spht-off,  713 
Compression  of  cord,  425 

caused  by  bony  hypertrophies, 
425 


Compression  of  cord,  caused  by 
cord  tumor,  426 
by  tuberculosis,  425 
syndrome  of,   in   peripheral 
injury,  376 
Compulsion  neurosis,  712,  719 
ceremonials,  725 
compromise  formations,  ~i 

symptoms,  722 
compulsive  action,  724 

reasoning,  725 
a  defense  neurosis,  720 
distortion  through  substit 

726 
doubting  mania,  725,  726 
expiatory  for  sexual  aggri 

721 
failure  of  defense,  722 
mechanism  of,  720 
obsessional  manias,  728 
obsessions  of  doubt,  728 
phobias,  725,  727 
reproaches  in,  721 
return   of   repressed    ma 

722 
sadistic  component,  727 
secondary  defense,  724 
symptoms  of,  724 
tics,  725,  727 
transformation  of  rcproac 
unconscious  hate  in,  727 
Conflict  in  psychoneuroses,  713 
Confusion,  acute  hallucinatory,  S41 
Con^nital  syphilis,  689 
Conjugate  deviation,  272 
Consanguinity,  23,  28 
Constitution,  general,  34 
Constitutional  inferiority,  904,  905 
Continuous  bath  in  dementia  preco 
in  manic  depressive  peyc 
771 
Convei^nce,  paralysis  of,  276 
Conversion  of  conflict,  95 

an  hysterical  mechanism,  714 
Convulsive  movements  localized,  79 
seimres  in  dementia  precox,  ; 
importance  of,  34 
typra  of  reaction,  786 
Cord,  atrophies  or  aplasias,  cereb 
and,  536 
reflex  paths,  103 
Corpora  quadrigemina,  487,  490,  5^ 

syndromes,  487 
Corpus  restiforme,  531 
Cortex,  disease  of,  in  lesions  of 
tract,  262 
organ  of,  local  attention  of,  58 
thalamus  and,  functional  reU 
of,  588 
Cortical  control  of  thalamic  activity 
focus  of  attention,  588,  590 
lesions,  sensory  changes  in,  58." 
compass  test,  5S( 
localization  of,  5t 


Digitized  by 


Google 


L\DEX 


915 


Cortical    Iceioiw,    MiiM>ry    rliiingts    in 
posnirc  ami  raanve 
tnovciiiL'iits,  S8S 
taclile.  585 
oedonUry  luthway,  274 

ivpnneDtation  of  relittn,  205 
CnrtJcoourJcar  port  ion  pvr&TnkliU  troci , 

80 
t'ortitviH|iinnl  iKjrtion  pyramirlal  inei,  SO 

iiri|iiili4i-jt.  wii»ur>'.  587 
Cnuiiiil-cerviral    portion   of   vegetatiTe 

non'ous  fiysu-iii,  100 
Oauuil  oervM.  245 

Fxnininntion  uf,  40 
nuf^lri  of,  466 
Cnmium,  i:xaiuinntion  nf,  3C 
Cretinism,  ISO.  isl.  S<iO 

bony  chiinKt^  in,  S91  ' 

(linenrKHB  of,  81K) 
(-'i)d4>iim-.  180.  185 
niunKnlJsm  and.  892 
Spunulic,  180-183 
pitninit  of,  S9:i 
'  liciittiicnition.  IM 
.Vflf  TntK-H.  Hypnthynticlixm. 
Cnrul  OL-uraliiiit,  'M7 
("rj-inn  in  multiple  svlprosip,  mvolunUwy, 

458 
Crutaneniw  ivflcx  zonca,  86,  87 

rrf  hyperaJfceaia,  325.  326 
CyclotbyuiiaM.  702 
CynticiTcus  t){  bmin.  COG 
i'yftii'  fortiiuti<in  in  iijiiniU  corti,  446 
C'yaU  itf  ci-rolx'Iluin.  ."iST 


iMy-^lmtdiitifE.  710 
IX-ar-tnutiBm,  314 
(■[iili'iiiic  1.S7 
Deafnt?'.*.  2!t4,  314 

wiinl.  .121) 
Dwrnrnpn-jwioii  in  brain  tumois,  630 
Deep  reflexc*.  75 

scitittbility,  lest  fur,  79,  82,  86 
bony,  80 

L«8CKur'8  twt,  87 
muMl«  nn<l  joint,  80 
norvp  tninks,  Si! 
Der«cl,  montid,  due  to  pliyeiciU  ill  hekUh, 

mi.t 

mild  jiradcfl  of,  (K>3 

morar  iliK  to  n<!uroei«  or  psyofao- 

nrurosis.  904 
inii»nikr,  ixmiccntla)  and  acquired, 

369 
Dtulnt.  nbiMHifioiilioii  of.  8S5 
Ct roliift;,-  iif,  SK5 
f(>olitc-inini)«dDcae,  886 
idioc}',  S8A 


DefocI  8tBt('».  i<]i(Mnilm-Jlity,  886 
imbrrililv,  SS6 
moriil,  H,SO 
Defect ivcntwa,  nuNtninR  nf  tenn,  884 
Defective**,  amaumt ie  family  ty|)es,  >W8 

Amorican  Indiiin  typ«<fl,  IH)],  902 

apalbcUr,  W2 

cliniral  varieties  of,  888 

oretinfjun,  NtKJ 

cptk'ptio  tyTnti  of,  808 

exritalik,  W2 

hvtlroiM'pImlie  Iy()tw  of,  894 

idioi-sAvant.t,  901 

infantilism,  003 

iuflanuiuitory  typf»  of,  S1K) 

microrpphalic  typc«  of,  W)R 

rni.ngoliwin,  89y 

N'pKioi'I  lyp*'J*  of.  901,  902 

parsiytic  lypc»  of.  8fl7,  SOS 
porcncophalufl,  898 

rhythmic  ifliutn.  U02 

it<4(Ti>tic  tvjxa  of,  S88 

sensorial  t>ins  of.  809,  iMJO 

RyphUitic  type*  of,  IKXI 

tJHiinutlJr  types  of,  S!WS 
Defense  macliiini«n»  of  dream,  96 
IVKPtienttiiinx  of  ttte  t^piii&l  coni,  roin- 

bioGil,  4:tO 
lJejerirn:^S>ttti8  tyije  of  muscular  atro- 
phy, 413 
Deiire  ile  IourIkt,  728 
Dcliria  'ini%,  854 
De.liriuni  uciituin,  838 

ooIlapK,  &40 

fovt-r,  K^S 

pnivp,  840 

infeetion.  SiJS 

HRnile,  874 

treuufua,  S4}j 
]>ellui(l,  U-Ht  of,  61 
Deinentin,  paraooidco,  822 

pTViMX,  806 

alcoUolism  and,  832 
ainbi\*a](ni('.y  of  tJcwi,  812 
"April  weather"  liehavior,  810 
art^nnir  type  of  reoPlion,  813 
autisiic  thinking.  800 
ciitiilppsy,  S20 
c.ilatonin,  819 
ratiitonic  exeitenient,  821 

rigidiiy.  K13 

stupor,  HID 
oonitnand  automalism,  K20 
complex  iiidiaitora,  812 
onnflirt  and  rpartion,  82S 
congenital  defect  an<l,  833 
converflion    into   bodily   symp' 

toDui.  829 
r(in\nil»ive  xniniireH,  814 
roiirso  nnil  [iniicreMi  of,  S29 
delire  chnmiqiie.  S22 
dcluiuoiial  formal  ion.  H11 

syvtcu]  an  coinprotuii^  nnd 
wish-fulBllmg.  822 


Digitized  by 


Google 


916 


INDEX 


Dementia  precox,  delusional  system  as 
.  defense,  818 
dementia  simplex,  815 
diagnosis  of,  831 
dilapidation  of  thought,  811 
disorders  of  memory,  810 

of  aensorium,  811 
displacement  and  compromise, 
817 

of  emotion,  826 
diaturliances  of  orientation,  810 
ocholalia,  820 
erhopraxia,  820 
emotional  deterioration,  817 

dulness,  809 
cncapsuiation  of  conflict,  828, 

S29,  830 
ctioloRy  of,  807 

heredity,  807 

metabolic       disturtmncca, 
808,  814 

psychological,  808 

shocks  as  exciting  causes, 
808 

toxic,  821 
failures  of  voluntary  attention, 

810 
fetal  attitude  in  regression,  827 
flexibilitas  cerea,  82) 
formes  frustes,  816 
forms  of,  815 

hallucinatory  experiences,  811 
hebephrenia.  816 
history  of,  806 
incestuous  ideas,  835 
industrial  training  in,  834 
interrelation    >)etwecn    mental 

and  physical,  825 
intrajtsycnic  atiixia,  809 
inlntvcrsicm,  809,  830 

of  libido,  814 

psychosis,  814 
liirk  of  interest,  810 
latent  jieriod,  815 
law  of  iintiripation,  830 
looseness  of  train   of  thought, 

817 
mannerisms,  812,  821,  822 
mei-hanLsm  of  displacement,  810 
mental  symptoms,  808 
mild  abortive  forms,  815 
mixed  ami  at>'pical  states,  823 

with  other  pyschoses,  831- 
833 
ukmIc  of  onset,  815 
muscular  tension,  820 
nature,  824 
negativism,  812,  819 
neologisms,  812 
organic  inferiority,  815 
paranoid  fiiruis,  822 
partial  adjustment,  835 
pathologj-  of,  824 
IHjrscvcration  of,  820 


Dementia  precox,   physical    cbai 
secondary,  827 
symptoms  of,  814,  82 
physicocnemical  changes, 
poverty  of  ideas,  817 
prophylaxis  of,  836 
psychoanalysis,  834 
psychologic^  interpretat 

826 
remissions  in,  830 
residuals,  831 
saltatory  associations,  82 
schizophrenia,  809 
shallowness  of  thiaking,  i 
somatic  processes  and    i 

sion  and,  825 
spUtting  of  personality,  8 
su^cstibility,  813,  820 
status  catatonicuB,  821 
stereotypies,  812 
stupor,  813 

surface  indications,  810.  ( 
symljolisms  of  tbe  conflic 
symptom  activities  in,  81 
symptoms  of,  808 
thought  deprivations,  82i 
toxic,  826 
treat  raent  of,  833 

mental  higher  level,  '. 
lower  disturbanw 
physical  conditions,  H 
social  relations,  835 
types  of  reaction,  826,  82; 
visceral  disorders,  814 
waxj-  flcxibihty,  820 
ways  of  getting  well,  827 
withdrawal  from  reality,  S 
word  salad,  818 
Depressio  apatheiica,  871 
Dermog;raphia,  88 
Dermoids  of  brain,  605 
Development,  general,  39 

genital,  39 
Deviates,  905 
Dial)ctes,  hereditary,  30 

mcllitus,  228,  856 
Diadokokinesis,  54,  79 
Diaphragmatic  neuralgia,  336 
Diffuse  neuritis,  269 
Digestive  tract,  innervation  of,  1  ] 
Diphtheria,  neuritis  due  to,  361 
Diplococcusintracellularis,  550 
Diplopia,  test  for,  46 
Dipsomania,  853 

compulsive  activity  in,  728 
epileptic,  797 

as  manic-depressive  phase,  76; 
Dislocation  synaromes  in  primary 
gressive  muscular  atrophies,  41' 
Displacement  in  dream,  96 
of  emotion,  95 
mechanism  of,  810 
Distortion  in  dream,  96 
Distractibility,  753,  755 


Digitized  by 


Google 


TXDBX 


fll7 


I)or^H<^-U>r»  <i(  tKo  foot-,  tfttt  of,  73 
D(irM>ltniilr(ir  ty)K.'  oi  ^ynngoencepbiJo- 

mvrliii,  442 
DoiiltU.     Sre  Anxiety    and    conipoUioD 

wurtMui. 
Drawins  diagrams  in  neatiil  ejcamina- 

Ikm,  91 
Dreams,  95 

nimlvsin  of,  95,  744 

tDL-cfiuimma  of,  90 
DniK  ili-liriu,  S^4 
DriiB".  hal'it-fomiing,  R-W 
DruiikL'iiiifm,  K4(l 
DunliHlic  h>'p«»lliC!n9  tif  nu*nlnl  snd  phy»- 

iiwl,  H-i'i 
Diirn,  inflmnriuilioii  of.  M? 
Dtirnl  liiisiitM'.  .>14 
l^ysiirtliriiw.  l^^■\ 

in  (vMK'llur  disease,  531 
l)y8pK'riit»li.-tiii,  'iU.'{ 
Djitmetriu  UaUttftki,  53 
Dyn|ii(uituriiuti,  214 

syHilryme  of  Heiw>n-Delillc.  216 

tn'ulu»;Dl  uf,  2U( 
Dyssyiicnria  rerebcilari?  prpcrossiva,  511 
Uyrdoiiin  imisniliit-iiui  ili'rriniintt.s,  51(7 
I)v>l rophiit  aiiiiKuoKiriiuliH,  JI2 
Dy!(lropliir,«.   iiiiiitnilar.     iS'ir   MuMnilar 
dyMrciphk-H. 


B 


EsmyciiArs'  tc*t,  93 

Erirntrir  I'liamrtrr,  fXM 

Kchinoooccus,  ft^lj) 

Kilpnui,  rhari  t>f  itihrriliuino  in  angio- 

nourotir,  15ti 
Kdunalinn  in  incntiii  pxnminnlion.  32 
F^iotf  nirinty  uf  epiVplio,  TM,  790 
JCi^ilh  iwrvi-n.  'i92 
t*«l  of,  61 
rjoculatian.  127 
KIImjw  or  thfL'ps-jtrk,  75 
I-Jtf(r!  m(  licrnpy  lu  tKuralKLaa,  331 
Klev«iith  iiiTVi',  tvst  yf,  6S 
KmanripatioD.  710 
KmlKiiiRin,  5711 
Emotioruil  fuctore  in  disease,  100 

etniiiH  in  inr-iilul  cxiiiiiinatiun,  OO 
Kncf  phalic  trunk,  SO 
Kocc^plialitic    fi  tni)    of    poUovni^plialo- 

myditia,  398 
KiiCL'iihatitia,  503 
acuU",  5ft4 

iullui'uui,  5(VI 
pciIiiH'ncf^phjililiii  [ipmorrhaBica 

superior.  .Vi-i 
piiliopiirrphnldfnvHitiii.  565 
pyopiciiic  l>^»«l,  iliO 
symptoins  nf,  504 
diafcnueis  uf,  Stiti 
eli4ilu^'  lit,  54t-l 
ilory  III.  5ti3 


Knecphnlit»,  mibiv^M-liral,  H7s 

li»etapy  of.  -Vi" 
Encliondninuita.  ri05 
EodomJc  cretinism.  ItiS 

dcaf-muliKiu.  IS" 
EodocriDopatbic  sj'ndmmv,  Hclcrxxlerina 

aa  an,  1U3 
Endo(TinDpathi«8.  167 
pnlvEliinHnlar,  l(t9 
uni'ttandular,  168 
Fjii|<irnni.'U8  liiininaliea,  Rlaiula  of,  99 
ditrtiirimnce^.  lanufto  hnir.  3S 
Khinda,  fxunilnulion  of,  40 

intcrrelalion.«hi|i  of,  l7() 
prtMliiiil,  {ffifiiilt»-opii>liyt)is,  lUO 
Htiji^na,  jviu^uilo-opipnyai!!,  243 
stnintiimf)  intliirnru  cm  uoe  anotber,  * 
17t 
Emlutlielioiiiiitu  uf  Ijrain,  (KM 
EriiTfty  ilivi rilKilioii  in  ppilqisy,  780-789, 

