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^00  P^s^w ";''■' ''Sir. 


JSTeryous  Diseases 


AND  IHBm 


DIAGNOSIS: 


A  TREATISE  UPON  THE  PHENOMENA  PRODUCED  BY 
DISEASES    OF   THE    NERVOUS   SYSTEM,  WITH 
ESPECIAL  REFERENCE  TO  THE  RECOG- 
NITION OF  THEIR  CAUSES. 


BY 


H.  C.  WOOD,  M.D.,  LL.D., 

MEMIER    or    TBE    XATIOKAL    ACADEUY    Or    BCIXKCK. 


PHILADELPHIA: 

J.   B.   LIPPINCOTT    COMPANY. 

1887. 


.    .   ..  Copyright,  1887,  by  H.  C.  Wood 


'87 
887 


TO 


Stogiom  JOHN  S.  BILLINGS,  U.S.A., 

MOEU  rmnaat  or  untOAi.  nxuoaKunnu, 


THIS  BOOK 


18    KB8PKOmn.LT   DXOICATKD,   AS  AH  ACKNOWI.XDGUEIIT  THAT  fnTHOtTT 

BI8  SXLr-SACRlFICIirO   LASOBfl   IT  VODLD  NOT  HAYK  BKKN  FOS- 

StBLK    TO    IT8   ADTHOR,   AND   AS   A  TOKEN  Of   THZ 

VARUSBT     FSB80NAL     ATTACBUENT 

AND   SBTSXU, 


THE 
PBOPEBTY 


By  way  of  apology  fur  again  lr€K]ias!jing  upon  ttie  patience 
of  the  proreesion,  ifae  author  of  (lie  present  volume  would  say 
that  llie  work  is  founcUtI  upon  a  hospital  service  continuous, 
except  for  one  !?hort  perio<l,  for  tweuty-five  years.  Of  this 
service  6fkeen  years  were  spent  in  the  medical  u-ards  of  very 
large  military  or  civil  gcnernl  hospitals,  while  for  the  last  ten 
years  nervous  wards  io  the  Philadelphia  Hospital,  aggregating 
one  hoadrcd  and  twenty-five  beds,  and  the  nervous  clinic  of 
the  Moapitol  of  the  University  of  PcDnsylvania,  comprising  over 
five  hundred  new  cases  annually,  have  been  under  the  cbat^ 
of  tbe  author.  In  his  youthful  days  he  al»D  served  as  resident 
physician  in  an  insaue  asylum,  and  more  recently  be  has  been 
couneded  with  several  such  institutions  as  a  consultant. 

Notwithstanding  this  experience,  the  author  would  aot  have 
ventured  to  add  a  uew  book  to  the  already  long  list  of  treatises 
upon  nervous  diseases  had  be  not  been  strongly  ui^ed  thereto 
by  Bomc  of  bis  former  pupils,  who  insisted  tliat  the  metlio<l  of 
teaching  whieh  had  been  gradually  evolved  tn  the  weekly 
clinics  of  the  University  Hospital  was  difTerent  from  that  cora- 
mimly  io  vogue,  and  if  followed  out  would  give  freshness  to  an 
old  subject. 

The  defects  of  the  work  are  perhaps  better  known  to  its 
author  than  they  will  be  to  any  of  its  readers  or  critics,  but 
they  are  not  the  result  of  lack  of  honest  effort,  and  if  the  kindly 
judgment  of  brother  practitioners  »ibould  by  any  chance  bring 
the  work  to  another  edition,  whatever  oritiuism  it  may  receive 


6  PBEFACE. 

will  be  thankfully  accepted,  thoroaghly  weighed,  and  duly  acted 
upon. 

Id  conclusion,  the  author  desires  to  acknowledge  his  indebted- 
ness to  Dr.  Qeoige  £.  De  Schweinitz  for  mnch  assistance  rendered 
in  varioas  ways  and  places,  but  especially  in  the  anatomical  por- 
tion of  the  book,  in  the  chapter  on  Eye  Symptoms,  and  in  pre- 
paring the  index.  Thanks  are  also  dae  Mr.  Joseph  McCreety 
for  his  extraordinarily  intelligent  and  suggestive  reading  of  the 
proo&. 

CiriTKBSiTT  or  Fbknstltaku, 
Jutouy  1, 1887. 


CONTENTS. 


INTROOUCTION. 
Ocner»l  OiaeuBtioa  of  i^Msse,  and  of  ^vurulbenift 


17-22 


OHAPTEB  I. 

DetMtton  of  PBrktyib. 

PUMCTJOXAL  Pitnts,  inclading  K«llcx,  AMtimH,  knd  n^raterical  Pnl- 
tim. 

Okoaxi''  pALKiEiK.  Osntral  PaUifs,  incUiding  Uyttttrioal,  Alcoholic,  lo- 
(ero)iu«ot,  Cerobritl,  Pona,  Bulbar,  and  Lenticalar  Fables.  Hemi- 
pUgia,  including  Spjuftl,  Cerebral,  Corpus  Strislum,  ThAlamua 
Optici,  Pons,  Pacial,  CroMod  PaUj-.  Parnplegia.  Functional  Parn- 
plvffis.  iDcluding;  Keflex,  K«nal,  and  Uy*Uri<»l  PantpleRiB.  Ur>;iuiic 
Fnraplcgia,  divldiKl  into  Al>rupt,  SubauuU),  and  Chrunlc  Purap1<-gia. 
Abrupt  Paraplegia,  including  Apoplexy  inio  the  cord  and  intu  Ita 
m«mbranM,  llnmatomjditit.  Subacute  Paraplegia,  including  Pnln- 
fbl  ParaplagiK,  Aicending  Paral}**!),  Acutn  Central  Aryuliliii,  Mul* 
tipic  Nvujiti*.  Tran»«-er»»  Slyeliti*,  Cerviciil  PBchym^iningitin. 
Chronic  Pnraplegla,  int^ludiug  Chronic  Ujelllii,  Spasmodic  Tabu, 
Amjotrophic  Lateral  Sclvrovis,  Uullipla  Spinal  Sclerotia.  Mvno- 
fiUffia,  inchiding  HystcrJoal  Monoplegia,  Double  Monoplegia,  Cere- 
bral Monoplegia,  both  Abrupt  and  Frogrossive,  Peripheral  Mono- 
plegia from  pn9Mur«,  m*  in  Crutch  PoJrj-,  from  diieonu  of  the  nervM, 
and  from  poiton.  Multiple  Fa/^y,  divided  into  Cerebral,  including 
Sypfcitlttc,  Sclerotic,  and  Spontic  InfnnLilo  Paralyiit,  and  Pcrlpli- 
era),  including  Diphtheritic  ParolTeis,  Potiomyelitia,  Local  Mus- 
cular AirophiiM^  Joint  Atrophia,  Toxmntfc  Pcriplioral  Pahics,  Pi»- 
greoBive  UuKulat  Alruphy,  *ud  Pseudo-Hyperlrophie  Paralysis. 
£«oaJ  Paraijfuu,  including  Ooulo-Motor,  Trochlvar,  Trigominu*, 
AbdncCDi,  Facial,  Olosso-Pharyngenl,  Spinal  AccMiory,  Long  Tho- 
racic, fiub-Scapular,  Suprascapular,  and  Clrcumtlox,  AnUnrior  Thct- 
racic,  Mu*cukxCulan(H)u*,  Mu*culo-Spir»l,  Mediun,  Ultiar,  Spinal, 
II io- Hypogastric,  Ilio-lnguinal,  Int«rco«lal,  Anterior  Orunl,  Ob- 
turator, Superior  and  Inferior  Qluteal,  Sciatic,  External  Popliteal, 

iDtvrnal  Popliteal,  and  Poet-Tibia)  Nerves 28-M 

1 


8  OONTENTB. 

CHAPTER  II. 

MOTOR  EXCITEMEirrS. 

VAau 

Gbnerai  DiscuBsion,  including  deflnitione  of  Convulsions,  Spasms,  Choreic 
Movements,  Tremors,  Automatic  Movements,  and  Contractures. 

C0NTDL8IONS,  including  Epileptiform,  Hysteroidal,  and  Tetanic.  Epi- 
UpHform  Convttlwms,  including  Idiopathic  Epilepsy  in  its  various 
forms,  Reflex  Epilepsy,  Convulsions  of  Childhood,  Pleuritic  Epi- 
lepsy, Cardiac  Epilepsy,  Organic  Epilepsy,  Convuliions  from  Cere- 
bral Hemorrhage,  Epilepsy  in  General  Paralysis,  Toxnmic  Epilepsy, 
and  Urnmia.  Hyaieroidal  Convulaum,  including  Minor  Hysteria. 
Tetanic  Convulaiona,  including  Hysteria,  Tetanus,  Trismus  Neona- 
torum, and  Tetany.  Local  Spaama,  Spasms  of  the  Muscles  of  Or- 
ganic Life,  including  (Esophageal,  Rectal,  and  Urethral  Spasm, 
Vomiting,  Nervous  Cough,  Phantom  Tumor.  Spasms  of  Volun- 
tary Muscles,  including  Laryngismus  Stridulus,  Occupation  Neuro- 
ses, Cortical,  Hysterical,  Inflammatory,  and  apparently  Causeless 
Spasms,  also  Facial  Nerve  Spasm  in  its  various  forms,  and  Spinal 
Accessory  Spasms. 

Tbemobs,  Senile,  Toxic,  Paralysis  Agitans,  Multiple  Cerebro-Spinal 
Sclerosis. 

Chobea.  Oeneral  Chorea,  including  St.  Vitus's  Dance,  Reflex  Chorea, 
Chorea  of  Pregnancy,  Hysterical  Chorea,  Rhythmical  Chorea. 
Local  Chorea,  including  Paralytic  Chorea,  Chorea  of  Stumps,  Habit 
Choreas. 

CoNTRACTUKES,  including  Cerebral,  Infantile  Paralysis,  Meningeal, 
Neuritis,  Hysterical,  Lateral  Sclerosis,  and  Thomaen's  Disease. 

Automatic  Movements  during  Chorea  M^or,  Psychical  Automatism 
and  Miryachit 96-179 

CHAPTER  III. 

EEFLEXEa. 

General  Discussion,  dividing  Reflexes  into  Superficial  and  Deep. 
SuFEBFiciAL   Reflbxes,  including   Plantar,  Gluteal,  Cremaster,  Epi- 
gastric, Erector-Spinal,  Scapular,  Palmar,  and  Cranial. 
Deep  Rbtlezes,  including  Knee-Jork  and  Ankle-Clonus        .        .  180-198 

CHAPTER  rV. 

DISTURBANCES   OF   EQUILIBRATION. 

General  Discussion. 

DiHTOBBAHCic  or  Co-Ordimation  ;    Loss  of  Co-ordination,  including 

Locomotor  Ataria,  General  Paralysis,  Multiple  Neuritis. 
Titubatioh,  including  Cerebellar  Aff'ections  and  Rotatory  Movements. 
VxBTiQO,  including  Organic,  Cardiac,  Epileptic,  Hysterical,  Peripheral, 

Special  Sense,  Toxsmic,  and  Essential  Vertigo  ....  194-212 


CONTESTS. 


CHAPTER  V. 


THOPIHC  LE3ION6. 

rjiOM 

OoBWfcl  IHMUuioo.  ctlritllng  Idiom  Into  Acuta  DMtructlre  wid  Chronic 

Aexrtm  DKMHrcrnrK  LEtilOMii,  including  l>«Rubitiis,  ParfonkUng  Ulner, 
sad  Acule  SytntnstrJcat  Oangrene 

Cbbosic  Lnions,  includint;  tho««  of  SkJD,  Bone,  JoiiiU,  Huicl»,  Mil 
KwTOu*  SjrBtom,  u  t««a  in  rariouB  diwaaec  sod  poisonint^;  also 
OloMo* Labial  Paliyand  ProgrcMire  Foetal  Hemlatroph;.        .  2I3-S51 

CHAPTER   VI. 


SBXSOAY   PARALVKIS. 

0«naral  DitcoMion,  Indudlng  MiidM  and  Intlramonu  of  TesUojt. 
VucvKAL  AuMBjnMttKS.  including  Ttmwl,  Reoiuru,  Vagina,  and  Blad- 

d«r. 
CDTAVKOtra  AxMHTBOiix,  Hystorioal,  Paychio,  Organic,  and  Toxomlc, 

inrltiding  MfttAllnthcTapj. 

iOwiAyic  Ax.«ATaEHiAs,  iticludiiig  Oen«raI  Anastbetia,  Haroisnawthviia, 
Cro»«d  Panlyelt,  and  the  L«GionB  wliiofa  produce  tbetn. 
Ohoaitic  Fk&xsjBsrraKstA. 
Obsakic  Mokoakaatdssu. 
IiOCAE.  AitfarSBaiAa,  including  dbinuiion  of  varioiu   norv»^i«tribu- 
Uon» 252-280 


CHAPTER   VII. 


JTyptrieaihtMa,     including 


Oenllalia, 


BXALTAnova  OF  S£KaUnJTT. 
0«n«rml  Dficunion. 
HTfiKjurBBBtA.      Hjftterital 
Kr^uu,  Joint*,  and  Baolc. 

PAKJMTHtaiAB. 

Pais,  Nvuralgio  TcmparamtnL  Paint  in  th<  Kx&emtiits,  including 
Gouty,  Neurhlc,  Uetallk,  Spinal,  I^ouralKic.  Trunkal  Paint,  Ro- 
flex,  RbeumaUc,  Toxttmiv  Paini,  Girdle-Painii,  alio  R{:ctal,  Giutrie, 
Int«etJnal,  Geaital,  Laryngeal,  and  Cardiaa  OHa«a.  Read-Pairu, 
Toi«mic  Iloadiich«,  including  lUioumatic,  Lithnmic,  Urvmio, 
Alooiiolic,  CaSelnii-,  Gaatric,  Diabetic,  Cardiac,  and  Pulmonic. 
BfmpatfiHie  Htadachea,  including  Eyv'Strain  and  Niusl  Ueodacbei. 
JVrraouf  BeadMhta,  including  Anmnlc,  Con^MliT«;,  and  nyst^rical 
UesdachM,  and  Mif^rainfl.  Faee~Fain»,  Neuralgic,  KeBez,  Meurilic, 
Pr.»opalgic Xei-816 


10 


OTNTBJPT8. 


CHAPTEE    Vm. 

OUrrURBAIfUEB  OF  TUB  SPECIAL  SEKaGS. 

V 

nemiKO,  iQcluding  Nervous  Dearnns  snd  ll;per(eaLhcii&. 

SioBT.  Moremenis  oj  the  Kyt,  Including  Stnibliimm,  Sofandftrjr  nnd 
Prim»Ty  Doriation,  Simplfl  and  CroMfld  Diplopia,  FalM  Projeclion 
of  tbft  VUual  Field,  Paralyii*  of  Oculo-Molor,  Triicblfar,  und  Al>- 
dac«nii  NervM,  OpbthaicnnplngiR  Intu-nti  and  Externa,  AfM>cUt«d 
Oeuliir  ParaljrsU,  Conjug&leil  Deviniluii  lyf  Head  and  Eyos.  Internal 
Ocular  Omditiotu,  inoludioK  Choked  Disk,  Atropbv  of  the  DUk, 
IrregiilDrlttcM,  RefloxM,  and  olh^r  r)«ningeinonts  of  tho  I'upfl, 
Ajaaurusit,  Viaion,  Indudini;  Method  of  Tescjnte,  Functiunal,  Or- 
ganic, and  Toxnmir,  Heiuian(i)>iiin  in  iti  vnriniix  rnrma. 

'i'AiiTB,  includios  HyperieGtbwia,  AmeethesJa,  and'Ilallucinitlloiis. 

Shell,  including  HjpsnMlhesU,  AnicstliCiiii,  and  Balluctnalioiu    .  S17-S66 

CHAPTER  IX. 

DI80RDES8  OF   MEMOBY   ASP  00XBCI0U8HB88. 

Qenernl  DiocuKMon. 

Word-Meuoby,  locludlng  Aphonia,  Apba^mla,  and  ApbuU  In  all  Its 
fomiB;  bKo  Word-BlindncM  nnd  'Word-Dfiafn«ae. 

OiKXiLAL  Ukuort,  including  ExaUallnn  and  Failure  of  Memory. 

OoRRKLATRo  l>i»0RDxa9  or  Hruort  AND  CoNscioosxies,  including 
LvM  of  P«noniil  Idvntily,  DouUo  PcrMtnallty,  and  Doulilo  Con- 
tdoanau,  or  Periodic  Amnesia,  also  Double  Perc«ption   .        .  867-176 

CHAPTEB  X. 

DPK>RDGR5  OF  COKttCIOUSNEaS. 

Oeneral  Diacusaion. 

SvDDlx  LOBB  OF  CoNSCiou^KBSB,  Including  H^-steHcal,  EpilvptlD,  and 
Syncopal  Lou  of  Conscloutnou,  ^unttrckc  in  both  iU  form*.  Apo- 
ploxf  and  tTtiountcioua [i«s>  froai  Indire<:t  CauMa,  sucb  ai  Alcohol, 
Opium,  and  Urwmio  aod  other  poisonB,  nnd  from  Malaria,  Emo- 
tional ExciUiiucnt,  and  Acxile  S^siomic  Disorders. 

SlRkp,  iu  Dtiorderaand  Accidenta.    Abnormal  Wakejulrtat. 

Morbid  Slkxt,  inoliidliig  Ooma-Vigil  and  otti^r  afl'octlons  of  Blrt^p  in 
acul"  fever*.  Neluvau,  Tr»no«or  Lethargy,  Calalep»y,  Lucid  Leth- 
argy, Epileptic  Sloop,  RvRi'X  Uiicnmcioutnoat,  KarRnlTpiy^  Hyatorl- 
enl  Sleep,  Hypnotisin,  Sleep  during  liuaniiy,  Toxnmio  Sleep,  such 
«i  Urstmic  and  Diabetic  Cnma. 

Urqaxic  Stupor,  or  Coma.  Noa-SpeeiJU  Stuporoua  Affeetiona  toith  Head' 
acA(,  Including  Drain-Tumor,  Meningilii,  Pachymeningitis  lliomor- 
rhagicR.  Speeijie  Stuporoita  AJfeeOon;  Including  Fulminating  and 
gradiially-derelopcd  Syphilitic  Coma.  Orgronic  Sivporcut  Affeetiona 
without  Utada-che,  Including  Polio<*nci^pbRlUix. 

AoctDxxTft  or  Blrrp,  including  Sen&eShock,  Nigbt-PnUy,  Somnam- 

bulii-m,  Night-Terror* S77-419 


CONTENTS.  11 

CHAPTER  XI. 

DXBTTTEBANCBS  OF  INTELLECnON. 

General  DiscuBsion,  iaclnding  AbulU,  Hyperbulia,  Increase  and  Failure 
of  the  Mental  Powers,  Incoherence,  Character,  Hall u<u nations  and 
Illusioni,  Delosiona,  Imperative  Conceptions,  Horhid  Impulses  and 
Horhid  Desires,  N'ymphomania,  Erotomania,  Delirium  in  acute 
constitutional  diseases,  Classification  of  Inianity. 

CoMPLiCATUTQ  Ihbahitixs,  including  Acute  and  Chronic  Meningitis, 
Acute  and  Chronic  Periencephalitis,  and  Cerebral  Sclerosis. 

DiXTHSTic  iKBAyiTizs,  including  Oouty,  Epileptic,  Hysterical,  Syphi- 
litic, Alcoholic  (Delirium  Tremens  and  Chronic  Insanity). 

Pubs  Iksakities.  CompUte  Insanitiea.  Complete  Non-Periodic  Insani- 
ties, including  Mania,  Acute  and  Chronic ;  Melancholia,  Acute  and 
Chronic ;  Katatonia ;  states  of  Mental  Deterioration,  such  as  Organic 
Dementias,  Hebephrenia,  Senile  Dementia,  Dementia  of  Cerebral 
Shock,  Primary  Conftuionat  Insanity,  Stuporous  Insanity,  Terminal 
Dementia;  Periodic  Insanities,  such  as  Periodic  Mania,  Periodic 
Malancholia,  Circular  Insanity.  IncontpUte  IttBanitiea,  including 
Monomania  and  Mania  of  Cbaracter 420-492 

INDEX 49J-601 


The  primary  raeaniug  of  the  word  "dis«a»c"  m  \mn,  itneaKi- 
DBBB,  or  disUOB.  In  its  derive<l  or  sec»mkry  siguificaucc  it  is 
defined  by  Weleter  as  a  deviation  from  health  in  function  or  in 
stmctnrc.  In  rondern  medicine  the  term  has  came  to  have  a  still 
more  restricted  technical  meaning,  being  u&ed  to  signify  a  simple  or 
oompicx  pathological  process  which  is  complete  in  itself.  Thu»,  a 
simple  enleritin  in  a  (lis<'a»^) ;  but  the  enteritis  of  typhoid  fever  is  a 
part  of  a  oomplex  psithological  process  which  constitutes  the  dis- 
easc  known  ex  typhoid  fever.  When  the  term  disease  is,  as  it 
ought  to  be,  lued  in  tliis  oarrow  sense,  the  diseases  of  the  nervous 
system  are  far  fewer  than  the  number  usually  aflsigned  hy  standard 
BUlhoritietf  U}K)Ii  the  subject. 

The  symptoms  produoetl  by  patbologi^jal  processes  or  diseases 
depend  opon  their  scat;  and  whilst  it  may  be  nect^wiiry  to  con- 
sider acute  iuflanirnation  of  the  brain  as  a  diSerent  dfaeasc  from 
an  acute  inflammntjon  of  the  apinal  cord,  the  various  parte  of 
the  nervous  syetem  are  so  interwoven  that  we  cannot  draw  jinee 
between  tJie  various  aCTections.  Thus,  a  chronio  poliomyelitis 
affecting  certain  regions  of  the  medulla  oblongata  gives  rise  to 
the  8o-ealleil  glusso-lablal  paralysis,  but  when  ailectiag  the  lower 
portions  of  ihe  spinal  cord  it  proflucos  progressii-e  muscular 
atrophy.  Not  rarely,  however,  both  regions  are  siuiultaneously 
attacked,  when,  Ju  deference  to  an  uni^ientiHc  and  misleading 
nomGnclature,,lhG  patient  is  said  to  suffer  from  two  dif^tlnct  dis- 

C&BCS- 

Partly  led  by  considerations  such  as  those  just  stated,  and 
{lartly  as  the  result  of  the  exigencies  of  clinical  teaching,  in  the 
ooun>e  of  years  I  have  gradually  adopted  a  method  of  instructing 
students  winch  has  seemed  to  me  more  in  acconl  with  the  ever}-- 
day  needs  of  the  medical  practitioner,  and  more  apt  to  lead  to  a 
practical  understanding  of  diseases  of  the  nervous  system,  tbmi 
is  that  adopted  in  the  ordinary  treatises  upon  the  subject.     When 

2  17 


nprROOTTcmos. 


a  catie.  nfient  itnelf  for  examination,  the  physician  must  needs 
travel  from  the  symptoms  back  to  the  lesion,  and  not  from  the 
leflion  tf>  the  flymptomn.  He  does  not  any,  thiA  man  has  a  dot  in 
the  brain,  therefore  he  hax  hemtpl<^a,  but  he  begins  with  the 
paralysis,  and  passes  from  il  by  the  process  of  induction  to  the 
lesion.  Hitherto  the  authors  of  text-books  have  travelled  from 
the  IcsioD  to  the  symptoms.  The  present  treatise  is  an  attempt 
to  fullow  the  route  which  the  practitioner  must  pass  over  daily. 

Ucfore  entering  upon  the  discussion  of  tlie  individual  symp- 
toms |)rfKluced  by  diseases  of  the  nervous  systeiu  it  seems  to  me 
neoeasary  to  consider  the  anbjotrt  of  neuraMh^nia,  or  neroom  weak- 
vess,  because  the  symptoms  of  this  state  are  so  indefinite  and  fugi- 
tive that  it  is  almot^t  iinpot^ible  to  marshai  Cliem  into  order. 

Much  effort  has  of  recent  time  been  wasted  io  attempting  to 
make  of  neurasthenia  a  disease.  Tt  is  a  bodily  condition  which 
is  frequently  aaociated  with  various  chronic  disorders,  and  not 
rarely  coexists  with  perverted  functional  activity  of  the  nervous 
centres,  which  pervertwl  nerve- functions  maVj  however,  exist  in- 
dejiendeiitly  of  any  [lerceptible  neurafithcnia,  and  are  not  simply 
the  outcomes  of  the  neurasthenia.  It  is  an  habitual  foundation 
for  hysteria,  chorea,  insanity,  and  various  nervous  diseases,  but 
may  exist  without  the  guperadditiou  of  any  of  tliera. 

The  onset  of  iteiirastheiiia  is  always  gradual,  ahhough  at  times 
the  condition  appears  to  develop  with  great  suddenness.  Under 
these  circumstances,  however,  the  explosion  h.is  been  preceded  by 
a  long  train  of  more  or  lesa  overlooked  phenomena :  tbii!:',  a  gen- 
tleman who  had  long  suffered  from  the  premonitory  symptoms  of 
neurasthenia  wa«  one  day  seizeil  with  violent  vertigo,  acotmifianied 
by  such  prostration  of  strength  that  ho  had  to  be  taken  home  from 
the  street  tn  a  carriage.  The  sym])toms  vary  greatly  according 
to  the  portion  of  the  nervous  system  which  is  esjiecially  affected, 
and  also  to  some  extent  according  to  the  etiolog\'  of  the  attack. 
Nervous  exhaustion  may  in  the  l>eginning  afl^t  the  whole  of  the 
nervous  system,  or  it  may  be  at  lii-st  purely  local  and  coexist  with 
general  nervous  strength.  Many  cases  of  spermatorrlioja  are  in- 
stances of  the  local  form  of  neunusthenia,  the  sexual  centres  being 
primarily  affected;  but  as  in  ihcite  coses,  sooner  or  later,  the 
whole  of  the  nervous  system  Ijecomes  implicated,  so  in  other 
forms  uf  the  disorder  the  exhaustion,  at  first  local^  Gually,  if 


■ 


d 


neglected,  implicates  the  wbole  orgaoism.  There  ere  not  rarely 
aises  of  bniio>e:[t)austioi]  in  which  the  aymptoma  are  at  first 
purely  locsU.  Almost  always  the  onuse  of  a  local  neurasthenia  h 
cotoeniv«  use  of  the  |iart :  lhut<,  cerebral  aHtheoia  h  usually  the 
ratilt  of  mental  overwork,  sexual  asthenia  of  sexual  excesses, 
etc.  Whf-u  to  the  iiitellei^ual  fatigue  are  adilei]  the  depressing 
effects  of  excessive  anxiety  or  allied  emotions,  the  tiyraptoms 
from  the  first  are  more  general.  The  exhaustion  may  affect 
diiefly  a  single  function  of  the  brain.  As  an  itutance  may  b« 
cited  the  case  of  a  pwtal  clerk  under  my  care,  who  has  been  nc- 
oustomed  to  dii^trihute  five  to  eight  ihoutiand  letters  ever}-  day 
from  a  funeral  moas  into  three  hundred  pigeon-holes,  representing 
a«  many  post-office  districts,  scattered  over  a  large  territory.  As 
sooo  aa  the  address  is  read  there  luuiit  be  an  iiutautaneuuB  aulo- 
nuitic  recognition  of  the  district  to  which  the  letter  goes.  It 
is  at  this  place  that,  in  the  case  now  under  conf^idenitioii,  the 
Bymptoms  manifest  tJiemaelvcs.  Kca<ling  the  addi'&is  fails  to 
I»vduce  immediate  recognition  of  the  locality  to  which  the  letter 
is  tu  Ik  assigned.  Askeil  in  what  district  Bucli  a  ^Kj^l-f^iOu'e  is, 
the  clerk  answers  ioatautly,  but  seeing  the  addre^  hiin»clf  lie 
h<^tate6,  and  sometimes  balks  so  that  he  can  distrlhnte  only  about 
one-third  as  many  letters  as  w*hvn  in  health.  As  in  most  cases  of 
lotMl  nerve-exhaustion,  in  this  patient  some  evideiicef  of  general 
implicsuion  exist,  there  being  decided  dii^lurbauce  of  the  sexual 
organs. 

A  form  of  local  neurasthcnta  whirii  is  fn?qucntly  assoeinted 
witli  braiu-«xliau»tiou  is  writer's  cramp,  I  have  repeatedly  seen 
it  come  on  as  the  hemld  of  a  general  break-down ;  bat  under 
each  circumtitancee  the  symptoms  have  nsnally  not  twen  those 
of  typical  writer's  cmmp  :  there  have  been  not  so  much  marked 
■pamas  as  loss  of  power  and  distress  in  the  arm  on  attempting 
to  write. 

In  pure  brain-exhaustion  loss  of  the  disposition  to  work  is 
ttdoally  the  first  symptom,  the  sufferer  finding  that  it  conataiuly 
requires  a  more  and  more  painful  effort  of  the  vrWl  to  ])erforra  the 
allotted  task.  The  basis  of  this  difficulty  is  largely  loss  of  the 
{x>wer  of  fixing  the  attuiitiou,  and  this  by  and  by  is  accompanied 
by  weakness  of  the  memory.  Disturbances  of  sleep  are  fre- 
quent.    Various  abnormal  sensations  in  the  head  are  complained 


20 


IKTRODUCTIOX. 


oC  In  most  cases  tltere  is  uot  absolute  lienclache,  but  a  feeling  of 
weiglit  ur  fulucee,  or  an  indescnbable  ilistress^  usually  aggravated 
by  tucutal  eSbrt. 