797 
Enteritiit,  3S,  120,  123 
Entumplusid,  120,  123 
EnurtM»,  '.i2 
Eosinoplulia.  166 
Ej»imtir.  wnKibititv.  79,  82 
test  of,  83 
tfiernui),  H6 
Ei>ilt'pfli«i,  7.sG 

unoitiuluus  and   Ixwlerlaud    oondi* 

lions  in,  "91 
aura,  Ihi.',  790 

lHiH.rl«nd  ounditionit  in.  790 
uf  Bratz  luid  Ltiulitisch^r.  79S 
rlitwical.  71W 

ci^natjtution  of,  794 
herwiity  in,  7114 
•eisure  in.  795 

jwychic    dmhirhanct^s    of, 
<9f> 
colony  In-ntniL-nt  uf,  80.1 
oouree  and  proftn'wwi  »if,  SOI 
eriuieH,  797 
de]Tth  of  rcartion,  SOO 
rliagncnia  of,  NOl 
due  to  faulty  piirrKi    diRtrilwitifiii, 

786-797 
cariy.  790 
wneiitial.  700 
genuine.  793 
({nuid  iiiul,  795 
of  CfDW)  liraio  disfoen,  790 
Jacksooian  tvpe,  700.  SOO 
late,  790,  SHI 
meaning  of  attjiek  of,  707 
nocturnal  nttaclui  uf,  SU2 
I»anin«id  i»veluo  states  of,  797 
pntli<>l<iKir.iif  gnmfia  of,  792 

QMOi-taUid    with    arrr^t   uf   dc- 
vuluptiiont.,  TlKt 
iirtcriowK-niMa,  793 
exieruid  [K>i»ong.  792 
focBJ  discasi!,  7^3 
atnictural  ctuuiges,  792 


1^ 


Digit 


zedbyGoOgle 


918 


INDEX 


Epilepsies,  pathological,  associated  with 
sj-phihs,  793' 
petit  mal,  796 
prophylaxis  of,  802 
psychic,  797 
symptom  groups  of,  790 
of  toxic  and  infectious  origin,  791 
transitory   conditions  in   states  of 

ill-humor,  797 
treatment  of,  802 

between  attacks^  803 
antiByphilitic,  804 
internal  secretions,  803 
middle-ear  disease,  803 
pharmacotherapy  in,  804 
surgical,  803 
of  the  attack,  802 
psychoanalysis,  804 
of  status,  803 
varieties  of  attack,  801 
continuous,  801 
isolated,  801 
myoclonus,  801 
serial,  801 

status  epilepticus,  801 
Epilepsy,  heredity  and,  30 

lesions,  788-791 
Epileptic  attacks  in  compulsion  neurosis, 
727 
in  multiple  sclerosis,  458 
automatism,  797 
confusion,  797 
constitution,  794 
deUrium,  797 
dementia,  795,  801 
depression,  797 
deterioration,  800 
dipsomania,  797 
discharge,  789 
dream  states,  797 
ecstasy,  797 
equivalent,  797 
excitement,  797 
fugues,  797 
furor,  796 
scars,  792,  793 
sclerosis  of  cortex,  787 
stupor,  797 

types  of  defectives,  898 
voice  sign,  795 
Epileptics,  egocentricity  of,  794,  799 
polyvalent  sexuality  of,  795 
social  position  of,  804 
Epileptoid  tj-pes  of  reaction,  798 
Epiphysis.  99,  217 
Equilibration,  tests  for,  53,  54 
Erb's  birth  palsy,  362.  364 
Erb-Westphal  sign,  76 
Erb-Zimmerlin   type    of    muscular   dys- 
trophy, 404 
Erection,  127 

Erector  muaclcs,  teat  of,  69 
Eroticism,  906 
Erysipelas,  842 


Erythromelalgia,  132 
course  of,  133 
symptoms  of,  132 
therapy  of,  133 
Esophagus,  118 

vagotonic  contraction  of,  115 
Ethical  questions  in  mental  exami 

91 
Eunuchoid,  222,  225 
Eunuchs,  221 

Examination     of    endocrinous     i 
38 
of  larynx,  57 
methods  of,  22 
mental,  S9 
objective,  35 
physical,  35 
sensorimotor,  40 
of  sensory  nervous  system,  79 
of  speech,  57 
of  taste,  56 
varieties  of,  22 
of  vegetative  system,  36,  37 
Exanthcms,  842 
Exhaustion  psychf^es,  837,  839 

acute  hallucinatory  conl 
841 
amnesic  variety,  842 
hyperesthetic       emc 
state,'  of  mental 
nesB,  842 
amentia,  841 
collapse  deUrium,  840 
acute  delirious  manL 
grave,  840 
treatment  of,  842 
Exhibitionism,  907 
Exophthalmic  goiter,  194,  198 

Bemard-Horher  syndron 

111 
course  of,  201 
diagnosis  of,  200 
etiology  of,  199 
extirpation  of,  194 
forms  of,  200 
occurrence  of,  201 
pathology  of,  199 
symptoms  of,  194 

physical,  195-198 
psychical,  198 
treatment  of,  201 
surreal,  201 
Explosive  diathesis,  860 
Extensors  of  foot,  test  of,  73 
of  knee,  test  of,  73 
of  thigh,  test  of,  73 
of  wrist,  examination  of,  64 
External  rectus  palsy  in  tabes.  276 
Extremities,  lower,  examination  of 
j         upper,  examination  of,  59 
]  Extroversion  type  of  psychosis,  767 
I  Eye  muscle  palsies  in  multiple  scl 

453 
'         palsies,.  45 


Digitized  by 


Google 


^^^^^^^^^^^^^^^ySJ!^^^^^^^^^^^m^^^B 

^H^  IDyc  pnlMt'A,  cpntntl  nrifiin  nm)  »yrinKc>- 

Fon^nrd  am)  iHicJiw.ird  ii»«wiat4nnH  in              ^M 

^H                myelic  Uimoiiutiun,  26ti 

menial  exsiuiniktion,  Ml                               ^^H 

^B            R-IU-x  putLs,  '17 

Four  renctiotui  in  i«ypliiliH,  <(2K                      ^^^| 

^H            n-floxctt  tD  nyphilis,  031 

Fourth  ncrvr,  2i^    '                                        ^^H 

^H            syiui)at)u.-tic,  1(H) 

puL-<>  i>[,  1271                                      ^^^1 

^H          tivmittoms  in  exophthalmic  Roiter, 

(lamlvfiH  of,  44.  271                          ^^^| 

^M 

lii'i                                                    ^^H 

^M            1  mphic  iitror  of,  279 

FoasA  nompliratimiH,  .>41                                    ^^^H 

^H    Kycbalt  iLiiroxias,  '^N 

■wociatuil  |KJiil«rii>r.  5-11                  ^^^H 

^M    Kyvs.  U-«l  of.  41 

eorelmliNMuncles,  541                   ^^^| 

eorporiL  (luarlriaciniiui.  541               ^^^| 

vrcHsoil    heniiptcKiii    ami    niv-             ^M 

H 

duceiu<  puUy,  Ml                                 H 

on-ipitut  \ithiv,  511                                  H 

^H    Facx.  uieHlhraiaor,  43)) 

•  liiiiMirs  of  fourth  ventricle.  571             H 

^M    Pnriiil  niM-ni.  rour»i>,  2M) 

Fo\il]c8Vudn)iiiL>,  4S0                                                ■ 

^H           Irvionif,  |H>titii».*.  'iS8 

^H            nf-rvi',  2.S7 

Fracturu  und   dUIocation  sytiilriHrnii  in              H 

^H                  iliagram  uf,  .51 

priniar>'  pro|nrsHivc               |H 

^^L                 (Iiwnm>  of.  2Kr> 

iiiUM-iilar  Htruphiot,         ^_^| 

^^^^L          mjuricfl  to,  377 

^H 

^^^^1           IMtlsics,  ^-ri  ilierul,  288 

diiifcmiNiii  irf,  422                ^^^| 

^^^H           proKreasivi*  trmialtx>ph>-.  285 

priTgnoxiA  of,  422                ^^^| 

syii4>lom.'(  of,  41S              ^^^| 

^^^K^^    test  of.  SO 

trcatmirot  of,  424               ^^^| 

^^^^^^Hdnt-."  ill  nniltipk-  HclemMii,  4.^3 

0(8ktta,544                                                  ^^M 
Fnini's  «HtiicsiomL<UTr,  84                                ^^^H 

^^^Vpiiky.  fiO 

^V                   |M>ripht.Tai,  2tH) 

Fieci  aasociation  in  pn'chunnalysis,  97,            H 

^H                    in  titlK-M,  671} 

743                                                                      ■ 

^m             tlM,  '2N.S 

Fniud  rcpn^iwicm  iheorj-  oC  byBtcria,  713              ■ 

^P    Pan«H,  ly)H>8  of,  30 

Fn<Nhimnn'9  rompirrv  HIH)                                       ^M 

~     Fatigue  neiiroeiii.  737 

Friedreich's  ataxia.  535                                   ^^^M 

Fatly  syiulrrjiiic',  23B 

diM^aDv,  53ti                                                   ^^^| 

^H     Febnic  |>6y(-]inM«,  837 

Fritpdity.  OOG                                                  ^^H 

B    Ft'cblf-tiitiiHcdnMB,  S&i,  880 

FnmtaL  lulw  Luutunt,  Oil                                    ^^^H 

^H           in  congenital  8>'philM,  6D3 

^^^M 

^H    Frmuml  nt'iiralgia,  ^7 

^^^H 

H    Fetichiiini,  006 

^1 

^1     Fever  ttclinum,  S3K 

^H    KiliDJUiatu  of  brfttn,  604 

Gait  in  mulliplt;  wli^rfMiH.  45f>                        ^^H 

^H    Kitirtutix  III  »di;nHliTina,  lti3 

Ganglia,    incomttaitl    ]iH^»liuttii>n   of,  in        ^^H 

^H     Kiiial  I'ditiliKiri  iKtChwH)*!!,  IS 

b(!ail,  Wi                                                           ■ 

^K    Finckli  iiicntiU  examination,  91 

Ganglion,  celiac,  105                                         ^^H 

^M    Fiftli  iiL-r\-i-,  27H 

Gowortan,  104.  2M0                                  ^^M 

^H           juiruJyi^iiii  of,  279 

inferior  oerv-irul,  104                                ^^^H 

^H            lesL  of,  mtH<ir,  48 

mraeiitcrrii-,  1U5                                 ^^^| 

^1                movtry.  49 

upper  cervical,  10-1                                ^^H 

1^^    Finftor-finger  tent,  7U 

Gatiglmnic!  avHtem  in  miin,  locatinn  nf,         ^^H 

Finjtf  r-iww  t*«t,  79 

101                                                                              ■ 

^H     FiiiKpry,  t(wt  (if,  fil 

Gaugremi  of  ifkin,  multiple  netinlic,  l&l              H 

^B    Fixed  idcad.     S<c  Computaion  oetirosifl. 

sweat  sccrctf>r>-  mcch              H 

^H    l-'IcxiKT  serum.  ffUG 

ooisme,  164                      ^^H 

^H    Ftexora  of  tioKi-'nt,  cxainrnntiuo  of,  64 

GaffH'riiiu  K;iugbon.  2S0                                  ^^^| 

^1           of  knee.  U-»\.  of.  73 

Gatttro-intosUmd  diJ^esJics.  857                        ^^^H 

^H           of  thigh,  tcMt  of,  73 

pyiidromiw,  117                                        ^^^f 

^H            uf  wri?l,  t-xuituiuition  of,  64 

GowTul  ul)cwn'atiuii8,  35                                    ^^^| 

^M    FliKht  of  ideas,  75:i,  75$,  750 

Grnirulat«  eangticm,  104                                     ^^^| 
bemorrhage  degcoeratioiui  in  opiio            H 

^H  Fttuhiiig.    See  rsychoucuroaea,  VmcuIot 

^H        »}■!)(  In  miiv. 

nidintiotiH,  262                                             ^M 

^B     FoIh'  di>  dmitc.  728 

betnian<^ia  due  to,  360                                 ^^ 

^m    Forif'il  mn%-emontH,  531 

leHon  |p\iuKiw*  t«  bemianop«)ia, 261        ^^H 
ftyndromc,  202                                          ^^^M 

^H   Forebnun,  cerebellum  cooneefioiu  with, 

■       208 

ChniitHl  di'Vi-lu]Hneiil,  39                                 ^^^| 

^1  Forecaitsdous,  707 

■lanclii,  examination  of,  40                     ^^H 

Digiiizeti  oy 


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920 


INDEX 


Genital  glands,  syndromes,  220 
Genito-urinary  Bystcm,  123 

autonomic  reflexes,  124 
bladder,  124 
sexual  organs,  124 
Gigantism,  209 
Glands  of  internal  secretion,  99 

non-nervous,  99 

related  to  nervous  structures,  99 
Glaucoma,  112 

Glioma  of  tcmiKiral  lol»es,  616 
Gliomata  of  brain,  603 
Glioroatoua  tumor  cavity,  434 
Globus  palli<lus,  progressive  atrophy  of, 

605 
Glossopharyngeal  ner\'e,  test  of,  59 
Goiter,  180,  184 

exophthalmic,  194 

heart,  180,  185 
Gonadal  systems,  diseases  of,  220 
Gono'rrhca,  33 

Gordon  great-toe  extension  sign,  515 
Gower's  tract,  523 
Grand  mal,  795 

Graves'  disease,     tiee  Hyperthyroidism. 
Grippe,  27,  842 
Gubler-Weljcr  syndrome,  483 
Gumma  of  bruin,  606,  634 


Habits,  nervous,  33 

sexual,  33 
Hair,  examination  of  trophic  changes  in, 

39 
Hallucinations  in  mental  examination, 

90 
Hand,  test  of,  61 
Head  and  neck  muscles,  nerve  supply  of, 

59 
Headache  in  brain  tumors,  607 

in  migraine,  144 

in  paresis,  650 

in  syphilis,  642 

in  syphiUtii^  meningitis,  635,  637 
nearing.     See  Auditory  nerve. 
Heart,  129 

disease,    psychotic    disturbance   of, 
865 

non-nervous  gland  of,  99 
Hcat-slroko,  562 
Hel>ephn*nia,  816 
Heine-Mcdins'  disease,  565 
HemutomyeJia,  421 
Hem i anesthesia,  581 
Hemianopsia,  42,  260,  594 

due  to  geniculate  hemorrhage,  260 

right  hoindnymous,  41 

test  for,  47 
Hemicrania,  137 

Hemifacial  atrophy  syringomyelia,  284 
Hemionic  pupils,  47 
llemipiegia,  5S0 


Hemipl^a,     cerebral ,     Fovilles' 
dromes,  268 
crossed,  541 
late  treatment  of,  599 
Hemorrhage  of  cerebellutn,  53G,  5! 
cerebral,  576,  578 
extensive  ventricular,  579 
of  pia-arachnoid,  545 
supradural,  546 
traumatic  meningeal,  544 
Hemorrhages  most  frequent  sites  f< 
Hereditary  dominaney  of  distinct 
29 
tendencies,  23 
Heredity,  23,  28 
Hermaphroditism,  221 
Herpes  comie,  112 

occipitocoUaris,  tjTnpanic,  292 
ophthalmicus,  112 
zoster,  348 
Heterosexual  stage,  710 
Hip-^oint  movements,  72 
History  of  family,  22,  23 
menstrual,  34 
objective,  23 
of  patient,  22,  30 
of  present  illness,  22 
subjective,  34 
Hoch  and  Ams;len  psychical   exai 

tion,  94 
Homosexual  conflict  in  alcoholism 
flxation  cause  of  drug  adtlictiui 

in  paranoia,  7S1 
narcissistic  stage,  710 
Homosexuality,  906 
Hoover  procedure  in  chorea,  515 
Hormone,  18,  21 