It  is  trae  that  in  some  cases  of  very  dangerous  brain-tire  cere- 1 
bratiou  is  p«rfuriu«l  witli  extraonlioHry  vigor  and  ease;  the 
power  of  work  is  for  tbe  time  markedly  increased,  and  eveu  the 
quality  of  tiie  pi'oduct  may  lie  raisml ;  ttie  jiaLient  may  glory  iu  a 
wild  intellectual  exaltation,  a  sense  of  mcutat  power,  with  an 
.almost  uncontrollable  brain-activity.  It  is  probable,  however, 
I  that  theoe  oaaee  are  not  instances  of  pure  ueutuetbenia,  but  that 
there  is  au  active  congtattion  of  the  cortical  gray  matter.  It  ia 
certain  that  they  are  very  prone  to  end  in  wrions  organii^  bmin- 
trouble.  In  some  cases  of  cerebral  asthenia  there  are  disturb- 
anoeis  of  tbe  8[>ec!al  senses,  tinnitus  annum,  flashes  of  light,  and 
eveu  tlte  eveing  of  visions.  Under  these  circumHtauoeB  it  ia  agaia 
probable  that  active  congestion  of  the  atfeoLed  centres  exists. 

Severe  cerebral  neurasthenia  may  be  aswciated  with  good 
spirits,  but  usually  there  is  marked  depreasion,  and  tbis  pcrvcr- 
eioD  of  function  may  finally  go  on  to  decided  nielam-holy.  The 
will-power,  like  all  tlie  otiifr  functional  aciiviiieH  of  the  brain, 
is  prone  to  be  weakened;  morbid  fears  may  6nally  develop; 
and  at  last  that  which  was  at  the  beginning  a  simple  brain-«x> 
haustion  may  «nd  iu  hypochondriasis  or  tu»auity.  According  to 
my  own  experience,  such  ending  is,  however^  very  rare,  unless 
there  is  an  inherited  tendency  to  insanity. 

Disturbances  of  scnhation  are  common  in  neurasthenia,  these 
disturbances  taking  the  form  in  many  instances  of  itcltings  or 
formications  or  similar  minor  ills.  Neuralgia  ts  often  severe  and 
itf^  attacks  frequent,  but  X  am  convinced  that  sonietliing  more 
than  Hiniptti  nervon>«  exiiaustion  is  responsible  for  It8  prodAiction. 
I  believe  that  there  is  a  ucuralgic  diathesis  or  temperament  which 
is  oflei>  a>>siKrialed  with  nennu^tlienia,  but  may  exist  without  it, 
and  whicli  prulHibly  liut>,  »(  leuht  in  muuy  cases^  relations  to  a 
gouty  ancestry.  When  such  temperament  exists,  the  neuralgic 
attmrks  are  greatly  Hggnivateil  by  the  nmiing  on  nf  neunisthenia. 
HypersMtbe^ia  and  anaisthesia  mark  the  lino  where  simple  neur- 
asthenia {lasses  into  hysteria.  The  same  also  is  true  of  the 
jHiculinr  lenderntsw  over  the  spina!  prooeGaes  of  tlie  vertebne^ 
which  is  atiMTcially  frequeut  in  women,  and  is  the  chief  symptom 


INTRODCCTIOS. 


21 


or  tlie  no-called  itpina)  trntatioo  or  spiual  aDsmia, — au  aflTectiou 
which  I  believe  to  be  a  form  of  ncunu^theiiiii  allied  to  hystoria. 

In  neurasthenia  disturbances  nf  the  sexual  organs  are  very 
ODtDmon;  in  women  great  pain  on  raeitstruatioo,  ovariflo  irrita^ 
tion,  the  Bo-catled  irritable  uterus  of  Hodge,  are  closely  connected 
with  general  nerve-weaknei*.  In  not  a  small  pmjKtrtion  of  the 
QOseH  of  ntcriDe  disorderB  which  arc  loeally  treated,  1  believe  the 
lortl  di.4ease  is  largely  the  expression  of  the  general  condition. 
It  is  well  knovrn  that  masturbation  and  rtexiial  excess  in  the 
male  may  produce  an  exhaustion  of  the  nerve-centres  especially 
iaiplicsted,  ami  al»>  »  general  nervouR  exlinui^iion.  This  is  tlic 
common  history  of  spermatorrho^.  It  is  no  less  true  that  a  gen- 
eral neiirawtlienia  may  produce  a  local  weakness  of  the  ivexual 
centres,  witli  symptoms  at  leafit  resembling  thone  of  spermtitor- 
rhfm, — namely^  great  irriiahiliiy  of  the  »!xual  organs,  with  a 
practical  irapotena?  due  to  immediate  seminal  discharge  whenever 
coition  is  attempted.  I  have  certainly  seen  this  condition  result 
from  excessive  intellectual  labor  wheu  there  liaa  been  no  sexual 
exeees,  and  at  a  time  when  die  rausoidar  e>trengtli  was  Ktill  good. 
Saeh  coacft  may,  jwrhaps,  be  distingiiifthed  by  the  fact  that  unpro- 
Toked  eraiwions  are  not  neftrly  so  apt  to  occur  aa  in  true  sperma- 
torrhoea. 

In  cHsoa  of  ncr^'ous  exhaustion  the  efforts  of  the  diagnostician 
arc  chiefly  directed  to  determining  the  cause  of  the  exhaustion. 
In  a  very  considerable  proportion  of  oiwes  which  have  heon  sent 
to  me  as  saSering  from  simple  neurasthenin,  chronic  malaria, 
citronic  diarrhoea,  Bright's  dii^ease,  or  other  serious  organic  aflTeo* 
tion  has  existed  :  it  is  tlierefoi-e  eMwntial  that  in  every  case  of 
allegetl  neurasthenia  a  thorough  examination  be  made  to  detect 
latent  chronic  dbiease.  When  no  such  dt-i^efwe  can  he  found,  the 
cause  of  the  neurasthenia  should  he  recognized.  Lii  rai-e  cases  it 
develops  in  women,  without  j)erccptible  cause,  at  puliescence  or  at 
the  olimacteric. 

Overwork,  especially  overwork  combined  with  worry,  ami  even 
oontinQOUS  emotional  depression,  unaided  by  excessive  work,  are 
apable  of  produi;ii)g  a  pure  neui'astheuia.  Ak  Samuel  .laokAon 
wae  accustomed  to  any,  in  his  lectures  at  the  University  of  Penn- 
sylvania thirty  years  ago,  "  Whenever  the  expenditure  of  nerve- 
[itxxe  is  greater  than  the  daily  iucome,  physical  bankruptcy  raouer 


22  IHTBODUCnoir. 

or  later  results."  It  is  to  be  remembered  that  the  nerve-capital 
of  persons  differs  almost  as  widely  as  does  their  moneyed  capital. 
There  are  numerous  families  many  of  whose  members  are  neur- 
asthenics from  birth, — i.e.,  are  born  with  less  power  of  creatiag 
nervous  energy  than  is  necessary  to  meet  the  requirements  of 
the  ordinary  duties  of  life.  There  is  every  grade  of  natural 
endowment  between  the  most  feeble  person,  scarcely  able  to  pro- 
duce more  nervous  enei^  than  is  necessary  for  breathing,  eating, 
and  drinking,  and  the  organism  that  is  capable  of  enduring  in- 
cessant toil.  The  development  of  neurasthenia  is  therefore  not  so 
much  the  result  of  a  strain  which  is  absolutely  great,  as  of  a 
strain  which  is  excessive  In  its  relations  to  the  organism  which  has 
to  bear  it.  I  have  seen  not  a  few  cases  in  which  the  neurasthenia 
has  appeared  to  me  to  be  an  expression  of  premature  old  age.  In 
such  cases  the  rigid,  atheromatous  radial  arteries  occurring  in  a 
non^outy  or  non-syphilitic  subject  have  pointed  to  a  similar  ex- 
cessive ripeness  of  tissue  throughout  the  body. 


CHAPTER  I. 


PABALYSIS. 


Panklysia. — The  word  iwralysiB  may  be  eorrectly  omployed  to 
signify  lo»  of  nerve-function,  either  motor  or  sensory.  But  in 
the  present  volume  it  will  be  usetl  to  m«an  loss  of  voluntary 
motor  power,  tlie  term  anastliwia  being  em])loyed  to  represent 
sensory  palsy. 

Paralysis  may  be  either  |HU-tial  or  (■omplete :  a  partially  paro- 
lysed  muscle  U  ea|>able  of  contracting  with  less  than  its  normal 
force  in  rcspoD^e  to  the  wilt ;  a  completely  paralysed  muacle  is 
incapable  of  voluntary  movemeaU 

Ddeetiim  of  Faralyais, — In  a  cuae  of  supposed  paralysis  it  is 
nec««Bary  first  to  decide  whether  the  allegcil  loss  of  power  results 
from  a  true  paralytMs  or  is  due  to  other  eause.  I  have  not  rarely 
geen  a  patient  safTering  from  an  immovable  joint  diagnueed  as 
paralytic,  when  the  immobility  waa  the  result  of  the  tnilatnmation 
of  the  stnicturcs  around  the  joint.  Again,  loss  of  power  may  be 
the  result  of  pain  arreftting  motion,  a8  in  a  rheumatic  musole. 
Spasm  may  also  cause  loss  of  mobility,  and  sometimes  a  failure 
of  exeeution  supposed  to  be  paralytic  is  due  tu  \tK^  of  co-i>rdina- 
Hod.  a  true  paralysin  ia  to  be  diBting^ulfliod  by  the  loss  of  the 
power  of  moving,  either  partially  or  entirely,  together  with  there 
being  no  pain  on  passive  or  active  movement,  and  no  eeoue  of 
rcEistanoe  experienced  by  the  phyaeiati  when  moving  the  aflcctcd 

2S 


* 


24 


DlAQSOSnC  NEITBOLOOT. 


part.  A  parali'sis  may  of  oourae  be  ooinddeat  with  a  \oail  in- 
flammation vhich  produces  pain  and  soreness,  and  still  naore 
frequently  is  it  aAsociated  with  spaam :  under  th«se  circumntaDoes 
careful  ezaminadon  during  btith  paaaive  and  ai-tive  moveiueats 
may  be  n^ce^eary  for  tlie  detec4ion  cif  the  underlying  palsy. 

For  the  c^ttimation  of  thn  degree  of  partial  paralysis  various 
instrumenti;  have  been  employed  :  of  these  the  only  one  com- 
mooly  Oted  is  the  hand-dyQamometer.  The  power  of  the  l^a 
can  nanally  be  judged  of  with  sufficient  aoeuniry  by  noting,  the 
height  to  which  the  patient,  when  sitting  in  a  chair,  cau  raise  the 
feet,  the  ability  to  get  out  of  the  chair,  and  ihc  power  of  en- 
durance during  etandiog  or  walking.  A  foot -dynamometer  may 
be  useful  for  eettimating  amall  gains  of  power  under  treatment^ 
but  is  rarely  employed. 


FUNGrriONAL  PALSIES. 

When  paralysis  has  been  found  to  exist,  it  is  neceeeary  to  deter- 
mine whether  it  it*  a  tnie  i>rgani(.'  palsy,  or  whether  it  is  assumed, 
hysterical,  or  reflex  in  ita  nature. 

Reflex  PaUiee. — It  is  well  known  that  paralysis  in  a  distant 
part  in  in  sotne  cases  closely  connectet)  with  a  violent  nervous 
irritation,  such  as  a  wound  in  the  nerve-trank,  stone  in  the  kid- 
neyn,  etc  To  such  cases  the  name  of  Reflex  Paby  has  been 
given.  There  are,  however,  two  entirely  distinct  clasMa  of  casee 
whicb  have  been  grouped  together  under  this  name.  In  most  of 
tiie  recorded  i-ae-es  ihe  inralyt^is  bos  dcvelo(>ed  gradually,  and  has 
nndonbtcdiy  been  the  result  of  a  secondary  organic  disease  of  the 
nerves  or  spinal  cord.  Thtut,  a  man  receives  a  wound  in  the 
hand  iovolvtug  a  nerve,  and  slowly,  step  by  step,  the  arm  loses  its 
power  and  becomes  livid  and  cold.  Under  such  circumstances 
there  is  umloubtedly  an  atK^riding  neuritis.  Or  from  a  olone  in 
the  kidney  a  paraplegia  gradually  develops,  the  resalt  of  a  sec- 
ondary myelitis.  (,See  Sulwu-ute  Paraplegia.^  There  are,  however, 
eases,  like  those  rejiorted  by  Dr.  S.  Weir  Mitchell  (Injurj*  of 
Nerves,  Philadelphia,  1872),  in  which  the  wound  of  a  nerve  is 
followed  at  onoe  by  a  diMant  palsy  ;  or  like  tliost-  in  which  a  para- 
pkgia  Is  at  once  remo\'ed  by  the  removal  of  an  irritation,  such 
as  an  adliercut  prepuce.     In  these  cases  there  can  be  no  organic 


PABALTS». 


of  the  nerve  or  cord,  ami  it  seems  to  me  no  more  extraor- 
dinary tliat  there  sliouM  he  a  rcSex  paUy  tbaii  that  there  should 
be  a  reflex  spasm.  To  enter  upon  the  theory  of  the-se  ufToctionit 
ia  beyond  the  province  of  this  l>o<»k.  A  true  reflex  palsy  can  ho 
recogTiized  only  by  its  historj-:  so  far  a*  the  paralysis  ilae!f  is 
coocemed,  there  are  no  positive  diagnostic  indicatioas. 

AaBomod  Paralyais. — A  paralysis  may  Iw  avmumcd.  M'hen  this 
is  suspected,  the  tone  of  the  muscles  should  be  carefully  examined, 
becan^e  in  most  palsies  not  af>c.inifHinied  by  spnsm  there  is  a. 
peculiar  retaxalJou  of  the  aOected  part ;  and  the  absence  of  such 
relaxation  would  of  course  strengthen  suspicion.  Sometimes 
the  deceit  can  be  vletected  by  watching  the  patient  when  off  lifs 
gnard.  Etherization  may  be  resorted  to.  If  the  palsy  be  as- 
SDtnt'id,  the  ma«k  will  n^ually  be  thrown  off  during  the  stage  of 
senii-uucou«ciousue»8,  and  moveiuetitx  vrlll  be  executetl  with  the 
paralyzed  limb.  1  have  seen  the  nature  of  an  assumed  paltry 
made  maiiif(Mt  by  the  patient's  falling  to  counterfeit  prn|ierly  the 
peculiarities  of  the  form  of  palsy  which  he  was  imitating.  Thus, 
in  an  a<aumed  hemiplegia  tite  fact-  was  drawn  towards  the  aflected 
side. 

HyBterical  Paleies. — The  detection  of  the  nature  of  the  hys- 
terical paUy  Is  sometimes  a  matter  of  great  difficulty.  In  some 
cases  the  hysterical  natui-e  of  the  affection  is  revealed  by  paralysis 
of  the  bladder,  the  intestines,  the  rectum,  or  other  parts  connected 
with  organic  life.  Of  course  in  some  forms  of  organic  palnics  such 
Bymptoms  are  UHttirally  pfeseiit;  but  their  diagnostic  im]K>rtauce 
oonaists  in  the  fact  that  they  are  frequently  seen  in  hysteria  asso- 
ciated with  hemiplegia  and  local  paUies,  which  are  rarely,  when  of 
an  organic  nature,  acconi|>anied  by  paralysis  of  the  non-striated 
lonscle-llhrcH  of  the  visceral  walls. 

The  piesenoe  of  other  distinct  symptoms  of  hysteria,  cither  in 
the  past  or  in  the  present,  is  of  importance.  Nevertlieless  a  vio- 
lently hysterical  person  may  be  attacked  by  organic  [wlsy,  and 
I  have  also  seen  hysicricai  paraplegia  occurring  without  other 
syni}Konis  of  hysteria,  ant!  without  an  hysterical  liiwbory  that 
ooald  be  made  out,  Tlie  hysterical  palsy  is  apt  to  be  Inmsient 
and  shifting  iu  its  character,  to  go  and  come  suddenly,  and  not 
to  conform  iu  its  minor  plienomena  with  tlie  sequencej^  and  v.o- 
incidenoes  of  organic  palsy:   thus,  the  reflexes  are  excited  when 


■ 


they  oagfat  to  be  depressed,  or  remain  natural  when  they  shoald 
be  affected  ;  or  <«enwrr  disturbamt:!?  are  prc«pnt  when  they  should 
be  ab^Dt,  or  are  situated  io  portiuu^  of  tlie  b>jdy  uot  curre-pondiug- 
with  the  place  where  they  ought  to  be  in  au  orpuic  pol^.  An 
atypiral  eaito  of  [iaruly<tti<  should  alwa}*!)  be  viewed  with  snspirion, 
especially  when  orctirring  in  a  woman.  Moreover,  it  must  not  he 
ibrgoLten  that  a  man  mar  suffer  from  hy«4eria. 

An  bystencul  pamlytiiis  may  so  closely  simulate  an  organic  oue 
in  its  pheuoinenji  and  its  surrouudings  that  it  will  fur  a  time  be 
impoBsible  to  decide  whether  it  is  organic  or  hysterical.  It  ia, 
therefore,  necemary  to  discnss  in  detail  the  diagnosis  of  hysterical 
paUy  during  the  study  of  each  uf  Lhe  dilTercut  furuis  of  paralysis. 

ORGANIC  PALSIES. 

All  paralytM)  are  beAt  arranged  for  -ttudy  under  six  heads: 

JF^nL  General  PaUy,  in  which  the  whole  moscular  av-^tem  ix 
involved. 

Second.  Hemiplegia,  in  which  the  palay  afl*ectK  one  side  of  the 
body,  or  at  least  the  ami  and  the  leg  of  one  aide. 

Tliird.  Paraplegia  involving  the  legs. 

Fourth,  Mo<io|>legia,  io  which  one  member  of  the  body  b  af- 
fected in  tlie  greater  part  of  it«  musctdar  structure. 

FijVi,  Multiple  Palsies,  in  which  two  or  more  disconnected, 
distinct  grou|»>  uf  inii$(!l€s  are  paralyzed. 

StrOi.  Ixtcnl  Palsy,  in  whii-h  a  :«inglc  muscle  or  a  single  group 
of  muscles  tributary  to  a  single  nerve  is  affected. 

OENEItAL   PALeiES. 

A  true  orgtinie  general  |>alsy  m  a  rare  condition,  and  of  course, 
except  under  extraonlinary  circumstances,  cannot  be  alisolute  or 
complete,  because  the  patient  uece»«arily  dies  so  iN>ou  as  the  trunkal 
mueoles  which  are  connected  with  respiration  ure  affected  beyond 
a  certain  degree. 

If,  however,  a  lesion  be  so  situate<l  that  it  interrupts  the  [»s- 
sage  of  ilie  nervons  course  between  the  cortical  brnin-ceutrea  in 
which  the  impulse  of  voluntary  movement  origiuates,  but  does 
not  afleet  the  [Mthway  between  the  automatic  respiratory  centres 


PARALYSIS. 


27 


in  th«  m<^ulln  oblotifi^tii  and  the  reflpimtory  muscles,  a  cumplet« 
gwitral  poralvsU  of  voluntary  movemeut  loav  Iw  coaaUteut  with 
life:  sucli  condition  1  have  i^een  iu  an  animal  when  the  medulla 
has  been  divided  fmm  the  pon!>,  but  I  have  never  witnessed  It  in 
man,  in  n-ham  it  must  be  iiiBnllely  rnre. 

Hysterical  Qeneral  Palsy. — Hysterical  general  palsy  is  ex- 
ceediui;ly  rai-e,  but  Hruet^ke  hab  reported  nix  oaaeti  in  which  the 
prin<j])al  muH^leeior  the  back  and  thoee  of  the  four  extremities 
were  paralyzed,  and  there  are  others  in  mefb'cal  litenitiire.  The 
natnre  of  such  a  general  patsy  ought  to  be  recognixcd  by  its 
coming  on  oudtieuly  without  being  accom{}anie<:l  by  severe  apo- 
plectic or  ooustitiitioual  Hyniptoni8,  such  a.'^  tnark  a  sudden  atltuik 
of  an  organic  general  patsy,  and  by  the  presence  of  distinctly 
hysterica]  aymptoni«t,  or  of  a  history  nf  previous  severe  hysterical 
tnauifei^tatioiis. 

Alcoholic  Falay. — A  general  loss  of  motor  power  is  one  of  the 
symptoms  of  chronic  nlcoholiRui ;  but,  with  the  knowlcilge  of  the 
habtta  of  the  patients,  a  mistake  can  hardly  be  made  as  to  the 
cause  of  the  failure  of  mnwie-power.  In  the  great  majority  of 
cases  the  arms  arc  afl'ecled  beftirc,  or  more  profoundly  than,  the 
Ic^.  The  disturbances  of  sensation  are  very  marked ;  indeed, 
ex«pt  in  rare  instinoes,  sensation  is  munh  more  profoundly  In- 
fluenced in  alcoholic  potsoDing  tlian  is  motion,  whiUt  the  union 
of  paralysis  of  Bensation  and  of  motion  is  excessively  rare  in  orgamo 
general  |xdt4y :  further,  the  pcvuliar  tremurH,  the  alterations  of 
brain-function,  also  5erve  as  sign-posts  In  alcoholic  palsies. 

There  are  <a»es  in  which  It  k  difficult  to  diagnose  between  an 
aloobolic  puUy  and  true  general  paralysis  of  the  intsaue.  Dr. 
Ounosct  reports  (Jnn.  Mid.  P^jro/io/.,  1883,  vol.  x.  p.  201)  cases 
in  vhtch  tremors,  general  loss  of  muwular  power,  dollnnm  of 
grandeur,  unequal  pupils,  fibrillary  contractions  about  the  mouth, 
ud  all  the  siippoi^Kl  characteristic  symptoms  of  the  org^inlc  dis- 
esse,  w«re  present,  but  wiiich  resulted  iu  cure  upon  the  forced  disuse 
of  oloohol.  The  only  tettt  in  the^  cat<es  is  the  efiect  of  abandoning 
alciiholic  potations.     (See  Creneral  Faralysis  of  the  In.'iane.) 

Intermittent  Palsy.— An  intermittent  general  palsy  may  be 
produced  by  malarial  poLtoning.  A  case  of  this  character  has  been 
re[)orte<i  by  CavarC  (Gaz.  ties  IM/i.,  1853),  in  wliirli  the  paroxysms 
lasted  from  five  to  eight  hours,  were  of  the  quotidian  typo,  and 


were  cured  by  quiuiue.  Roiiib«i'^  has  reportetl  a  case  of  iuter- 
mittent  purapiegta  attm  of  the  qtiotidinn  lyjie  und  cured  by  qui- 
nine. There  would  a|)]xiar,  however,  to  lie  cases  of  intermittent 
general  palsy  not  due  to  malarial  poiftouing.  A  most  retnnrkable 
iostance  of  tliis  is  that  reportetl  by  Professor  C  Westphii!  (Berl. 
K/in.  iVochcnjKla-ift,  4S9),  in  wliidi  the  [latient  PuRcrcd  from  a 
number  of  attacks,  commencing  with  ]Kiin  in  all  four  extretiiiti^, 
with  rapid  loss  of  itower  deepening  into  almost  eoraplctc  paralysis, 
ending  in  twelve  or  fourteen  hours  in  sleep,  with  complete  return 
of  power  ou  awakening.  But  tlie  most  remarkable  features  iu 
this  case  were,  that  tlte  sensibility  waK  normal ;  that  the  knee-jerk 
in  the  height  of  the  paroxysm  was  wanting;  and  that  the  elec- 
trlcal  reactions  were  greatly  weakened,  and  in  nome  of  the  mutK^le^ 
entirely  disappeared.  After  the  paroxysm  the  electrical  reactioua 
becume  normal,  except  that  the  oontractious  were  weak  in  tho6e 
raus(*IcM  which  had  been  moKt  afTeiited.  This  [Mitient  rpoovcrod  iu 
four  weeks.  A  case  similar  in  character  to  this  waa  reported  by 
Hartwig  [huiuif.  Dinn.,  ITalle,  1874),  but  the  electrical  reactionfl  of 
the  mudcle  did  not  dr^ppvar,  although  Uiey  became  weak.  la 
tills  cose  quinine  at  first  ap|>eared  to  prevent  the  paroxj-sms,  but 
finally  failed  of  effccl",  although  the  patient  had  had  tertian  fever 
some  years  before.  Seveu  and  one-half  inouths  after  the  begin- 
ning of  this  disease  the  patient  had  not  recovered. 

Multiple  Paralysis  simulatinsr  Oeneral  Palsy. — A  wide- 
spread tuultiple  paralysis  niuy  closely  siroulote  a  general  palsy, 
and,  indeed,  in  certain  conditions  of  the  botly  may  be  said  to  pass 
into  a  general  palsy:  if  two-lhtrds  of  the  muscular  slnicture  be 
involved  in  a  multiple  palsy,  the  syniptoniB  closely  simulate  a 
general  paralysis,  and  if  more  than  this  proportion  of  the  muscles 
arc  attacked,  the  symptoms  become  those  of  general  palsy. 

Toxtemic  Goneral  Paralyals. — An  apimrent  general  palsy 
which  la  the  outuomc  of  a  multiple  palsy  is  usually  due  to  a 
toxsmia,  eitiier  by  alcohol  or  by  such  metals  as  lead  or  areenia; 
hut  it  may  be  pnKluceti  by  a  mulli[dH  neuritis. 

Ascendiner  Pajralysis. — The  so-callcfl  ascending  paralysis  in 

ils  latter  stages  gives  rise  to  a  general  palsy,  the  nature  of  which 

Uklv^  be  recognizei]  by  tlte  gi-adual  but   rjjiid  8prca<ltng  of  the 

syroptoniB  from  the  feet  or  the  bauds,  or  simultaneously  from  eacL 

towards  the  centre.      The  symptoms  of  ascending  palsy  in  its 


\ 


PABALYBIB. 


29 


various  forms  will  be  fully  discut«cil  uiider  the  Iiead  of  Subacute 

For  diagnostic  purposes  Organic  Geuenil  Puttsies  may  be  divided 
into  those  which  origiuiiu.- — 

firsts  In  lliti  cerebral  liemisplicres. 
Second.  In  the  ponei. 

Third,  In  the  apiiiat  cord,  incKuling  the  medulla  oblongata  or 
tbe  intntrraiiial  [»ortion  of  the  cord. 

Oorobral  Oeooral  Palsy. — A  gvneral  palsy  of  brain-origin 
b  always  iuoompletc,  and  is  ol^'a^'s  a'^ociatc^l  with  symptoms  of 
profound  alteration  of  other  bmin-fiiiictiniig.  The  lesion  which 
produces  it  most  afikrt  both  heiuispliores  of  the  bruin,  and  is, 
when  suddenly  developetl,  almcet  inviu-inbly  of  the  nature  of  a 
trcniendouH  out|H>uring  of  blood  into  one  liemiephere,  or  tlie  rup- 
ture of  an  abacesg,  or  a  double  apoplexy  affecting  each  side  of  the 
Ebndo.  If  Ihe  symptoms  be  slowly  developed,  they  mark  tbe 
preseooe  of  a  very  widespread  aud  serious  degeneration  of  tlie 
cerebral  oortejc,  and,  unless  the  attack  dates  ba<;k  to  infancy,  aro 
almost  diagnostic  of  the  ito-oailcd  general  pnrnlyii!)  of  the  insane. 
(See  Disturbances  of  Intellectiou.) 
Id  some  rare  cases  Spcuiw  Int'aniik  Pnraiyga  is  so  wide-spread 
18  to  take  the  form  of  a  general  piil^y,  although,  pruperly 
speaking,  tt  is  a  multiple  pulsy,  under  which  hcflding  its  symp- 
toms will  be  fully  deflcribe<I.  The  fhararrrer  of  such  n  pgeudo- 
geoeral  palsy  is  to  be  recognized  by  the  diseaae  dating  back  to 
early  childhood,  and  by  the  presence  of  distorlion»  due  to  ex- 
oenive  muscular  contractions  with  more  or  less  atrophy  of  the 
afiecte<1  ports.  There  is  also  more  or  less  pronounced  arrest  of 
mental  development. 

fPooa  PaJsy, — A  suddenly-developed  general  palsy,  due  to 
lesion  of  the  jions,  ii^  lUways  the  result  of  a  hemorrhage  which 
involva';  iKtth  sides  of  the  pons.  TlicKe  casrH  are  very  rare,  and 
are  always  accompanied  by  severe  apoplectic  symptoms.  The 
rocognilinD  of  a  general  palsy  in  severe- apoplexy  is  excessively 
dtflicult,  owiug  to  the  gettcml  musi;ular  relaxation.  Xuthnagel 
affirms  that  there  is  do  case  in  literature  in  which  a  patient  lias 
recovered  conscinusnejts  with  a  double  palsy  due  to  hemorrhage  in 
tbe  pons. 


DIAQNOariC   NEUHOIOOY. 


A  more  or  less  pronniiruKxl  m-ncral  palsy  may  !«  gradually 
protluoed  by  a  progreasive  lesion  of  the  poos  or  by  tiimora  pressing 
upon  the  pons.  Tn  a  case  recorded  by  TTiiIloppau  {Architys  H^ 
Phyttiot.  Twmi.,  1876)  the  (symptoniK  slowly  involvud  first  the 
right  side  of  tlic  body  and  afterwards  the  left,  as  the  lesion  pro- 
gresi^d  throiigl)  tiie  pons.  In  a  similar  case  reported  by  Stein 
(Memorabiiien,  1863, 198)  disturbances  of  seDsatton  precoded,  and 
exceeded  iu  praraiiiciice,  those  of  motion. 

'Dm  diagnoHit)  of  tumor  of  the  pons  must  be  made  partially 
by  exclttsian:  tlitia,  au  organ  in  general  patsy  which  is  not  of 
brain  or  of  spinal  origin  is  u-snally  dne  to  dii»ease  of  the  pons. 
The  gradual  impliiiation  of  one  side  of  the  body  after  the  other 
is  very  strong  evidence  that  the  lesion  is  in  the  pons.  Disturb- 
anccH  of  temperature,  vomiting,  a  nearly  rornplute  facial  iwlsy,  or 
early  implication  of  other  nerves  which  arise  in  the  pons,  would 
oou6rm  a  di^nosis  reached  by  excliHioii,  The  cimracteristic 
sytuptoms  may,  however,  be  nearly  or  even  altogether  wanting. 

Bulbar  Gonoml  Palsy. — Theoretically,  a  general  palsy  might 
Im!  pro<lace<l  by  a  niijiiile  hiunorrhage  into  the  central  portions  of 
the  medulla.  The  medulla  is,  however,  so  small  and  so  lilleil 
with  vital  nerve-cells  that  hemorrhage  into  it  usually  produces 
death,  either  insianiaueouuly  or  in  a  few  momeDts, — a  result  wliioh 
also  follows  thrombus  of  the  basilar  artery,  which  supplies  the 
respiratory  centre.  I  know  of  but  one  case  in  liieratnre  in  which 
it  has  been  proves!  by  a  sulis^eijuent  autopsy  that  tlie  patient  had 
survivotl  hemorrhage  into  the  medulla.  This  a-ise  is  reported  by 
Hnghlingt^-Jackhon  in  the  London  Lancet^  vol.  ii.,  1872,  p.  770. 
Wlii;never  a  series  of  symptoms  jKiiiiting  towards  apoplexy  of 
tlie  medulla  oblongata  is  followed  by  recovery,  the  strong  prob- 
ability is  tliat  there  haa  been  a  temporary  arnstt  of  circulation 
ill  the  anterior  spina/  artery  or  in  tJio  pogla'ior  (inferior)  ccrebtUw 
artery^  branchc*  of  the  vertebral  artery  which  supply  the  me- 
dulla. Any  arrest  of  tiie  circulation  in  the  branches  which  the 
bagiiar  artert/ sends  into  the  medulla  is  followed  by  immwliate 
death,  since  these  do  not  anastomose,  but  are  terminal  arteries 
supplying  the  respiratory  oentrcs. 

People  have  been  suddenly  attarke<I  with  violent  headache, 
[iddineiM,  severe  l)tc(;ough,  various  diaturbauce*  of  sensation, 
difiiculty  ia  or  total  loss  of  the  power  of  swallowing  and 


I 


» 


speftkiDg,  ooDScioa8iK89  being  preserved  and  the  attack  being  at 
onoe  followed  by  a  more  or  Ie$fi  pmnoiin«cd  ^oneral  palfiy,  with 
Tartotu  local  facial  [Miralyses  and  great  diaturbnuces  of  respiration. 
There  has  alst>,  in  these  cases,  usually  been  excesaJve  dyspniea  and 
general  fTanosis,  ending  in  denth.  In  such  nttuoks  the  Icaiun  ts 
Aromf'iijf  or  emhoiHti  in  the  ivrtftn-al  aiit^ri/,  with  oonsequeut 
•oAening  in  the  medulla  oblongata.  In  etorae  cases  of  this  char- 
acter, when  the  anterior  pyramidi^  have  escajied,  there  has  been  no 
paralysis  of  the  limits;  and  there  hiive  been  instances  in  which 
only  two  pxtrcmiti<s  have  been  paralyzed.  Anfe^lhesia  has  not 
b««D  noted  in  any  of  the  cases. 

Inflammatory  Bulbar  Palsy. — An  acote  palsy  wliich  may 
involvu  one,  two,  or  more  of  the  exti'emities  and  give  rise  to  tt 
monoplc^a,  hemiplegia,  or  general  palsy,  may  be  the  nsult  of  a 
very  rapid  localizwl  myelitic  process  oticurring  in  the  me<hdla. 
It  beema  lo  me  moet  pirobable  that  in  these  cueeid  the  alleged  iu- 
flammatory  change  has  been  preeedei)  by  degeneration  of  (lie 
veseln,  and  e)(tn»p(|nent  tlirombng.  However  iJiia  mav  t>e,  the 
diagnosis  of  an  acute  lesion  of  the  medulla  is  to  be  made  out,  in 
these  as  in  all  similar  cases,  by  noting  llie  paralysis  of  one  or 
more  of  those  orgmui  \Yhoee  nerves  ariee  in  the  region  of  the 
medulla.  A  full  statement  of  these  palsies  will  he  given  under 
tlie  head  of  J,.opal  P.iralysc-S. 

A  slowly-developed  geuenil  palsy  may  result  from  a  tumor  or 
other  progressive  disease  afiecting  the  metlulla  oblongata,  and 
^Cothnagel  a>vcrts  that  it  may  \xi  Lite  only  symptom  uf  Hiich  u 
lesion.  In  such  a  case  the  nbaenoe  of  evidence  of  impliciition  of 
ibc  higher  nerve-centres,  and  the  preseJice  of  blindness  or  other 
symptoms  of  basal  brain  di^^ase,  might  enable  us  to  locute  the 
lesion  at  the  hose  of  the  brain,  and  yet  it  might  at  the  same  time 
be  impoasible  to  decide  with  certainty  wliether  it  waa  the  pons 
or  the  medulla  that  was  involved.  IJsnally,  however,  the  seat  of 
the  lesion  is  revealed  by  disturbance  of  the  fiinctiona  of  the  nerves 
which  originate  in  or  pat»  through  tlie  medulla:  so  that  the 
abeoioe  of  such  disturbanoe  indicates,  but  doe»  not  prove,  that 
the  pons  is  afiected.  Vomiting  is,  I  think,  more  frequent  in  dis- 
cs»e  of  the  pons  than  in  aflfeclions  of  the  medulla. 

Senaation  in  Bulbar  Pal^y. — Contrary  to  what  might  be  ex- 
pected, loss  of  sens:iiion  in  the  extremities  is  not  usually  jiromi- 


32 


DIAONOSTIC   NBOROLOGY. 


Hftiit  in  a  pri^ressive  g(»nrral  palsy  of  bulbar  origin,  and  I  know 
o(  no  case  in  which  there  hoji  been  pronounced  anxotbesin.  In 
some  insbuicefl  complaint  hag  been  made  of  a  feeling  of  sU0iiess, 
formication,  or  nunihii»»  in  tlie  extremitie?;.  The  lack  of  dis- 
turbance of  sensation  is  probably  due  to  the  fact  that  nsually  the 
Ipflion  is  a  tumor  springing  from  the  braiii-inembrane  and  pressing 
upon  the  rae<lulla :  moreover,  if  the  lesion  has  its  seat  in  the  me- 
dulla, it  is  commonly  situated  in  the  anterior  portion.  In  either 
CUM!  di>Hth  inuKt  re^iult  liefure  the  lesion  is  sufliuiently  advanced 
to  affect  markedly  the  sensory  ref^an. 

Vflflo-motor  diaiiirhanccs  have  not  been  prominent  in  the  re- 
ported cases  of  diseikse  of  the  medulla,  but  diabetes  insipidus  and 
even  true  saccharine  dinl>etcs  have  been  noted. 

Lenticular  or  Corpus  Striatum  General  ParalysiB. — Sudden 
loss  of  power  in  the  tongue,  lipa,  and  muscles  of  mastication  and 
deglutition  has  occurred  from  hemorrha^  into  the  lenticular 
nucleus  of  each  hemisphere,  and  in  other  eases  slower,  bilateral 
changes  in  these  nuclei  liave  produced  a  more  gradual  develop- 
irient  of  these  palsies,  with  a  general  Kiss  of  itower,  uiaking  a 
picture  resembling  that  of  bulbar  patsy.  To  these  cases  lias 
t>ccn  given  the  name  of  Pseudo-bulbar  Paralysis.  In  a  case 
reeoitlecl  in  the  Kew  York  M^vxd  Reeonl  none  of  the  extremi- 
ties were  paralyzed ;  but,  as  a  lesion  of  the  lenticular  nucleus 
usually  causies  hemiplogin,  it  is  clearly  possible  for  a  double  \eskm 
to  cause  a  general  paUy  which  may  ver^-  closely  referable  that 
caused  by  disease  of  tlie  medulla. 


HEMIPLKQIA. 

A  beniiplegia  in  its  fullest  development  afTccUi  tlie  arm,  legj 
face,  and  tongue;  the  paralysis  in  the  arm  and  leg  is  complete; 
the  paralysis  of  the  face  h  inr«mplete,  and  usually  aflet^ts  almost 
solely  the  muscles  of  eipreasiou  about  the  mouth,  the  upper  [wr- 
tion  of  Ihc  face  ordinarily  responding  to  the  will.  The  muscles 
of  chewing  are  very  rarely  involvetl.  The  corner  of  iha  mouth 
is  usually  drawn  towards  the  sound  side,  but  the  tongue  protrudes 
towards  the  paralyzed  side,  owing  to  the  intact  geuio-glossua  muscle, 
whicli  thrusts  the  totigue  forwar<l,  ntit  Ixiug  op|M)ecd  by  it*  fellow. 
In  old  hcniiplegies  the  face  is  sometimes  drawn  towards  the  par- 
alyzed side  by  the  late  contractures  in  the  paralyKe<l  muscle,  and 


in  acute  keiuiplegia.  If  the  paralysis  be  aouonipaiiicd  by  s{iafitu,  a 
similar  di^lortioD  may  occur.  The  palsy  in  these  cases  of  facial 
dtslorttnn  from  ee(!<)ii(la.ry  Bfuisiii  m  to  l>e  rerogiiiiuH)  hy  tlie  gen- 
eral immobility  of  the  paralyzed  side,  by  the  abt^^nec  or  softening 
of  the  natural  vrnnkles  and  linee  of  expression,  aud  by  the  loss 
of  the  ability  to  <;lfime  the  eye.  Somctimcfl,  whi>n  ^[la^m  ohf^cures 
the  paralysis,  on  forced  smiling  the  logs  of  power  is  evident. 

The  mu*cl«  of  the  trunk  and  of  mastication  are  very  rarely  [lar- 
nlyzed  in  hemiplegia,  auless  the  baso  of  the  brain  or  the  medulla 
be  involved.  The  ordinary  respiratory  movements  continue,  be- 
cause the  Icsiou  is  sitnaiod  above  tlie  automatic  refipiratory  oentre. 
More  than  this,  in  most  cases  the  mu»:les  of  the  trunk  respond 
to  the  will  (o  a  certain  extent :  frequently,  however,  wlien  the 
pfttieut  cootractji  the  muscles  either  of  mastiualton  or  of  respira* 
lion  IIS  powerfully  as  he  can,  it  will  be  noted  that  the  muscles 
upon  the  sound  fiide  act  more  vigorously  than  tlios^e  on  llif  [Hira- 
lyeed  side.  The  most  plausible  theory  which  has  yet  bcwu 
brought  forward  to  account  for  the  escape  of  the  masti<-Ati>ry  aud 
trunkal  muscles  is  that  of  Broadbeut.  The  muscles  which  et^'ape 
are  always  tliose  that  arc  habitually  used  together:  thus,  the  two 
maaetent  in  eating  contract  Hiroultancoufily,  and  the  respiratory 
muscle?  of  the  two  sido»  of  the  trunk  always  act  iu  unison.  It 
is  believed  that  by  this  habitual  aotioti  the  pathways  are  opened 
between  tlic  centres  iu  the  spiiuU  cord  which  control  the  mii^clee 
under  disai^ion,  eo  that  the»e  two  centres  finally  act  in  unison, 
and  when  one  of  them  receives  an  impulse  from  a  hemisphere 
this  impulse  overflows  to  its  fellow.  For  this  reason,  if  the  lesion 
oocur  in  the  left  hemisphere  the  right  hemisphere  is  able  to  reach 
by  ita  impulse  the  centres  on  each  side  i)f  the  cord  connected  with 
tnasticatiun  or  with  respiration. 

According  to  Dr.  W.  R.  CJowcrs,  immediately  after  the  hemi- 
plegic  fttrtjke  the  sound  leg  sometimes  distinctly  shares  iu  the 
weaknow.  This  al»i>  is  to  be  explained  ou  the  theory  of  liabit- 
nal  BcdoD.  Dr.  Gowcrs  further  states  that  iu  some  cases  of  hemi- 
plegia when  the  patient  tries  to  show  his  teeth  the  mouth  may  Iw 
moliouletis  on  the  paralyzed  side,  and  yet  un  smiling  there  may 
be  little  or  no  dilfercnoo  iu  the  action  of  tlic  two  sides.  Dr. 
Gowers  explains  this  by  supposing  that  emotional  movements  are 
indiflerently  innerx-ated  from  either  hemisphere. 


I 


HyBterical  Hemiplegia. — Ueaiiplt^ia  in  a  very  frequent  form 
of  livrtterical  palsy,  Imt  iti  moel.  of  tliese  rasee  one  extremity  \a 
distinctly  more  jifi<?i.-te(l  than  the  other,  and  paralysis  of  the  fa<*, 
altliough  it  doed  occur,  is  go  rare  that  any  case  in  which  it  is 
preHfiit  in  jirolKiltly  itot  hyf^tiTiiiil.  The  palftv  Ih  ntitily  ami- 
plctc :  so  that  a  patient  unable  to  walk  or  even  to  stand  may  be 
able  to  raiiie  the  foot  when  in  bed.  There  is  munlly  more  or  less 
pronoubced  loss  of  sensation  in  the  pwralyzed  part,  and  the  coex- 
iHteDct'  of  a  bemianteatheaia  with  hemiplegia  ahoutd  always  incite 
U)  a  very  careful  dia^Miofitic  examination.  Tliu  fanulic  oontracttl- 
tty  is  usually  normal,  but  in  some  casm  galvanic  sensibility  is  lost. 
Such  loss  is  a  very  strong  indication  that  the  attack  is  hysterical. 
The  retlexes  which  are  usually  excited  in  llie  6r8t  days  of  or- 
ganic imIsv  are  in  most  oases  of  hyuteria  not  affected,  and  may  be 
lessened.  By  attention  to  the  poit3t»  just  citunieratiMl^  and  to  the 
history  of  the  piitiert,  the  diagnosis  can  usually  be' made  with- 
out difficulty.  In  some  cases  aid  may  be  obtained  hy  the  appli- 
cation of  powerful  electrical  currents  to  the  affected  meiubrancs, 
or  by  the  practice  of  the  so-ailled  metallo-therapy.  Ijapid  altcr- 
ation.4  of  sensibility  produced  in  tliis  way  are  very  chsracteristic 
of  hysteria.  Sudden  changes  in  the  degree  of  ptiralysis  are  almost 
pathoguomoQio  of  ]iy»teria :  they  do  occur  iu  cases  of  brain-tumor, 
but  not  in  cases  of  cerebral  hcnjorrhagc. 

Diaffjwm  bftmTti  Tiiie.  ami  Fni»r.  UaitijArfjia. — True  hemi- 
ptiT^ia  is  usually  the  result  of  a  fo»il  brain-U^inn,  but  it  is  neces- 
sarj*  to  distinguish  carefully  between  a  true  hemiplegia  and  one 
in  which  a  multiple  paralyiiiit  aflect«  various  groups  of  muHcles 
upon  one  side  of  the  body.  If  a  majority  of  the  leg-  and  ariu- 
muscles  on  one  side  areaffecled  by  a  multiple  pal^y*  the  symptoms 
may  very  closely  simulate  those  of  hemiplegia,  hut  the  true  nature 
of  the  affection  can  usually  be  recc»gntzed  by  the  irregniarities  iu 
the  inteni>itie!i  of  the  palaics.  In  a  brtuu-hemiplegia  the  law  is 
that  the  nearer  the  muscles  are  to  the  trunk  the  lei^^  apt  are  tlu^y 
to  be  completely  jKilHied.  Thus,  the  forearm  Is  more  thoroughly 
affected  than  the  upper  arm,  and  the  leg  than  the  tliigh.  In 
multiple  paralyses  simulating  hemiplegias  this  rule  !»  almost  in- 
variably departed  fn>m.  A  lu'uiiplegic  multiple  palsy  may  be 
due  to  disease  of  the  brain-cortex,  and  might  well  be  considered 
to  l>e  a  double  monoplegia^ — U:,  a  brachial  and  a  crui-al  monopl^ia. 


I 


Bible  to  (listiiigui&ti  the  nature  of  the  affectiuu  exc-ept  bv  the 
collateral  gymptoms,  which  in  the  multiple  poUv  will  generally 
show  either  that  the  brain-cortex  is  affected,  or  that  there  are 
two  distioct  lesions.  When  a  lieiuipli^ia  dates  back  to  chiI<lh<Kxl, 
and  U  associated  with  marked  contractures,  it  is  usually  a  multiple 
brain-[>aUy.  (See  S|)a.stic  lursntile  Paralysis,  under  heading  of 
Multiple  Palsy.) 

Spinal  Hemiple^, — A  hemiplegia  may  Iw  of  spina!  origin, 
due  to  pressure  of  a  tumor  or  to  hemittetrtion  of  the  upper  oord  : 
such  hemiplegia  h  rarely  complete,  and  ia  almost  always  asso- 
rialed  with  hemianaestheBia,  the  paralysis  of  Hensation  invariably 
being  on  the  oppo$iU  side  of  the  body  from  that  of  motion.  When 
cerebral  hemiplegia  and  hemianiesthesia  coexist,  they  are  inva- 
riably on  tlie  tatiie  «ide  of  the  body,  except  in  verj'  phenomenal 
cases  in  which  the  paralysis  of  motion  anil  the  loss  of  sensation 
are  due  to  different  foci  of  disease  situated  id  opposite  bmin- 
henuBpfaeres. 

Oarebral  Hemiplegia. — When  in  any  case  the  existence  of  a 
true  brain-hem i|il^ia  lias  been  determined,  Uie  next  etep  le  to 
find  out  whether  it  has  developed  suddenly  or  gradually. 

Sudden  or  abrupt  brain-hem iplegias  may  be  due  to  cerebral 
hemorrhage,  to  arrest  of  cerebral  circulation  by  an  embolus  or 
thrombus,  to  an  absccee,  or  to  a  tumor.  Progressive  or  slowly- 
developing  hemiplegias  are  the  renult  of  absccsfi,  localized  oerehral 
wftening,  or  other  prc^ressivc  focal  brain-degeneration,  including 
tumors  and  gummatous  indammatloo. 

In  a  progressive  hemiplegia  verj'  little  can  be  learned  from  the 
palsy  itself  as  to  the  nature  of  the  lesion.  A  paralysis  produced 
bj  sof^Ding  is  usually  more  Btefulily  prngre^ive  and  less  variable 
than  one  cauwd  by  tumor;  the  hemiplegia  of  tumor  is,  in  its 
turn,  surpassed  in  its  perpetual  variability  by  a  liemipl^ia  of 
specific  origin. 

Abrupt  hemiple^ifl.1  produced  by  tumors  are  ugunlly  the  result 
of  suddeti  local  congestions  around  the  ttmior,  and  are  (o  be  dis- 
tinguislied  by  their  iucompletcDess  and  by  the  rapidity  with  which 
tfaey  subside.  Their  diagnosis  is  es{xx:ially  to  be  made  out,  how- 
ever, by  the  presence  of  headache,  epileptic  fits,  choked  disk,  or 


I 


olher  erideooa  of  progreaBve  oenifaral  iliwwi.  Wlwii  a  complete 
mad  pfMwnt  hwuplegkoeeimeBddiriynia<— of  pfogreaeive 
hrrin-^BMae,  H  h  Qsnallf  doe  to  heoMfringe.  Tbe  absolnte 
abrupt  beaniplegia,  which  aometOMS  ranlta  fnoi  tbe  but^tiug  of 
■D  abaoai  in  the  rentricle,  a  apt  to  dcvtlop  alncHt  at  once  into  a 
geBoal  palsf ,  «ad  is  alwajs  aaoompaiued  b^  atonoy  oeicbral  dis- 
tnrfaaiue,  soch  as  profaood  oonia,  great  altaiiioiw  of  teMperature^ 
eoambtoos,  etc.,  atkd  a  followed  fajr  death  in  a  few  boan.  If  the 
previoo*  hailofj  of  tbe  caae  be  kixnra,  the  nature  of  tbe  attack 
cut  ntdHy  besormiBed. 

Abmpt  Cerebral  Hemiplegia. — An  abnipt  complete  hemi- 
pkgta  m»j  be  due  either  to  a  bemorrbage  into  tbe  snfattance  of 
the  bcaio,  to  tbromboei^  i^^  arrest  of  tbe  cimilatioa  br  the  for- 
nwtkiD  of  a  ooagnJam  insde  of  tbe  artefr,  or  to  embolism,  Lcj 
ami  of  drailatioD  by  the  lodgmeBt  of  a  smalt  mas  swept  from 
a  Jieeaaed  bcart-Talve  or  ocber  fooos  into  tbe  general  arrolatioD. 

Diagmmt  httv^en  BnboSmm  amd  Htmorrltagt. — Id  tbe  gnAt 
iiui}<jnty  of  OMB  the  caase  of  a  sodden  bemiplcgia  is  a  rup- 
tuK  of  a  blood-vessel  and  tbe  forsMtkui  of  a  dot  in  the 
bnun.  A  hemiplegia  doe  ehber  to  a  dot  or  to  an  amst  of  cir- 
oubtioo  ttutj  oot<nr  with  or  withool  tbe  ^mpl^oM  of  apople^. 
Tbe  J*«g-n«i*  between  bemonbi^ic  and  embolic  bcmqitegta  » 
often  tDpaesibfo.  Varioas  wfmpuna  oonnectod  dinctly  with  tbe 
paial^Kk  have  been  asigned  from  time  to  time  as  diagDoetie  of 
Ibe  arrest  at  eerebcal  drcnlation,  bat  these  symptoms  are  of  no 
diagnostie  valoe,  and  they  ahtll  oot  here  be  dtKoeeed.  Wheo 
the  onset  of  a  hemiplegia  ia  aooompanied  by  violeot  action  of 
the  heart,  a  fall,  aroog  poise,  and  i  general  expitesion  of  great 
■jratemic  power,  it  is  almost  invariably  due  to  a  dot;  bnt  a  Hot 
may  be  formed  without  each  syeteniic  reaction,  and  it  is  ia  such 
oaan  that  the  difficulty  of  diagnosis  o^ieoially  exists.  It  is  as- 
aerted  by  some  writers  that  hemiplegia  accompanied  by  aphasia  ia 
oanally  the  result  of  arrest  v^  circntarioo ;  but  in  a  aamber  of 
anlopaiea  upon  soch  caws  I  have  found  a  dot,  and  I  believe  that 
«Tta  thia  coojuiictiou  of  «ym{jtani8  ia  moet  freqnently  due  to 
hcnofTfaage.  When  pliy^itsi  sigus  indicate  the  preooooe  of  nu- 
merous amall  vegetations  npon  tbe  valves  of  the  heart,  or  when 
tlieae  valves  are  nodergoii^  rapid  dcstnicliou,  a$  in  Ktme  cases 
of  ulcerative  endoauditis,  a   sudden   hemiplegia   may  be  very 


I 

I 


PARALYSIS. 


reasonably  snspeoted  to  be  doe  to  eroboliBm.  This  sospicion  is 
of  oourse  iocHMsod  if  previous  embolic  attacks,  cither  of  the 
brain  or  of  other  parts  of  the  ftyatem,  have  occurred.  Tims,  in  a 
case  whidi  cume  imder  my  noti<X!  tJiere  had  been  previous  attacks 
of  violent  local  pains  io  various  [wrta  of  tlie  rauBcuIar  system, 
Associated  with  pronouncerl  local  disturbances  of  circulation,  as 
shown  by  discoloration  of  the  parti.  It  must  also  be  remembered 
that  large  nambers  of  minute  miliary  aneurisms  may  exist  in  the 
brain  aud  prmUicc  n^iKaitol  atiaiik^  of  slight  hemiplegias,  due  to 
the  formation  of  very  slight  clots  outside  of  the  vessels.  If  such 
a  condition  were  coincident  with  otrdiac  disease  it  might  very 
well  be  mintaken  for  embolic.  Auconiing  to  Buiirneville  {£!twie» 
cUnitjuai  d  tbermom^riquen  mir  lea  Malndiea  <Im  Si/kHuu:  tiBrmwr, 
Paris,  1872),  there  ts  usually  immediately  after  the  formation  of 
a  thrombus  a  slight  fall  of  temperature,  followed  by  a  i^light 
rise,  which  may  not  pass  beyond  the  norm,  or  in  rare  cas^e 
reaohes  to  40*^  C,  aud  Is  apt  to  be  aeconi{)aiiied  by  reioarknl>le, 
im^Iar  oscillations.  Then  there  is  usually  a  prolonged  [mriod 
in  which  the  temperature  remains  nearly  uniform,  a  little  above 
normal  and  sometimes  gradually  rising,  but  not  reaching  a  point 
equal  to  that  very  frct^ucutly  attained  in  cerebral  hemorrhage. 
These  changee  of  tem|}crature  are  not  sufficiently  diSerent  from 
those  seen  in  cerebral  homnrrhago  to  be  of  mnoh  diagnostic  im- 
portance: they  differ  chiefly  in  intensity.  The  first  fall  and  the 
subaequeiit  rise  of  temjM-raturv  are  lees  than  thos^e  which  occur 
in  heraorrltagic  a|X)plcxy,  so  that  if  in  any  tn^^c  tlie  tlici-mo metrical 
changes  are  ver^'  great,  the  symptoms  arc  probably  due  to  hemor- 
rhage. A  very  great  rise*  of  temperature  immediately  afler  a 
hetiiiplegie  apoplexy  may  be  considered  as  patli(^nomouic  of  clot, 
and  usually  indicates  a  fatal  tf^rtiiination.  Hounicvilic  has  also 
noted  tliat  after  death  from  acute  brain-sofientng  the  tenipera- 
tnre  falls  more  rapidly  than  after  cerebral  hemorrhage. 

Diagnoiti*  of  Ponition  of  Clot. —  The  diagnosis  of  the  exact 
seat  of  a  brain-lesion  in  hemiplegia  iovolves  a  knowledge  of  the 
OOUraeof  tlie  motor  fibres  which  run  from  the  spimd  cord  lo  the 
cerebral  cortex.  The  region  of  the  cortex  in  which  tJiese  fibre-i 
arise  is  so  large  that,  unless  by  extraordinarily  extensive  lesions, 
only  moooplegias  or  local  palsies  are  pi*oduced.  (Sec  Local  Palsies.) 
The  motor  fibres  converge  from  the  bmtn-uurtex  Into  a  fascieulus 


CIAOKOSTTC   NETTROLOOY. 

(see  Fig.  1),  wliicli,  in  its  entirety,  is  known  as  the  dareei  eerdiral 
tract,  or  as  the  peditncxilar  tract.  Thu*  band  of  fibres  (m)  runs  be- 
tween tLe  external  border  of  the  tlialanms  optici  (T.  O.)  and  the 
lenticular  luicleuB  (L.  K.)  of  ihe  uorfms  striatum,  anil  ounetitutes 
a  portion  of  the  internal  capaulc  so  ealled.  None  of  these  motor 
fibres  have  been  traced  either  to  the  optic  thalamus  or  to  the  len- 

Fio.  I 


Dtaimnntlle  rtfmBraMilon  of  ooum  of  <UrM«  oMwlinU  Umi-t-  Q,V„  eaailit* 
□adaoi;  m.  DbiMsJ  dltMl  Mr«bthl  tttei;  e,tA»Wtram,  T.  0.,  o)-liG  Uialuuni; 
L.  IX.,  Inullmlar  nucUnt. 

ttcular  nucleus,  The  fasciculus  passes  from  the  brain-peduudcB 
into  the  pons,  ami  finally  into  the  medulla  oblonjfata. 

LeeioD  of  Thalamus  Optaci. — Theoretically,  the  only  lesions 
iu  the  interior  of  the  brain  which  should  produce  hemiplegia  are 
thiiAO  situated  in  the  direct  cerebri  tract.  In  accord  with  thia, 
clinical  records  show  that  hemorrhages  couBned  in  their  influ- 
ence to  the  thalamus  optici  do  not  produce  motor  symptoms.  It 
is  true  that  oflou  there  is  a  temporary  paralysis  produced  by  hem- 
orrhage into  ihe  thalamus,  and  that  lesions  of  the  middle  third 
of  the  thalamus  are  not  rarely  aocompaniod  by  permanent  hemi- 
plegia. The  middle  third  of  the  thalamus  is  that  part  of  the 
ganglion  in  which  the  pressure  from  within  would  most  affect  the 
internal  capsule  and  Uie  [>edun(Oe.  It  would  a|)[>t&r,  therefore, 
that  the  paral}-sis  in  these  coses  is  due  to  pressure  upon  the  direct 
cerebral  tract. 