Hormones   not   independent    arti% 
173 
products  of  endocrinous  glands 
Homer's  syndrome,  111 
Huntington's  chorea,  517 
course  of,  519 
etiology  of,  517 
pathologj'  of,  519 
pedigree  chart,  29.  See  Ch 

Huntington's, 
psychotic  disturbance  of,  S 
symptoms  of,  518 
therapy  of,  520 
Hunt's  syndrome,  292 
Hydrocephalic   types   of    defective 

894 
Hydrocephalus,  559,  895 

cause  for  hypopituitarism,  213 

in  c<mgenital  syphilis,  692 

due  to  tumors  of  fourth  veoti 

541 
symptoms  of,  561 
therapy  of,  561 
Hydrotherapy  in  dementia  precox, 
Hyperadrenalemia,  220 
Hyi»ralgt.«ia,  cutaneojis  reflex  zone 
325,  326 


Digitized  by 


Google 


IT^DEX 


921 


Hj-porftlKCttia.  n-ttfx.  8S 

testt  ftjr,  SC 
H>li«'pcniia,  fi74 
l1y]K^iviiiiui.  totiir,  132 
Hyix^rKt'tiitnlixm.  220 
Hyi)orglofi»il,  fto 
Hy]«'ro«riiin,  2-111 
HyiKTuvnriaii  sigiut,  223 
lly|)(rr)>iliiiuiri»m,  100,  209 

Bcroiii*iwly.  20W 

|ii'UKiiiisLi<  t)f.  212 

sj'mploms  of,  210 
HyjKirthyn-wBis!,  IIH 

mental  sjinptoiDatoloity  of,  198 

Kiincitiil  trc-nlJiirnl  nf,  201 
HyiHTiri:]>hy  of  u|)iK'roxtrcnutira,61 
Ilypmili»'s,  771 
Hyjiuailrcimloiiua,  210 
Ily|)Oclio[iilnajii&     See  l^syvhonvnnim:*. 
HyiKiKt-iiituliftin,  320 
Ilypo^useut  DCrve,  diseaiie  of  the.  ."MG 
HypMcl(M»un,  :t07 

cliiiiuil.  309 
Ily|K>niAiiic  (nrial  cxprnsinn,  7AI 
Ilyp(M)v.')ri(in  aigns,  223 
liypi»-i)Vuri«m,  39 
tlypopli>i9J»  chauges  id  crctinisn,  186 

<lu«ea8es  of,  208 

cnitoorinoiu  ^uul  of,  09 

c-uiiiiuuttun  of,  40 
Hyv>»piliiitsrism,  100,  212,  216 

aili[K>t«  Ki^'itilAl  (lyetropliy,  210 

(Ifhnilinn  f>f,  213 

dvstrophui  a<li|K»M))^iutalu,  212 

oii(ili>«.v  of,  213 

jietliugt-Deeu  of,  213 

poiti-trnutnntie,  213 

^mptoiiiH  of,  214 

tapprinji  huiitl  at  udolcwwiit,  212 
Tlyporcbisimis,  liifl 
HyiiDthyiroeo!,  174 
Hyiiotbyruid  oousiipaiion.  U<0 

diBlurtianef-,  laiiuKu  httir.  188 

States,  mild  nnrl  mixr^l,  188 
palbulniQ-  of,  IHl 

•Ijgina,  ptM!uao<p(phyiNi>,  243 

type,  180 
rypothyroidinn,  170,  177,  186,  180 

therapy  for,  192 
Hyitou^nuii  of  upper  extmnitiu!,  61 
Ilyslfria,  7)2 

auuusukfi,  717 

uudety^  728 

conveiBion,  714 

diturlMin<!««  of  nuiiility,  710 
oi  Hctuiihility,  715 
vuried  Mimutic,  716 

e{)i«Klii-,  716 

huitory  of,  712 

disauciaiioQ  theories,  712 
n:|»ro(Hnun  lhe(ir>-,  713 

ttirriiiuiUiii  of,  713 

xtii^iintfl  of,  718 

syiupUiuiBof,  7t& 


llyHt<Tia,  nymploma  of,  viw^ral  of.  718 
Hj-st(rri<ml  beiniplc^ut,  aQ5 

phiotasies,  710 
HysUMe  graDde,  712 


Idioct,  884.  SSO 

Mic>-iiiil«^<Mli(v.  SSO 

l(liol-siivsnl-<,  UOl 

ltiil)Ocile.  8<t5.  IK)3 

IniU-rility,  SS4,  SSO 

ImpiXC'ncy.    St*  Psychonoiiit^wi. 

Im|iu1»ivf.     .Scf  ('oRipiilNHiii  iK'itmnB. 

Inct^nt  rnTnpk'x  in  cli'rnontia  pn^cDx,  S35 

l^\^ani3ts^n<  in  [wycdiuni'iinotr-s,  70<t 
IncjtmplcU'  or  minor  f'>rm  of  nruto  polio- 

i>ii(X'^pIttJotiiyWi1i»,  'too 
Incontinence.     .S^^  (j<?nito-urinary  ayn- 

ilroinL-H. 
InoriiiKltly  of  piipiU,  46 
Infatililf  iT-i\'hnu  pnby,  50O.  567 

Jii'n^litiiry  fnrni»  of  Hpiiuil  proRTW- 

■livt-  niK'Irar  atrophi*"*,  407 
mvMilfmft,  I7.'i 
InfftRlili^m,  222 
inftictioii  rlcliriuiii,  H8K 

psycliftst^.  aniK-  arttnilar  rheiima- 
liKni,  S43 
coniplications  of.  843 
oryBilMjliifi,  S42 
exiuithirns,  S4'i 
fcvir  ilelirium,  S38 
priptte,  812 
infention  aUil  initial  <lelirJuin. 

838 
malaria,  S42 
pIii'iiT  tin  Ilia,  843 
po»-(f<>l>rili?  iwychoses,  839 
pri'ri'itri)!.-,     fclirilt'    ariil    post- 
febrile jwniThtjswe.  S37 
IrratliiRlit  of,  .S42 
Inf««tion-exhaiw1ion  psyi-hosps,  S.17 
Infeoljoiui,  role  of,  in  mental  palholony, 

33 
Infectious  fcx-er  d«lin'um,  epilapliform 
rxcilonK'nl,  838 
inftx-ljotitii  dn'iiin  state,  839 
pM>ThoBO(,  typlimd  fevrr,  843 
Infcriiir  utlcrn.'itc  lutmlyxi.'),  478 
Influenza.  27 

eQce(>IiaUtie,  564 
nfuntix  iIiip  lo,  362 
InfornMiion    tn     nicnlnl    rxntniiintton, 

wrncml,  HI 
Infuiiiiiljular  syndromes.  217 
Inlu'rit.incp    io    iiii|{ioiioiin)lic    od^inu. 

chart  of,  156 
Iiiner\'alioo  of  breathing,  L28 
cardiac,  130 
of  digestive  tract,  117 
external    muacln  of  lower  extrem- 
ities, radicutar  and  peripbera),  70 


DigitizeObyGoOgle 


922 


mDBX 


Innervation  of  internal  muflclea  of  lower 
extremitiea,    radicular    and    per- 
ipheral, 71 
intestinal,  119 
of  lateral  muscles,  peripheral,  67 

radicular,  66 
of  liver,  spleen,  kidney,  227 
of  mechanism  of  swallowing,  118 
of  muscles  of  leg  and  foot,  74 
of  shoulder  girdle,  65 

joint,  65,  68 
which  turn  the  head,  274 
pelvic,  122 

of  salivary  glands,  113 
of  stomach,  119 
of  vasomotors,  129 
Inrotation  of  thigh,  test  of,  73 
Insanity,  meaning  of  term,  884 

not  an  entity,  29 
Insolation,  5C2 

Integrations  of  nervous  activity,  590 
Intelligence    testa,    relative    value    of 

limited,  93 
Intention  tremor,  78 

in  multiple  sclerosis,  45S 
Intercostal  neuralgias,  340 
Intermedius  nerve,  287 
Intermittent  claudication,  135 
and  neuralgias,  329 
thcnn»y  of,  136 
Internal  secretion,  glands  of,  99 
secretions,  99,  167 

action  on  muscle  and  connective 
tissue,  172 
on  spinal  reflex  arc,  172 
on  sugar  mobilization,  171 
Intemuclear  fibers,   oculorotary  paths, 

274 
Interruption     Byniiromea,     motor     and 
sensory  recovery,  373 
in  peripheral  nerve  injuries,  370 
Interstitial  bodies,  non-nervous  glands, 
99 
optic  neuritis,  visual  Gelds  in,  258 
peripheral  neuritis,  257 
Intestinal  innervation,  119 

worms,  32 
Intoxicants,  miscellaneous,  854 
IntoxicatiouH,  361 

Intramedullary  lesions  of  spinal  cord,  421 
Introversion,  717 
of  libido,  814 
psychosis,  814 
Involution  melancholia,  765,  866 

endopsvchic  cdnfhct,  869,  870 
internal  secretions  of,  868 
manic-depressive  jisychosis  and, 

868 
pathology  of,  870 

central  neuritis,  870 
symptoms  of,  866 
treatment  of,  870 
lodothyrin,  thyroid  hormone,  107 
Irritation,  syndrome  of,  377 


Jackson,  syndrome  of,  469,  470 
Jacksonian  epilepsy,  790,  800 
Jacobsohn's  reflex,  75 
Janet  dissociation  theories  of  hi 

712 
Joint  sense,  test  of,  86 
Juvenile  paresis,  660.  662 

congenital  <lisorder,  690 
tabes,  680 

congenital  disorder,  691 


Kalmdc  type  of  defectiveness,  81 
Keratitis  neuroparalytica,  112 
Kidney,  innervation  of,  227 
Kleptomania  a  compulsive  activit; 
Klumpke  palsy,  365 
Knee-neel  test,  79 
Knee-jerk,  76 

Knee-joints,  movements  of,  73 
Korsakow's  psychosis,  849 
Kroepelin  definition  of  paranoia,  7 
Krafit-Ebing   description    of    pai 
776 


LADYRiNTn,  destruction  of,  299 
Labyrinthine    and    cerebeUar    di 
ances,    differential    diagnoe 
296,303 
oculorotary  pathway,  275 
tonus,  296 
Labyrinthitis  circumscribed,  303 
diffuse,  303 

purulent  and  cerebellar  at 
303 
Lacunar  syndromes,  595,  596 
Landouzy-Dejerine  myopathy,  238 
Landry's  paralysis,  397 
Lange  s  colloidal  gold  test,  631 
Lanugo  hair,  38 

hypothyroid  disturbance, 
Laryngeal  disoraers,  304 
nerves,  diseases  of,  304 
paralyses,  organic,  56,  305 
psychogenic,  305 
larynx,  test  of,  57 
Lasi^giie's  phenomenon,  343    ' 

test,  87 
Latent  content  of  dieama,  96 
Lateral  sclerosis,  428 

congenital  type  of,  430 
diagnosis  of,  430 
forms  and  varieties  of,  421 
hereditarj'  familial  types  o 
history  of,  428 
infantile  types  of,  430 
mixed  types  of,  430 


Digitized  by 


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^^^^^^^^^^^^^/VD/fJt          ^^^^^^^^S^^^B 

^HjUlltfHil  udonNHM,  p»()i'>lofO'  of,  429 

Ijuwaiicr  t\i>t''  of  iHircflis,  ft59                        ^^^B 

^^V                   8Vtiipt<mi»  nf,  42^ 

UUk>')(  diMiu^-.  430                                           ^^H 

^B                   (fcntinpiil  of.  43U 

Livn-,  innrn'ation  i»f,  '227                              ^^H 

^B                    uiiilatcrni    luurnilinf;    and    di>- 

luiii-nfn'uus  glojid.  99                            ^^^B 

^H                         MX'ndiriK,   tyiws  of,  430 

lioromotor  aUuia.     See  Tfthrs.                     ^^^B 

^M     l^lissimui^  (loTvi,  tost  of,  61 

LoHK  thoracii-  norvo,  37S                               ^^^B 

^M     lyiiifchitiK  'n  mulliplc  sclerosis,  invtdun- 

Iavm  uf  tci>n.'4iili(jii,  tuHlx  for.  KR                      ^^^B 

■        Uity.  4o.s 

Love,  infantile,  for  fftmily.  TOO                     ^^^B 

^^     ]MVi  uf  tiiiticiimliuu,  83B 

Lowvr  i.'xl[¥initit«,  reflext«  uf,  76                  ^^^B 

iival«nch<>,  7S8,  780 

tc«C  of,  73                                         ^^B 

1^^     Lr-ad  m-urititt,  3W0 

fur  M-niniUlity,  70            «        ^^H 

^K             Pu1f>-,  300 

Lovi'8  iitai, )  12, 195                              ^^B 

^H                pdlHtJlliDft,  KA.^ 

Luutiu  tcKt,  tl30                                               ^^B 

^V     LcRpnd  fthbrcvi;ilions  ol  medullary,  pon- 

Lumliar  plexus,  343                                        ^^H 

^H          litK!.   jirdiinoiilnr   nnd   miilhniin   ttjii- 

iKMirHtRia.«,  34 1                                     ^^^| 

^H        dniiiMW,  465 

jmncturc  in  tumlv  IcpKimriiiniti tides,       ^^H 

^1     LtimiiiKciiH,  mmlinn,  SO 

.''^'i3                                                           ■ 

^B     I/<nA,  exaniinatinn  of  trophic  chanitcfl  in. 

in  iniiltipk-  i^rkrnsi.x.  457                   ^^^H 

■         40 

I,iimlHi-iilMliiriiiiL,tl  iteunilidjis,  340                  ^^^B 

^M     Ltiiliirular  iIoKprn-nitioii,  iirotcns'sive,  509 

Lunibdfiacnd  pii-xiis  psiby.  3<i7                        ^^^| 

^B     Lc]4oiueaiiigilidc-M,  aeute,  fi4t) 

Lungs.  nuii-iifrv')W  ulnmis,  W                               V 
LymphcicyU'S  in  riTi'linwimial  fluid,  Oljd               H 

^B                      rauw'fl  nf,  SM) 

^H                     cuuPM*  mid  |ir(>Kno(tui  nf,  S.'iS 

Lympbur^vtuaia  uf  cerebri >!:(pinal  fluid  ill              H 

^^^                    rriiniid  luTve  hIkiih  of,  952 

syphilis,  027                                                   M 

^^^H               headarlie  in.  ant) 

^^^H 

^^^^k            hyppn^lhraiR  in,  5S1 

^^^B 

^^^^1             LTT^i^ular,  5o3 

^H 

^^^^B             luinlmr  iniiiL'tiirc  in,  553 

^^^H 

^^^^B             rtflrxos  iif.  &A2 

MACCNDIS-nRRTVCifi  syndrnmr,  532               ^^H 

^^^^H            stifTnt^Ntt  uf  DL'ck  in.  SAO 

Mnceulk'.  Hyndnmieof  HnhinKki,  471            ^^^| 

^^^H           vyniplom?  of,  yw 

Maenofi  di?9cnptinn  of  ptirHnoia,  n^            ^^^B 

^^^^B                   ni»ntal,  f>.il 

Malarm,  H42                                                         ^^B 

^^^H             temperfttiin-  in,  .'i.^il 

Mammary  nouralRiH,  340                                   ^^H 
Mania.    .Sw  Manir-ileprL'Nsivi:  iwyclHnts.        ^^B 