Lesioua  of  Corpus  Striatum. — Lesions  of  the  corpus  strt- 


PAHALYSB. 


alum  Usually  prwluce  licmiplegin,  wbich  m&y  be  m  oomplet«  as 
wfaea  the  lesiou  is  in  tlie  ioterual  cajtaule,  stfectiiig  the  face, 
tODgue,  trunk,  and  extremities.  Wlietlier  the  pnmlysis  in  these 
casen  is  alwaj-ndue  to  pressure  npon  the  internal  fa|wu]e  or  not  is 
an  unj»«ttle(l  question.  There  is  sarrm  reaaon  for  believing  that 
the  corpus  striatutu  k  in  some  way  connected  directly  with  voluu- 
tary  motinn.  At  pr(«c-nt  there  is  no  method  of  diagnosis  between 
lesions  in  the  internal  capsule  and  those  in  either  i>orlion  of  the 
corpus  striatum, — i.f.,  in  the  caudate  nuclenn  or  the  Icntjculor 
bodies. 

Facial  Palay. — In  all  casea  of  hemiplegia  iu  which  the  lesion 

in  the  central  brain  the  jmralysis  of  the  face  is  upon  the  same 

le  as  that  of  the  body. 

Diitorder  of  Sensation  in  Hemiplegia. — A  lesion  in  the  central 

tin  very  rarely  affects  sensation ;  for  a  discussion  of  such  oases 
Bee  the  cliapter  on  Dtsturbancw  of  Sensation.  In  the  medulla 
oblongata,  the  pons  Varolii,  the  peduncles,  aad  also  in  certain 
portions  of  the  internal  rnpHule,  the  motor  and  the  henwiry  fibres 
are  sufficiently  close  to  be  involved  in  a  commoa  lesion.  In  the 
peduncles  slow ly -growing  tumors  are  the  only  lesions  that  produice 
purely  motor  hemiplegia:  under  Btich  circunistjmces  it  is  not  pos- 
sible during  life  to  locate  the  lesion  with  certainty. 

When  hemianicsthesia  and  hemiplegia  arc  produced  by  a  focal 
brain-afiectiou  they  coexist  upon  the  side  of  the  body  opposite 
to  the  lesion,  since  the  injury  is  sltuntal  above  the  decussatiuu 
of  both  tlie  motor  and  the  ^ti^^iry  fibi'cs.  The  detailed  discuNsioa 
of  the  exact  positiun  of  the  lesiou  in  such  cases  most  be  deferred 
to  the  cltnpter  on  Dislnrbatu'es  of  Sensation. 

Hetniplegria  with  Apbaaia. — A  clot  in  the  brain  may  give 
rise  to  hemipl^ia  with  apliasia:  the  diagnafis  of  tlie  scat  of  the 
lesion  in  tli&«  cases  will  be  fully  discuswed  in  the  ohapti^r  ou 
Aphakia. 

Hetniple^a  from  Lesion  in  Pons. — A  hemorrhage  into  the 
pons  Varolii  may  protluce  a  simple  hemiplegia  which  c:inuot  be 
distinguished  from  one  in  the  central  brain-regiou  ;  otten,  how- 
ever, there  are  distinctive  symptoms.  In  the  small  spa**  occupied 
by  the  {>ons,  there  are  gathered  together  motor  and  sensory  6brcs, 
B8  well  as  fibres  belonging  to  the  facial,  hypogtossus,  abduoios, 
ami  trigemiuus  nerves :  the  symjitoms  of  a  clot  iu  this  r^iou 


40 


lAOKOHTIO  KEUtlOLOOT. 


may  be,  therefore,  very  various.  It  is,  however,  exoeptional  for  an 
acute  IcHiou  uf  tlie  ]>ons  to  affect  other  than  the  facial  nerve  and 
the  general  motor  tract.  When  tlie  abchioen^  iierve  is  iinpliculMl, 
there  is  an  internal  )>(]uint;  it  (le{>end!^  upon  the  [lortion  of  the 
p<»ns  attacked  wliether  the  misdirected  ere  is  upon  tlie  side  of  the 
lesion  or  opposed  to  it:  thus,  if  a  riglit-sided  Icsioii  be  in  the 
up|ier  Jialf  of  the  pons  the  t<quint  will  be  in  the  left  eye,  but  if 
in  the  lower  half,  in  the  right  eye  :  in  like  manner  in  hypoglosius 
paral^-sis  the  tongue  when  projected  turna  from  or  towards  the 
para1yze<l  extremities  according  as  the  lower  or  the  upper  portiou 
of  the  [>ons  h  affected.*  Accnitiing  to  Nothnagcl,  a  conjugated 
palsy  of  the  ahtlurens  and  the  internal  rectus  muscle  is  diagnostic 
of  lesion  of  the  pons.  General  oculo-mntor  [mlsy  can  occur  only 
wlien  the  lesion  in  a  tumor  sufficiently  large  to  press  upon  parts 
near  to  but  outaidc  of  die  pons. 

Facial  Palsy. — In  the  majority  of  eases  of  heinorrliage  into 
the  pons,  facial  palsy  h  either  wanting  altogether,  or  is  upon  the 
same  side  of  the  body  as  are  the  other  paralytic  symptom-s. 
Under  the^  circumstances  it  is  the  proximal  half  of  the  pon*— 
i.e.f  that  which  is  next  to  the  peduncle  of  the  cerebrum — that  U 
affected. 

Small  hemorrhages  or  other  lesions  in  the  lower  |>ortion  of  the 
pons  may  cause  hemipl^ia  without  paralysis  of  the  facial  nerves ; 
if  the  hemorrhage  Iw  at  all  large,  there  will  be  pamiysisof  the  facial 
nerve  opposite  to  the  affected  arm  and  leg.  This  iitteniate  or  croesed 
paralysis  is  produced  by  a  lesion  in  the  lower  half  of  the  pons, — 
i,e.,  the  half  nearest  the  medulla  oblongata, — because  a  lesion  so 
situated  i^  IxUow  the  decussation  of  the  facial  nerves,  but  above 
the  decussation  of  the  general  motor  tract.  The  facial  {lalsy  pro- 
duced by  apoplexy  of  the  jjons  is  usually  more  complete  than  that 
caused  by  lesions  in  the  ivrehral  hemisphere,  but  even  in  it  the 
frontal  and  orbicular  muscles  almost  invariably  escajie.  In  crossed 
paralysis  the  fibrett  of  the  facial  nerve  are  a0ected  l>elow  their 
origin  in  the  facial  nucleus.  This  nucleus  belongs  really  to  the 
spinal  system,  and  is  a  trophic  as  well  as  a  [outor  centre.  Con- 
sequently, it)  alternate  palsy  the  facial  muscles  are  separated  from 


*  TliG  effect  of  palsiw  of  tbEsc  and  all  other  individual  n«rT««  will  hv  iU- 
Itd  in  dciAil  In  tbcHCClion  on  I^orsl  Piiby. 


tbeir  trophia  oeutm,  ttml  uudci^  ()egeDcmtion»  similar  to  tho«« 
which  occur  in  the  muscles  of  tlic  extremities  when  the  »<[iinal 
trophic  oentrefi  are  itivolvec].  The  nature  of  tliese  (legeoeratioiis 
will  be  HiacitAsed  in  detail  io  the  tueetiou  on  Trophic  Chaoges.  It 
IS  enoagh  tor  the  present  to  state  that,  as  first  observed  bv  Prof. 
Rmentha]  {Wifnn-  Mai,  Halle,  1863),  the  facial  nerve  rapidly 
Joses  its  faradic  excitability,  and  develops  an  cxee^ive  sensibility 
to  galvanic  stimulation.* 

Oowed  paralyois  i^  iiHualty  dae  to  a  lesion  in  tlie  lower  half 
of  the  pons,  but  is  not  abt^jlutely  diagnogtiu  of  such  lesion,  ob  it 
may  be  caused  by  a  lesion  in  the  niediilla  oblongata.  Thus,  Rondot 
reports  (/oum.  rf«"  MM.  de  Bordeaux,  vol.  xiii.  304)  a  case  in 
which  softeDittg  wa^  confined  to  the  left  pyramidal  tract  in  the 
medulla,  and  H.  Senator  (Arch.  Jur  PjtjivA.  u.  Nervatk.,  xi.  3)  one 
with  aofiening  extending  from  the  calamus  to  the  nstiform  body, 
doe  Io  thrombus  nf  the  leCl  vertt^bral  artery. 

OroBBfld  Oculo-Motor  Palsy. — There  are  certain  cases  of 
hemiplegia  In  which  the  face,  arms,  and  leg  are  paralyzed  upon 
one  side,  although  the  uculo-niotor  nerve  is  affected  vu  the  opposite 
side  of  the  body,  as  is  shown  by  dilatation  of  the  pupil  ami  pla'^is. 
lutheee  cases  there  are  usually  temporary  or  pcrmanont  di»^turb- 
ances  of  sensation  on  the  side  of  the  hemiplegia.  Yen*  frequently 
there  are  marked  dititurbaiKres  of  temperature,  the  pai-alyi'X'd  nlde 
being  from  two  to  nearly  five  degrees  warmer  than  the  normal 
side.  The  Iwion  under  these  rircunwiances  is  in  the  cerebral 
])eduDcle.  (For  cases,  «ee  Ramey,  Ha-ur  de  Mf-iK,  1886,  402.) 
Although  Budge  and  Afa^aniefiT  plaoe  the  centre  which  presides 
over  the  i^ntmctility  of  the  bladder  in  the  )K><luricli>»i,  it  is  rare  for 
the  rectum  or  the  bladder  to  be  affected  in  peiiimcular  hemorrhage. 
It  is  much  more  fret^uent  for  oedema  or  redili-->li  coloration  of  the 
skin  to  show  evidences  of  vawtt-inotordiHturbtiuee, 

Aiioj^hesia  in  Lesion  of  J^ons.  —  Anic$ithcsia,  uaually  ab%nt, 
may  be  present  in  lesion  of  ibe  pnn.i.  So  far  an  the  extremities  are 
coDccmc<l,  it  always  affects  those  which  are  paralyzed.  In  some 
cases  byperssthesia  of  the  [taralyzed  part  lias  been  noted  directly 


*All]wit;h  tbii  cfa«ns«  of  »leclrical  roliition  bw  b«n  noticed  by  ravera.1 
otocTTsn,  f  know  >^f  no  recorded  ckw  in  vhtflh  tfaa  exact  e«Bl  af  the  lesion 
lui  been  L-onflrmcd  b;  an  autoptf . 


42 


DIAONOBTIO  NKDHOLOer. 


a  hemorrhage  Into  tbe  iioua,  but  it  always  tlLsappeans  m  the 
course  of  two  or  three  days. 

ProfisttMtr  Lftydpn  ha>t  ilescribeil  a  cose  of  left  hemiplt^ia  in 
which  a  high  grade  of  ansesthesia  existed  in  the  course  of  the  right] 
trigeminus  nerve,  and  also  in  the  left  estremiiies;  and  Ilujih- 
liDgs-.Taekson  states  that  lie  Iihs  seen  a  similar  crossed  sensory 
palsy.  It  would  appear,  therefore,  that  there  may  bo  aitcmatA 
sensor)-  ns  well  as  alternate  motor  pntsy  in  disease  of  the  jwns. 
Under  these  circumstances  it  is  probably  the  lower  half  of  tbe 
pons  thtit  is  aSected. 

Pro^esaive  Hemipleg'ia  from  ItBuion  of  Pons. — A  progree- 
wve  hemiplegia  with  or  witltoiit  sensory  disturbances,  and  with  or 
without  |»aralysiH  of  the  abduoens,  hypoglossua,  or  trigeniiuus* 
nerves,  may  be  pwduced  by  a  slowly  progressive  lesion  oa  one 
side  of"  the  pons.  The  diagnosis  of  sucrh  an  afl'ectlon  mnst  be 
made  nut  by  ini  applioation  of  ihe  faela  aixl  prliictpli?^  n'hlcli  have 
just  been  discussed  in  detail  in  the  consideration  of  acute  pons 
lesion-s.  As  already  slated,  tbe  gradual  convei-sion  of  a  hemiplegia 
into  a  general  palsy  is  very  characterislic  of  a  tumor  in  the  [k>u«  or 
in  tbe  membranes  beneath  it.  I  know  of  no  studies  of  tempera- 
ture under  those  circumstances;  but  vf^ry  markpd  diffprenccs  in 
temperature  of  the  two  axillce,  and  especially  iu  the  temperature  of 
cxpoi^d  extremities,  are  to  be  lookei]  for.  Tn  any  caiw  of  pni- 
gressive  hemiplegia  with  o  persistent  marked  inci-case  of  the  tem- 
perature of  one  axilla,  the  proliabilities  are  that  the  lesion  is  on 
one  side  of  the  puns. 

PAIUPLEGIA. 

Paraplegia  ia  a  more  or  less  complete  palsy  confined  to  the 
lower  limbs,  and  may  be  either  functional — i.e.,  reflex  or  hysterical 

—or  orgaiiio,  it  btitig  underxttMRi  that  for  tliy  pl■e^eIlt  we  are 
forced  to  class  under  functional  paraplegia  cases  in  which  after 
death  no  lesion  can  l>e  demonstrated  by  the  microsoope. 


Ftmctional  Paraplegia. 

Reflex  Paralsraes. — Paralysis  of  a  single  group  of  muscles,  or 
more  usually  of  a  number  of  asMiciated  groups,  may  result  from 
the  in-itatioQ  of  peripheral  ocrve-Qlaments  not  immediately  con- 


Dectif)  with  siicli  miiMiles.  loi^tanoes  of  this  arc  the  various 
atrophic  poleie!!  astHX-tatt^d  with  trail iiiiitii^iiiH,  inflameH  jitiiits,  hikI 
other  surgical  aflPecttons,  which  will  be  discu&scci  in  detail  under 
the  beadiog  of  Multiple  Palsfr.  Omitting  these  surgical  cases,  the 
moBt  usual  form  of  rcHcx  jmnilysii^  ii?  imraplegia.  For  many 
reare  it  has  been  known  thai  pamplegia  is  uot  rarely  associated 
with  severe  Clonic  <lU«biM  of  the  genito-urinary  organs,  and  in 
1S64  BrowD-S6quard  showetl  that  similar  lotts  of  po%ver  in  the 
legs  mar  be  produced  by  irritations  of  the  intestines  or  other 
viscera^  and  gave  to  the  affection  llie  iianie  of  Reflex  PanilysiH. 
It  does  not  lie  within  tlie  ;icope  of  the  present  work  to  enter  upon 
a  detiile*!  discussion  of  the  ]>athoi(igy  of  renal  paraplegia.  Suffice 
it  to  etate  that  in  my  opiuion  the  more  serious  case^  are  the  result 
<^  aa  oi^nic  di&ea&e  of  the  cord  (see  page  44).  This  explanation, 
however,  cannot  l>e  given  of  the  not  extremely  infreqiieut  cases 
to  which  a  complete  paraplegia  without  anaathesia  has  occurred  in 
a  pemon  sufTenng  from  a  geiiito-urinary  irritation  and  has  disap- 
peared within  two  or  three  days  alier  the  removal  of  such  irrita- 
tion. To  cases  of  this  character  the  name  of  lieQcx  Paraplegia 
should  be  restricted.  The  point  of  irritation  may  be  in  the  in- 
testines, and  it  is  possible  that  iu  some  of  the  casetf  In  which 
paraplegia  occurs  during  a  severe  dysentery  the  symptoms  are 
reflex.*     Ubuslly,  however,  the  jiaraplegia  [lersiats  long  after  ilte 


*  AlmMt  any  form  ot  pinl^sU  may  b<>  developed  AoAng  tho  conTslRaoencc 
from  lli«  otMta  fcTsrs  or  ezatilhsmfttA  proper.  Them  may  b«  nothing  in  tfac 
panlf  sis  tu  diflin^ui.*]!  it  from  caatB  of  similar  cliarnctur  produced  by  oll>«r 
cKtn*.  Exp«rt«tiDe  has,  howef«r,  nhown  Lb»l  in  «  canHidprablQ  proportion 
of  Umm  post-fobriltt  or  poni-cxnnthematoui  cJImiucii  lbs  i«yniptoniii  nro  «iinply 
m.  motor  p*rapl«gta,  nod  ar«  much  moro  Hnienabln  to  treatnent  than  in  <irdi> 
tiirj  panslyoi*  of  tlw!  miinfi  cla**.  1  have  >>(-rn  vsrlon*  InrtancM  of  paraple£;ia 
f6tlowiii(;  acul«  dvaoitlerjr  and  typhoid  fev«r  in  wllieli  I  was  unubU  tu  dxlect 
■ymptoini  difforvnc  from  llio*"  prmdufod  by  oriliitary  vury  mild  iny«liti»  lo- 
ouad  In  tbe  tnotcr  imci,  but  in  which  mora  or  lees  perfect  raoovciy  look  plaoo 
in  ihs  eouna  of  a  few  moutha.  Tliu  Itvion  in  noine  of  tfacfo  raSM  ii^  a  multiple 
neuritis  (eee  Multiple  NenntlB) ;  but  that  a  myelhi*  may  occur,  and  ox^tn  hb 
btsl,  nffGr  nRo  of  ihi^Hc  fev<:r«,  i-«  >hown  by  the  cane  reported  by  Wvstphal 
(AreA.  fir  Ptyehiat.,  tid.  iv.,  I8T3'74-)  In  this  case  the  paralysis  uppoftrbd 
on  ik«  eleTcnth  day  of  smallpox,  and  resulted  fatally  in  four  weelo.  At  the 
pMt-mortctn  tmall  foci  of  softening  were  found  ihroughimt  the  cord,  It  i» 
pnib*ble  that  the  myelitis  vai  septic.  Cases  of  dyaeoteric  paraplegria  bnve 
also  bc«ii  report^  in  whitrh  thu  nutupsy  has  revaalod  diffLued  myelitis. 


44 


clire  of  the  dx-senter)-  or  Hiarrhaa,  and  tlie  disease  must  therefore 
be  looked  upon  as  scmetliiug  Diore  tliaii  a  reHex  aCrection.  My 
belief  is  that  in  some  of  these  oases  there  is  organic  change  in  the 
cord,  but  that  in  others  there  is  only  a  condition  of  profound  de- 
pression of  the  spinal  function  from  loss  of  nutritive  tone,  The 
iads  that  in  most  ca;^^  the  symptoms  gradually  yield  to  treatment, 
and  that  sensation  ia  rarely  if  ever  Kprit)U»]y  afleeted,  indicate  that 
there  is  no  serions  myelitis.  A  true  rcfles  paraplegia  may  be 
pn>diiced  by  the  irritation  of  worms  In  the  intestinal  tract  A 
number  of  cases  liave  been  reported  in  which  t}ie  jiassage  of  lum- 
briooid  or  tape  worms  has  been  fullowed  by  immediate  relief  of 
[the  par:ilyttc  ttyniptomH,  Dr.  Moll,  of  Vif>nna,  hm  n-portetl  a 
lease  in  which  the  arms,  and  not  the  lej^s,  were  paralyzed,  with  an 
inunodiate  cure  of  the  palsy  on  the  expulsion  of  the  tape-worm. 

In  reflex  [laraplcgta  aeiiaation  is  not  disturbed,  the  bladder  in 
not  puiBlyzed.  and  there  are  no  trophic  changes. 

lAajor  Renal  Paraplegia. — There  have  been  not  a  few  aLsea 
of  gen i to- urinary  diseaw,  and  especially  of  renal  calculus,  in  which 
ayniptoiiis  far  more  severe  than  those  just  s[>okeii  of  were  present. 
The  motor  Ila^Hly.^is  in  such  ouvk  IncreaHeti  until  it  becomea 
almost  complete,  and  is  acoompatiiod  with  marked  perturba- 
tion of  sensation.  Not  rarely  violent  pains  shoot  down  the 
affected  limbs,  and  are  a^jociated  with  various  paneethe8i»,  and  a 
continually  deepening  anaesthesia  which  may  become  complete. 
In  the  earlier  etagvs  l-lie  rellexes  are  sometimes  exaggerated,  but 
sooner  or  later  they  grow  less  active,  and  in  most  cases  finally  dia- 
isppear.  The  moecles  rapidly  wa»te,  and  the  electrical  reactions 
of  degeneration  appear.  Bulla;,  bed-sores,  and  other  trupbio 
clianges  incrcaae:  all  ci>ntrol  over  the  bladder  and  rectum  is  Inst, 
and  the  patient  finally  dies  from  exhaustion.  In  some  caAes  the 
progreaa  of  the  disease  w  very  rapid ;  in  others  it  is  slow,  and  arrest 
witli  partial  recovery  may  occur  if  tlie  original  irritative  lesion  be 
removeil.  The  symptoms  in  these  cases  are  due  to  a  secondary 
myelitis,  whii:li  in  some  insUuices  is  certainly  produced  by  a  neuritis 
creeping  up  the  nerve-trunk  implicjited  in  the  original  ilisease, 
and  finally  reaching  the  cord  itself.  I  am  inclined  to  believe, 
however,  that  a  myelitis  may  be  induced  without  this  ascending 
neuritis,  or  in  a  manner  |Htrallel  to  that  in  whieh  the  i*(mdition 
of  violent   functional   excitement  of  the  spinal  cord  known  oa 


PARALYSIS. 


-15 


tetaDtui  is  oaused  by  au  irritatiou  uf  a  |>eri|>heral  ruTve-fi lament, 
Thia  eocandary  myelitis  may  be  produced  by  any  suffidently  severe 
and  permanent  irritation  of  nerve-filam^ntjj.  Cases  have  been 
reported  in  which  it  has  followed  a  din.'ct  traumatism  of  a  nerve- 
trunk. 

Id  some  caeee  of  pelvic  or  abdominal  inflammations  in  whii:h 
paraplc^'a  has  been  supposed  to  be  reflex,  ihe  symptoms  iiave  Ix>cn 
doe  to  a  direct  implicarion  of  the  sarral  nerve  in  the  lesion,  and 
a  consequent  wide-!»prfad  neurit!-^  of  llie  loM-er  extreniilles, 

HyBterical  Para plearia.— Hysterical  paraplegia  is  frcijueut, 
and  may  simulate  any  of  the  organic  varieties.  It  usnalty  tle- 
vdops  rapidly,  but  may  eome  oa  slowly.  It  may  be  associated 
with  the  most  marked  muscular  relaxation,  or  with  the  greatest 
rigidity,  due  to  excessive  contractures.  The  kuee-jerk  (sL-e  Re- 
flcixes)  is  in  some  cases  nornui),  in  others  it  is  aliseut.  l'erlia[>s  in 
the  majority  of  instances  it  is  exaggenited.  The  nniHclen  do  not 
UDfiergo  rapid  trophic  changes,  but  a  slow  progressive  wasting  of 
ibem  may  occur.  It  has  been  ass^rtetl  by  Gowers  that  the  er- 
i»teucc  of  ankle  clonus  fee*  Retleivs)  is  proof  uf  the  oi^;aiiio 
nature  of  a  paraplegia;  but  this  is  not  correct,  1  have  seen  a 
paraplegia  whi<-h  had  lasted  for  many  months,  associated  with 
greatly  exaggemleil  knee-jerk  and  pronounted  ankle  clorms,  gtt 
well  in  a  few  days  during  the  adnjinistration  of  subuitrate  of 
bismutii.  The  m<i>^t  oliai-aulertstic  Hymptonis  are  ci^nnocled  with 
sensihilitv  :  in  some  cases  there  is  excessive  hypenesthesia,  with  or 
without  pain  ;  more  frequently  the  »en.sibiliiy  is  les.'^ned  or  abol- 
ished ;  usually  the  muscular  aense  is  at  least  as  much  afiectei]  as  is 
cutaneous  sensibility,  in  thost-  forms  of  organic  ])HrapIegia  which 
are  most  frequently  simului^l  by  (he  li)'sterical  nffec^tion,  sensi- 
bility is  not  altered.  According  to  my  own  exj>erience,  a  distinct 
girdle  sensation  is  diagnostic  of  organic  disease;  but  hysterical 
palieuls  are  wry  prone  to  Lake  on  suggested  symptoms:  conse- 
quently lliey  frequently  complain  of  the  girdle  sensation  after 
it  has  been  mentioned  in  their  presunoe.  M.  Charcot  appears  to 
believe  that  the  presence  of  fibrillary  muscular  contractions  ia 
diagnostic  of  organic  diseases,  but  this  is  denied.  (See  Jievnc  de 
Mtti.f  1885,  p.  229.)  The  diagnosis  of  hysterical  paraplegia  is 
ttBually  to  be  made  out  by  ctmsidcring  the  post  history  of  the 
patient,  the  mode  of  onset,  the  condition  of  the  sensibility,  and 


MAONoarrc  xettroi/wy. 

the  shifting  unture  of  the  ahcrations  of  motility  and  of  sensi- 
bility. Tt  la  also  ajwerteif,  but  on  thifl  point  I  am  nnt  |K»ltive, 
that  ill  those  t-oses  of  liysteriii  in  whicli  there  are  cou tract ures,— 
casva  rn  whioh  the  diSicnIly  of  the  diagnosis  is  usually  greatest, — 
muscular  n^kxation  taktw  place  in  the  early  ulages  of  etheri- 
zatioD,  whiUt  ill  tlie  orgauic  spastic  paUy  the  aneeatlietic  exvrt» 
little  or  no  ioflueuw  on  the  muscles.  Unless  the  diagnosis  can 
be  umde  by  the  use  of  an  anaKthetic,  tliere  are  certainly  ca»efi  in 
whicli  it  is  impossible  to  decide,  within  n  brief  space  of  time, 
whether  the  iwiralysis  in  organic  or  hysterical. 

Organic  Paraplegia. 

Anatomy  of  the  Spinal  Cord. — Tu  onlt-r  t«  nxxignijHJ  tlie  dif- 
ferent forms  of  organic  jtanijilf^ia  it  is  neocsaary  to  have  a  clear 
understanding  of  the  physiological  regions  nf  the  spinal  oord,  and 
of  the  functions  connected  with  each  of  these  regions.  In  the 
following  diagniui  it  will   be  uottoed  iu  the  fir&t  plaue  that  the 

TiQ.  3. 


9^1 


«»«Q 


O    6 


cord  is  uomjMkwtl  of  gray  and  white  matter,  and  that  in  the  gray 
matter  of  the  cord  arc  silUEiCed  d'rtaiii  cells  whose  platteB  are 
marked  in  the  diagram  by  dots. 

Thwt'  cells  arc  furnished  wltli  long  processes,  whidi  are  the 
orifj^n  of  ncrve^roots.  They  are  gnngliouiu  in  their  nature,  and 
have  the  double  power  of  exciting  motion  and  of  influencing 
uutritiou  in  the   muscles.     When  a  disease   atlnvks  tbeeti  gao- 


'  glioDic  c«1U,  paralysis  of  tlie  muscleii  ensues,  wttli  rapid  wnstiag 
an*]  change  in  the  electrical  reactiuiiif.     (Sec  Trophic  Clianges.) 

Placed  laterally  to  the  gray  matter  are  the  soM?nlIed  taicrnl 
Mt/umnj!  (A,  Fig.  2),  ma'wes  of  nerve-fibrw,  which  paas  nlong  the 
cord,  constantly  receiving  accessions  from  the  Derve-roots,  and  in 
tbe  uppex  part  of  the  medulla  oblongata  Income  the  pyramidal 
tratii',  which,  crofieing  over  to  tlie  oppiisite  side,  [muw  tlin)Ugh  tlie 
pons  Varolii  into  the  peduncle  and  then  upward  as  the  dircd 
fwrrbral  tracts.  Situated  on  the  extreme  horders  of  the  an- 
terior Bssure  in  the  white  matter  of  the  cord  arc  tlie  so-called 
ooiumna  oj  7urc£,— composed  of  white  acr^'e-&bres  pa^ng  up- 
ward to  the  brain  (C).  Their  fnnclionH  are  wimilar  tu  t}in6e  of 
a  lateral  column, — namely,  to  conduct  impulses  from  tlic  brain. 
The  essential  diflerence  is  that  the  lateral  columns  cross  over  to 
tbe  opposite  brain-hemitipliere,  whilst  the  columua  uf  Torek  pass 
dire(!tly  lo  the  horaiBphere  of  the  same  side :  hence  the  lateral 
columns  are  aometimes  spoken  of  as  the  eroMtfl  jttjratmtial  froclM, 
and  tlie  colamna  of  Tuw^k  an  the  dir«i  pyramidal  tracta. 

From  the  ^ray  matter  of  the  oord  pass  out  the  anterior  and 
posterior  nerve-nxits.  The  n^iou  of  white  matter  in  the  neigh- 
borhood of  the  poflterior  roots  is  known  as  the  ptMcrior  root- 
soiMa,  and  is  connected  with  sensation  and  ro-onJination,  fho  that 
in  dlseaiM  of  this  portion  of  theooni  theee  functions  are  eH|>ecially 
affected.  In  immediate  contiguity  with  the  posterior  Qssure  are 
the  small  tractj*  of  while  matter  known  as  the  volitmna  uj  Gotl  (]{). 
A  disease  which  attacks  the  posterior  root-zone  usually  affects  also 
the  columns  of  GoII,  bnt  there  are  very  few  cases  on  record  of 
primary  diseased  of  the  cotumntj  of  Goll :  so  that  their  functions 
art*  at  present  not  de6nitely  known. 

Out  of  the  spinal  cord  spring  nerve-fihres,  which  pass  into  the 
90-called  itympathotic  ganglia.  Such  fibres  arising  in  the  cervical 
spinal  coiti  pass  through  the  cervical  sympathetic  gaoglia,  and  go 
with  the  carotid  artery  into  the  cruuial  cavity.  Some  of  these 
fibres  are  probably  distributed  aa  vaso-raotor  nervca  of  the  brain 
and  its  raembranes ;  others  renrh  the  rye,  and  Ijecome  con- 
nected with  the  movements  of  the  pupil.  Certain  spinal  sym- 
pothetic  fdanients  pass  from  the  cervical  dorsal  region  to  the 
heart,  and  are  essentially  connected  with  its  movementt),  It  is 
owing  to  these  fnctA  that  diseat^s  of  the  cervical  dorsal  cord  are 


DIAONOamO  NEUSOr-OOY. 

frequently  associated  with  dcrongements  of  the  pti|)illary  nnt\ 
cardiac  movements. 

Id  the  Itmihar  cord  are  placed  centres  which  pr^ide  over  the 
genito-uriaar)'  tract,  and  hence  disease  of  thin  |K>rtioQ  of  the  curd 
18  prone  to  be  eoniiected  with  priapism,  impotence,  or  other  i^nital 
symptoms,  and  with  very  early  spasmodic  or  paralytic  aflfectiona 
of  the  bladder. 

ParaplBgia  from  Multiple  Paralysis. — When  a  multiple 
paUy  attacks  ihc  lower  portion  of  tlie  tipinal  ettrd  eHjKrcially,  it 
may  produce  a  |iaruplegia  which  might  be  mistaken  for  one  due 
to  general  myelitis.  Under  tho.'se  ciroumstanccs,  however,  it  will 
usually  be  found  tlint  some  muscles  of  ihv  lower  extremiti^  have 
escaped,  or  that  tliey  have  been  irregulurly  aSbctcd.  In  a.  mye- 
litic paraplegia  the  general  rule  is  that  the  tuuscl&4  farthest  from 
the  trtink  are  first  paralvKod  ;  althrtugh  this  does  not  apply  to  cases 
of  traiisver^te  niyelitii^  or  to  some  rare  instances  in  which  localized 
regions  of  the  cord  are  especially  attacked.  Almost  always  in 
tliese  cases  of  multiple  palsy  some  muscles  iti  the  upper  extremity 
will  be  found  to  be  atfecied.  The  diagnr)sis  of  the  true  disease, 
however,  is  lo  be  especially  based  upon  the  rapid  wasting  of  the 
aHected  muiK-les  and  the  change  in  tlieir  electrical  reactions. 
Cases  of  mulliplc  (mralysis  wliich  most  resemble  myelitic  |)ara- 
plegia  are  those  due  to  lead  or  arseuical  poisoning.  That  such 
coses  belong  in  tlie  multiple  {Mtlsies  is  shown  by  the  trophic 
changes  which  arc  present  and  by  the  irregularities  in  the  gn>u[»- 
iug  of  the  palsie!j.  The  dtagnusis  betweeti  these  cases  and  those 
of  ordinary  poliomyelitis  or  of  multiple  neuritis  will  be  fully 
considered  under  the  head  of  Multiple  Palsies. 


Oi^nic  paraplegia  having  been  found  iu  any  case,  the  first 
point  to  be  settleil  is  as  to  the  length  of  time  n3quiml  for  the  de- 
velopment of  the  symptoms.  For  diagnostic  purposes  all  these 
leases  arc  armngeil  under  three  heads: 

F^fM.  Those  in  which  tlie  symptoms  are  develo]>od  with  great 
npidity. 

•S'omri^.  Those  in  which  some  days  are  required  for  the  full 
production  of  the  paraplegia. 

Third.  Those  in  which  the  symptoms  pn^ressively  increase 
during  a  period  of  many  months  or  years. 


Ahrupi  Parapffffia. 

When  the  syiiiptotns  of  paraplejjia  develop  in  Ihp  course  of 
two  iir  tliri:<e  days,  aiid  are  not  coniiede*!  witii  a  trauniatism,  they 
are  doe  either  to  a  hemorrbiige  luto  the  oord,  to  a  hemorrhage 
ioto  the  vertebral  caoal  outblde  of  the  cord,  to  ascendiag  (or  Lan- 
dry's) panilysis,  ur  to  a  very  auiite  inyolitiB. 

Spinal  Apoplexy. — In  aome  cases  of  sudden  para])lcp:ia  the 
patient  falls  to  tlie  ground.  Very  rarely  the  cerebral  disturbance 
is  so  marked  iliat  the  attack  may  appear  to  lie  a  true  apoplexy ; 
but  when  ooDsciousnesa  is  restored  it  will  be  found  tiiat  thero 
is  ft  ouDiplctc  palsy  of  the  lower  Itmbe,  both  of  ^euBatiou  aud 
of  motion.  In  the  very  beginning  of  iho  attack  there  may  be 
violent  pains,  but  tliese  soon  sulfide.  Theoretically,  spinal  apo- 
plexy might  be  expected  to  produce  localized  paUJuet  in  tlie  parte 
below  the  loiion,  but  pructictdly  the  cord  is  so  small  tJiat  wlienever 
hemorrlia^  does  occur  it  intluencoi;  the  whole  of  the  cord,  mi  that 
both  sides  of  the  body  are  affected.  Pain  is  not  usuallv  a  promi- 
neot  ^raptom,  even  at  the  beginning  of  an  attack.  The  an- 
lestiiesta  19  very  characteristic.  It  is  usually  complete,  but  it  ia 
K[iecially  lo  be  recijguized  by  its  abrupt  termination  in  a  line 
or  a  vcrr'  narrow  zone  which  extends  ontiri'Iy  around  the  body. 
The  bladder  and  rectum  are  completely  paralyzed. 

Htematomyelitis. — In  »ome  cases  of  lieniorrhage  into  the  cord 
the  sudden  paraplegia  has  been  preceded  by  cvidenooa  of  subacuLe 
myelitis,  such  as  fevt-r,  fomiitiillunft,  partial  or  complete  paral- 
ysis of  the  bladder,  girdle  sensations,  sjiasms,  or  muscular  twitoh- 
fngs^  To  the^  (^aee^  the  name  of  htematomyelitis  has  been  given, 
but  tlie)'  are  to  be  viewed  us  instances  of  !^|>inal  apoplexy  occurring 
in  a  myelitis.  Softening  of  tlic  oonl  and  other  evidences  of  in- 
flammation may  be  found  after  death  in  the  neighborhood  of  the 
clot,  oven  when  there  have  been  no  distinct  symptoms  of  myelitis 
before  the  liemorrbage.  The  natural  explanation  of  these  comsi  is 
that  Uie  iullanitnatiun  of  tlie  cord  was  provuke<l  by  t  lie  hemorrhage. 

Hemorrba^  into  Spinal  Mombranee. — In  otlier  easee  of  very 
urttte  pampl(^ia,  instead  of  the  [mralysis  being  abrupt,  many  rain- 
atcEf,  or  even  hourv,  are  requii-ed  for  its  complete  development,  and 
during  this  lime  there  is  very  great  pain.  Under  these  circum- 
Btances  the  lesion  is  a  hemorrhage  outside  of  the  cord  Into  the 
•pinal  merobraoes.     The  rate  of  the  development  of  the  paralysis 

4 


ri 


GO 


DIAONOSTrC  NEtmOLOGY. 


varies  awortling  to  the  amount  and  rapulitv  of  the  hemorrhage. 
The  loss  of  iwwer  is  due  imt  to  an  immediate  Iwion  of  the  cord, 
but  to  prciuurt}  u|K)U  the  cord,  uud  e8|)ec.'iully  upou  the  iiiotor*Derve 
roots,  by  the  exuded  blood.  Unless  the  blood  be  in  great  aruoiint 
and  thrown  out  with  exceswivp  rapidity,  the  pnralpis  will  grow 
more  and  more  marked  during  sevenil  hours,  and  will  ascend 
higher  and  higher.  As  the  blood  creeps  up  the  spinal  cord  or 
fonxti  it«  way  downward,  tt  tearK  the  memhnines  away  from  ihe 
cord,  presses  or  stretehes  or  perhaps  tears  the  posterior,  as  well  as 
the  anterior,  apinal  roots,  and  pro<hices  by  this  irritation  of  the 
sensor)'  nerve-rools  shooting,  tearing,  or  burning  pains,  with  more 
or  less  tuarked  lossof  fwnsibility  in  the  iifief^ted  parts.  The  antea- 
thesia  Ib  UHunlly  not  an  compl{<t(-  or  an  abrupt  tm  in  cases  of  intra- 
spinal apoplexy.  Nevertheless,  if  the  olot  be  a  large  one  the 
sensor)'  palsy  may  Ik  complete,  and  the  mne  between  the  anaes- 
thetic and  Ihe  sensitive  portions  may  be  very  narrow.  The  blad- 
der  and  rectum  are  very  frequently  paralyzed.  Priapism  or  other 
eviden<»tjof  gcnito-urtnan,'  irritaiioii  might  tiatumlly  be  cxpcctodj 
bat  I  have  never  in  my  own  cases  seen  them. 

Paraplegias  of  rapid  or  alow^  but  not  uf  immediate,  <levc]op- 
mcnt,  are  best  studied  under  two  headings  :  first,  tho.%  wliich  are 
Bocompanied  with  exce^^ive  pum  ;  .-tccond,  t\\o^  in  which  there  is 
DO  pain,  or,  at  ino«l,  only  moderate  Mufleriitg. 

PaiufUl  Paraplearia. — In  tlie  !*ocaiIcd  painful  paraplegia  the 
suSering  is  uHually  inti^nse,  is  oflcii  won»e  at  uight,  and,  althougli 
it  may  be  po^8i^teut,  is  at  least  in  it.-*  exacerbations  paroxysmal. 
The  i>ains,  which  are  described  as  stabbing,  Hghtnirtg-like,  burn- 
ing, etc.,  lake  almtfst  every  conceivable  form.  They  are  fre- 
quently felt  in  the  neighborhood  of  the  rectum  or  alouj:;  the 
urethra.  Motility  is  generally  very  >-lowly  lost.  The  paralysis 
may  be  acoorapanied  by  s|>aRni,  but  almost  invariably  at  last  the 
muscles  are  relaxed.  The  knee-jerks,  at  first  in  many  cases  ex- 
B^crated,  are  finally  alM)tished.  Hy|MTiesthesia  amy  exist  in  the 
beginning,  but  at  last  gives  plaee  tonnsesthesin.  Trophic  changes 
usually  come  on  early,  and  may  be  complete. 

lu  painful  paraplegia  the  le^io^  i»  either  a  ilisease  of  the  lower 
vertcbnc  or  else  a  growth,  usually  sarcomatous  or  distinctly  can- 
cerous, so  uUiated  as  to  involve  the  ner\'fB  in  their  emet^noe 


PABAT^YBiS, 


5T 


from  tliesacrum.  When  thevertebne  (faemselvea  arcaffcct^,  the 
dbesiie  in  ftlmnnt  iiivnriul>ly  mnoeroiii^  An  aneurism  hv  pressure 
apoo  the  lower  vertebne  may  destroy  them^  and  aa  the  nerves 
become  implicuted  the  pressure  prcxluoea  symptonis  somcwbat 
KBembliug  t]io>4r  lainsed  by  malignant  growtbft. 

Non-Painftil  Porapletria. — A  paraplegia  without  excessive 
pain  may  be  developed  in  the  connte  of  from  one  to  stx  days : 
sadi  cases  constitute  a  gmnp  suSiciently  marked  to  be  studied 
together,  and  to  be  subdivided  into  several  sub-groups. 

Of  these,  Hub-grtnip  the  first  ineUides  those  tsises  wliich  so 
Dearly  correspond  to  those  described  by  L-antlry  that  they  may  be 
known  a.--  LandryV  palsy,  or  ascending  paralysis. 

Ascending'  Paxalysis. — Id  »onie  of  the  cases  of  ascending 
paralysis  the  symptoms  are  preceded  by  evidences  of  nervous  dis- 
tnrboooe,  such  as  feelings  of  weaknesn,  irregular  formicntions, 
spoa  of  onrobness^  weariness  and  diseomfort,  and  possibly  occa- 
sional spasmodic  contractions.  Either  with  or  without  these  pro- 
dromes  great  weakness  of  the  lower  extremities  mmes  on,  and 
increases  until,  in  the  ooiirsc  of  a  few  hours,  standing  or  walking 

Eis  impoeeihie. 
The  palsy  usually  appears  fin^t  in  the  mtiseles  of  the  foot,  then 
in  the  Iq^  then  in  the  thighs,  until  the  whole  leg  is  fiaettid  and 
without  power.  The  symptunis  steadily  progress  upwiiwl,  in- 
volving soon  the  arms  and  tinally  the  muscles  of  respiration,  and 
in  this  way  produang  denth.  The  temperature  of  the  bodv  is 
very  rarely,  if  ever,  above  normal ;  but,  auconling  to  Hammond, 
the  a^ctcd  limbs  arc  distinctly  lower  in  toraperatura  than  normal. 
The  knee-jerk  is  in  most  cases  diminished,  and  is  not  rarely  in  the 
latter  stages  of  the  attack  abolished,  but  early  in  tlic  pamlysis, 
and  even  when  voluntary  motion  is  profoundly  aflfected,  it  may  be 
well  preser\'ed :  neither  the  bladder  nor  the  rectum  is  usually 
paralyzed. 

According  to  Landry,  who  fir^t  gave  tlie  name  of  ascending 
paralysis  to  cases  of  this  character,  the  order  in  which  the  muscles 
are  affected  by  (he  paralysis  is, — 

I^irgt.  The  muscles  which  move  the  toes  and  foot,  then  the 
posterior  muscles  of  the  thigh  and  pelvis,  and  lastly  the  anterior 
and  internal  muscles  of  the  thigh. 

Second.  The  muscles  which  move  the  fingers,  those  which  move 


fi2 


mAQKOsnr  nboholoot. 


the  hand,  and  the  arm  upon  tlie  Noaputa,  aud  lastly  the  muscles 
which  move  the  forearm  upon  the  arm. 

'Jliird.  The  muscles  of  the  trunk. 

Fourth.  The  muecles  of  respiration,  then  those  of  tbe  tongue, 
])harvnx,  and  ccsophagus. 

lu  many  vasen  the  parulysLs  does  not  follow  the  onunw  laid 
down  by  I^andry ;  it  is  ofltcn  more  irrej^nlsr,  one  arm  or  one  1^ 
being  more  paralyzed  than  the  lUlier;  and  cases  are  affirmed  to 
have  existed  in  which  tbe  symptoms  began  at  the  upper  portioD 
of  the  cord  and  ran  rapidly  dovvnwtird,  involving  therefore  the 
upper  exIremitieB  first.  It  is  statetl  by  L*vi  {AreJuveg  Gftt.  de 
Med,,  sixth  series,  vol.  i.,  1885,  129)  that  Ciu-ier  died  from  an 
acute  descending  panilysiit,  afleutin^  the  meduUu  ulmo&t  in  tlie 
bi^nning  of  tbe  attack. 

There  is  no  pain  during  the  whole  attack,  or  at  lefwt  nothing 
beyond  diwomfort,  formications,  or  more  or  less  distinct  numb- 
ness. Usually  cutaneous  neiii^ibility  is  not  entirely  destroyed; 
someiimes  it  appears  to  be  but  Utile  aflected;  but  in  a  few  cases 
there  has  been  .ilmost  complete  aniestbesia.  There  arp  usually  no 
trophic  change!^,  so  that  bed-sores,  if  they  ever  occur,  are  v«y 
rare.  In  a  few  cases  of  acute  psiraplegia  of  doubtful  character 
perforating  ulcers  have  appeared.  OEdcma  of  the  ekiu  wa*. 
noted  by  EiHcniohr,  and  in  some  ohkiw  there  lias  been  a  pn>fuse1 
secivtiou  of  swftat.  In  a  case  under  my  own  care  it  was  found 
by  staining  the  nails  with  nitric  aeid  that  there  was  a  partial 
arrest  of  growth,  which  was  much  more  marked  in  the  iito6t 
completely  paralyzed  portions  of  the  body. 

A  very  important  diHtinrtion  which  divides  the  oases  of  acute 
parflpte);;ia  just  spoken  of  is  that  in  some  the  symptoms  pro- 
gress slowly,  reciuiring  several  days  for  their  full  develupmeut, 
whilst  in  others  the  symptoius  rapidly  increase.  It  is  uncertain 
whether  there  is  a  vital  diflerence  in  the  patholojjj'  of  these  cases, 
but  clinically  they  differ,  in  that  the  symptoms  when  slowly  de- 
veloped arc  prone  to  be  arrested,  so  that  the  patient  escapes  for 
the  time  being,  and  in  some  instancfc*  entirely  recovers.  On  the 
other  hand,  when  the  palsy  rapidly  rises  np  the  body  during  the 
first  twelve  hours,  it  is  rarely  arrested, — the  patient  usually  dying 
in  a  few  days  of  asphyxia  from  respiratory  palsy. 

A  much  mure  infre<£ueoi  form  of  acute  paraplegia  than  that 


PAKALY818. 


fi3 


just  de«oril»ed,  and  which  is  (wrliaps  worthy  of  con^titutiog  a  second 
sab-group  of  caws,  is  typififKl  1)y  a  can;  reported  by  C.  Eiseu- 
lohr,  in  which,  after  exposure,  a  man  was  taken  with  pains  in  liia 
timh^,  foUowwl  by  a  rapid ly-a«oentling  paralysis,  vrhioh  became 
M  complete  tliat  he  could  not  move  either  biit  bandi<  or  bia  feet. 
Tfiere  was  fcviTj  exuj^ratcd  knee-jerk,  a?denia  of  the  extremi- 
ties, presen>*atiou  of  the  normal  tilixtru-<xintractility  of  the  mns- 
cl«,  and,  after  a  few  days,  rapid  recovery  {Archh  f.  Ptti^dimtm,, 
Rl.  v.,  219). 

Acute  Central  MyeUtia. — In  the  uecoud  group  of  caj«es  of 
acute  paraplegia  symptotiu^  somewhat  similar  to  those  of  ascend- 
ing palsy  are  present,  but  the  following  important  difiereoees  are 
well  marked  :  the  aosestliesia  is  mnch  more  pronounced,  and  may 
be  complete;  paralysi:^  of  the  bladder  aud  rectum  occurs  early; 
the  rc6exes  arc  soon  abolished,  and  trophic  changes  take  plaoe 
alrooHt  at  once  in  the  pnruly/tHl  niitst^h^s,,  ao  that  in  the  coiin^e  of  a 
very  short  time  faradic  conirnctility  ia  lost  and  the  reactions  of 
degeneration  appear;  trophic  changes  in  other  than  muscular 
tioeue  also  occur  early ;  slonghing  bed-aoren,  esfiecially  in  tlie  but- 
tocks and  heclB,Boon  appear,  and  rapidly  increase;  oKlema  of  the 
pfflpalywd  parts  occurs.  Dc-alh  in  these  cases  may  take  place,  aii  in 
acute  aai^nding  palsy,  from  implication  of  the  niuacles  of  respi- 
ration, but  usually  the  patient  dies  from  exhau!<tion,  due  io  part 
to  betl-Boi-es.* 

This  form  of  acute  paraplegia  is  clearly  separated  from  tho 
'other  varieties  by  the  rapid  trophic  changes.  It  cnnstitulef*  the 
so-called  acute  central  myelitis,  an  a0ecliou  in  which  the  central 
gray  matter  of  the  spinal  cord  ia  attacked  :  the  ganglionic  ccIIb 
swell  up,  lose  their  prooestee,  become  granular  in  the  interior, 
are  convened  into  shapeless  round  masses,  and  finally  disappear 
entirely  ;  whilst,  at  the  same  time,  di^ititegration  occurs  in  the  tia- 
>Eue  around  tJiem.  (For  cased,  nee  Boss,  Jfmxise^  of  tfie  Nrrvtms 
Stfatan,  also  M'igglea worth,  Liverpool  Med.  Journ.,  July,  1H85.) 

Legions  of  Atoauiing  Pahtf. — In  our  first  group  of  cases  of 
acote  paniple^,  the  so-called  a^weodiug  or  LandryV  palsy,  a 
large  number  of  post-mortem  oxaminationt;  have  been  made  by 


*  Thcoe  c*aes  will  be  mor«  fully  described  in  the  next  gnai  ffroup  of  para- 
p)«Ki«*.    Seo  page  R4. 


u 


DIAGNOenC   NEUKOLOOY. 


trustwortliy  oWrvers,  and  the  i^pinal  oord  hat  been  cxainii 
most  thorough ty,  wtUiout  auy  lesiuu  being  det«cteJ.     We  must 
therefure,  conclude  tliat  in  the  tuujority  of  these  eas&s  in  which'' 
death  orcnrs  in  a  few  duy^  no  Icxions  can  be  found  in  tlie  >tpitial 
oord.    In  some  cas^,  however,  of  a^ceoding  paralysis  the  whit« 
matter  of  the  spinal  cord  has  been  found  greatly  altered.    (See  my 
own  ease,  Tha-apmiic  OazcUe,  ]885,  al-so  ea.-e  reported  by  Hoff- 
mann, ArekwfSr  pgi/cJiiairie,  1884,  p.  340.)    In  these  cases  of  dc 
generation  of  the  white   matter   the  wymptoms  vary  somewhat' 
ftooordiiig  to  tlie  tract  o(  white  matter  which  is  especially  attacked. 
The  absence  of  muscular  alteration  is  very  well  accounted  for 
the  lack  of  change  in  the  trojihie  ganglionic  ir«l)s,     Thorte 
of  ascending  paralysis  in  which  no  lf;sion  of  the  spinal  cord 
been  found  may  be  theoretically  accounted  for  by  supposing  that 
time  bait  nut  elapH^l  for  cbaugea  ^liulliciently  groM  to  be  recognized 
by  the  microscope  to  be  produced.     I  do  not  think,  however,  that 
thl^4  can  l>e  acv^pted  aa  a  riulBcIent  explanation  of  all  the  caseti. 
It  is  probable  that  sometimes  the  symptoms  arc  the  result  of 
rheumatic*  or  other  toxwmic  arrei^t  of  function  in  tlie  spinal  oord^ 
wliilf-t  I  still  believe  thai  engorgement  of  tJie  vaf-t  plexuH  ofveiai 
in  the  vertebral  canal  outside  of  the  cord  may  cause  an  aaccnding 
paralysis.     Tt  is  probably  these  cases  of  conge!»tion  that  const)- 
tute  the  clinical  group  of  aticending  jwiralyses,  in  whidi  the  symp-^j 
tome  fail  to  reach  a  fatal  issue  and  recovery  oocars.  ^H 

There  are  cases  of  ascending  (jaralysis  in  which  the  nymiitoma^^ 
seem  to  be  half-way  between  those  of  group  No.  1  and  group  No. 
2.     These  may  be  explained  as  cases  of  organic  disease  in  which 
the  lesion  atlacka  both  the  white  and  the  gray  matter, — the  cliar- 
acta"  of  the  symptoras  varying  as  the  white  matter  nf  the  oord  orj 
the  gray  bears  the  bnuit  of  the  attack. 

It  muat  also  be  remembered  that  in  moet  of  the  ca<(es  of  ascend- 
ing paralyeis  in  which  no  lesioo  has  been  found  the  nerves  were 
nut  examine^l,  and  that  un  inflammation  or  degeneration  of  Uie 
motor  nerve  may  have  existed  in  some  of  these  cases;  especially 
a"  l^jerine  and  Goei7  have  found  in  a  case  in  which  there  was  no 
demuugtrable  lesiou  id  tlie  spinal  cord,  changes  in  the  anterior. 


*  It  MfttnH  lo  mo  VQT7  -prob&ble  that  such  oum  m  Ihote  of  Bbcnlohr  Mf« 
chaiinuttio. 


PAim-^tiis. 


55 


Qcrve-roots  siniiltir  to  tho^  of  pareiicliymatous  inflammation  or 
dc^Dcrative  atrophy, — cimugcs  wlilcli  appear  to  be  very  similar  in 
ofaaroctcr  to  those  nhicli  I  found  in  the  white  matter  uf  a  uunl  iu 
a  ca»  of  TjanHry'fi  pamlysw. 

Multiple  Neuritis. — There  is  a  group  of  cases  in  which  para- 
plegia Doay  develop  very  rapidly  and  deepen  into  genenil  palsy, 
with  ^mphiius  simtilatiitg  tluMe  of  true  usLHtudiiig  paralysis,  in 
which  the  leeioii  is  an  inHammntton  of  the  nerve-trunks.  As 
niarb  can  be  accomplished  by  tr«itment.  it  is  very  important  to 
recognize  the  Irue  nature  of  multiple  nearitU.  The  disease  may 
take  a  very  acute  form,  with  death  in  the  course  of  a  few  days  from 
paralysis  of  muscles  eswntijil  to  life,  or  it  may  run  a  prolonged 
snbacutc  coui-se.  When  vccovctj  followa  cither  the  acute  or  the 
fiubaoute  form,  more  or  less  ]>ermanent  structural  clmng*^  of  the 
masclea  may  be  left.  In  cane^  of  a  subacute  tyiw,  instead  uf  the, 
symptoms  simulating  those  of  ascending  iKiralysia,  various  discon- 
nected portions  of  the  body  may  he  aflbi^teil,  and  a  true  multiple 
palxy,  or  a  single  or  a  double  monoplegia,  be  produced.  Certain 
caaea  of  violent  sciatica  with  rapid  losa  of  power  in  the  leg  af- 
ford  instances  of  monoplegia  from  iiillamnuttion  of  a  nerve-trunk, 
and  I  have  seen  a  severe  subacute  multiple  neuritis,  with  all 
(he  cbaraeleristic  symptoms  confined  to. the  arms,  pnylucing  a 
double  brachial  monoplegia.  The  otiiiical  evidence  shows  that 
any  ner\'e  of  the  body  or  any  combinations  of  nerves  may  be 
affected  by  a  neuritis. 

In  a  vcr)-  laq^c  proportion  of  the  cases  acute  general  multiple 
ueuritis  has  followed  excessive  exposure,  and  not  rarely  the  ex- 
posure ha**  been  associated  with  cxtruortliuary  physical  exertion. 
In  many  ca*c3  llie  disease  seems  to  be  rheumatic,  Leydeu  asserts 
that  the  salicylates  act  remarkably  well, — a  statemenl  which  I 
can  confirm  from  experience.  Ordinary  sciatica  is  very  closely 
related  to  multiple  neuritis,  Usually,  but  not  always,  in  sciatica, 
as  in  other  forms  of  neuritis,  the  sensory  filanientsof  the  nerve 
arc  ehiefly  attacked ;  but  it  will  lie  shown  later  that  it  is  probable 
that  inBamniation  of  the  motor  filaments  of  nerves  may  occmr 
without  the  aOVrent  or  sensory  fibres  being  distinctly  influenced. 

Although  multiple  neuritis  is  often  of  rheumatic  origin,  it  is 
not  invariably  so.  It  is  especially  frequent  In  persons  who  use 
alcahol  tn  excess,  and  not  rarely  follows  various  infectious  diseases 


56 


DIAGNOSTIC   NECROIXWY. 


of  a  low  type.  The  so-called  iliphtheritic  paralj-sis  is  < 
a  multi|i]e  nciiritU.  The  loss  of  power  which  may  follow 
typhoid  fever  (see  page  43)  lias,  aL  least  lu  euuie  cases,  similar 
on'gin.  Lowenfelci  has  seen  multiple  ucuritis  aHer  reciirrrent 
fever  and  after  cn'sipclm,  whilst  D^jerinc  has  noted  it  in  syphi- 
litics,  and  ita  presence  in  the  Japanese  disease  beriberi  has  l>een 
fully  establitihed. 

Mali^rnaut  Multiple  Neuritis. — In  the  acute  forms  of  multiple 
neuritis  the  constitutional  synipttmis  may  be  very  severe,  and  ^j 
marked  by  great  prostration  and  high  fever.  The  onset  u  often  ^H 
very  sudden,  but  may  be  more  gradual.  The  loss  of  |>ower  may  ^^ 
be  pronounced  within  twenty-four  hours.  It  usually  begins  aiui  ^J 
develo|)s  »4ymmtnricit1ly  in  two,  and  »oraetiraeH  in  all  four,  of  the  ^| 
extremities;  but  perhaps  in  the  majority  of  cases  the  arms  are  the 
more  ui^ntly  attaeked.  The  muscles  of  the  hands  and  forearms 
aud  those  of  the  leg  proper  are  the  first  to  lose  tiieir  power,  liap-  , 
idly,  however,  the  palsy  creeps  towards  the  trunk,  and  pas&ea  (in  ^H 
some  <^sc8)  to  the  muscles  of  the  face.  Double  vision  may  develop  ^^ 
as  the  result  of  paralysis  of  the  eye-muscles.  Speech  ami  swallow- 
iDg  beoume  involved,  and  its  the  respiratory  muefcltiH  fail  in  power 
the  patient  niiiks  into  a  fiital  ai^phyxia. 