^^^^■^            tn-ntini-nt  of,  iVM 

^M                   tiilH'rruloii-4  meniuftilis  in,  556 

acute,  731,  'nh                                                   V 

^M    LcptAtneniDKiti".  M9 

ilpliniiUA,  751,  T5t>,  757.  H40             ^^fl 

^H            ntironir,  T>K> 

757                                             ^^^B 

^H            difTfrt-ntial  diftftnosia  of.  557 

&fanio-4lvprei«ive  paychoais,  740                    ^^^B 

^H           epidemic  oer^lmMuinal    mcninftiUs, 

aeiiu*  niaiiiu,^7d5                                        H 

ainbivalem-viLiid  nmlHtentlrncy,             M 

^H                                     trcutriinnl  iti.  56lt 

7tVi                                                ^^B 

^H          inferiious,  &54 

chronic  mania,  757                          ^^^| 

^H           niulor  irritation  or  pamlytir  p|ie> 

rnnipmmiar  and  di-fi'iiite,  7lUl           ^^^B 

^H                TinrnTia,  JiAt 

ixmliniion^  Indh.  771                          ^^^B 

^H            nauwa  and  viiiiiilinK  in,  5,'jI 

ixiiiR«o  nnd  pniKurKiis  t4,  70H            ^^^H 

^H          eeroufi  nu'nitifcitis,  557 

cydoth>'niiBA,  762                             ^^H 

^H                          (rf  idcnhtilir  origint  557 

dysthymic  1>'pe«  <it,  763           ^^H 

^B           syphditir.  (J3<J.  602 

hyiH'fthvmic  typ<-»  uf.  763          ^^H 

^H                  iiK'ninuiti.'',  557 

paranoid  ly|irH  uf,  7tt4                        fl 

^B           trvatiDi'nt  itf,  hUH 

viscpml  dislurixincos  in,768              fl 

H            type*  of,  553 

ddirHiuB  Runia,  756                                1 

^B    IxiiioiiK  uf  nipdulk,  ponx,  hntin  fltcm 

acute,  757                           ^^M 

^B     .  ruid  midbniin,  HH 

ddusiona,  7fiO                             ^^M 

^B    Levels  of  iiiTvttUR  ai-tivity,  18 

depccfluvc  phase,  757                      ^^^| 

■     IJhido,  125 

acute  nielanchoUa,  758            ^ 

^fl            tntro\*pniinn,  171 

chrouii^  dopr(««inn, 'ifO              1 

^B           rtutrttii-o.  706 

depr«««ive  sttiixir,  75^              H 

^B           aexuol,  708 

simple  retiirdutiijn.757              ^m 

^™^            sublimation,  708 

differential  diimnoiH  of,  768            ^^^| 

Liguuentuti^  eiyiidruuR'«,  241 

dialrBrLibdiiY.  ^'k3.  755                    ^^H 

LignmrntH.     i-xnminaticm   -  i>f     trophic 

etnotionA]  exaltation.  754                ^^H 

rluuiici'S  in,  40 

etinlofty  of,  750                                    ^^^| 

Liglit  imicb.  K3 

t*xtrov«rled  type  of,  767                 ^^H 
lliKht  of  idnu  m,  753,  7fiS,  75(1              V 

LtpoDUttu  of  hrKtti,  fU)5 

Digitized  by 


Google 


924 


INDEX 


Manic-depressive    psychosis,    hypnotics 
in,  771 
hypomania,  751 
involution  melancholia  as,  766, 

868 
leveling  of  ideas,  756 
manic  phase,  751 
mixed  states,  764 
nature  of,  765 
pathology  of,  765 
»  periodical  types  of,  760 

physical  conditions  of,  768 
pressure  of  activity  and  speech, 

754,756 
prophylaxis  of,  772 
psychoanalysis  of,  772 
psychomotor  activity  of,  756 
smcide,  772 
treatment  of,  770 
Manifest  content  of  dream,  96 
Marie's  hereditary  cerebellar  atrophies, 

536 
Masochism,  906 

Maaseluii,  mental  examination,  91 
Mastodyniu,  340 
Masturbation,  33,  906 

auto-«rotic  phenomenon  of,  738 
cause  of  neurasthenia,  737 
function  of,  738 
genital,  not  only  tjiw,  34 
Median  lemniscus,  80 

nerve,  380 
Mctlidla,  80 

lesions  of,  464 
Medullary  syndromes,  466 

abbreviations  of,  573 
Melancholia,  acute,  758 
involution,  765,  866 
vera,  871       , 
Memory  in  mental  examination,  general 

and  s|X!cial,  90 
Mendel-Bechterew  reflex,  78 
Mendelian  laws,  28 
M<Sni^re-like  attacks,  299 
M^oi^re's  syndrome,  298 

apoplectic  form,  301 
Meningeal  apoplexy,  544 

diagnoflis  and  therapy  of,  547 
ctiologj',  pathology  and  symp- 
toms of,  544 
hemorrhage,  traumatic,  544 
Meninges,  diseases  of,  544 
Meningitis  forms  of  acute  poliocncepha- 

lomyelitis,  399 
Meningi  tides,  cerebrospinal,  549 
Meningitis  of  base,  syphilitic,  635 
cerebrospinal,  epidemic,  554 
of  convexity,  syphilitic,  637,  638 
hydrocephalus,  559 
serous,  557 

syphilitic,  557,  641,  661 
tui>ercui()ua,  556 
MeningoroccuH  inlraccllularia,  554 
Mcningomyelitis,  syphilitic,  6i85 


Menstrual  history,  34 
Mental  defect  as  failure  in  sublitnal 
708 

disorders  in  ancestry,  28 

examination,  90 
methods  of,  89 

symptoms  in  multiple  sclerosis, 
in  syringoencephalomyelia, 
Meroury  poisoning,  855 
Metabolism,  neurology  of,  99 
Metameric  system,  remnant  of,  101 
Metro-erotiflm  of  epileptic,  799 
Microcephalic  types  of  defectives,  8f 
Micromelia,  242 

in  achondroplasia,  241 
Midbrain,  lesions  of,  464 

syndromes  of,  573 
Migraine,  abortive  attacks  of,  137 

<»rebellar  symptoms  of,  144 

classical,  139 

diagnosis  of,  149 

early  symptoms  of,  139 

etioloB'  of,  137 

facioplegic,  153 

headache,  144 

hemiplegic,  153 

heredity,  30 

history  of,  136 

motor  disturbances  in,  143 

ophthalmic,  136 

ophthalmoplegic,  153,  154 

paralytic  phenomena  in,  144 

peycmc  disturbances  in,  147 

scotomata  while  reading,  142 

secretions,  147 

sensory  syraptoms  of,  140 

treatment  of,  149 

of  attack  itself,  152 

trophic  disturbances  in,  147 

vasomotor  disturbances  in,  146 

visual  phenomena  in,  141 
Migraines,  symptomatic,  148 
Miliary  plaques  in  senile  dementia,  S 
Millard-GuHer    syndromes,  .  478,     ■ 

541 
Millard-Gubler-Foville    syndrome,    ■ 

481 
Mobius'  symptom,  276 
Mongolism,  893 

cretinism  and,  892 
Moral  iml)ecile8,  904 

imbecihty,  886 
Morbid  fears.    See  Compulsion  neun 
Moron,  903 
Morphinism,  855 

Morvan's  disease,  syringomyelia,  284 
Motor  disturbances  in  multiple  sclerx 

454 
Mott  law  of  anticipation,  836 
Movements  of  ankle-joint,  74 

of  toes  at  interphalangeal  joints 
at  metatarsophalangKil  joi 
74 
Mucous  glands,  113 


Digitized  by 


Google 


IXDBX 


925 


Muooua    membranot,    exoininaLion     of 
trophic  chaitp!)!  in,  40 
involved  in  an|[ioneurotic  ed^ 
ma.  158 
MrtllprV  miwcJp.  109 
Multiple  Deuritis,  355 
alcoholic,  357 
neurotic  saDgrciie  of  skin,  164 
adtrrosis,  447 
a^  ID,  450 
ataxin  in,  454 
apoplR'*!  iform  An<l  oiMlci>t)form 

at  larks,  4.'>K 
Hfthiiwki's  ph4.TW»nH'[Mjn  in.  457 
liliulik^r  in,  457 
chamctorimlic  forms  of,  458 
duiKiiosijt  o{,  4fiO 
etioioK>'  of,  449 
eye  muwrlft  palsies  in,  453 
fnrial,  453 
Itnit  ill,  456 
hwtury  n[.  447 
iutctition  Ir^^mor  in,  455 
invrilinilAry  iHiifthinR  iind  rT>'- 

ing  in,  458 
liiintiiir  piihcturr  in,  457 
molnr  >iir<tiirl>finrr*  nf,  454.  455 

lIlllMrulltr  Mtrri|>)|ii>^  of.   I5ij 

iion-rlmrui'tfristie  furniH  ofj  459 
T>Bthol4)qB>'  and  pntliugciicsM  of, 

4lil 
pneuulo^a81  ric,  454 
pn>pi<»is  of,  4112 
sensory  phcnonicmi  in,  45B 
Sfx  in,  -l.'A) 
skin  n'rti'xc.'*  in.  45^1 
iffjuuiti^'  pHrMiH  in,  4.)ti 
tpwch  >liKriir>iiini-<<fi  in,  454 
syuiptouia  of,  I'lH 
nicriuil,  457 
oi^ular,  453 
olfactory,  45t 
opiic,  451 
UvU'  in,  4.54 
irnd'in  reflcxL-w  in.  457 
tlMTwpy  of,  -IM 
viu'ori>t>tor  aotl  iroptuo  sit;u9  of, 

4.'»7 

writinR  in,  455 
tiIuM4e  anii  nmnoctive  ijKfur,  action  of 
ink-rniil  wt-n-lions  upon,  172 
aouw,  lojil.  >A,  8ti 
Kvmiriinii',  22H 
MtucKfl,  anterior  |>enplwral  intMnvation 
of,  lU 
radicular  innervaiion  of,  02 
»f  anil,  68 

pranatioQ  of,  W 
(fpinal  KvnapBCiwt^enUi  of,  68 
MipinutioD  of,  A9 
.(...-.,....  .,f,  2-^»8 

I  ion  of  trophic  chaoicn  in.40 

'■      :   r-.   r,   tjO 

of  loot,  t»Mt  of,  74 


MuflcW    lateral  pnriphcnil  inncrvaticm 
of,  tt7       • 

riulinilar  innprvalion  of.  66 
of  Itg  and  futit.  innervntions  of,  74 
of  lower  exirpmilif*.  external,  inner- 
vations of,  70 
iutcruid,  imicn'nlions  of.  71 
rotary,  of  hra<l.  innervation  of,  1274 
of  abouMcr  i^inllc  and  jnint^  65 
of  thigti  and  biittocke,  xjMnalsynnpso 

segnu-'ntii.  72 
of  tlnunb,  60 
of  trunk,  test  nf.  69 
of  wrirt-joint.  69 
Miiomlar  atmnhii^  in  multiple  seleraaia, 
456 
in  ayriniioeiuvplialoinycilia,  433 
dyBtrofihiwt,  2'M,  404 
fornw  of.  2:t4 
pathiilngy   and    pftttioccuv   of, 

232 
symptoinH  nf,  238 
tmitaii'nt  of,  '23» 
pnwrr  of  upper  rsirpmilics,  61 
MujifulocuL-meous  nerve,  3tsO 
MuHnilospiniii  nr-rvf,  '.iS'i 
MitiLKin.  c-atatooic,  M9 
Myiustlioniti  K>^viy,  228 
Myutoniu  atrophiim,  231 
Myelitis,     tire  Mi'ninRi)myrliU-4,  Tumor 
of  spinni  cord.  Hyphilis  of  spinal  «iril, 
Couiprt»Hinn  of  nord,  Polioinyolilin. 
Myngonir  types  of  proRn'Msivo  muscular 

ntropKies,  404 
Myopnlliirs,  232 

distal  typo  of.  239 
fBcio-«aiiii]|i"huiniTal  typu  of,  237 
juvenile  forrn  «>f,  2^)7 
[>i!Clldo)iviN'rtnipliiF  tyi«r  of,  2^(5 
Myopathy.  f-nndoiiTy-iVjcriuo,  2as 

pec-udohyiH-rtm|>hi(%  23;i-ij7 
My^ilonin  atrophica,  230 

eanKcnita,  £itl,  2.'t7 
Myxcdcum.  174 

diaKUofiiK  nf,  INO 

fflilurp  of  (iHsitiaiUon  in.  179 

infanlile,  175 

akin  in,  174 

synixrtf'ins  of,  174 

types  uf,  179 


N 


N'ail  liitinfc,  32 

Naib,  exuniinution  of  iruphic  chAOga  in. 
39 

Xarctssism,  906 

Xarctwfuttic  Hxaiinn,  muse  of  drug  addic- 
tion, 855 

Xaroalc|»y,  792 

NarcolJcs,  use  of,  33 

Nerk,  59 

gyntpatliclic,  114 


Digitized  by 


INDEX 


02: 


Oculomolitr  nuckn,  InLsal  proiection  of, 

1270 
fuicittal  projenlinn  of,  270 
Oculopupillarv    filwis,  ucrvical  «ynipft- 
thelio,  110 
Ocuii)rotary  i>aths,  274 
ucfiudiic.  :f73 
rputral  wriHor>*,  'J75 
^m  trJKcniinal,  275 

^B  rochlfiir.  275 

^1  corlical,  274 

^H  iiilrrriiirlmr  liliore,  274 

^H         Uiltyriiil  hinc.  275 
^B  liTt(W|iiiiiil.  275 

^p  l<-icni*-ntum.  274 

wstibutar,  275 
visual,  275 
(Eilrinn.     Nfv  Kilnnin. 
(i|f«ct<>riu,-t  ru'iin)ri*,  247 
^  Olfuctory    iliiiliirtmitos,    ctioloio'    and 
^m  rlintont  Mgns  of,  246 

^B  IwOifi.  24K 

^B         jvrciitflrs,  r-xU'nl  of,  24(*i 
^H        nymptonui  in  nmltii>l<!  (sdntxiui,  451 
^H         tnui,  tliHcaais  uf.  24.*) 
^P  tmtmcnt  of.  24K 

^■^  IwyrlviRpni-siH  f»f,  248 

(*livo-}vmn*-<'cn-l"c!lar  atrupby,  534 
^^  Ophrhatniin  tiiiKrninp,  130 
^B  liiTiwIir  puliucs  and,  153,  154 

^H         p«yrh(Mi.4,  SU2 
^B  f  >|>lii:h»tmi>ptcgifi,  4K 
^B  olmmic  |)ni)£r««8ivi',  4(K) 

OpIitliHliiiiipfrcijis  in  enciephalilw,  565 
Ophlli;iliiM>p]i.-^ir  tiunriiitiv,  IXi,  IM 