Tim  heart  may  be  afiecled,  aud  degeneration  of  its  nerves  aud 
muivnilar  fibrcii  has  been  detected.  The  sudden  syncopal  dcntha 
whieli  sometimes  occur  after  diptithena  probably  have  this  origin. 
Sometimes  preceding  and  nomeunies  immediately  following  the 
motor  sympt<im»  great  difiturbancesof  sensation  appear.  Violent 
rheumnlic-like  pains  occur  iu  the  limbs,  or  futgnrant  ugoniee 
abi-iot  up  anil  down  the  nerve-trunks.  Formications, — a  [W><'nliar 
feeling  of  miiubiiess, — all  forma  of  [Mnestlnaiie, — may  be  pre&cut. 
Hyperffisthesia  often  aiooompanics  the  first  stages  oi'  the  disorder, 
but  in  iidvitncin^  cases  it  is  followed  by  ann>stIieHia,  wlileh  may 
be  a  true  anc^tJifsia-  tloforoga.  (See  section  on  Aniesiheaia.)  An 
almoe^t  [>athogitoraonic  symptom  is  anaasthesia  of  the  skin,  njiso- 
cinted  with  t'xcoasive  Beneitiveneas  of  the  muscles  and  other  struc- 
tures reached  by  deep  pressure.  All  kinds  of  sensution  seem  to 
be  af1e<-ted  :  not  only  does  the  patient  fail  to  ref^^gnize  the  points  of 
the  awtbesiomcter,  but  scratching,  or  finally  even  pinching,  pro- 
duces no  psiu,  and  heat  and  cold  elicit  no  response.  Dretichteld 
and  lA.>ydeu  have  noted  a  very  pronounced  girdle  sensation,  which 


PARAI.Y818. 


57 


the  first-namnl  observeri  wiUi  pmbablo  aoftaraay,  believes  to  be  the 
resnlt  of  the  inflammation  of  the  trunkal  nerves.  The  trigeminnl 
Derv«  usually  «sc«pM ;  but  two  I'uses  in  wliich  it  was  attacked  have 
bten  rcporlwl  by  Lowenfuld  (Keurot.  CkrUra&.,  1885,  p.  I-IO). 
Pain  on  movement  may  be  prei^snt,  wrL'nesa  of  the  muscles  is 
nften  mttetl,  but  marked  tenderness  of  the  nerve-trunks  npon 
prfissuro  is  |Kithogaomoi)ic.  In  a  few  cases  the  nerves  of  special 
KftiiKs  have  been  attacked,  and  partial  blindness  and  deufnttis 
have  been  UDticet], 

In  marked  coses  of  acute  multiple  neuritis  the  trophic  changes 
arc  pronounced.  In  the  cotirse  of  a  very  few  days,  or  even  hours, 
tbe  affected  muscles  begin  to  waste.  Brciiiter  and  Beruhardt  statu 
that  there  is  usually  ioweriug  of  the  electro-escitability  of  the 
muRcleA,  and  not  a  qualitative  alteration  ;  but  cases  have  been  re- 
ported in  which  there  have  been  true  reactions  of  degeneration. 
(See  chapter  on  Tmpliic  Changes.)  The  [taralysted  mui-cle  is  fljidcid 
and  hodf  the  abbeuce  of  coutmctures  is  chamcteristie^  but  in  very 
old  cwBB  deformities  from  contractures  of  the  normal  antngonistio 
muscles  may  l>e  pre;*nt.  Even  late  contrartures  of  the  [Mifsilyzed 
ntiscles  are  usually  held  to  iudicale  the  presence  of  some  sewud- 
ary  disorder  of  tbe  nerve-centres;  but  this  seems  to  me  doubtful. 
(See  G.  H.  Roger,  VEm-epfuiI6,  1H85,  p.  140.)  Tmphie  chaiiK^ri 
in  other  than  the  muscuhir  tissues  are  not  rare,  such  as  pignicn- 
tatioa  and  thickening  of  the  skin,  ec7.ematons  eruptions,  altera- 
taoDS  of  the  naiU,  oedema,  bed-wres,  etc.  A  peculiar  lividily  of 
tbe  affected  extremities,  due  to  voso-motor  weakness,  has  bcca 
maoh  oomincDted  on. 

Very  early  in  neute  multiple  neuritis  the  knee-jerk  disappears, 
but  the  suf»erficial  skin  reflexes,  such  as  that  of  tickling,  may  firet 
be  exaf^emied,  and  for  a  long  Lime  reniaiu  fully  as  active  as 
normal ;  finally,  however,  they  too  diminieh.  The  sphinclei's 
rarely  are  attacked,  although  Leyden  reports  one  case  in  which 
tbe  bladder  was  afll-ctei]. 

The  diagnosis  of  cases  of  multiple  neuritis  conforming  to  tbe 
tyi»e  just  detailed  i»  easy.  The  combination  of  paralysis  with 
ati-ophy  of  the  muscle,  excessive  disturliantxa  of  sensation,  and 
tenderness  of  the  nerve-trunks  marks  the  disorder  at  once.  On 
the  other  hand,  the  reoi^nitiou  of  some  of  the  subacute  forms  of 
maltipic  neuritis  is  difficult 


■ 


58 


DMoyoanc  yErnoLOOY. 


The  i»ralysia  of  acute  multiple  DcuritU  is  csosed  by  a  nutnber 
of  distinct  legions,  and  is  therefore  a  true  multiple  paUy,  altliotigh 
it  niay  simulate  a  jiani|)legiu  or  u  general  ixilnv.  Not  rartljr, 
however,  the  neuritis  is  llraitod  to  certain  nerve-region  a,  aa  the 
Krachial  plexns,  or  even  to  a  single  nerve.  In  this  way  monoplegia 
and  local  paUies  are  produced.  The  oounte  of  such  an  affeetion 
may  be  vcrr  rapid,  but  usaally  it  Is  subacute.  Although  this 
subacute  multiple  nenritiK  ought  ]>erlia]K  to  be  considered  under 
the  heading  of  Multiple  Palsies,  for  convenience  I  sliati  discuss 
it  here. 

Subacute  Multiple  Neuritis. — The  symptoms  of  the  subacute 
cases  of  multiple  neuritis  may  differ  from  those  of  the  acute  dis- 
ease only  in  Wing  more  confined  tn  their  seat  and  leas  rapvd  in 
their  course.  In  other  cases  the  symptoms  arc  in  the  subacute 
affections  very  different  from  those  of  the  acute  disorder.  Tbas, 
LeydcUj  Lowenfeld,  and  utltt^ni  have  iiolioeJ  as  a  lirtit  sym[>< 
torn  in  some  eases  a  loss  of  co-ordinating  power,  producing  a  well- 
marketi  ataxic  gait.  Whenever  in  any  case  of  niultiplc  palsy 
there  are  marked  disturbances  of  sen<uition  and  tenderness  of  the 
nerve-trunk  on  pressure,  the  diagnosis  is  suffu;icutly  made  out, 
even  though  the  trophic  changes  come  very  slowly. 

Diagnotcut  of  Midtiplf.  Srwriii*. — Although  the  diajifnoBis  of 
a  tvpi<-'al  multiple  neuritis  is  very  easy,  it  is  otherwise  with  aber- 
rant forms.  Thus,  in  the  case  recorded  by  H.  Hietli  {DeuUche 
Mfd.  HWMrH.,  1885}  thtre  was  panilysis,  with  diminished  reflexes 
and  great  difficulty  of  swallowing  and  of  8{)et>ch,  without  trophic 
changes  in  the  mascles  or  in  the  tt.'isues,  and  without  distinct  dis- 
turbauces  of  sciisutiou.  It  is  well  kuowu  that  sciatica  may  occur 
without  pronounced  palsy  or  rapid  wasting  of  the  muscles,  evi- 
dence that  the  sensory  nerve-filaments  may  be  attacked  without 
serious  involvement  of  the  mnior  fibres,  and  it  is  probable  that  in 
ca.'ses  like  that  reporte*!  by  Mieth  the  motor  filamen(/»  of  the 
uerveii  are  affected  without  the  sensory  l>eiiig  disLiuctly  implicated. 
Desnos  and  Joffrny,  indeed  (quoted  by  G.  H.  Koger,  VEtioepkaU, 
1885,  140),  have  prove<i,  by  post-mortem  examination  of  a  (Use 
where  there  had  been  uo  distinct  disturbance.*  of  »en?yition,  tliat 
this  uoD-sensory  multiple  neuritis  docs  occur.  As  Bcruhardt  says, 
the  diagnu«^is  between  this  affection  ami  puliurayelitis  becomes 
excessively  difficulty 


I 


The  matter  is  made  more  troafalesoraf!  by  the  foot  (oases,  Fitres, 
Arrfuv  de  Xtatrof.,  B(l.  vi.,  180)  ihat  in  locomotor  ataxia,  in  ariite 
myelitia,  and  probably  in  all  spinal  diseases,  the  peripheral 
nerves  oocasioDally  undergo  acute  defeneration.  There  is,  there- 
fore, a  descending  ai^  well  as  an  ascending  neuritis ;  and  whenever 
there  U  found  at  an  aulopBy  a.  degeneration  both  of  the  spinal  cord 
and  of  the  nerve-trunks,  the  qupstion  arises  whether  the  original 
l«sion  wzs  peripheral  and  centripetal  or  centric  and  centrifugal. 
In  very  few  cases  of  the  ascending  palsy  have  the  peripheral 
Dervea  been  pro|)«rly  studied.  Indeeil»  it  la  probable  that  the 
lesioa  of  the  cord  which  was  found  in  the  case  reported  by  Dr. 
Derciira  and  myself  was  the  result  of  an  overlooked  ascending 
neuritis. 

It  is  not  probable  that  a  multiple  neuritis  can  exist  without 
the  sentwry  i!lament8  being  at  least  so  far  tmptiiat£<l  as  Ut  canae 
tenderness  of  the  nerve-trunks,  and  in  the  absence  of  positive 
clinical  evidence  we  must  insider  that  the  diiignosis  between  a 
multiple  ueuriiid  and  a  poliomyetttiti  can  be  made  by  pressing 
U|x>D  the  nerve-trunks.  It  is  poesible,  however,  that  the  future 
may  reveal  the  esiHtence  of  a  pure  motor  neuritis,  and  it  iri  ex- 
ceedingly imjMrtant  thai  observers  should  note  in  doubtful  cases 
whether  the  nerve-trunks  are  or  are  not  tender.  Literature 
shonld  not  be  furtJier  encumbered  with  rejmrts  of  cases  without 
autopsie^  or  with  imperfect  autopsies. 

RencHonx  of  Defftnnation  in  ?^etiritiM. — It  has  Iwen  statal  by 
various  oljservers  that  true  reactions  of  degeneration  are  never 
to  be  obtained  in  the  atrophied  muscles  of  multiple  neuritis;  hut 
tliis  ia  undoubtedly  an  error,  a»  I  know  from  my  own  GX[>orii>-nce, 
which  is  ounfirmed  by  Dr.  L.  Lowenfcld  (  (Jfher  Mxdtipk  Natrit'is, 
Munich,  1885)  and  by  Professor  Ijancsitaux  (^Vhhn  Mhhy  -luly, 
1886).  Without  doubt,  however,  as  Beruhardt  ( VcrhandL  lid. 
Cowfr.f  188-1)  states,  the  ohanr^s  of  electrical  reactions  come  on 
less  rapidly  in  multiple  neuritis;  than  they  do  in  polioniyeliti.s. 
Proffssor  Remak  considers  that  the  localization  of  the  palsy  is  of 
diagnostic  importance,  between  the  two  diseases;  but  in  this  he 
is  not  borne  out  by  the  cliniuiil  retwnlH. 

Alcoholic  Spinal  Paralyeis. — Under  the  head  of  alcoholic 
spinal  paralysis  Dr.  TI,  Hrondbent  {MMico'Chlr.  TWtn*.,  vol. 
Ixvii.)  has  reported  a  form  of  disease  which  in  probably  alcoUolxtt 


80 


»IAay08TIC  XETBOLOGY. 


multiple  neuritis.  Indeed,  the  abuse  of  alcoliot  seems  to  be  a  very 
impirtarit  etiological  factor  ia  multiple  neuritis.  Cases  similar  to 
tinMse  of  IJroadbeut  have  been  reported  by  Lanoereaus  and  others. 
They  vary  considerably  in  their  features.  There  is  at  Brst  grad- 
tiftlly-inereaaitig  wonkness  of  the  lower  extremities,  when  sud- 
denly marked  lost  of  power  becomes  raantfeiit  in  the  extensor 
muscles  of  the  forearm,  giving  rise  lo  double  wrist-drop.  The 
flexorti  of  tile  hand  may  lie  utrected  very  early.  Usually,  some- 
what later  they  beoome  paralyzed,  mi  that  the  hand  is  like  a  flail. 
Alihongh  the  patient  can  walk  and  the  movements  of  the  elbow 
and  shoulder  are  vigorous,  the  paralysis  rapidly  a<lvauces,  until 
alt  four  cxtrccnilien  are  almost  completely  niotionle»^,  the  ann^,  as 
a  rule,  lieing  more  serioualy  implimtcd  than  the  legs.  The  re- 
flexes are  aboliahetl.  There  is  usually  no  pain,  though  the 
muscles  may  be  tender  on  liaudliug,  and  the  sphincters  retain 
tlieir  funetional  power.  In  one  of  Dr.  Brondbcnt's  cases,  bow- 
ever,  sharp  pains  shot  down  the  1^,  and  there  Tras  inconti- 
nence of  urine.  In  rlie  course  of  a  very  few  days  the  muscles  of 
the  trunk  become  implicated,  and  the  patient  dies  of  paralysis  of 
respiratiau,  precisely  as  in  aMcending  palsy.  1a»«  of  tone  in  the 
capillaries,  with  eotieequent  livid  congestion  of  depctidcut  parts,  is 
sail!  to  l*  diagnoftticof  this  form  of  paralysis.  Careful  exnmi- 
nation  of  tlie  spinal  coi*d  failed  to  detect  any  lesions.  The  cases 
are  said  to  be  tnuoh  more  frequent  in  women  than  in  men. 


Subacute  Paraplegia. 

The  second  group  of  organic  paraplegias  comjirise  those 
in  which  the  iMiralysls  develops  so  slonly  as  to  ro(|uire  many  days 
or  weeks,  but  not  montk-i,  fur  the  symptoms  to  become  very  pro- 
nounced. In  tliu*  grou|)  are  inclmled  cases  of  transverse  myelitia 
and  of  general  myt;Iiti».  It  must  be  remembered  that  in  excep- 
tional fxnes  cither  "f  tlie^e  alTectiouK  may  develop  with  plieuunieual 
rapidity  and  give  origin  to  an  acute  {luraplegia. 

Transvere©  Myelitis. — Tmn-svei-se  or  ounipression  myelitis  is 
invariably  the  result  of  disease  of  the  vertebra  or  of  the  mem- 
branes of  the  cord.  The  most  frequent  cause  is  scrofulous  or 
gyphilitir  degfnemtioii  of  (he  verteline;  but  syphilitic, catioeruus, 
or  other  tumors  may  produ(«  the  disease. 


Td  the  majority  of  cases  local  pntna  precede  the  development 
of  thoAC  symptoms  wliich  are  directly  tiue  to  tlie  myelitis.  The 
seat  of  these  pains  varies  aocorditig  to  the  scat  of  the  discast*, — the 
rule  tieing  tlial  the  paioK  are  in  tlie  distribution  of  thoec  nerves 
irhoec  roots  poas  through  the  ititlamed  or  degeueratei)  vertebml 
t»6ue!>.  Along  with  these  «ymptnmi*  (»f  irriration  of  the  posterior 
apinal  root*  there  may  bo  cram [w  or  convulsive  movements,  evi- 
deoocs  that  anterior  or  motor  uerve-roots  are  implicated:  except 
in  ver^'  rare  in)^tances,  tlic^  motor  symptoms  are  muob  less  marked 
than  iH  the  sensory  distnrbanoe. 

When  the  caose  of  a  transven^e  myelitis  is  cancer,  the  pain  is 
geDeratly  atrocious,  radiates  in  all  <]ir«ctioti«  along  the  trunks 
of  the  nerves,  is  d<£cribed  as  shooting  and  teiLring  and  burning, 
and  is  usually  associated  witli  very  pmnounccd  liypcrmsthesia  of 
the  skin.  The  pangs  themselves  are  paroxysmal  in  violenw, 
aJthough  present,  to  some  extent,  the  whole  time.  The  crises 
of  the  paroxysms  are  said  by  Graeset  to  occur  almost  invariably 
at  night.  They  arc  increased  by  any  attempt  at  motion,  aud 
seem  at  times  In  be  brouglit  on  by  .flight  touohc^.  Ilypcnes- 
thcsia  in  these  cases  is  often  Bually  replaced  by  ai]n^the:4ia  wiib- 
oat  the  pains  t^ing  relieved,  and  herpetic  eruptions  appear  along 
the  courses  of  various  nerves.  In  its  ixniic  fonn  tlits  afTccliuo 
is  the  painful  paraplegia,  or  paraplegia  dolorosa,  already  de- 
smbefl  (see  page  50).  Painful  paraplegia  may  also  be  due  to 
cancerous  tumors  outside  of  the  spinal  column,  so  gituate«l  in  the 
neighborhood  of  the  sacrum  as  to  involve  the  numerous  nerves 
coming  from  the  cauda  equina.  The  i>uin  may  precede  the  piilsy 
by  a  considerable  time.  I  have  known  it  to  he  the  fii-st  symptom 
of  pelvic  cancer. 

The  symptoms  directly  due  to  the  transverse  myelitis  itself  are 
most  marked  in  regard  to  motion.  Voluntary  power  is  finally 
lost;  the  reflexes  are  exaggerated,  hut  n<itto  the  degree  seen  in 
cases  of  general  myelitis,  exoept  when  secondary  spinal  lesions 
have  followed  upon  the  transverse  myelitis. 

Ill  the  hitter  stages  of  transverse  myelitis  there  if*  always  para- 
plegia, but  in  the  beginning,  if  the  inflammation  be  more  intense 
on  one  side  of  the  spinal  corti  than  on  the  other,  one  extremity 
may  be  more  profoundly  a0ecte<l  than  another,  and  a  brachial  or 
crural  monoplegia  or  even  on  apparent  hemiplegia  may  lie  \)ret%nt,. 


62 


DIAOKOSTIO  NBURDLOOr. 


Close  inspection  will,  however,  almost  always  detect  some  weak- 
nem  of  Llie  leg  at  6nl  thuiig^Itt  to  \k  intact.  When  the  transverse 
myelitis  is  high  up  ia  the  coi-d,  the  arms  may  bo  affected  before 
the  legs. 

Sensibility  in  tran8ven*e  myelitis  at  first  h  dulled,  but  finally 
it  ia  completely  lost.  Paralygie  of  the  bladder  and  roctutu  oocursj 
and  ill  many  casm  the  Hymptnms  tinally  are  not  to  be  distinguished 
from  those  of  a  more  gt'^pral  subacute  myelitis.  Indeed,  a  Biib- 
aeute  myelitis  may  very  well  be  developed  out  of  a  trausvenje 
myelitis. 

Early  Diagnoalf!  of  JVansverae  Myelitis.'^ It  is  a  matter  of  the 
greatest  importance  to  recognize  early  the  preuenoe  of  vertebral 
inflammation,  especially  vrhen  the  latter  is  of  a  ftcrofiilous  char- 
acter. By  paying  attention  to  the  pain  lliis  can  frequently  be  done 
before  the  occurrence  of  a  transverse  myelitis,  or  the  appearnnoe 
of  any  strikitip;  local  evidences  of  disease  of  the  vcrtehrffl.  This 
ia  especially  true  when  the  disease  is  located  in  the  upper  dorsal  or 
the  lower  cervical  region.  Whenever  a  patient  with  the  a.sj»ect  of 
a  person  sulferiug  from  severe  disease  has,  without  obvious  cause, 
an  intense  tixeil  pain  ahont  the  shoulders  or  in  the  arms,  It  should 
be  home  in  mind  (hat  this  pain  may  be  due  to  irritation  of  nerve- 
roots  caused  by  incipient  disease  of  the  vcrtf-brie  or  of  tJie  spina! 
membranes.  When  other  causes  for  such  pain  can  be  excluded, 
and  deep  pretsiin-  over  the  i^pine  proiluoes  pain,  or  pain  can  be 
caiificd  by  jars  of  the  spinal  ooJumn,  or  by  blows  u|k)ii  the  top  of 
the  head  directtd  downward,  the  diagna«;iR  i.^  .tnfticlcntly  probable 
for  (herapeullo  purjKises.  Some  aid  may  be  gained  by  the  appli- 
cation of  HosenUtara  tfst^  upon  which,  however,  in  my  exfterience, 
not  much  reliance  ciiri  lie  placed.  The  l&n  ih  maile  by  placing 
one  pole  of  n  faradie  battery  in  contact  with  the  front  of  the 
body,  aoJ  |*assing  the  oilier  polo  down  the  centre  of  the  vertebral 
oohimn.  when,  if  any  inllummalor}-  lesioi)  exists,  pain  will  be  de- 
velo|i«l  at  the  sent  of  the  change.  Unfortunately,  tenderneas 
may  often  be  fotinil  when  tlicrc  i.s  im  verlebrni  disease,  and,  if  the 
anterior  p<iriions  of  the  vertebra;  alone  be  implicated,  pain  may 
nut  bo  elieitei]  by  tlie  current. 

Care  may  at  times  be  necessarj-  not  to  confoinul  incipient  ver- 
tebral disease  with  the  so-called  spinal  rma^nia  or  «pinai  irrUaiion 
(see  article  on  Pain) ;  but  the  a.<ipect,  mode  of  talking,  and  general 


I 


PAfiALVSIS. 


Wi 


conduct  of  the  paticnta  arc  so  different  in  the  two  <:1i8eaftCA  that  the 
experience<l  pbysiciao  can  hardly  be  mialed,  altlioiigh  these  difier- 
enow  may  be  very  hard  tv  put  in  uunU,  Moreover,  in  spinal  irri- 
tatiou  there  is  intenK  tenderness  la  the  slightest  touch,  whilst  in 
the  early  stages  of  true  verlebral  disease  tenderne^?  is  evoked  only 
by  firm  pn^'wure.  Further,  the  distant  pains  of  spinal  irritatioi]  luok 
tbc  fixedne»  and  intensity  so  charade rifitic  of  vertebral  disease. 

It  mast  be  borne  in  mind  that  a  Hvphilitio  ur  other  yrawth 
springing /rom  Oic  manbnmtn  of  the  eord  may  involve  the  nerve- 
roots,  and  may  produce  transveree  myelitis,  with  early  symptoms 
reiy  like  tltooe  of  vertebral  caries.  Deep  vertebral  tenderness 
under  these  circuni^^taiiec-H  developB  only  lul<>  in  tlie  diKeafti*,  when 
the  bodies  of  the  vertebne  are  aflectcd,  although  hyi)orn><(thesia 
over  the  vertebral  column,  ss  over  other  parts  of  the  body,  may  be 
cau&«d  by  a  secomlary  uouritis. 

Cervical  Pachymenio^tis. — A  cI^h  of  rare  cases  which  are 
especially  liable  to  be  oonfunnded  tn  llieir  first  stages  with  io- 
cipient  Pott's  disease,  and  in  their  latter  stai^  with  organic  dis- 
eaite  of  the  spinal  cor<l  itself,  is  contained  in  (;ervi«il  pachy- 
aieiiingitift,  an  afTectiun  \rhui»e  history  was  especially  cluborutml  l>y 
Charcot  and  Joffroy.  This  disease  is,  indeed,  in  its  latter  singes 
jcoompanind  by  a  tranj)ver<ie  myelitic,  and  many  of  the  fiymptoma 
hich  are  at  such  time  present  are  due  lo  the  transverse  myelitis. 
In  the  first  stage  there  is  vague  pain  in  the  neck  and  in  the  occipital 
region  of  the  lu-ad,  which  it^  exnggfralcd  by  pressure  and  movc- 
menlH  and  is  associated  with  more  or  \\ss  marked  spasm  of  the 
muscles  of  the  neck.  Fnxjuently  there  are  paroxysms  of  pain 
ialed  with  temporary  torticollis.  These  symptoms  slowly  iu- 
,  often  for  from  two  to  five  or  six  montlui,  until,  at  last,  the 
suffering  is  vt^ry  great,  es|iei:ially  at  night,  and  in  irregular  parox- 
isms, whilst  immobility  of  the  neck  from  s|)asm  becomes  com- 
lete.  Radiating  [>ang<i  <ihoot  along  the  nerves  of  the  neck  into 
the  arms,  back,  and  head,  and  hypersestbesia  and  fulgurating 
pains  of)en  occur  in  the  hands.  In  some  cases  the  pain  in  the 
neck  is  not  at  all  marked,  whilst  the  peripheral  pains  are  exoessively 
violent.  Digestive  disturbance  and  vomiting  are  not  rare.  As 
the  diaease  increases,  paralysis  appears  usually  first  in  the  arms; 
sometimes,  however,  it  ]»  disLiuctly  paraplegio  in  ly{>e,  and  in 
cases  even  hemiplegic. 


MAONOSnO  TTETROLOOY. 


Subacute  Central  Myelitis. — Arnong  the  cases  of  subacute 
paraplegias  belong  many  of  (he  cases  of  central  myelitis.  In  this 
disease,  with  or  without  piwlromes,  the  patient  is  lakeu  vvHli  a 
{ever,  which  may  be  prwKdetl  by  a  ohill  and  be  acciHopanied  by 
much  stt-ealing.  Pains  of  greater  or  Iciss  severity  arc  felt  in  the 
legs  and  in  the  himbar  regions.  These  rapidly  increase,  and  may 
take  a  girvlle  form.  Power  is  also  rapidly  lost  in  the  legs,  but  at 
the  same  time  sposmotlic  jcrkings  and  irregular  oinscular  a>n- 
tnictioiis  are  devulopud.  To  verj-  rapid  cases  in  the  course  of  two 
or  throe  days  the  paraplegia  may  be  almost  complete,  and  death 
has  oocnrred  as  early  as  the  fifV.h  day.  The  reflexes  are  exagger- 
ated, imt  before  death  may  be  weakened  and  finally  abolished. 
Paralysis  of  the  bladder  early  appears.  The  urine  has  to  be  drawn 
cA"  by  a  catheter,  ami  is  strongly  animoniat'nl.  Large  eschars  now 
form  u[mn  the  buttocks,  or  upon  the  heel.s  where  they  rest  iiixm  the 
bed.  These  rapidly  iuerease,  and  add  greatly  to  the  exhaustion 
of  the  patient  ISensibility,  usually  less  early  affected  than  motion, 
LaooD,  however,  bccoiu^n  bltinted,  and  at  last  there  may  be  com- 
plete aneesthcsla.  The  symptoms  which  have  just  been  mentioned 
constitute  a  typical  case  of  a  general  acute  myelitis,  and  may  be 
developeil  m  rapidly  as  to  put  the  caae  in  the  group  of  acuta 
parnplf^ioa. 

In  some  instances  of  myelitis  the  evidences  of  motor  and  sen- 
sory exoiteroent  are  more  marked  than  haa  l>een  indicated,  the  Ir- 
regular muscular  contractions  are  associated  with  an  almost  tetanic 
rigidity  of  the  niuscicj^  of  tlie  trunk  and  of  the  limlw,  and  along 
with  the  pain  there  is  marked  hy[K>rKsthesia.  If  the  myelitis 
attack  the  upper  dors.nl  region,  the  symptoms  in  the  arms  may 
be  even  more  prouounced  than  those  iu  tiie  legs,  and  cough, 
with  marked  dyspnau,  may  be  prominent.  (lastrie  crises  with 
violent  vomiting  may  be  very  distnesaing,  and  may  simulate  in 
their  severity  those  of  locomotor  ataxia.  The  difficulty  of  .<?wal- 
lowing  is  often  very  great.  If  the  cervical  region  be  affected, 
irregular  dilatation  or  cuutractiou  of  tiie  pupils  may  be  pro- 
duced J  and  a  very  prominent  symptom  in  some  cases  lias  been  an 
extraordinary  reduction  of  the  pulse,  which  has  been  noted  to 
fall  B»  low  as  28  [)er  minute. 


PARALYSIS. 


€6 


CHRONIC  PARAPLEGIA. 

Chronic  paraplegia  (groap  three  of  my  arraDgement)  iuoludes 
those  cases  iii  which  many  wcqUr,  months,  or  years  are  required 
for  the  full  (levekipment  of  the  syniptoiiis.  lu  arriving  nt  a 
fliagnoflia  in  these  cases,  sensation,  the  condition  of  the  bladder, 
aod  the  stale  of  the  muscular  system  are  especially  to  be  studied. 

There  ore  two  diseaKs  which  are  commoD  causes  of  chrouio 
paraplegia.  This  does  uot  include  ua^cs  of  multiple  puUy,  which, 
■B  airoody  stated,  when  located  especially  in  the  lower  I^^,  may 
give  rise  to  ao  apparent  paraplegia,  and  may  pursue  a  chronic 
course.  The  nature  of  these  cases  cau  almost  always  bv  recog- 
nized by  the  irregularities  in  the  development  of  the  palsy,  and  by 
the  wasting  of  the  afTet^^'d  muscles,  conjoined  with  the  absence  of 
the  ^mptoms  of  chronic  general  myelitis.    (See  page  6fi.) 

Both  in  chronic  myelitis  ^nd  in  sclerosis  the  symptoms  vary 
[aoourdiag  to  the  region  of  the  cord  attacked;  but  in  sclerotiis 
wilh  motor  pamlysis  distinct  distiirbiinccs  of  sensation,  or  well 
M  paralyns  of  the  bla<hlcr  or  of  the  rentum,  are  extremely  mre. 

Chronic  Myelitis.— lu  chronic  myelitis  anaasthesia  is  present 
only  in  exceptional  cases,  and  still  more  rarely  is  it  preceded  by 
hy|iera»tliusia.  Very  seldom  is  there  severe  |>aiu,  althcmgli  formi- 
cations and  pancsthesia  are  fi-eqticnt.  When  the  disturbances  of 
sen.<)3itir>n  arc  marked,  the  whole  of  the  structure  of  tlie  cord  mm^t 
be  considered  as  implicated.  Trophic  changes  may  occur  in  the 
muscles  and  other  tiasnes,  but  it  is  remarkable  how  frequently  the 
trophic  cells  of  the  gray  matter  escape,  even  when  all  iJie  rest 
of  the  oord  is  attacked.  In  the  beginning  of  the  disease  the 
reflexes  may  be  increased,  to  be  finally  abolished. 