^B  t>]>peDb«im    grait-tM    ttxtetMion  siipi, 
^B  51.^ 

^  rf  flM.  7S 

t>pp<pnpii*t  i»nllicis,  1M 
Optic  uKiHwia.  2G2 

iitniphy  in  1mIk-«,  251) 
nerve.  2.W 

oluin^v  in  bmiii  tiumirt),  HIO 
III  tahw,  075 
pnlhfl  «ud  thii-'f  I'oiinf^t-ljntu)  erf.  251 
milistiotui,  ilrxen<Tati(in8  of,  due  to 

geiiiculnK''  tii'lin>n-li!iBi>.  202 
etviiiploiikH  in  iiitiltiplr  f«nliTr»i»,  451 
ttwlftimi^,  p<Mition  cuul  nUaliitaK  of, 
582 
[Optical  dis(ur))ann<«.  eUolo|ctc»l  factors, 

lociiliuilintiH,  diiiical  injpia  of,  204 
[tlrnftn  iiifmonly,  QUi 
fJrpiiiie  iiir>>riunty,  015 
Oni-ntntion,  90 
[.OmtcitiK,  425 

ijffuniuuiA,  425 
[OslwMtlintifi,  -125 
[OHtmtiifilnrja,  243 
LOKteomala  of  l>niin,  005 
|Ostajpathifs.  241 
"  It  rotaion  of  iIukIi.  test  of,  73 
iricM,  Quu-u«rvuu«  gUuids,  00 


Ovenlel4>miinuU<>n  of  drfiitu,  00 
Oxycephalic  skull,  Sd7 
Oxyocplialy,  243 


pACHTWESlNfilTIR,  440,  547 

exli-rnn.  .M7 

I^TJcnropliJca  ccrvicjilin,  OSS,  OSU 
iuUnia  lu'iiKirrlLiKicii,  547 
cfmrsp  of,  .V4if 
liinitnusiB  of,  549 
hislor>'  of.  547 
occninviirr  iif,  .Vt8 
pftrh<>Iiig\'  of,  54S 
RjTiiptonis  of,  548 
therapy  of,  540 
siniplpx.  ii4'7 
Byphilitic,  002 
Pud.  tvst  fur.  70,  SO 
PallJAlion  in  Irniin  tiitnors.  020 
PuIIiilal  svsteiii,  primiir)-  atruphy,  ."((W 
Pttlmns,  im 
PoUies,  brachial  plexiu,  302 

hiilhtir,  rhninic  |)n)gmtt<ivc,  408 
in  wrobral  8)i>hilia,  042 
Rorlicnl,  2K(i 
eye,  45.  277 

ivntruj  (irifdii  and  Byrioiffimye- 

lic  fliiwociation,  209 
tsulutiil,  272 

muM-lc  in  muttipic  scleroma,  453 
in  puiitiui-  synilnitue,  439 
im-joilar,  27S 
LiryiifKal.  :t04 
nriilnr  m  Inlne,  076 
pwiwlic,  153 
peripheral,  300 

diMlinftiiitihed  from  niickar,  207 
facial.  2WS 

Hiir  iiijiirits,  370 
(ilexiis,  302 

Uunl  nerve.  208 

and  fourth  Den'ts,  mi^ihlic, 
636 
PaUv,  altdiiccn!',  .Ml 
Krl.H  iHrih.  ;«2 
Oxtcmal  rectus,  270 

in  ceivhral  -sy{>liitis,  44 
in  Uihes.  27G 
facial.  50 

in  lalx-s.  070 
fuiirtli  tKTVf,  271 
itifaniile  cerebral,  505,  507 
inferior  n»oI  lyim,  30ft 
Klumnke.  305 
Uteral  amnciated,  273 
niixnl  types,  305 
ppnphcnd  facinl.  'ZM 
peetiilntiiilliitr.  2SS 

from  a>-plulitio,  043 
sixth  ucrvo,  27L 


DigiiizeO  by 


.oogle 


928 


INDEX 


Palsy,  superior  brachial  plexus,  385 
thini  nerve,  266 
trochlearis,  273 

vertical  associated  lead,  273,  360 
Pancreas,  diseases  of,  227 
examination  of,  40 
non-nervous  Sjland,  99 
Pancreatic  infantuism,  228 

syndrome,  227 
Papillitis,  254 
PapiUomacular  bundle,  253 

course  of,  256 
Paracusia,  294 
Paradoxical  reflex,  78 
Paraffanf^lia,  106 
Paralyses,  orgsuiic  laryngeal,  56,  305 

peychoKcnic  laryngeal,  305 
Paralysis  agitans,  498 

attitude  in,  502 
course  and  progress,  504 
differential  diagnoeis  of,  505 
disturbance  of  equilibrium  in, 

503 
cl  iology  of,  499 
history  of,  498 
juvenile,  .505 
pathology  and    pathogeny    of, 

506 
I)sychir  diHturbancca  in^  503 
Iv«*ychotic  disturbance  m,  864 
nifloxcs  in,  504 
secretory,   vasomotor,    trophic 

disturbances  in,  503 
symptoms  of,  499 
sensory,  504 
therapy  of,  507 
trrmor  in,  502 
of  convergence,  276 
of  external  nsctus,  45,  439 
of  fifth  nerve,  279 
of  fourth  nerve.  44,  271 
inferior  alternate,  478,  479 
of  right  spinal  accessory  nerve,  307 
of  seventh  nerve,  439 
atrophic,  45 
of  thini  nerve,  270 
of  upward  eye  movement,  272 
Paralytic  tyiMW  of  defectives,  898 
Paranoia,  accjiiire:!,  776 
acute,  778 
attenuated  form  of  dementia  precox, 

822 
combinatoria,  776 
delire  chmnique,  775 
delirium  of  interpretation,  777 

of  revindication,  altruistic  type, 
777 
egocentric  type,  777 
delusion,  enort  at  adjustment,  780 
tlelusions  of  grandeur,  781 
of  jealousy,  781 
of  iM'rsccution,  781 
description  of,  775 
Kraeijclin's,  777 


Paranoia,  description  of,  Krafft- 
776 

Magoan's,  775 
S^rieux  and  Capgraa's, 

diagnosis  of,  781 

erotid,  776 

erotomania,  781 

expensive,  776 

group,  773 

hallucinatoria,  776 

homosexual  fixation,  781 

interpretation  of,  778 

Freud's  conception  of,  * 

inventive,  776 

late,  776 

litigious,  776 

not  a  disease  entity,  774 

origin  in  complexes,  779 

original,  776 

paraphrenia  confabulans,  7^ 
cxpansiva,  777 
phantastica,  777 
systematica,  777 

persecutory,  776 

phantostic,  825 

projection  mechanism,  780 

psychoaDal>'Bis,  783 

querulous,  776 

reformatory,  776 

religious,  776 

suspiciousness,  affect  of,  779 

treatment  of,  781 
Paranoid  states,  782 

t>'pcs  of  manic-depressive  psi 
764 
Paraphrenia,  777,  822.    Sec  Para 
Pftra])legia.    See  Myelitis. 
Paraaympathetie  system,  99 
Parasvphilitic  disorders,  643 
Parathyreonriva,  206 
Parathyroi'l  pathology  in  tetany, 

syndrome,  202 
Paratnyroids,  endocrinous  glanda, 
Parenchymatous  types  of  syphilis 
Paresis,  agitated  forms  of,  658 

alteration  of  emotiooal  acti\ 
649 
in  reflexes  in,  652 

Ammon's  horn  in,  646 

brain  atrophy  in,  667 

cell  degeneration  in,  666 

cerebrospinal  findings  in,  652 

character  alterations  in,  65(1 

convulsive  phenomena  in,  65: 

cortex  in,  664  ¥ 

cortical  changes  in,  648 

(rutaneous  sensibiUty  in,  6d0 

delusions  in,  649 

dementing  form  of,  653 

depressed  form  of,  654 

disorders  in  speech,  650 

expansive,  655 

eye  symptoms  of,  651 

forms  of,  653 


Digitized  by 


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^^^^^^^^^^^^^^rySS^^^^^^^^^f       929    ^W 

^^M'Wntia,  Kcncnil,  &13                                     PcripbcriU  polfios,  due  to  war  in{\m^            | 

^H       ~  fSroupH  of.  &17 

^H          impijvcrialimcnt  of  jJeas  in,  548 

irntutiun  .ivniromf)             H 

in, 377                                  ■ 

^H             irre^itar  I'oniiH  of,  i>.W 

ro^turation   sMulruioe            H 

^H                           Lia^aucr,  659 

in.  377                                  ■ 

^1             juvenilo,  mi),  Wi 

BtoKcis  of  n*co»*ry.  373            ■ 

^M            loHs  of  judgment  in,  649                                                     treatment  of,  37A                    B 

^M             ciintnr  incoftnlmalionft  in,  A50 

PerivoHcuUr  Kli"!*)^'  H7tJ                                        ■ 

^H             nciirolr>}ar-Al  ^gns  of,  650 

Fcrom»iMorcartn   typo  nf  npiuitl  utro-       ^^H 

^H              rciiiis^iiiMis  in.  G.'i'i 

pltiefl.  410                     ^^H 

^M           rvtvnUon   uiid   rnvmurv  dctecU  oT, 

i^tiinip  of.  412                   ^^H 

■                647 

•■liolosy  of,  410                 ^^^H 
p:iihitT7)g}-  uf.  413             ^^H 

^M            symptoms  oF,  &15 

^H            tubopaivHiK  in,  U5U 

Rymptouiii  of.  410              ^^H 
Pomiciotis  anninin  and  apjnnl  txtni,  387,            H 

^H            varatnolor  rrnil  trophic  diatitrbnnccfi 

^V                in,  6n2 

3ftN                                                                    ^^ 

^H             witli  Korsiik'tw  Ryndmrnt*,  566,  648 

Por^vtrnUim,  820,  H34                                 ^^M 

^B      I'nikiiiM>ti'ti     (liitcasc.       Sm     Furol^'sis 

Pc-til  uutl.  7DG                                                ^^M 

^m          ngiltinH. 

HhAniNir<it>s  winh-riilKllinR,  707                        ^^^H 

■      roniamia,  24fi 

i'nnitjd  gkind,  114 

rhantasy  tliinkini;.  707                                 ^^H 

Pliarnimv)tuft:i<'al  itsls  of  vegelative  per-           ^M 

Patdlar  t«iid<^tn  reflex,  76 

\i7U!?  t'V'^ten),  10(1                                              H 

Path  of  upiMwiUx,  7tiH 

Pharynx,  teisl  tjf.  55                                              H 

I'aihnlonicjJ  liiir,  ^f04 

PlHttiias      Sfie    .\nxipty    m-unMis     anil            H 

^_      Favor  iiocturaun,  7:}l,  733 

Cuiiipub-ive  m-iir<wi:^.                                 ^^^| 

^B     Pawlonr,  HtudieB  in  rvtu<iiun  of  veKelati%-e 

Phrenir  itfunttKi^t^.  HitO                                    ^^^H 

^m         mtrvous  8)'Btem  to  nwntAl  stimuli,  KM) 

I'li^'siral  cuiiiunution.  ■t.'>                              ^^^| 

PoctomI  mmclcs,  tost  o(,  04                               alniolunw,  inU'nvlfttuinship  of,  101             V 

Peclinree  chai-t,  23,  26                                      Pli^'aiajt-heuiii-ttl  uclivity,  19                            ^^M 

^K                      of  vongcniutl  xypliiitK.  31                        8>-MU?init,  99                                                  ^^^| 

^1                    of  defective  iniH^riutnx'.  23 

Pia,  dtscafies  of.  540                                       ^^H 

^H                      (if  UuntiiiKtun'H  E^haiva,  2*) 

Pia-ararhnui'l  liviiHirrliagc,  545                    ^^^H 

^M      PeiiuHcle  »>*ndromw.  4S;i 

Pilomotor  ?<yst4'm.  lfV3                                   ^^^| 

^B      Pfi<itiiu.'iilur  losiiins,  nruilvtiis  of  (tympUmis 

PiniKi],  f-xuniiuatioi)  uf,  40                               ^^^| 

^M                    n>xiiitinK  ririni,  402 

orttan,  diM^trii  of,  217                              ^^^H 

^M              eymlrrmie,  nntmnr.  4K4 

HVmlTORH-,                                                                 ^^^1 

H                     pdHlerior.  486  ' 

lumor.                                                     ^^H 

^B             synilronicii,  >'i7:{ 

Pituitaiy  Kliutd,  20S                                       ^^H 

^m      PutliiKrn,  S57                                                                fiwltntt  hyp<)pit*ii1anxin,  213          ^^^| 
^M      PeltivKr»iilii(liiii,  ^7                                      Plantar  extvoffiun  ijlieumnenoo,  77               ^^^| 

^m       Vp\viK  iiiiicrvuiion,  122 

He-cure. '.'{                                               ^^H 

H              ticn-^.  106 

reflux,                                                      ^^^1 

^1      I'mottiL-  pnUicK.  IM 

PIcxtiH,  bniL'hial  plan  of,  337                         ^^H 

■                     etifitoicy  of.  l^ 

lutflhftT.  343                                            ^^M 

^^^^^               fndoplrKic       and       licmiplngic 

luinlxMarral,  iH\T                                       ^^^M 

^^^^P             opiil  inluu>pli>Kic    nitfcnviiie    in, 

paiak*.  362                                             ^^M 

eaiim>  of,  3&A                                    ^^H 

^^^                  154 

HiosDoets  of.  367                             ^^H 

^H                    nyniptomsor,  1o4 

inferior  nmt  type  of,  30S               ^^H 

^B             TiianntotoriHilsim.  liM 

nuxcil  t)-p*^*  of,  365                        ^^H 

^H      IVripberal  ilislrilnitiui),  vcgelBtive  syv* 

Irmtnient  of,  3li7                            ^^M 

^1                 tern,  1f>2 

pudendal  plan  of,  342                            ^^H 

^H            facial  p:itD>c«.  288.  2m 

lUK-'ral  plan  of,  342                                            ^M 

^H                              gpnirulal«!  syiiitnime,  292 

Pnoutu[>Ra.<)tri(r  ilisturlmnresi  in  mullitile      ^^H 

^V             innerv'iitJDn  of  ntilfrior  DiiurjM,  6^ 

8clnt(wi)<,  454                                               ^^^1 

^M                Itwidlifi,  irtinrl:  nf,  2Wi 

PtiflUiniinui.  K43                                                 ^^^| 

^H                      (liCfcn-ntiiition  «f,  2fNi 

Poltoencopluilumyclitis.  566                          ^^H 

^H             nervefl,  RfTertions  nf,  H22 

iictitf,  3tt8                                               ^^M 

^B            lutein,  360 

''"  •"'■souf.  402                          ^^H 

^H                    due  to  war  injurit«.  37f) 

form  of.  307                     ^^M 

^^■^                          compiraqon  8>'n(Ironie 

UtKCsof,  402                       ^^1 

^^K                               of.  376 

illttt^lkOhili  uf,  400                                                        B 

^^^H                         iolcmipUuntfynilrunK 

incompleiv  or  minor  forms 'of,           H 

^^H                               in,  370 

3<I0                                                      ■ 

■                             ^ 

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930 


INDEX 


PoMoencephalomyelitis,    acute,    menin- 
gitic  form  of,  399 
polyneuritic  form  of,  399 
prognosis  of,  401 
prophylaxis  of,  401 
treatment  of,  401 
bulbar  and  pontine  forme,  397 
encephalitic  or  cerebral  form  of,  398 
hemorrhagica  superior,  565 
nervous  symptoms  of,  393 
spinal  form  of,  394 
superior,  566 

Wernicke,  548 
Poliomyelitis,  acute  posterior,  348 
chronic,  405 

spinal  form  of  acute  poliocnceplialo- 
mj-eiitis,  394 
PoljTnorphous  perverse,  906 
Polyneuritic  form  of  acute  polioenceph- 

alomyelitis,  399 
Polyneuritis,  355 
course  of,  357 
diagnosis  of,  357 
etioiogj'  of,  355 
occurrence  of,  356 
psychotic  <iisturbance  of,  865 
symptoms  of,  35G 
treatment  of,  307 
Pons.  80,  541 

hemorrJiage  of,  478,  482 
lesions  of,  464,  472 
Pontine  and  cerebellar  tracts,  descending, 
525 
facial  lesions,  288 
form  of  acute  polioencephalomyeli- 

tis,  397 
syndromes,  45 

abbreviations  of,  573 
alternate  hemianesthesia  of  tri- 
geminus, 282 
anterior  478,  479 

and  posterior,  268 
jntemal,  474 
cephalic,  473 
eye  palsies  in,  269,  439 
middle.  485 

Millard-Gubler  type,  478 
Millard-Gubler-Foville  type, 

481 
posterior,  480 
posterolateral,  475 
tracts,  descending,  525 
Pontomesencephalic  forms  of  progressive 

nuclear  atroi)hies,  409 
Popliteal  nerve  branch  of  sciatica,  384 
Citernal  and  internal,  lesions  of, 
384 
Porcncephalus,  898 

Postero-infcrior     cerebellar    syndromes, 
482 
longitudinal  fasciculus,  80 
Postfebrile  psychoses,  837 
Postoperative  jjsychoses,  862 
Pott's  disease,  420 


;  Prefebrile  psychoses,  837 
Pregnancies,  history  of,  34 
'  Presbyophrenia,  874 

couree  of,  874 
!         diagnosis  of,  874 
fasciea  of,  875 
pathology  of,  876 
similarity  of,   to  Korsakow's 
chosia,  874,  875 
I         treatment  of,  877 
Presenile  psychoses,  866 

anxietas  pneseniUs,  871 
delusional,  870 
I  depressio  apathetica,  871 

melanchoha  vera,  871 
j  physical  changes,  871 

'  Prison  paycuOTes,  905 
i  Progressive  bulbar  psdsies,  chronic, 
'         facial  atrophy,  285 

muscular  atrophies,  406 

amyotrophic  lateral  sc 
I  sis,  413 

I  bulbopontine  typea,  4t 

combined    sclerosis,    i 
.  bined  degeneration, 

'  compression  of  cord,  4 

fracture    and    disloci 
I  syndromes,  417 

lateral  sclerosis  group, 

]  multiple  sclerosis,  447 

neural,   neuritic   or   s{ 

I  neuritic,  409 

j  pontomesencephalic  ft 

of ,  409 
i  primary,  403 

syringoencephalouiveli 
i  432 

I         nuclear  atrojihies,  404 
'  spinal,  404 

^  Pronation,  C9 

i  Protopathic  sensibility,  79,  82 
Provocative,  Wassermann,  630 
I  Psammomata  of  brain,  605 
'  Paeudobulbar  palsy,  288 
Pseudoepiphysis,  190 
■         hypothyroid  sti^a,  243 
Pseudohermaphroditism,  221 
I  Pseudohypertrophic  myopathy,  233, 
Pseudologia  phantastica,  904 
j  Pseudotabetic  syndromes,  669 
Psychic  activity,  18 

disturbances  in   paralysis    agil 
503 
Psychical  disturbances  in  migraine, 

or  symbolic  syBtems,  705 
Psychoanalysis,  94 

analysis  of  phantasy  formations, 
dream  analysis,  744 
free  association,  742 
interference  of  repressed  compl< 

743 
length  of  time  required  for,  98 
technic  of,  97,  741 
therapeutic,  object  of,  98 


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^^^^^^^^^^^^^                  ^^^^B             1 

Ptnrcbntui  ttlysis,    tniiwifcrciiaT    pbenutn- 

Rnbim,  ?<vinptoiiis  of,  49ft                               ^^H 

cnon,  7-ttJ 

Irmlmriit  (if,  400                                         ^^1 

INyclioBt'ilii-  lifpnasioii,  WM 

Itadial  ncr\''c,  ditt'iuiPA  uf,  :1H2                        ^^H 

cmntiomil  fm-tnrs  nnil  nlU-rations  of 

ityn)|»loni.s  nf,  382                       ^^H 

piiVMii'al  atniclure«.  101 
Psychu  ogical  upe,  elnssificalion  or,  fW, 

trcataient  of.  ZM                     ^^B 

Ruilimlnr  inru<r%'utiun  uf  uiiirriiir  niuii-             ■ 

S87 

rlea,  «2                                                                M 

pByfhutH.Mjn>»4%  anil  actual  Dcuru»s,  71 1 

Radiciilit  iH,  3.11                                               ^^M 

conflict  in.  713 

acmiNirvtithcsia,  3^                             ^^H 

OS  failure  in  suLiliniatiui),  70S 

'lii)gmi»iK  uf,  35^                                          ^^^1 

hysteria,  712 

^ympt^imfl  of,  3^1                                         ^^^| 

l'pv<-hotK>itr(uu»  u  wiali-fiilfillinic  m^^lmii- 

tupoftTDpliy  »i.  in  aj-philU.  .TM                ^^H 

iKiii,  710 

trpiitmcnt  <kf,  354                                     ^^H 

I^Q'cliopattiio  mnstitution,  Wl 

Riidiciilu>£»niiJionic  tiymlruriic.  31^                 ^^H 

■  tcprewioii,  IH)4 

KAfliiiH,  }irri()^t<^jil  n-Hvx  uf,  75                         ^^H 

exsllntion.  904 

Runii  (.'omiiiunimDt4.'»  ulbi,  102                        ^^^| 

PoychiKKS  aMucialol  with  irrgnnte  dis- 

Ra>-nAU<rH  (liAeaw,  133,  134                           ^^H 

eancs.  8W» 

arutv  cliortti,  802 

nyitiptuitut  uf.  134                                ^^^| 

chronic  chon^.  S05 

trrainif'nl  of,  135                             ^^H 

^H                              h<-arl  ilisrasf,  .Hiir) 

Iti'altty  tliinkiuK,  707                                         ^^^| 

^^^H                          niiilti|ilo  «rknwi«,  >krl 

^^H 

^^^H                              punUyi'iF  nKiians,  .stil 

lied  nurleiiK.     Stf  Midbrain.                         ^^^H 

^r                                 piilyTiciinii^,  i>^ 

ItHlrx,  21,  124                                                 ^H 

^1           Oft  falluif  iit  mililiiiuitiiin,  708 

anal,  124                                                   ^H 

■           priiun,  !»).■> 

rtrc  (J  \*cp>lAli  v<j  nervous  Kvslem,  103              V 

^B           «ilualioii  uf,  1105 

blna<ler,  124                                                         M 

syphilitic,  Wil 

K<'uiUl,  124                                                   ^^H 

Psvc'hoacxual  dcvclopuieDt.  atttgea  of,  710 

]nil\is  ill  bulbiu-  reiiiun,  104                     ^^H 

^      IlimtK.  iiilnl'Tiil,  tiiinr*.  4K 

iu  wjni,  103                                           ^^M 

H           <frel>ral  sypjjilis,  2(j<l 

in  len4l*>n  in  mul(ii>]e  tivlvruiiis,             1 

^H     Pu'lfiiilul  uIl-xiu.  iii-umtgias  of  ihi?,  iMS 
■                   pkn  r)f,  342 

4.'i7                                                       m 

ivctal,                                                       ^^M 

^^    PupiUary   iocpuUilicK,    siRnilivanMi  far 

SITUtAl,  124                                                         ^^H 

^B               iituYtiiAi'KfUii  n)iil<>riiil,  110 

otcnu,  124                                               ^^H 

^1           iiinervatiaii.  ID!) 

9!nni>,  vulAneoti^.  8li                                ^^H 

^V            rcHexc^  in  tulMit,  Ii75 

of  hypcrnlKCflia.  325,  320          ^^H 

H     I'upiU,  inequuJity  uf,  40,  270 

Ke(lex£8,  7S                                                     ^^H 

H                li>Ht  III,  -lt» 

acixiinmntlatiiin,  47                                  ^^^| 

H     PvramidiJ  fibers,  rotirac  of,  2fi*i 

Aoliilli'^j^rk,  70                                          ^^^| 

■            lrai'1 ,  80,  81 

BiMitf.-  k-pUiim'ninKitidra,  T>5'Z                  ^^^| 

H                  aberrant  lilicm.  SI 

ainJitoiy-a.iclHculuns.  n2                             ^^^H 

^K                                    nw^lulltiry,  HI 

rliMinfC  rypft  to  ItK^tl-,  47                             ^^^| 

^^^^B                                tiwliillnponlini;',  SI 

corneal.  47                                                ^^H 

^^^^1 

doep,  7,1                                                    ^^H 

^^^^B                               pmp<T, 

elbow  or  triwi«-jerk,  7!)                         ^^^B 

^^^H 

cfpctiw  ml*,  (li.igmwtic  importuioc              m 

of,  ita                                            ^M 

^^^H           MirtinnRpinnl    uinl   cortinucWr 

^^^^P                |Mtrt  iiiiiii,  SU 

eye  patia,  47                                            ^^H 

^H^P            disUirlnincim  of,  in  churvo,  S)4 

in  syphilis.  631                                  ^^H 
JacobBonn's  nidiiu,  If*                            ^^H 

^PfVmniiuiiii,  <xitn|>ubi\'c  ucm'iiy,  728       ' 

■     * 

jaw,  soeezinR,  plutr)iig(>al,  281                 ^^M 

of  lowvr  vxt  n-'titil  iot.  70                               ^^H 

■ 

in  midiiple  scknwt.^,  156                           ^^H 

^H 

in  parc:^,  t>52                                       ^^H 

H  QI7AUEICKMIKAI.  txxly,  iutU->riiir,  487 

piinillnr}',  47,  280                                         ^^B 
railiiu  periosteal,  75                                 ^^H 

^M                  |KMt(-riiir,  41(0 

■  Qiimtiomioirc.  22,  24 

pii|H*riir.jal,  75                                               ^^^| 

^M 

supinator  jerk.  75                                    ^^H 

H 

Rvinpatttetic.  4S                                            ^^H 

■                     a 

in  s}rtnKorn(.-'.'i)lialormreltd.  440               ^^H 
in  (abos.  pupillary,  075                           ^^H 

^H 

H    It  IIIIDK,  41>l 

lL>ndon,  t>75                                       ^^H 

^H              ptltliril»|t.V  "f.    IW 

vrinking.  47,  2M}                                           ^^H 

Digitized  oy 


.oogie 


932 


INDEX 


Renon-Delillc  syndrome,  216 

Repression,  707 

Reproduction,  instinct  of,  125 

Eespiraton-  ajsparatus,  128 

Restiform  liody,  522 

Restoration  s>Tidrome  in  peripheral  nerve 

injury,  377 
Reticular  formation,  80 
Retinitis,  2.52 

Rheumatism,  acute  articular,  143 
Rheumatoid  arthritis,  244 
Rinn6'8  test.  52 
Roml)erg's  sign  in  tabes,  675 

test,  53 
Root  sepment  distribution,  352 
Rubrospinal  syndrome,  267 


8 


Sacral  autonomic  system,  104 

plexus,  plan  of,  342 

portion  of  vegetative  nervous  sys- 
tem, 100 
Sacrolumbar  types  of  syringoencephalo- 
myelia.  442 
Sadism,  HOli 
St.  Vitus'  dance,  513 
Salivarj-  glands,  innervation  of,  113 
Salvarsan,  700 
Sarcomata  of  hrain.  604 
multiple,  614 

of  cord,  multiple,  426 
Scanning  speech,  58 
Schizophrenia,  809 
Schizophrenic  group,  806 
Kchmiat,  sjTidrome  of,  469 
f^ciatic  nerve,  384 
Sciatica'*,  341 

clinical  forms  of,  344 

course  of,  344 

diagnosis  of,  345 

clcctrotlieraphy  in,  340 

ctiologj'  of,  341 

history  of,  341 

symptoniB  of,  342 

therapy  of,  345 
Sc'lfTiidernia,  162 

treatment  of,  164 
ScU-nises.  <ombined,  430 

senile  forms  of,  432 

toxic  anemic  forms  of,  432 
Sch'Fosis,  acute  disseminated.  449,  4.59 
'    !iniVMtrii])hir  lateral.  413 

(.f  brain,  tuberous,  SSS-890 

liitcnd.  12S 

multiple.  447.     Sic  Multiple  sclero- 
sis. 

primiiry  laicnd,  6.H0 
Sclerotic  tyiH's  of  dcfcrlives,  SSS 
Sciilomata  in  acute  a>dal  neuritis,  ccntrul. 
254 

ill  ln'iiring,  294 

in  migraine  while  reading,  142 


Scotomata  in  multiple  sclerosis, 
ular,  452 
test  for,  90 

in  tobacco  or  alcohol  axial  w 
255 
Seasickness,  302 

Secondary  elaboration  in  dream,  £ 
Secretions,  internal,  167 

in  migraine,  147 
Secretory  disturbances  in  panda's 

tans,  503 
;  Segmental  spinal  sensory  areas,  82 
Senile  cortical  devastation,  879 
involution,  normal,  872 
psychoses,  866,  872 

Alzheimer's  disease,  877 
'  intermediate  conditions,  ) 

presbyophrenia,  874 
senile  delirium,  874 
simple  senile  deterioratioi 
Sensation,  loss  of,  88 
Sensations,  spontaneous,  88 
Sensibility,  deep,  86,  370 
epicritic,  83,  371 
of  glans  penis  to  measured  prii 
of  ncr\'e  1  ranks  to  direct  prcssi 
protopathic,  86,  371 
scheme  for  testing,  88 

loss  of  sensation,  88 
spontaneous  sensatioi 
89 
testicular,  89 
Sensorimotor  activity,  18 
examination,  40 
neurologj',  245 
system,  245 

reflex  paths,  bulbar,  104 
in  eord,  103 
Sensory  dissociation  in  syringocncei 
myelia,  435 
disturbances  in  pandj-sis  agitan 
filjcrs,  three  systems  of,  370 
nervous  system,  examination  o 
.     oculorotary  pathway,  central, 
jjhenomena  in  multiple  sclerosL 
Serieux  an<l  Capgras'  description  o: 

anoia,  770 
Serous  meningitis,  557 
Serratus  magnus,  examination  of,  0 
Seventh  nerve,  285 

atrophic  paralysis  of,  45 
syndromes  of,  etiologj',  hicj 

clinical.  291 
test  of,  50 
Sex  inheritance,  alternative,  906 
Sexual  nneslhesin,  006 
liyptTcsthesia,  906 
instinct,  anomalies  of,  906 
invor.sions,  906 
organs,  124 
Ijcrversions,  900 
Siiell  shock,  862 

neiirosi's,  905 
Shingles,  348 


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^ ISDEX M3 1 

H    Sbcwk,  Oil 

'  Siiinnl  jioliomyelilii'.  atrophic  ^Iukus,  307     ^^M 

H     ShtH-lcA,  montal,  33 

form  of.  304                                        ^ 

^M     8hnitltl(!r,  L-uiiiiiiiiktiun  uf,  til 

Mtmity  disturbances  of.  390 

^^             Kirillc  inmirleM,  iiuii-rvHtioii  of,  ti5 

vcsWntive  invuhTtnenlsof.  390 

^B        '    jitiiit  imir^Ofi^,  iimtTvatiun  uf,  65,  OS 

progresBive  inUM-uUr  atrophies.  404 

■    "Shutm"<-li»r»arr,  tl04 

Arori*  Dui'luimc    lvp« 

^1     SinuB  thTxiiiibu-ii»,  tUM 

of.  *m 

^1                      rAvi-ni»ii><,  IKK) 

fhronie   pulioiiivehliii. 