There  is  a  form  of  chronic  myelitis  iu  which  the  refluxes  re- 
main exaggerated  for  many  months,  and  in  some  of  these  cases 
they  are  groesly  exaggerated,  and  a.  certain  amount  of  tonic  spas- 
modic contraction  exists  in  the  affected  muscle  ;  but  the  ngidtty 
does  not  oooipare  with  chat  winch  is  seeu  in  the  sclerotic  form  of 
porapl^ia.  On  tlie  other  liaiid,  irregular  spoiitaueiius  jerkings  of 
the  1^,  spaMnodic  twitcliings  of  the  muscles,  and  painful  coutrao- 
ttons  at  night  are  more  frequent  in  myelitis  than  in  sclerosis. 

GirtUc  SoMatUm. — A  very  important  symptom  which  is  yreacnl 


66  WAGNU«IC  KKL'KOLOOV. 

ID  boil)  forms  of  clironic  [Hirnplegia  is  tlie  girdle  scDsatioD,  usually 
felt  in  the  abdomen,  but  io  some  coses  very  distinct  at  a  lower  or 
higlier  |)06ition  in  tlie  l<^.     Its  seat  is  probably  connected  with' 
the  iMwitioQ  of  the  dlHcaae  in  the  spinal  oord. 

In  chronic  myelitic  the  patient  walks  slowly,  dragging  the  feet 
with  evident  effort.  The  [xxture  <](*«  not  esjtentially  JilTer  from 
the  norm,  there  ore  rarely  bizarre  movements  of  the  legs,  and 
any  tottering  or  uni^tuidine^  is  evidently  from  ft«bleut>KA. 

Spaamodic  Tabes. — When,  in  n  case  of  clirtitiic  [uiraptegia 
develope*!  during  aihilt  life,  the  mitsclM  of  the  ]eg  am  exceedingly 
rigid,  firmly  cimtractetl,  witli  their  teinlons  projecting  and  lianl,  and 
the  legs  and  feet  are  more  or  leas  distorted,  tlie  jMiticnt  is  suflering 
fVom  spasmixlic  tal>e«.  In  tlie  early  Ktage^  of  this  afleplion  the 
patients  complain  that  they  arc  readily  fatigued,  and  that  their 
gait  is  dragging.  Even  before  there  U  distinct  loss  of  }Mtwer 
tlie  patient  will  be  troubled  at  night,  utpedally  after  a  hard 
day's  march,  with  clonic  or  tonic  spasms,  which  cnitsc  the  legs 
to  stiftVn  sudd('iily  or  to  lie  jerked  about.  A  little  later  the 
gtiffiiojvs  and  Utcm  of  power  combine  to  produce  a  verj-  diaracter- 
istiu  gait.  The  contractures  of  the  various  muscles  prevent 
the  bending  of  the  Joints  of  the  knee  and  hip,  whilst  the  great 
[Hiwer  of  the  muscles  of  the  eiilf  tend^  to  drnw  ilie  heel  up  and 
to  thrust  the  toe  downward.  Consequently,  the  foot  can  be  lifted 
gufliciently  fnmi  tiic  ground  to  make  a  step  only  by  raising  and 
rotating  the  jjelvis  so  that  the  body  is  inclined  towards  the  leg 
upon  which  the  patient  rests  during  the  step,  whilst  the  moving 
fot)t  is  slowly  thrust  forward.  The  tof^  appear  to  stick  to  the 
ground,  and  are  only  mth  the  greatest  difficulty  eufliciently  ntl««d 
to  be  pushed  forward.  The  steps  are  of  ueceisity  very  short, — it 
may  be  only  ttirec  or  four  inches.  As  the  leg  is  put  forward,  not 
rarely  violent  tremblings  atfoct  it,  and  in  some  cases  these  move- 
menCs  are  so  rhytlimical  as  to  throw  the  heels  of  the  patient  up 
and  down  in  regular  vibrations.  As  the  disease  progresees,  the 
contractures  of  the  muscles  of  the  calf  become  so  great  that  the 
heels  are  permanently  drawn  from  the  griKind,  and  the  patient 
rests  u|H>n  tin!  toea.  Under  these  oiroumstanccs  the  trunk  ts  of 
neee.«it\'  thrown  forward^  and  is  preserve*!  fronv  falling  only  by 
means  of  crutches  or  canes  held  well  in  advance  of  the  body.  A 
little  later  than   this  all    power  of   locomotion  is  lost,  and  not 


rarely  the  pflti(>nt  is  con6ne4l  to  bed,  or,  if  he  attempts  to  nit,  must 
be  propped  up  In  a  chair,  with  his  feet  supported  in  front  of  him. 

Wheo  the  jjower  of  luconioiinu  is  lost,  tlie  leg  is  usually  flexed 
apoB  the  ihiffh,  the  heel  drawn  up,  and  the  toes  turned  inward, 
theise  positions  being  due  to  the  sitperior  power  of  the  posterior 
rauMles  of  the  thigh  :ind  log  and  of  the  sb(Iu<Ttor  munclea  its 
cntnpared  with  thi;ir  antagonists.  lu  some  cases  the  patient  lies 
with  the  legs  stiffly  extended,  very  rigid,  the  feet  inverted  and 
oflen  crf»9s«l.  The  bladder  and  rectum  are  not  nffeetwl.  In 
RKMt  CAses  of  spasmodic  tubes  tlie  muscles  do  not  undei^  ^meting, 
and  their  electrica)  reactions  are  not  altered  in  quality^  and  »re 
even  more  sensilive  tlian  normal.  The  ripinal  lesion  in  qMisraodic; 
tabes  13  sclerosis  of  the  lateral  columns,  usually  known  on  taJeral 
aeteraia». 

Amyotrophic  Lateral  Sclerose. — In  certain  cases  of  spas- 
modic taben  the  muselett  ore  very  much  wHstci.l,  and  may  finally 
disappear  (see  chapter  on  Trophic  Clianp^j,  although  their  elec- 
trical reaetionH  are  exceedingly  dlow  to  alter.  These  are  instances 
of  the  ^-<-nllcd  amyotrophic  lateral  8clcra'(i3,  in  which  the  lateral 
colorans  and  the  lar^  niulti[K>lBr  cells  of  the  adjacent  gray  mutter 
are  aimultaneously  diwsi^.  Frequently  in  these  oases  the 
wa.«rtinp  of  the  variou.s  muscles  is  irregular  and  unequal,  so  lliat 
the  case  prewnts  the  aspect  of  a  multiple  paii^y  attacking  a  person 
already  utftx'tetl  with  diiwH^e  of  the  lateral  column;  but  in  Kome 
instances  the  trophic  changes  develop  pari  paamt  with  the  paralysis. 

Multiple  Spinal  ScleroelB. — When  the  symptoms  of  spiis- 
modic  talxs  an-  associated  with  more  or  les.s  irregularly  develo[K*d 
dtsturbauoes  of  sensation  similar  to  tho^e  of  locomotor  ataxia, 
disseminated  sclerosis  will  lie  found  after  <lenth  ;  that  '\h,  [Kitchcs 
of  aclcro»8,  irregular  in  Hize,  t^liaiKf^  and  :''ent,  arc  ^^catterifd  ihn^ugli 
the  cord.  The  symptoms  in  sach  cases  vary  as  the  lesions  pre- 
dominate in  one  or  other  of  the  spinal  tractA. 

MONOPLEGIA. 

A  monoplegia  is  a  paralysis  of  one  extremity.  When  of  the 
arm,  it  is  spoken  of  as  brachial  monoplegia;  when  of  the  leg,  as 
cnuul  monoplegia. 

Hyaterioal  Monoplegia. — Hysterical  monoplegia  is  rare,  but 


I' 


DIAGSOSnC  SECROLOOY. 


may  oocar,  and  is  nut  inireqnently  attributoc]  to  a  real  or  an  al 
leged  injary.  Under  such  circumstances  the  (rue  nature  of  llie  \om 
of  power  in  apt  to  be  overlooked.  If  contractures  oomcon  iromc- 
dtfllcly  after  a  real  or  an  alleged  injury,  the  paralysis  is  probably 
hysterical;  bui  complete  relaxation  may  exi^t  in  an  hy^Merieal 
monopl^a.  When  after  a  traumati.-^m  the  paral}'Bis  and  tbe 
relaxation  are  complete  and  there  is  no  wasting  of  the  muscles, 
the  affectioD  is  usually  hysterical,  since  in  all  cases  of  total  ot 
nearly  total  loea  uf  power  from  injuries  lo  a  nerve  the  muscles 
rapidly  change  Irn?gularititis  in  the  anatomical  relalioo?  between 
the  disturbRticefl  of  sensibility  and  the  nltcrations  of  mobility  in- 
dicate an  hysterical  origiu,  but  these  relations  may,  in  hysteria, 
oonform  to  the  organic  type. 

Irrn/ulariiy  of  hnjiiintiion  of  MuaeUft. — An  organic  moi 
plt^ia  may  be  looked  upon  ns  a  collection  of  local  palsies:  thus, 
in  a  caise  of  centric  brachial  monoplegia  (see  [mge  72)  tlie  oortical 
nerve-centres  which  preside  over  the  varioujt  grouiw  of  muscles 
in  the  arm  are  located  so  near  to  one  another  that  they  are  in- 
volved in  a  onmmou,  vride-rracliiiig  clot  or  other  lesion ;  and  in  a 
peripheral  brachial  monoplegia  many  dislioct  nerve-trunks  or 
many  distinct  groups  of  spinal  gangliouic  cells  are  involved.  It 
IK  owing  to  these  factJ^  that  the  inteiiKiiy  of  ihc  jkiIkv  in  brachial 
monoplegia  vuriot  in  the  difibrcnt  group-^  of  arm'iiiiiscle.s  accord- 
ing as  one  centre  or  the  other  is  more  implicated  in  the  lesion. 

DoxtUe  Monopla/ia. — Two  muiiojjWgiiis  may  <ioexist  in  the  same 
patient,  and,  when  they  happen  to  be  ou  tlie  E^me  side  of  the^J 
body,  may  simulate  a  hemiplegia.     The  distinction,  however,  be-^| 
twcen  such  a  double  monoplegia  and  a  hemiplegia  may  bo  vital.  ^ 
In  a  double  monoplegia  there  are  necessarily  two  legions,  whilst  in 
a  hemiplegia  the  paralyKiM  is  tlie  result  of  a  siugle  lesion.     When 
an  enormous  clot  upon  the  brain-surrace  affects  the  whole  motor 
zone,  it  gives  rise  To  a  t^aralysiu  whicli  must  be  considered  a  hemi- 
plegia. 

A  monoplegia  may  be  due  to  a  lesion  of  a  nerve,  or  of  the  large- 
multipolar  cuIIh  in  (he  anterior  curtma  of  the  ^plIlal  (.tml,  or  of  the 
bniin-ourtex.  In  making  the  diagnosis  in  any  cose  the  general 
situation  of  the  lesion  i.^  first  to  be  determine^]. 

VariHict  of  Monoplft/ia. — There  in  iiotbiug  in  the  jutralyzed 
muscles  which  distinguishes  a  palsy  due  lo  a  disease  of  the  iinte- 


» 


rior  Kpinal  ooruaa  from  one  whidi  is  Uie  result  of  an  ofieoHoti  of 
the  nerves.  These  two  claf>ses  of  caae^  are  for  (he  purpnsc«  of 
duigiKwtic  diticusuion  profitably  gruiiE)e(l  togettier  oi^  peripheral 
palsies.  Paralystes  due  to  le«ons  of  the  brain-cortex  are  readily 
disttu^raished  from  peripheral  palsie.«  by  a  study  of  the  affected 
muscles.  C-erei>niI  iKimlysen,  therefore,  eonstitiite  a  weootid  group 
of  raoDOplq;ias,  which  may  be  spoken  of  as  centric  palsies.  It 
muHt,  however,  be  rememlwred  that  a  nerve-trunk  may  be  para- 
lyzed by  a  lesion  within  thecraiiiurn  and  yet  the  palsy  belurig  to 
the  peripheral  group.  Thu^,  if  by  an  organic  chan^  in  the  pons 
or  in  the  medulla,  or  by  an  exudation  or  a  tumor  at  the  bat>e  of 
the  brain,  the  integrity  of  one  of  tlie  cranial  nerves  be  interfered 
with,  the  results  are  palsy  and  structund  changes  ideutical  with 
thoee  which  would  follow  section  of  .such  nerve  after  tt.s  emer- 
gence from  the  cranium. 

An  acute  peripheral  paraly-^is  is  always  to  be  di^^tinguished  from 
a  centric  pabty  by  the  rapid  occurrence  of  strucliiral  chancres  in 
affected  rauseles, — changes  the  nature  of  which  will  be  fully  dis- 
in  the  chaph;r  on  Trophic  Alterations,  to  which  the  reader 

refenwi  for  detail.  Suffice  it  for  tht'.  present  tn  state  that 
in  centric  palsy  the  muscle  does  not  undergo  change,  whilst  in 
peripheral  palsies  the  muscle  in  three  or  four  days  aA«r  the  in- 
ception of  the  lesion  b^ins  to  lose  il£  power  of  responding  to  a 
rapidly-'interrupteti  faradic  current,  and  in  the  counae  of  a  week 
or  two  sensibly  wastes. 

AnaUtm^  of  the  Qii-U-x. — In  order  to  understand  the  produc- 
tion and  diagnosis  of  cerebral  monoplegias  it  is  necessary  to  pay 
attention  to  (he  following  oonsidcrations.  The  gaaglionir  c^lls 
of  the  brain-cortex,  which  originate  the  impulses  that  call  forth 
voluntary  movements,  are  jwaittered  over  a  considerable  portion 
of  the  cortex,  so  that  a  lesion  may  very  readily  affect  some  of 
the  cells  without  influencing  others.  The  nerve-fibres  which  pass 
downward  from  (licse  cortical  centres  are,  however,  gathered 
together  into  a  fasciculus  so  small  that  a  lesion  affecting  one  por- 
tion of  the  fibres  almost  invariably  exerts  a  greater  or  less  in- 
flucucc  U[>on  the  remainder.  For  these  reasons  centric  ur  brain 
monopli^ias  are  of  cortical  origin.  It  frequently  happens  in  a 
hemiplegia  tliat  the  arm  or  tlio  leg  is  more  affected  than  is  its  co- 
sufferer,  because  the  clot  presses  more  severely  upon  oue  \wrtVou 


^ 


70 


DIAGNOSTIC  NEUBOLOGY. 


of  the  condacting  fascicnlus  id  the  brain  than  upon  another.  It 
is,  however,  excessively  rare  for  a  single  set  of  fibres  of  this  fas- 
cicaluB  to  be  affected  by  itself,  and  a  monoplegia  to  be  thus  pro- 
duced. 

Fia.  3. 


For  the  purposes  of  diagnosis  the  cortical  structure  of  the 
cerebrum  may  be  divided  into  three  portions.  That  which  in 
diagram  No.  S  lies  in  front  of  the  letter  A,  Fig.  5,  comprising  the 


FiQ.  4. 


80-called  frontal  convolutions,  is  the  inert  zone.  Extensive  lesions 
may  exist  in  this  portion  of  the  brain  and  produce  no  symptoms 
whatever.      The  region  between  letters  A  and  B  coriiprisea  the 


PAHAI.T9K. 


71 


motor  zone  of  the  brain,  cKtcmliD^  as  far  downward  as  Uie  fissure 
of  Svlviu.-.  The  cvtrtinil  region  j^Misttrior  to  the  letter  B  may  be 
coDsiderotl  as  chiefly  Bcusnry  in  its  function. 

The  motor  zouc  of  the  cerebral  cortex  is  composed  of  the  an- 
terior central  oonvuUiiiDn   [uscemliiig    frontal  coDvuIution),    the 


Fto.  ft. 


nu*i>  M  ftduJi 


^; 


»-<•* 


y'- 


y^_ 


■•«.  If  i|t<ta 


rior  central  aHivoItition  (n-siviiding  parietal  convolution), 
and  the  ]»arnc(,'ntnil  lobule,  aud  appears  in  some  coses  to  reach 
into  the  lobuluH  qiiadrntas,  the  suprn-marglnal  convolution,  and 
even  the  gjTus  foniicaius.  According  to  the  collection  oi  case*) 
mode  by  Exoer,  the  extent  of  this  zone  is  lU'^ually  greater  iu  tho 
Il'A  than  in  the  right  beuiiKphere.  Tlie  cortical  cells,  which  are 
situntcti  in  the  motor  zone,  appear  to  t>c  more  or  less  imperfectly 
g^uped  together,  to  that  those  muscles  which  are  anatomically 
clueely  related  to  cue  another  and  habitually  act  tt^elher  receive 
Uieir  impulse  from  contiguous  cortical  celts. 

Various  attempLs  tuivc  Iicen  made  tn  ii^late  and  locate  thcee 
groups  by  the  study  of  the  recorded  cases  in  which  the  sympioms 
have  been  oKserved  during  life  and  llie  leaion  after  death.  There 
appears  to  lie  a  certain  amount  of  uniformity  in  the  position  of 
the  ami-,  leg-,  and  face-centreu,  but  this  uniformity  is  not  rarely 
dc[)artcd  from.  It  ifi  very  clear  that  the  groups  overlap  one 
anollier.  It  may  l»e  asserted,  as  a  gcueni!  rule,  that  the  anterior 
centra)  oonvotution  iii  uiore  active  as  a  motor  centre  than  b  the 


DiAoxorrro  NEPROLoev. 

posterior  central  •jouvolution,  and  that  tlie  c«]Is  wliicli  are  ooo- 
nected  wJtU  the  lower  extremities  are  situated  in  the  upper  por- 
tion of  these  nonvohitiotiR,  with  the  arm-neiKreB  below  tliem  and 
tiie  centrea  oonnwted  with  the  face  chiefly  located  in  the  anterior 
central  convolution  close  to  its  foot. 

Exner  arrives  at  the  ooiicUisioii  tiial  tlie  oorticnl  arm-oentrea 
occupy  the  paracentral  lohiile,  the  anterior  caitral  oonvolution 
with  the  exception  of  ils  lowpst  portion,  and  the  npper  half  of 
the  posterior  central  convolution,  reaching;,  iu  rare  caset,  into  the 
lobulut^  quadratuuond  the  gyrus  fomicatua.  The  field  of  the  lower 
extromilv  he  locates  iti  the  [Kiranentral  lobule,  the  opjwr  third 
of  the  anterior  central  convolution,  and  some  portions  of  the 
up|>er  third  of  the  posterior  central  oonvolution.  In  rare  cases, 
this  field  seeiiis  also  to  cuter  the  lobulus  qua^lnitus  (ctspecially  in 
the  left  hemisphere,  in  which  it  may  even  reach  the  cnneus). 

The  facial  nerve  w»ie,  afx-iinling  to  Exner,  occupies  the  lower 
half  of  the  anterior  central  convolution  and  the  lower  third  of  I 
the  posterior  central  convolution.  The  centre  for  the  tongne  is 
in  the  foot  of  the  anterior  centnd  convolution,  although  there  is 
at  least  one  case  on  record  in  which  a  lesion  in  the  supra- nmtginal 
convolution  proiluced  hypoglossal  .■symptoms. 

Certhrcd  Monoplegia. 

Abrupt  Cerebral  MonopleGria. — Sudden  monoplegia  of  cere- 
bral origin  may  be  due  to  traumatisms,  to  hemorrhage,  and  to 
arrest  of  the  circulation  by  thrombi  or  embolisms.  There  are  no 
known  symptoms  which  enable  us  to  decide  whether  the  cause  of 
a  Hnildeu  brain-monoplegia  is  a  hemorrhage  or  an  arrest  of  eircn- 
lation. 

ProgreaBive  Cerebral  Monople^a. — A  cerebral  monoplegMi 
may  be  developt'd  suddenly  or  gradually.  When  it  oomes  on 
slowly  it  is  due  to  a  progressive  lesion  situated  in  the  motor  r.oiM 
of  the  cortex.  Such  a  lesion  is  of  the  nature  of  a  tumor,  of  an 
outgrowth  from  the  likull,  or  of  a  localized  meningitis  with  much 
exudation  or  great  disturbance  of  the  circulation.  It  mu^i  be 
remetu1>ered  that  the  cortical  layer  of  the  bruin  is  supplied  by 
blood-vejwftls  which  pa's  from  the  mcrabranea  into  the  brain- 
substance,  and  are,  in  the  cortex,  terminal  arteries  whicli  do 


PARALYSIS. 


uiSAlomnse.  Any  clmngp  in  Uie  membrane!-  may,  by  producing 
prcsBure  upon  the  blotxl-veswls,  interfere  so  seriously  witb  the 
rirculation  ia  the  cortical  stibiitanoe  of  the  brain  as  to  causm  pro- 
gnsRve  degeneration  resulting  in  losfl  of  ftinction  without  there 
being  a  direct  propagatiou  of  diseajw  from  the  membranes  to 
tbe  brain -«ub¥itance.  In  uypliilitio  meningiti!!  the  lesion  ha3  a 
very  ilistiiKJt  tcndenc}'  to  invade  the  oontiguoiiR  brain -substance. 
Syphilitic  disea^  altw  much  more  frequently  loctttes  itself  in 
the  motor  eone  than  do  Iwnign  tuninrs:  consequently,  in  ii  very 
Iftrge  proportion  of  the  cases  of  progressive  cerebral  monoplegia 
the  lesion  is  a  local  syphilitic  meningitis. 

Peripheral  Monopktjia, 

Monoplegia  from  Preeeure  on  Nerve. — Very  frequently  a 
man  will  awaken  from  a  dninken  titupor  to  tind  that  his  arm  in 
paralyKe<l;  and  it  w  onmnmn  for  a  yonng  liridegnrnm  to  gi^t  up 
in  the  morning  with  his  arm  in  a  similar  condition,  in  either 
preature  nf  a  head  upon  the  arm  liaa  been  the  cause  of  the 

luble.  The  loss  of  motor  iwwer  in  llicso  cases  may  Iw  more  or 
leas  complete;  there  is  usually  tingling  an<l  a  distinct  feeling  of 
deadneAft,  but  pronounced  anresthcsia  is  very  ran*,  although  it  may 
occur.  The  mu3cuio-fi]>ind  nerve,  on  account  of  the  manner  in 
which  it  winds  around  the  arm,  is  especially  apt  to  Buffer,  and,  as  it 
cliiefly  RupplicH  the  extensors  of  the  forearm,  these  moecles  are 
Dfiunlly  most  severely  aftected.  A  not  rare  form  of  pr«Bure-palsy 
ia  Uie  ao-called  cruich-pabty,  m  which  a  double  or  single  mono- 
plegia is  produced  by  the  pressure  of  the  crutches  or  cnitch  upon 
the  nerves  in  the  axilla.  I'ressure-piilsy  in  most  ("ajses  yitdds 
readily  to  treatment,  and  Is  rarely,  if  ever,  sufficient  to  produce 
trophic  changes. 

Monoplegia  from  Injury  or  Diaeafio  of  Nerves.' — Complete 
paUy  of  the  arm  may  result  from  injuries  to  the  brachial  plexus, 
AS  well  as  from  multiple  neuritis  or  other  idiopathic  diseases  of 
the  same,  and  fmm  art«-tions  of  the  cervical  spinal  conl  whioli 
in\*oU*e  the  nerve-roots.  Under  the  latter  circuniHtanocs  the 
monoplegia  is  almost  always  double.  If  the  functional  power  of 
the  brachial  plexus  be  abolished,  the  muscles  will  mpidly  waste 
and  die.     I  have  seen  a  oonditiun  of  the  brachial  plexus  allied  to 


* 


74 

cerebral  and  spliinl  ooncuMiou,  cniiired  by  aii  octmu  wave  titrilciiig 
fr<>m  above  dawuward  ou  tlie  supra-clavicular  regiou  ami  fol- 
luwt^  by  total  Ivan  uf  nerve-funvtion.  Traumatic  and  idiopathic 
dii'cnsciB  of  the  sclalio  ner\'e  oiay  cuuiie  a  crural  nionopliigta. 

Toxic  Monoplegias. — Various  metals  nre  capable  ol*  producing 
U)i>nopIegia»,  but,  practiLsiIly,  lead  is  the  ouly  ooe  wliich  fre- 
(|Ueully  causes  audi  palsy.  Plumbic  uioiioplcgia  is  usually  bra- 
chial, and  rerseiiibletj  nicHt  clwH^ly  that  ibrni  cforguulc  tuonnplegia 
which  iR  due  lo  pressure  upon  the  ncrvi^  It  is.  to  l>c  separated 
from  litis,  usually  at  a  glance,  by  being  double ;  but  I  have  seen 
one  case  of  single  brachial  monoplegia  due  to  lead,  and  one  caw 
of  prertiiire-moiioplcgia  in  which  Iwtli  ariiw  wen;  aflfecte*!  on  ac- 
count of  the  patient's  work  requiring  him  to  labor  with  out- 
stretched armii  reeling  near  the  body  upon  a  narrow  boanl.  To 
tlie  plumbic  aiugle  mouoplegia  the  paratysU  wati  caused  by  the 
local  ahfiorptioD  of  the  metallic  salt,  iu  whose  aolulion  the  hand 
and  arm  were  hahiiually  immerse<!.  Under  such  circumstances, 
tlie  diagnosis  must  be  made  out  by  careful  attention  !o  the  history. 
In  plumbic  monoplegia  the  extensors  are  almost  solely  affected; 
but  this  may  also  be  true  uf  the  paral^-sis  produced  by  pressure, 
aim-'e  the  musculo -spiral  nerve  may  be  alone  implicated,  and  it 
chiefly  supplies  the  exten^tom  of  the  hand.  It  is  affirmed  that  in 
plutobio  paralyoia  the  abort  extensor  of  the  thumb  escapes,  and 
that  this  is  polhoguomouic 

MULTEPLE  PALSY. 


A  multiple  palsy  lit  cue  Eu  which  two  or  more  groups  of  dis- 
sociated muscles  are  involve<I.  The  symptoms  vary  aoeording  lo 
the  seat  ami  natnre  of  the  leiiion,  and  are,  in  a  woTxJ,  the  associated 
symptoms  of  ihe  various  local  palsies  of  which  the  multiple  paUy 
i»  compi>sed, 

A.  multiple  puUiy  may  be  of  cerebral  &c  of  peripheral  origin. 
The  nature  uf  any  individual  ca^  is  lo  be  determined  in  the 
same  way  as  in  mouoplegia,  and  tlic  reader  is  referreil  to  page 
69  tor  tlie  diutiuctioa.  There  ie,  however,  one  form  of  per- 
ipheral multiple  palsy  iu  whichj  although  tlie  muscle  watiUs,  Ute 
reaction^)  of  degeueniliou  ilo  nut  ap|ieiLr.  (Sec  Pmgr^sive  Mus- 
cular Atrtjphy.) 


» 


CtT^ral  MiUtfpte  Patmn. 

The  cells  in  the  cerebral  cortex  which  are  ci^onected  with  motion 
are,  as  has  already  been  explained,  so  placed  tlint  thuee  which 
lie  near  one  aiirjther  affect  associated  or  tluisely-relaled  mtiscles. 
Cerebral  multiple  |»alsifs  are  theivfore  rai-c,  because  a  small  Iwlou 
of  the  cerebral  cortex  affecting  contiguous  cells  pnxlmie*  a  mono- 
plvgia,  whiUt  a  legion  sninicieutly  large  to  affect  the  whole  motor 
zone  of  one  hemit^phcre  produces  a  hemiplegia.  A  nmlliplc  <«re- 
bral  |.KLralyt^ij?  <.un  he  prinluced  only  by  two  lesiunH,  or  by  a  lesion 
of  sueh  character  that  it  affects  scattered  aretm  of  the  cortex.  A 
clot  or  an  enibotua  affects  almost  iiivariHbly  a  definite  ari^a  vf  the 
oorte^i,  either  large  or  small,  and  produce?,  therelbn.%  a  hemiplegia 
or  a  moDopli^a.  Consequently  acute  ecrcbrul  multiple  jialMicA 
are  among  the  nitwt  iiifre<|uent  of  diseases. 

Syphilitic  Mtiltiple  Palsiea. — Syphilid  is  es[)ecially  apt  to 
produce  two  or  more  lesions  in  the  brain :  eouse<juently  a  pro- 
greasivH  cerebral  multiple  ]m\sy  ia  in  the  adult  usually  syphilitic, 
due  to  the  action  of  two  or  more  slowly-developing  patuhei)  of 
gnmmatons  meningitis. 

Multiple  Oerebral  Sclerosis. — Occasionally  the  disease  known 
as  multt|ile  tx-rebml  scleiiniit^  affcclti  the  t-ortitml  regioti,  or  its 
minute  mattered  putcheg  may  even  invade  the  interior  portion  of 
the  brain  in  audi  a  way  ih  to  produce  multiple  )tal(iieH.  The 
diagnosis  of  this  disease  is  esi^ecialSv  to  be  made  upon  the  exist- 
ence of  tremoifi,  which  occur  in  the  ailected  parts  only  dariog 
volantary  niovement.  The  Fyuipfoms  ami  uourse  of  llie  aflVctiim 
will  Ix'  discussed  in  detail  under  the  head  of  Tremors. 