■                      Inh'iai.  IXM^ 

40d 

^^^             lUHMteH^'ar  fli9Ciu)o  atiJ,  000,  602 

infiuilih'    hcrcdilary 

form  of,  407 

^^^H              Hymi'iloiiuj  of,  (*i(M> 

rtrflcx  uTL',  uctjuii  of  inlpniul  socrc- 

^^^P                 tJV)ttllt4'4lt  of,  iKI^ 

tioii3  upon,  172 

f^inmet,  vrrimiiH,  itl  iiriul.  liOl 

ruot  m*gin('nld  tuut  culiuiootu  refUix 

Sixth  craniiil  di-Tvc,  'i*V> 

r«n(«.  S»> 

]>alKy  of,  '/il 

9cn.<»r>'  oreus.  seicmental.  ^'2,  fQ,  83 

t«rt  of.  43 

^^yiiiptuiiu    in     muliiplL'     ii<*lurosi». 

Skew  (ifvialiou.  27*^ 

4on 

J^kin  (ii-ainlftw  iw  sjiiilMiUr.  KHJ 

xyoapsi:  M-Knicnlti,  mm  mu-^rhw,  08 

miiltiitlo  iii!Un)li('  (tauKicito  of,  163 
rcRcxes  in  nuiltipln  «J<>msifl,  4.W 

miisclw  uf  ihigh  anil  huU      ^ 

loeks,  72                               ^H 

(i>'ni|>tofua  iu  exophthalmic  Kuiler, 

9>'philH,  GSo                                           ^^M 

IW 

Spin>rlta-tii  piilliiitt,  0^3                                    ^^^| 

sy&rlruioM.  1()2 

Splci-d.  iiitK-rviition  of.  ;!37                           ^^H 

8kull.  fmrtun-  uf,  j41 

S)>on(lyliiisih  rlii/niiii-liriiie,  4^*j                        ^^^| 

Huicll,  l'>-*  of,  ■J4o 

SiHJiitaiii^uun  Miis;itiiiiii<,  S8                             ^^^| 

U«l«  fill',  Itl 

S[H)niiiii^  CMMinifiii,  1^2                                ^^H 

SoftcninR  in  spiiiiil  rohi,  14*1 

StaiiitiicririK.  3'i                                                 ^^^| 

iJpuKin  uf  uppiCr  L-xtrt-'itutit-s,  01 

Htudis  curporii*,  VJ                                           ^^^M 

SpiL^rcwvlic  Uiriii'olliM,  '.VK 

rnilppliniH,  80)                                               ^^^| 

Spnstic  ftactuie  Ktoup,  133 

I  lymolyniphaliciui,  324                         ^^H 
SlellwaK's  Bign,  196                                       ^^H 

ntiutio  tyitfs  of  conibinfl  <^;lr^MiH, 

«7 

Stor«0)eQo«u,  67                                          ^^M 

)i«niplcici:i.     .Sep  XTyelitU,  Moningri- 

Htomnch,   inhihitrd   through  splanchnic       ^^M 

myelitis.  Spinal  oonl  (umor. 

ncr*-c.  101                                                  1 

purvsi^  ill  iiiulliplf  M'lrnwts,  450 

innervation  tif,  MO                                  ^^M 

Speech  connpcliotw,  whctm*  of,  312 

sccivtory.  UK)                                    ^^H 

(lisortlpre  in  pun-His,  630 

lonLc  motor,  100                                ^^^| 

disturbanroM.  3)  I 

vaiKvui.  101                                           ^^H 

ill  i-4'rfhi'llii.r  liiifortler,  531 

DDiv-n<.T\-oiLj4  glniid.  M9                              ^^H 

^              rlifio'ul.  JI4 

Sforitw  in  iiiMital  HXuminnlion,  'jO                   ^^B 

^^B                    ileofni^.  314 

:itrfplO(s>ccm  virnJjuw,  M3                                 1 

^H-                      (1^..,,,.,.,,...   :,j., 

Stnicliiral  V!tn»tiiifi.H,  i nuimm&'^inn  of,  29             1 

^T                    ill  mull  1                <iH,  454 

Striiuipt'Il'H  acuta  «4icvirfitilitis,  5&!>                       1 

H               itl  iiteiitul  t"                 H,  ."i?,  1K> 

TL-rti-x,  "S                                                             ■ 

H      ijpinsl  arocwary  ncEve,  ;}7H 

Stuttmc^,  58                                                        1 

H                            «lii«ui»«»  uf,  300 

f-ubiwtivc    tfrliuiity    tinil    uiK'trUuiilv,             M 

871                                           ^m 

H                           psndysia  of  nid>t,  307 

■                           U«t  uf ,  SH 

Subliiualiun  of  libiilo,  70S                            ^^H 

^1            ecntL-rs  of  swpftt  sfcivtiiiiw.  101 

Sublinpisl  itlanil,  114                                    ^^H 

^M             c(>nn^rtiuiu>  uf  ccr^-bf-lhirti,  :AI7 

Submaxillar}'  eland.  111                                   ^^H 
•SulMtitiitinn  of  aflect,  95                                  ^^B 

^M              Vatii,  MlviUi  in%-nlvrvl.  3S7 

H                  ohiff  flytupixiuui  tti.  :iHS 

Suii^ido  in  luiuuc-dt-pnMiive  iHn'uhosid,            1 

^^^^                     pyiwlmmt'  u(j  ;jS7 
^^^B             BMwra)  (liiupiniliti  «>-inbuI  of, 

772                                                               ^1 

Suuatroke.  562                                               ^^H 

^H 

rrupi>Ki(!ial  n^ftuxoH,  "3                                      ^^H 

^^H             kttons  of.  380 

t^upioation,  09                                               ^^H 

^^^H             locAtiuti  of  Imion  of,  388 

{Supinator  longuit  jerk,  75                             ^^H 

^^^H                    of  fi%tnploTn3  at  ili/TcruRt 

t€«t  of.  04                                        ^H 

^^H                        k-v.^Hul,  iX 

Hupraretiul  body,  disaucB  of,  31S                 ^^H 

^^^H             iMirjticKl  (rr-ntmciit  of,  42-i 

Bvadromca  of,  21S                         ^^M 
■  Siiprarenab,  eiulotTinoim  ifJniiiU.  93             ^^H 

^^^H              «ynipnthitti<!  iiimloi,  lU'i 

^^^^L^^      lunKK-,  rtuuiing  conl  comiirai- 

cxMitioatioti  nf.  40                              ^^H 

^^^^K         MOD,  4:!0 

Suprftthnlamie  pftthwayit,  585                       ^^H 

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934 


INDEX 


Swallowing  mechanism,  innervation  of, 

118 
Sweat  secretions  of  spinal  centers,  164 

secretory  mechanisms,  164 
Swindlers,  904 
Sydenham's  chorea,  513 

pB)'cbotic  disturbance,  862 
Symbol,  21 

carrier  of  wishes,  95 
Symbolic  systems,  705 
Symbolism,  95 

in  dreams,  96 
Symbolisms  of  conflict,  811 
Sympathetic  and  autonomic  systems,  an- 
tagonistic actions  of,  108 
division,  106 
nervous  system,  99 
nuclei  of  spinal  cord,  102 
paralysis,  111 
Ijortion  of  vegetative  nervous  sva- 

tem,  100 
system  reflex  paths,  bulbar,  104 
Sympathicotonia,  37 
Sympathicotonic  activity,  tests  of,  HI 

drugs,  106,  107 
Symptom  activities,  812 
Symptomatic  migraines,  148 
Synapses,  central  or  spinal,  102 

mconstant  localization  of  distortion 
in  head,  103 
Syncope  in  anxiety  neurosis,  732 
Syphilis,  additional  tests,  eye  reflexes,  631 
Lange's  coUoidal  gold  test, 

631 
luetin,  630 

provocative    Wasscnnann, 
630 
biological    or    serological    tests    of 
blootC  625,  629 
of  cerebrospinal  fluid, 
625,  629 
cerebral,  640,  644 

abnormal  sleepiness  in,  642 

atrophy  of  tongue  in,  310 

dizzmess  in,  642 

external  rectus  palsy  in,  270 

headache  in,  642 

insomnia  in,  642 

psychical  disturbances  in,  642 

symptoms  of,  640 

local,  642 
vascular  types  of,  640 
cerebrospinal  nuid  in,  627 

cytological  examination  of, 
625 
trochlcaris  palsy,  273 
chemical  examination,  628 
clinical  forms  of,  633 
congenital  or  hereditary,  689 
effect  of,  689 
feeblc-mindedness  in,  693 
gencology  of,  690,  691 
hydrocephalus  in,  692 
pedigree  charts  in,  31 


!  Syphilis,  cranial  bones,  634 
I         diagnosis  of,  624 
I         first  rank  in  adult  diseasea,  32 
heredity  in,  30 
history  of,  621 
intermediary  forma  of,  621 
laboratory  findings  in,  628 
meningitis  of  base,  635 

of  convexity,  637,  638 
4)f  nervous  system,  621 
Nonne's  findings  in  cerebrospinal, 
in   paresis   or   tabopari 

629 
in  tabes  without   pan 
630 
parenchymatous    types   of    gen 

paresis  in,  643 
search  for  organisms  in,  624 
spinal,  685 
with  third  and  fourth  ncr\'e  pa!: 

636 
treatment  of,  694 
injections  in,  697 

general  scheme  of,  69S 
of  salvarsan  and  ncosal< 

san,  700 
of  solutions,  699 
intensive,  plan  of,  704 
inunction  in,  696 
I  iodides  in,  703 

mercury  by  mouth  in,  702 
oleate  of  mercury  in,  696 
Syphilitic  leptomeningitis,  639,  662 
i  meningitis,  557,  641,  661 

causes  of  interstitial  periph< 

neuritis,  257 
chiasm  changes  in,  261 
jwripberal  paltiies  in,  26G 
memngomyelitis,  685 

hypertrophic    cervical    pac 

meningitis,  689 
meningeal  symptoms  in,  6S( 
myeUtic  syndromes  in,  688 
pnmary  lateral  sclerosis,  6S 
root  syndromes  in,  687 
1  symptoms  of,  685 

system  syndromes  in,  688 
I         pachymeningitis,  662 

psychoses,  661 
j  forms  of,  661 

epileptic,  665 
hcreoitary    luetic    mei 

disturbances.  665 
mental    disorder    due 
syphilis  as  a  i>sych 
neurasthenia,  66t 
paranoid,   combined    w 
t^>es,  663 
without  tabetic  syi 
toms,  663 
pseudop^resis,  663 
iwycbotic  disturbances 
sociatcd  with  syphil 
cardiac  disease,  (>65 


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^^f                         ^       JlfDBX                     ^           ^5         1 

H     SyphiUUc  iwyubusvx,    fomu  uf,   reeeoi- 

1  Tabes  donsaliii  aud  ncuntli^c  juiitut  in,  3'2\)           1 

■                            btine     mnoic-doprctieive 

eiiDlog.v  and  (K-ctuTnii^  o(,  <i61)            ^^M 

1         external  rectus  palux-  in.  276               ^^M 

^^^^^^_             short     luUliiriDalory    ftyu- 

1         fomut  of,  6»0                                         ^^1 

^^^^^^B                 fuM^l  elsU%,  6D5 

1          liiiitoloicy  uf,  6S2                                       ^^1 

^^^^^^P            simple  IiipiJc  wmknisB  of 

hifitorv  uf.  665                                           ^H 

luiorl,  Otia 

iuvfuilc,  680                                          ^^H 
[ate,  tiH()                                                      ^H 

ri'liiiitiK,  252 

gymplairm,  32 

leHJiino  boalion  in,  (\M                          ^^H 

■    ly|ip»  of  lif-Jeotiviw,  IKK) 

inu.sriilnr  Htrophin^  in,  1)77                      ^^^| 

^-lUK'Ulur  (l)lHMiWS,  ti3<l 

optic  ittrophy  in,  250                                ^^H 

SypUiliMiuitti  or  bmiii,  005 

puitL-  in,  671                                               ^^H 

SyriuBobiitbia,_4*l,  142  • 

pHl  hoccni'Mh  of,  682,  685                      ^^H 
patlioiog;}'  of,  68'J                                      ^^H 

SyriniitM'rfccphiiloMi.vfliii.  132 

biiHtar  symptnm.-i  of,  -140 

pupillary  reflcxra  in,  675                         ^^H 

typra  of,  442 
CTTVirw  lyppB  (if,  4-)2 

rapi<l,  6^1                                               ^H 
Hotubt'i^'e  Mgn  in,  675                          ^^H 

chiU-iuUiristic  grtiupiiiRii  of.  443 

soiiKor)'  invulvcimrnl  in,  672                  ^^H 

CQunte  niiH  prupta-i-''  of,  441 

lot«  in,  rniliciiUr,  l>X7                       ^^^| 

difTor^nliul  dia^iositt  of,  443 

dove,  681                                                      ^^M 

(|iin«tiliim1ttir  typi^  uf,  442 

xtattonury  or  lH-ni)(ii.  fiSl                       ^^H 

his!..r>-  i>f,  4.f2 

f(>'llipfl1  lirT i(-  aijcn  in,  <>Sj                          ^^H 

diciiInI  syiiipltiiii."  of,  441 

KyiiipUiuis  ut.  670                                      ^^^1 

imiHcutur  aii-ofihiiTH  ami  oilier  trophic 

tetKkm  rcflexeij  in.  675                           ^^H 

c]iAiig4'8.  4:)5 

Irupliir.  677,  U78,  670                            ^H 

pHtlinRcny  of,  445 

\'iHiN>rn),  676                                           ^^H 

^m      pathology-  of,  44'i 

viHiuU  held.  259                                      ^H 

^^B     rrflfxra  of.  \Ht 

Tabetic  ooni,  ms                                          ^H 

^^^B    sorntluQibar  iyitt-A  of,  442 

rlianfti'n  in,  flsS                               ^^H 

^^^H     senMiry  (lii^tiK'iattoiiof,  4^15 

ty\)c  of  nmimt  iitropbicti,  113                  ^^H 

^^^P    R>'mpi'oni8  of,  4:13 

Tabo|>ara)is,  GoiJ                                                ^^H 

'           treatinenl  of.  44fl 

Taste  f1bfr»,  patliway»,  30S                             ^^H 

trophiti  rlLstuiliiutcos  of,  4^)7 

teet  of.  56                                               ^^1 

vitirtTHl  (iyni|)U)ni8  of,  440 

Tay-Sa<!lis  <liitai£f.  S88                                  ^H 

HyriiigomwliM.  2X4 

Tear  ^rU.  1 13                                            ^H 

licrtiiluviiil  alrupliy,  3&4 

Tcchoie  of  psyi-h(NuuityK)h-,  97                         ^^^ 

Mon-iin's  Hiiwuw,  'iM 

TeploKjiiTinl  oculorotftry  pjithway,  275                J 

whoniiUJv  repniM'iitution  of,  444 

Teoth,  cXBinitiation  of  tJDiiluc  rhiuiKGB  in,        ^^fl 

HyriiiKomyHiaB,  446 

^M 

t?yringoniyt4ic  co\Tly,  434 

Tegmeotiun,  8fl                                               ^^| 

mcdulJjirv.  pontine,  pcdunr^ulivrpor-            V 

tioos,  274                                                    1 

T 

Tundun  ri'lk-sm  in  multiple  srJrrustM,  457             1 

in  tabcfl,  675                                           1 

Tabkr,  605 

Teinlh  nurvf.  ti-st  of.  5.S.  50                           ^^1 

atuxia  in,  674 

Tcratotnata  of  bmin,  605                               ^^H 

gftit  tli^t  urbimns  in,  G74 

TfietJcles,  uott-nvrvniis  glands,  t^9                  ^^H 

bibt^nU  pUisiii  in,  4S 

Tetoiuc  sp&sm,  315                                        ^H 

blood  HTUtn  Butl  certibnwpuuLl  fluid 

produrvd,  200                                     ^^H 

in,  677 

Tetanus,  496                                                  ^^M 

eoiinc  aod  ^'ariatioQ  of,  C79 

TclAny,  202                                                    ^^1 

rrunial  nrn'**  tnvolvnn<<nt  iii,  675 

course  o(,  204                                          ^^H 

acoustic.  676 

diagnoais  of,  206                                  ^^M 
etioloRy  of,  203                                        ^H 

^^^_                           Argy]I->t«]l)«rt«ou  phc- 

^^^H                              nuiiienon,  675 

incidence  of,  203                                          ^^H 

^^^^^^^                   fwiul  pAlsy.  G7D 

putlii'lu^'  of,  204                                        ^^H 

^^^^^K                  ocuUr  piilbiifj. 

prognosis.  207                                          ^^M 

^^^^^^^H                  uptiv    iM^vc  c'lmii|EB&, 

■^tnitmprivn,  206                                          ^^H 

^^^^H 

^of,  202.  204                               ^H 

^^^^^^H                    Irigi-niiutu^  <176 

207                                        ^H 

^^^^^■^                  Mm»iti  wkI  «rc<»Hiry, 

ThitiitiiiK  .'Oxlronio,  &SI                                 ^^H 

■                                    67tf 

sriifior^'  diaujrhiini-e,  500                 ^^M 

■           criau  of,  671 

TliidMttus.  m                                                 ^H 

■          (Uiifi)Ofl»  of.  6S1 

disenso  uf,  261     ^-^                                   ^H 

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«:»; 


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Tlirniial  RpnftftlkHi,  IMl  for.  79 
TIiImI  ncrvi\  2G5 

fi\^u^»  tint's,  2G7 
pftralvsii*.  'J70 
trat  of,  A'A 

'lliomric  liimhRr  {urtion  nf  tlin  vcgrtib- 
1  ivc  niTvoua  s^tjicd,  100 
nerve,  lonii.  'SIS 
Tliruinbufiis,  5(6 
Thrombotic  soriotiinn,  S8l 
Ttittml)  siickitiK.  -t- 
T^lJ^ml.'«,  224 

vxAiiiiiml ion  of.  tit 
iioii-ncn-iius  eirtiiilii,  jjft 
Tliyreopa)  liiee,  173 
■fliyrt^isfs,  173 

etiology  ftnd  patholoier  oj.  VW) 
furnie  uiid  diiiKiH***!"  ui.  '^!0U 
Thyroid,  173 

i-MUiiitmtidli  ijf,  40 
prodiicl,  pM'iii)(>i<]ii])li>-atii,  10(1 
slatvtt.  uulil  loxit;,  195 
tlwrnpv,  lOli 

(■ff«!|fr  «f.  (HI  skoWon.  176,  177 
in  iiifiintilp  myu^lpiiiii.  175 
m  sfwriKiir  crc'tinisni,  1S2,  193 
in  tdtHfiv.  'J04 
Thyrofcis,  ("Qdooriti'ms  (•lands.  99 
Til-  (iuuluuri'ux,  "iSl.  S'S2 
Tira.  79 

in  coinuulHioQ  n*urowie,  725,  727 
ccirlirai  und  )i«ych()Ki4iir,  30fi 
facidl  p6voh*»yi"nio,  iHS 
Tiiuiiliw.  -Mi 
'I'.t'  ("rtwision,  77 

moveriivntji,  74 
'I'lirittnc.  Atrophy  uf,  310 
'IWticoUia.  s|>juwodic,  306 
Tuueh,  U(^t,  >a 
Toxemias,  CK-i-u[niiion,  33 
Ttixic  ptiyrhoacs,  H44 

alcoholinn.  M4.  See  Aloofaoliflu. 
brnmidi<a,  ><5.S 
carbon  iiionoxiflr,  H55 
miriiiiic,  S54 
diab(^j-»  nwllifiii*.  So6 
(toirtro-iiitwtimal  lUtteiiiM'^  8fl7 
ePiHTul  mnsidiTnljoiu  i>f,  SS5 
lead.  S55 
nH*ri'wr>',  S5j 

mi<t<-rll»n(y>iiiii  intoxiruits,  854 
oiiiiiiii,  .S.U 
IX'lhiKm.  ^7 
uroinia,  S^d 
TmnsfpiT'nw  in  i»9>'choftnidysiR  716 

ft  umvoraaj  [ilieiKiiuL'nou.  747 
Tni|M>aiun,  H"s1  of,  01 
Trnutiiatio  typ<«  of  deJoctivea,  SO* 
TrniiiutitiRin.  SiH) 

fdiTt^  of,  in  nervous  oyBlcm.  801 
)>c>rlii)a(>.  Mil 


'  TiBLututLum, 

«!■ 

!>»»['•  I 
past-(; 

fthr^n  - 

tl: 

Ir.    ■■■ 


-  W-J 

r, 


St'iin 
tifT 
Tnyiior  in  < 
in  pur ■ 
Trenion*,  7'> 

of  t«>iif(ut>,  57 
TrfiM.nrtna  pnllitla.  623.  GftH.  6^ 
ill  iivuni.  1192 
in  t.ilM'v.  000 
Triprjis-jork,  75 

Itvl  nf.  tu 
Trident  han.I,  .i   ' 
Trigciiiiuiil  rfisi; 
r.i r  i, ii,^ 
hc-n 

iKriii'  .  ,     .       ,  _ 

nrn-c.  .V.s 

(Iisnua4*«  of  mntoT 

of  «rtViiri->  part, 
Ittiphir  di.'4t<irb(Uitr« 
m-iirnUci-t.  332 
nfuriliit.  -JUi 
Trigitiiiiriit^,  -tS 

nll^rntil**  Iiciiiia- 
rcutrol  |u>l.hi:i  nf    i 
motor  |j«t  ijf,  -iJi 
niKlt^ar  di.'Hf:uw  r>r.  2SO 
puUi»»>  vrbrml.  JUl 

«ii»orv  I 
ftvini."..-  ....UipJc«-*i-n-i 

Tr>N-|ilci'  -JTii 

Tn>j)litr  'I  n  I'l.t..,}.  40 

in  drmi.i  i;* 

in  bair  wmt  u^uia,  39 
in  Ifos,  40 

in  U(nun^nt-^,  mtwrJrai, 
in  niii<-«iti9  tnv 

iu  ^k.in,  :i*t 

in  «>Tirtgp»noeph»lcuiivi£] 

437  "  ^ 

in  trtih.  TO 
diaturh^ron  in  micruBf,  147 
III  iMimlvBis  BiptHU.  fi03 
te*l  for.  SS 

in  thyniKl,  tmt  fur,  40 
stttuH  in  niutUpJe  ffrlercMU.  1S7 
Tropifiui^.  20,  21 
Troiuenui  -4  pnuiU.  3^5,  .1X1 
Trunk  iwi-m*  3<i 

inu"  ■  '■•'* 

Tiibciv'tl  n.  005 

Tuln-n^itl'-.-.r.    ,.,.,  —  •  runil 

4W 
Iirmlirv  of,  .H 


mu«rJnB,faH 


037 


'roiin'i'  fif  bruin.  Vm'i 

.11  !ui-.ii-yiiWM.  film 

;tin*  ni-'rniil.  ft()l) 

ciin'iiKMiiut.1,  Wi 

ciinliiip  nii'l  n-^piMlory  figiiB  of, 

(■^ntrnl  <-<-iiivi>luiii)nH.  ftl3 
rJilurutuiila,  ■jM4 
riuinliiiim  ul  bu0e,  UOJ 
clKickimatft,  tUJ4 
4MrpiiH  ntil<LHiiin,  tilH 
■  liagiiiHi.4  of,  '>]D 
fiM|i)t|i<>l>tfiiiixtn,  (MM 
«-tii»lt)«>  i.I.  )i*>:t 
fihniiimlu,  ti(M 
fn>rital  ).>lu-.  HI  I 
icliiiiiiutii.  *M,i 
BMSamn,  CttA,  tilM 
htfulju-tK-  ill,  IH>7 

lulxjix'tilumnln,  1105 
meninpvAl.  till 
nienUtl  saefxfi  in,  609 

lot^HlUiiiK  valnouf,  010 
mctiibolic  (lmiiir)>iiiut-H  in,  009 
inolor  pbcwmtonb  in.  tilll 
nHUSCH,  vomiline  aiiii  ilisztnms 

in.  0(18 
noiiniJtIminuUa,  004 
orcipitii)  Itibr,  617 
uplir  iit-rvi-  cIihiiuvk  in,  tilO 

thiiltinni.''  in.  Glf) 
piunfetWi'  i'\hlit-.  UNj 
finrii'i.'il  totx-s,  616 
pruKiKMLs  u(,  Olt) 
Riircomiitn,  (M)4 
sytuptutii^  of,  WXi 

fiTal  or  l<w:i),  Oil 
B<-n<Tul.  Oi»0 
F\'phitiinmlii,  (Kt^j 
U^iilMinil  Uihot.  CI5.  010 
UfiiUrx-nl  of,  Q-A) 
true.  003 
c<^h>bcILir,  :i87,  53S,  539 
i-prdxTlloiMinriiip  nngliv  \i'2 
(-crettrul  iii<i|Ui>litv  itf  p(i]>ilB  in,  40, 

270 
«jf  (ounb  vcnirk'li:.  Ml 
u(  hv.....  *. 

.ifl. 

will 

(wt  uf,  ,)9 
TyplrtiiJ  fovrr,  J7,  S42 


ii.:>it  nui  (nim  rqirntiUin,  707 


1115 

SIX) 

f  crtrhi'llum,  018 


Upper  pxlrcmil Uk,  cuuniunliun  of.  5tl 

Uniiuia,  S5d 

UtcruR,  non-nervoiu  itland,  99 


VA<;ripAn;^i.YTic  (Inyp,  lOB 

V:i|;i)><[iitNtk-  druits,  100 

VagntoiitH,  37 

VnKutuniv  (r(>ntnirti(m  of  woptmgtiM.  tl-^ 

ilniKs,  108,  107 
Vaguaiipcvc.  101,  105 

cliii^f  n^m-w-nlntivr   of    autti- 

nomic  ^vMimi,  100 
rttnii-liirp  of,  117 
test  of,  5S,  50 
Viilh'ixV  [winix,  324,  asa 
Van  Frey's  bain.  »4 
Vascular  Hp)mriitil«,  V2^ 

clistiimanci-ji  of  bmin  diwtue,  572 
instability  of  rm-hrAl  v««Mk,  £7-1 
typ(Tft  nf  Bjlihilii*.  610 
VoaonKitor  diBturbuiii't-^  in  iM>nil>-8b  n^i- 
lans,  WA 
iMt  for,  S.S 
imtAbility  KTonp,  Uto 
nvurosts,  130 

t^ign-N  ill  tiiiilliplo  wrIprORia,  AX7 
Va«omotor9.  innervation  of,  120 
Vcgi'Uilivf  arlivify,  18 
ticn'otif*  s>'Htpin.  Ifl 

ctintraJ    cuiinfctiaiu    ami 
im-ipliuiid    dislrtlMilion. 
1U2 
and  nitnnrous  n>flcx  tonrs, 

W>,  S7 
ili.itributi'in    uf    division.-*, 

107 
I'xaiiitnatinn  of,  37 

circulatory  signs,  37 
tTuiiiul  uutunomiu 
Hiitns,  38 

ruUUIL-UUlt    HlgUA.    37 

dipcrtivoBijiiwi,  3S 
KPUttu-uiiiULr^'  siitiK, 

3H 
inn  iiholif*  ripWt  37 
nwpimlory  si^s,  37 
ti'tU-x  jwtliB  in  conl,  103 
n'lntton  Id  eilti-iiia^,  lIMl 
rolationnhip  to  affectivily 
lUid  :unbivalt3irv , 

mi 

lu  .-inaptly  lartiv  plH<- 

tir>[uur)n.   100 
n-itb  oirti-x,  101 
mnnnni  of  (ptnHlionic  or 
niMaiiicrii;  aynUHii,  |U1 
muintliiio',  HI,  00 
or^tns  of  ey<.  10!» 
akin  «yndroiiira,  lt>2 
Ventricle,  tumonof  tliv  fuurUi,  .'rll 


938 


IXDKX 


\'ertipiil  a8soc'iatt>d  piilny,  1*73 
N'crtigo,  53 

in  anxiety  npurosim,  732 
in  cerclHuiur  ditionler,  529 
N'ertigoee,  vostibtiliir,  298 
Vwrtibiilar.  cerchr-il  paths  of,  301 

dirtturbii-  ■  -■.  in   niultipln  8i;len>(«b), 

454 
nen'c,  29fi 

test  i)f,  .■)! 
nystaRiniis.  i)2'.) 
oculonttiiry  patbwiiy,  27o 
pathways,  iIi-xciLses  of,  292 
vortJEops.  29S 

nonnier'n  syndroms,  3))0 
trcHtnu'nt  of,  301 

of  sfiisickncss,  302 
N'iaceni   of   tlie   pclvib,    inncrvntion    of, 

101 
\isceral  m-iirolocv.  19,  W 
Viswwily  (listiirbiiiii'c,  iJ72 
Vision.  (;i)lor,  41 

(listurl)iui('o  (if,  bv    Imllct    wmind, 

13 
field  of,  t«>st  of.  42 
Vittiml  !in]>iiratU!',  discuses  of,  2oO 
fiolu  in  taljOH,  2i)f) 

with  diffusr;  neuritis,  2ri9 
fields  in  axial  neiirilis,  257 

in   interMtitiiil   iwripbeml   optie 
neuritis,  25S 
oeulorotiiry  pjitliway,  27.') 
Yon  Ciraefe's  sinn,  1!)5 


W 

Waunsinn,  deprcHuive,  S70 
War  injuries,  pfriphcral  nfr\'0  pain 
Wftflsormann  rciietion,  625,  620 
in  tribes,  fi77 
reaetions,  eonKeiiituI,  30 
test.  imiKirtaiice  of  tcelinic  ir 
Weber-Gubler  syndrome,  54 1 
Weber's  svudmnie,  4S3,  4H4 

test,  52 
Werdnijt- i lofTniann    lyjx'    of     mi 

atrophy,  404 
Werner's  "artifieial  memory,"  44 
Woniickc'a  heniiaiiopie  pupils.  47 

)X}lii>cneephaiitis,  5W>.  (i4S 
Willis,  cirrlc  of,  Ui't,  n7'2,  573 
Word  blindness.  320 
(■orlieiil,  321 

.-.ubi-orlical  or  pure,  321 
desifnens,  320 
Wrilini;  disturliaiices,  321 

in  multiple  selerosis.   15;> 


ZlEllicv,  ine[>t:i1  e\:iinin:itinlt,  01 
Zona,  3  tS 
Zoster,  dorsal,  3."iO 
ophthalniie.  3.")0 

symptiiTiiiil  ic,  3."iO 

zone  of  the  ic('iuciil;ili',  21>lJ 


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i41  JeUiffe,   S.   ^.      45383 
"48     Diseases  of  the  narvcus' 
.917  system.      2d  ed. 


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