Spaatic  Infantile  Paralyais. — One  of  the  most  t'reijUent  of 
the  progressive  or  clirouic  multiple  paralysca  of  verebial  origin  ia 
tlie  attizctiou  which  is  known  as  spastic  purnlysia  of  childhood. 
ThiA  18  a  di.<ieai>c  or  ixindition  which,  beginning  in  enrly  child- 
hood, continues  through  life.  The  palsy  may  take  the  form  of  a 
hemiple}ria.  iNiraptc^'a,  monoplegia,  or  multiple  pnlsy,  and  ia 
suiufl  caaee  tlie  paralyze^t  n-gion  is  so  small  that  the  patient  might 
beoHimdered  to  be  sutlering  from  a  local  paralysis.  The  name  of 
spttBCic  infantile  palsy  which  has  been  given  to  this  diseaac  ex- 
presueei  well  its  cliaractenritic  features,— namely,  the  preeenoe  of 
conlRictures  and  the  age  of  attack. 


76 


DtAOKoerno  nephotxwt. 


The  oontracturpB  are  bo  severe  as  to  give  rlBe  to  very  pronnuiioed 
distortions.  In  the  hand  the  fingers  nre  partially  ftexw!  and  ir- 
regularly drawn  ajiart,  whilst  the  jhiIiii  is  usually  somewhat  ftip- 
shaped,  anil  the  wrist  and  even  the  elbow  may  he  iii  a  |)crpeliia] 
flexitin.  In  tlie  feet  almost  any  variety  of  pes  equinuf  may  occur, 
but  most  commonly  tlie  toes  are  drawn  downward  ami  inwanl, 
and  the  sole  ia  somewhat  inverted  ;  not  rarely  the  f«et  are  erossed. 

Xot  only  may  the  mnscles  of  the  extremities  be  attacked,  but 
also  those  of  the  trunk  ;  and  more  frequently  the  neck  ia  afTocteil, 
80  that  the  head  h  held  in  various  bizarre  positions.  The  mus- 
cles of  the  faco  are  rarely  paralyzed,  hnt  permanent  grimaocs  and 
even  various  sf^uints  may  show  that  the  muscles  of  tlie  head  have 
not  e.sca]>ed.  Tlic  rigidity  is  usually  not  so  complete  but  that  by 
mean»  of  moc]eratc  force  an  im]>erreet  return  of  Uxe  limb  to  its 
normal  position  may  be  temporarily  produced. 

Spfmtaneoizs  movements  in  ihe  Hnilis  are  rare,  but  there  may  be 
a  aiugle  or  double  athetogis  and  even  true  choreic  movemeuts.  It 
IH  es[)eoial]y  in  this  disease  that  the  so-ailled  '*  as^rocJa/et/  jnovi'.~ 
ment^^  first  deAcrlbed  by  Wesiphal  oocuir.  When  iVin  (condition  is 
present,  movemeniB  made  in  the  non-paralyz-ed  extremity  are  sim- 
ilarly but  imperfectly  executal  in  the  paralyzed  part.  Thus,  in  a 
rightrjiidcd  hemiplegin^  when  the  tinkers  of  the  left  hand  are 
openeil  or  shut  those  of  the  riji^hl  hand  follow  the  impulse.  As 
HtatctI  hy  Westphal,  these  ass(knate<l  movements  do  oortir  in  the 
clot-heiuiplegia  of  adults,  ahliough  they  are  very  rare. 

In  spastic  infantile  paralysis  partial  loss  of  power  in  frequent, 
the  tnueclcs  n>Kponding  alowly  and  im]>erfectly  to  the  will,  but 
without  choreic  jactations.  In  other  c&ies  the  affected  mui^cles, 
although  unable  to  res]M:md  pro]ierly  to  the  will,  are  thrown  by 
its  eflTorts  into  more  or  le^  irregular  and  varied  choreiform  cod- 
tractions. 

The  muscles  themselves  are  wailed,  firm  in  Rul)stance,  with  dis- 
tinctly tenae  tendons,  but  never  offer  anv  electrical  reactions  of 
degeneration,  and,  indeed,  pi-eserve  fully  their  relations  with  the 
electric  current.  The  reflexes  are  never  lessened ;  usually  they 
are  somewhat  cxaggeratml,  and  in  some  cases  thev  arc  very 
markedly  incrca.sed,  so  that  the  condition  known  as  itpiruU  eptlijuty, 
in  which  violent  general  contractions  are  produt^ed  bv  slight  ex- 
ternal irritation,  may  esiaU     The  preseoce  of  these  grossly  exag- 


PABALYSIB.  77 

ger&ted  reflexes  or  of  sptnal  v|>ile|j8y  in  any  individual  case  secma, 
however,  to  show  that  the  spastic  palsy  is  not  of  Uie  pure  ty|)e,  but 
tJ»t  there  are  ai^ociaLed  with  IL,  cither  an  a  re(«iilt  nr  an  an  a(^^^l)m- 
panimeut,  sclerotic  changes  in  the  spinal  cord  cs|>eclally  afiecting 
the  lateral  colaraoa.  As  already  stated,  no  distinct  trophic  changes 
ooeur  in  dte  miiKiles.  ni-ither  arr-  true  trophic  chaiigOH  to  he  found 
in  the  other  ti;«4Ucs,  but  there  is  very  frequently  a  jiartial  arrest  of 
development  of  the  nfircted  limb,  so  tliat  not  o'hly  is  it  \esn  in 
diameter  but  also  in  length,  and  the  bottes  and  joints  are  unduly 
small. 

There  is  do  disturbance  of  sennatiun. 

Epilepsy  is  common,  and  of^en  severe.  In  the  earlier  stages  of 
thedl4ea<te  theoonvuIiiionA  usually  be^in  in  the  afFectc^l  limbft,  and 
they  may  for  a  time  eveu  bo  completely  luouoplegic  or  uuilatoral, 
but  aioueror  later  they  become  universal.  Nut  rarely  the  attacks 
of  major  epile))r;y  are  asAoctalcd  from  lioin  to  time  with  pronounced 
pedt  mal. 

In  most  csaes.  there  is  a  lack  of  mental  power.  A  partial  or 
oomptete  aphasia  is  frequent,  and  every  grade  of  imbecility,  from 
idiocy  to  the  nearly  normal  condition,  may  be  found.  Of^u  also 
there  is  marked  asymmetry  of  the  skull;  or  the  head  may  be 
excessively  large,  or  perhaps  more  frequently  abuormally  small. 

Almost  invariably  spastic  infantile  yyalsy  dates  back  to  very 
fsriy  childhood,  although  oceattioiial  ca.scs  are  devclo|>ed  a^  late 
as  the  tenth  or  twelfth  year.  I  have  t-ceii  a  number  of  caaes 
in  which  the  symptoms  were  noticed  a  very  whort  time  after  a 
birth  which  had  becu  iostruineutal,  aud  I  believe  that  not  ioft%- 
quently  the  disease  is  due  to  a  meningeal  hemorrhage  caused  by 
the  injur)-  to  tlie  child'e  head  by  the  fi]rcc|M  of  the  oocouclicur. 
In  another  set  of  cases  the  attack  dates  to  convulsions  occurring 
during  early  childhood.  These  case$  afford  a  twofold  history.  In 
some  of  them  there  is  no  apparent  cause  fur  the  convulf^ious.  The 
cliild  is  seized  with  unoonsoiousness  a{?compaDied  with  violent 
ixuivulsive  niovemenia,  and  is  left  ftaralyzed.  Under  those  dr- 
cumstunces  the  coiivulgions  liiive  been  invariably  more  severe  in 
the  aubsequently  paralyzc<l  limb.  I  believe  that  tlie  pathology 
of  these  cases  is  tliat  an  a|Hiplcxy  has  oiKiirred  with  a  clot,  aud 
Uiis  clot  has  been  the  cause  of  the  oonvulsive  seizure  and  of  the 
ofter-pftlsy.     In  the  second  set  of  cases  the  convulsions  result  from 


• 


rs 


DiAONoerrc  XEaitoLOOT. 


BO  olivious  cauw^  such  a»  gastric  irritation  or  tlie  comiiig  on  of  a 
ficnrlct  fever  or  other  exantliematous  di.sease.  If  unrler  these  nr- 
cuiniilaiux^  the  child  t^mei^i^  with  a  {M'rruanenlly  parulyictHl  IJniU, 
the  coDvulaion  has  probflbly  protluocd  a  rupture  of  the  blooil- 
V€ssc1  in  the  braiu  nml  coii^ticnt  hemorrhiige.  It  would  appear, 
however,  that  it  is  potwibh;  for  a  cunviiigioii  otxriirriu^  in  a  diild 
to  be  owonipanted  with  so  much  cerebral  c^ongestion  of  a  local 
character  as  to  prodaco  a  slight  lemiKirary  loss  of  jmwor  in  the 
timb  withotil  the  presence  n{  a  riot  in  the  brain;  and  when  this 
congestion  is  frequently  repeated,  a  progr««ive  rtniotural  cliange 
of  Ihe  affected  portion  of  the  brain  h  set  up.  At  least  such  is  (he 
explanation  of  cases  like  tlio«e  deHcrilM?d  by  .Julen  .Simon  {Hcvaa 
mnui.  df»  MalatUeti  de  Phhfance,  December,  1883),  in  which  ibe' 
child  poiDses  through  a  series  of  more  or  les^  distinct  convid^iona, 
each  followed  by  evidences  of  UksiI  wwikiiewH  and  a  little  stilTDePK, 
di8ap|>earing  after  a  few  hours,  but  continually  growing  nioro 
pronounred  and  morv  permanent  after  the  auooessive  fits,  until 
finally  a  true  contracture  is  prmluced. 

Lmum  of  Spwiic  Pora/ysw. — Infantile  apastio  i^iralysis  is  the 
resnkof  sclemlicanil  atrophic cbanges  in  the  bniin.  Such  changes 
in  most  caws  date  back  to  the  oocurrencc  of  the  hcmorchago,  but 
in  other  rnstances^i'^l  especially  in  tlie»lowly-develo{Kxl  caaes  last 
Bpoken  of,  they  an*  llie  resnlt  of  frequently-repeated  irritative  eon- 
gi^tions  of  the  broin-suliKtauoe.  The  seat  of  tli&te  hsiuns  variea 
inttetiiiitely,  w^  ilocs  the  pot^ition  of  tlie  resultant  palsies  and  the 
degradation  of  the  mental  wuidition  of  the  chihi. 

The  only  dijie^we  with  which  spastic  infantile  [Kiralysis  c«>uld  be 
confounded  is  lateral  .ipinat  sclerosis  and  multiple  sclerosis  of  the 
brain  or  cord,  which  oortainly  may  exiKt  in  children  a'^  in  adults. 
Jn  spinal  lateral  wierosia  there  arc  no  oonvuUiona  and  no  arrest 
of  niPJitai  deveIopnn;nt,  whilst  the  reflexes  are  grossly  exaggerated. 
In  multiple  i^pinal  sclen^is  the  ityniptutua  j-uheuible  thone  of  lateral 
sclerosis,  but  are  less  severe,  and  usually  pains  or  other  evidences 
jiof  aenaory  diitorder  mark  tlie  presence  «f  sclerotic  patches  in  the 
Benaory  region  of  the  conl.  In  multiple  ocrcbro-spinal  scleroeii 
the  peculiar  tremors  are  present.  It  must,  however,  be  remcm- 
I>crcd  that,  especially  in  childhood,  oorttcnl  brain  Hclerwis  is  very 
prune  to  give  rise  to,  or  to  b«  associated  with,  secondary  conditions 
of  the  spinal  cord,  and  that  not  rarely  cases  occur  in  which  the 


PARALYSIS. 


79 


B^mptoras  of  these  three  so-calle<)  diseases  are  minglerl  ))ec»U!ie 
the  snlproiic  changes  are  ao  widely  KcaUered  thrt)Ufi;li  the  nervous 
^tetn. 

Pniphrral  Muitiplr  Pa/mfs. 

Periplicral  muUiple  palsies  may  he  acute  or  chronic  An  ncute 
or  fiiihjifiiie  organic  jieriphrral  miiltipte  paralysis  is  Hoe  either  to 
a  ledioti  of  the  nerves  or  to  an  affectioii  of  the  ganglionic  celU  of 
the  anterior  coniua  of  the  gray  matter  of  the  oord,  called  polio- 
myeliiig.  Thf  diagnonis  as  to  wliicli  of  these  jiarts  is  iifteoted  may 
be  diflSruIt.  The  history  of  the  caac  ia  of  great  iniportance.  in 
ihe  ali§<*n»_-e  of  traiimallsni  the  i>aralysis  is  almosi  invarialily 
due  eitlier  to  potium^'elitia  or  to  multiple  neuritis.  The  diaguogis 
of  ninlliple  neuritis  has  been  fully  (lisciisi^d  under  the  head  of 
Ascending  Palsy.  The  reader  is,  however,  remindei)  that  the  im- 
portant jMiints  are  tJie  presence  of  pain  and  tenderness  over  the 
nerve-lrtiiiks  in  neiiriilii,  and  their  absence  in  poliomyelitis;  also 
that  in  i>olioaiyeliti»  the  trophic  changes  occur  much  more  rapidly 
and  completely  than  in  neuritig. 

Diphtheritic  Paralysifi. — A  very  imjiortant  form  of  peripheral 
multiple  paralv^is  i«  that  which  follows  diphtheria.  The  symp- 
toniA  usually  commence  in  two  or  three  weeks  after  the  inception 
of  the  disease,  but  may  come  on  :ih  early  as  the  sixili  day,  or  may 
be  delayed  for  four  weeks  or  even  longer.  In  the  majority  of  caaea 
the  original  attack  of  diphtheria  ha>s  heen  iiiiJd,  and  in  the  lower 
cla-wev  I  have  on  several  oocaaions  »ecii  the  primary  disease 
eutircly  overlooked.  In  its  typical  form  the  palsy  begins  first  in 
the  palatine  mui^cles,  and  Ib  usually  revealed  hy  a  imuiiliar  twang 
of  the  voirt-,  resembling  that  commonly  spoken  of  as  naaal.  At 
tlii*  time,  or  shortly  afterwards,  there  is  a  difficulty  in  swallowing, 
which  may  Ijecorae  so  severe  that  all  liquids  are  returned  by  the 
nose,  and  even  the  power  of  swallowing  snlids  is  almost  lost. 
If  the  palate  be  at  tins  time  examined,  it  will  lie  noticed  to  he 
flabby,  molionlew,  and  more  or  less  anesthetic.  The  laryngeal 
muscles  may  now  Iw  attacked  and  difficulty  of  respiration  be 
experienced  from  pandyais  of  the  abduclofH  of  the  venial  cords. 
"When  the  laryngral  symptoms  are  aevere,  the  nasal  voiee  is 
replaced  by  a  whisper,  or  by  a  total  extinction  of  sound.  The 
tongue^  the  lips,  and  even  the  muscles  of  mastication  may  he  af- 


80  DIAOSOflTIO  ȣ(J&OLOOY. 

fected,  M  that  the  jwilleut  is  unable  to  chew  food  or  to  retam 
(he  iialiva,  which  ooDstantly  dribbles  from  the  mouth.  Tht;  eye- 
muscles  are  usuully  the  first  afirtrted  afler  tlio^e  uf  ilie  throat. 
Furalysis  uf  HccommodatioD  comes  on  early,  am]  is  soon  accom- 
panied by  loas  of  ]>owcr  of  somt  of  the  mnsrlcs  of  the  eyeWll, 
giving  rise  to  strabismus  and  dipiojjia.  Complete  mydriasis,  with 
ptosit),  may  altto  occur  from  loss  of  |>ower  in  the  ocuLo-motor  nerve. 
About  tliis  time  weaknc»s  uf  the  legs  is  uotiued  and  rapidly 
deepeus  into  a  more  or  htiH  complete  |)araplegiu.  The  arms  also, 
and  even  the  muscles  of  tlic  trunk,  may  be  affectetl,  so  that  in  some 
cases  a  ^ueral  palsy  resulU.  Kven  the  muscles  of  organic  life  may 
be  implieatetl,  as  is  shown  by  obstinate  constipation  from  paraly- 
sis of  the  iut&itinal  walk,  paralytic  retention  of  urine,  and  cardiac 
failure.  The  circulation  in  severe  cases  ts  feebte,  and  the  surface 
cold  and  blue.  In  the  majority  of  <.aaca  diphtheritic  jMiralyaii!  U  re- 
covered from;  but  deaCh  may  result — from  choking,  produced  by 
theslippingof  apieoeuf  fowl  into  the  larynx;  from  inanition,  the 
effect  of  the  loss  of  power  of  taking  food  ;  from  asphyxia,  due  to 
paralysis  of  the  respiratory  muscles;  or  from  cardiac  failure,  which 
may  develop  with  great  suddenness.  In  wme  esses  paralysis  of  the 
diaplirugm  ti$n.>vculeilby  tlieepigu»triuni  uud  hypochoiidriuui  twing 
drawn  inwaiil  instead  of  being  curved  outward  dnring  iiispimtion. 
This  cwndition  is  one  of  grave  danger.  When  it  occurs,  or  when 
tlio  pulse  ia  exceedingly  weak,  or  the  first  sound  of  the  heart  is 
ujai-kedly  diminished,  ab^clute  i^niet  is  uf  the  utmot^t  importance, 
as  any  exertiun  may  produw  Kuddeu  death  from  purElyticaHphyxia 
or  synooiw.  Sensory  disturbances  always  aocompaiiy  diphtheritic 
palsy.  They  consist  of  anpe^the-sia  rather  thjin  of  pain,  though 
numbnestt  and  tingling,  with  formications,  are  occnftiunally  felt.  The 
distribution  of  the  anoisthcsia  varies  greatly.  It  may  be  almost 
universal,  or  may  be  confined  to  the  throat,  and  in  some  cases 
it  nffcfrt.'*  other  muctius  membranes,  so  that  defecation  and  micta- 
ritiou  may  be  performed  without  conscious  feeling.  Only  in  rare 
cases  are  the  nerves  of  special  »euBe  affected. 

Poliomyelitis. — The  diagnosis  of  a  fully-developed  poliomye- 
litis is  rarely  obscure,  but  in  very  acute  cases  the  nature  of  the 
attack  is  in  its  Ijcginning  often  overlooked.  Not  infrequently  the 
sj'uiptuniB  develop  with  comparative  slowness,  weakness  of  the 
part  affected  being  the  first  evidence  of  disease.     On  the  other 


PARALYSIS. 


haod,  ID  MOM  cases  there  if  thiriiig  Uic  earlier  dap  of  the  atlaok 
gnat  systomio  disiurbanoe,  wilh  high  ievor  and  an  array  of  sym]j- 
tonw  Rufficiently  resembling  those  of  malarial  or  typhoid  fever  to 
be  readily  mistaken  for  th«ni.  An  examiuatiou  of  the  leg;^  and 
arms  under  these  circamstances  will  detect  the  presenoe  of  some 
localteed  or  wide-sjir«iil  Ut^  of  power,  and  thereby  reveal  the 
natnre  of  the  disease  Unless  the  practitioner  habitually  ex- 
amines the  muscleft  of  the  extremities  and  irunk  in  ca-ses  of  ob- 
•oare  fever  occurring  in  children,  he  will  be  very  apt  to  make  a 
mistake  in  tlie  early  diagnusis  of  acute  pt^liomyelitis.  The  gen- 
eral OdUr^f!  and  symptoniij  of  aeute  poliomyelitis  will  be  discussed 
in  the  chapter  on  Trophic  Changes.  At  present  I  shall  only  fur- 
ther point  out  certain  affections  which  may  be  confounded  with 
the  diaeaae. 

Local  Atrophiea. — Care  is  sometimes  necessary  not  to  con- 
found nritli  a  iKiliomyetitiH  certain  atrophies  of  the  rouseles  which 
folloir  injuries  or  are  associated  with  surgical  inflammations. 
Very  common  among  thwe  are  ]xtlxff  of  the  fUUoid,  the  result  of 
a  fall  upon  the  ^houldeni.  Panilysiii  and  atrophy  of  other  mus- 
cles fnmi  a  direct  blow  may  bapgicn,  bill  on  acconnt  of  its  situation 
the  deltoid  is  much  more  frequently  afTected.  After  the  miig4L-le 
has  more  or  less  completely  recovered  from  the  immediate  eSect 
of  the  bruise,  it  is  found  to  be  completely  palsied.  I  believe 
that  in  such  a  cose  the  loss  of  power  \f>  due  tu  concussion,  or  even 
more  severe  injury,  of  the  peripheral  uerve-enctinga  in  the  muscle. 
AArr  fractures  and  luxations,  palsies  of  the  neighboring  muscles, 
with  atrophy,  are  prone  to  occur.  In  Aome  eases  they  are  the  re- 
flolt  of  a  direct  injury  lo  the  nerve,  or  of  pressure  upon  the  nerve 
bjr  callus,  etc.  In  other  cases  no  such  immediate  lesion  can  l>e 
made  out.  Kven  when  a  nerve-trunk  has  lieen  injures!  it  may 
oAeo  be  noted  that  (he  [>aral>'sid  aud  atrophy  are  not  ounfined  to 
the  muscles  innervated  by  the  nerve,  and  they  may  become  so 
geoenl  aod  wide-»pr»id  as  to  involve  all  the  musolee  of  the  ex- 
tnmity.  More  rarely  the  muscles  upon  the  opposite  side  of  the 
body  are  affected  with  the  same  cltanges.  To  the  atrophies  in  the 
octghborhood  of  the  lesion  the  uauie  of  Atrophy  by  Propagation 
baa  bacai  given,  whilst  tlic  changes  at  a  distance  arc  ^metimetj 
■pokeo  of  as  Retlex  Atrophies.  The  lesion  in  these  csoMes  ie 
pfobably  au  o^oendiug  ncuritia. 


82 


DIAGNOSTIC  yKTBOLOOY. 


Joint  Atrophies. — John  Hunter  wan  the  first  tn  call  attention 
to  the  njnsoular  alrophief  wliidi  ff:»Ilii\v  tliseaw  of  the  joints,  and 
ill  1845  Bounet  discuKed  the  qmsliou  at  length,  ami  showed  thnt 
chronic  Hvnovial  inflammaiions  may  produce  wasting  not  only 
in  the  immediate  neighborhood  of  the  affected  articulation,  but 
also  throughout  the  limb,  aud  that  the  affected  muiH-lct?  are  much 
paler  than  □oriual  and  lose  a  portion  of  their  Gbres.  Most  fVe- 
qiicnlly  in  cawfi  of  arthritis  the  extensors  jinj  the  first  to  be 
profoundly  aflectcd.  This  atrophy  is  not  r«inip!y  loss  of  miisicie- 
tone  from  want  of  use.  It  Is  always  •accompanied  by  paralysis, 
and  Sfoniftime*  the  [siralysi*  conie»  first-  It  may  continue  loug 
after  the  arthritis  has  been  cured.  It  la  usually,  bnt  not  always, 
in  pr(ipf>rtinn  to  the  inflammation  in  the  joint,  and  is  more  fre- 
qucDt  with  blcnnorrhagic  and  scrofulous  inflammations  than  with 
rheumatic  arthritis.  M.Go!*&eliu  has  called  attention  to  tlie  i)ecu- 
liar  atrophy  witli  contracture  of  the  long  |)eroneal  muscle,  which  is 
not  rarely  seen  in  inedio-tarsal  artlirilis.  The  toRs  of  opposition  to 
antagonistic  mu^K-Iet^  sometimes  in  these  cases  produces  ^at  dia- 
tortioii  in  the  foot  and  hand. 

ToxGDinic  Peripheral  Polmoa. — An  affection  whicli  is  liable 
to  be  confoundeil  with  idiopathic  poliomyelitis,  and  in  which  the 
lesion  is  probably  degeneration  of  the  ganglionic  spinal  cells,  is 
produced  by  poisonous  doses  of  lead  or  of  arseoic,  and  probably 
of  other  metals.  The  1'J6s  of  power  sometimes  affects  alrao^it  the 
whole  nuificular  system,  but  may  be  irregularly  located  either  in 
the  up|)er  or  iu  the  lower  extremities.  According  to  my  cxperi- 
eiKc,  almost  complete  paraplegia,  with  comparatively  trifling  «rm- 
paralyxis,  i^  moHt  frequent  after  arsenical  |H>isouing,  whilst  in  lead- 
Ijoifiouing  the  upper  extremities,  and  especially  the  deltoid  muRcleSj 
are  prone  tn  he  attacked.  It  must  be  remembered,  however,  that 
in  cither  of  the  poidoninga  any  aMociated  or  scattcrwl  groups  of 
muscles  may  be  affected.  The  symptoms  develop  rapidly,  the 
affected  muscles  wasting  and  preseutiug  in  a  very  short  time  the 
electrical  reactions  of  degenenitioii,  and  finally,  in  exln-me  cases, 
jtaasing  into  a  comlitton  in  which  they  fall  entirely  to  react  to 
electric  currents.  The  symptoms  are  similar  to  those  of  ordJuaiy 
cases  of  acute  }>oIiomyelitis.  The  toxic  nature  of  tlie  affection  is 
indicated  by  the  disease  occurring  iu  adults,  in  whom  acute  polio- 
myelitis is  exoesRively  rare,  by  the  rapidity  of  the  cltauges,  by  Uie 


PARAI.VSra. 


» 


wide  dHtrihiition  of  the  pnralysis,  nnil  Bometi'mes  by  the  loss  of 
power  over  the  bladder  and  riKHum.  The  dingnoAis  \s  furtlier  to  be 
nmde  out  by  tlie  histor}-  uf  the  c&se,  or,  if  this  be  wantiug,  by  the 
occurrence  of  diwirders  of  seoBtitiuii  as  well  as  of  motion.  Wide- 
spread or  oarrowly-limited  spotfi  of  aneesthesia  can  usually  be 
dtecovered,  at  least  in  the  early  stages  of  the  disorder.  Not 
iufrvqueotly  the  anaesthesia  liiially  diitappeurs,  altliiAigh  the  motor 
paralyeis  reniainn.  Espeuially  in  arsenicul  [>oi80iiiiig,  and  iti  the 
enrly  stages  of  the  attack,  violent  [>fiiim  shoot  through  the  limb<t, 
following  more  or  ]ess  ditttiiietly  nerve- trunks,  and  ^'ving  rise 
to  the  «iispicii>n  that  the  pathology  of  some  of  thew  cases  is  a 
peripheral  neuritis.  It  is  csfKciatly  iniportdnt  that  a  correct  diag- 
noetei  be  maile  of  these  (Ta»(«,  hueaiisc  they  arc  nearly  alwHys  cura- 
ble by  ircntmeot.  The  oocurrenoe  of  im  a^-ute  poliomyelitifl  in  the 
adult  should  alwayR  create  in  the  mind  of  tlie  practitioner  a  strong 
0UApi<non  of  a  toxic  origiu,  aud  the  uriue  should  be  exaiuitied 
for  lead  aud  arsenic.  Finding  the  nietui  of  L-uursc  decides  Lhe 
diagiioRJs,  although  very  frequently  the  (KLralysis  oullatitti  the 
apparent  cliroirTatiou  of  the  poison,  and  do  mct^il  con  be  detected 
in  the  urine.  In  lead -poisoning,  the  occurrence  of  the  blue  liue 
upon  the  guoiA  is  daMsive;  but  its  abtienoe  is  not  proof  of  the 
abaeuoe  of  lead  from  the  system. 

Chronic  Peripheral  Palsy. — The  mast  frequent  form  of 
clirouic  jK'ripheral  iHinilysis  occurring  in  adults  is  that  which  is 
known  as  proffr^isive  mtucuiar  airophtf.  In  this  disease,  without 
an  obviou-s  lause,  wasting,  with  lo»  of  power,  appears  in  the  af- 
fected muscle,  and  progresses  so  sloM-ly  that  years  may  be  required 
for  tlie  destruction  of  the  jmrt.  Under  thei»eeirciim!itam-es  the  loss 
of  power  ii^  in  direct  propurtion  to  the  wasting  of  the  muscle,  but 
normal  electrical  rcuetions  of  the  wusted  mu!ri>le.s  persi(>t  until  almost 
the  last  6bre  is  deetruyed.  The  explauation  of  this  ehamcteriHtio 
symptom  will  bo  given  in  the  chapter  on  Trophic  Change*,  where, 
^no,  the  course  of  the  disease  will  be  spoken  of  in  detail.  The 
lenon  if,  a  progressive  degeneration  of  the  ganglionic  motor  celU  of 
tlie  Hpinal  cord,  and  lu-noe  the  term  chronic  {Mliomyelitie  which 

eometime»*  employed  as  the  name  of  the  di-iiejise.  Progressive 
lu&cular  atrophy  is  to  be  recognized  by  tlie  slowness  of  its  course, 
the  peculiarly  irrcguhir  groupings  of  the  pals-ies,  the  fibrillary 
contractions  and  u'asting  uf  the  muscles,  with  oonsecvallua  of 


• 


DIAOMOflnO  HBt;ROIX)OY. 


their  normal  electrical  reaetioiut,  aaO  tlie  absence  of  paia  and  of 
panilvflis  of  the  tmwcis  or  of  iKc  bladder. 

Paeudo-Hypertrophic  Paralysis. — A  dtsease  which  causes 
multiple  paliiieH,  and  therefore  requires  menlion  here,  although 
pmlmbly  not  an  aflccnou  of  the  ut-rvous  system,  is  [iiset»do-liy|>er- 
tropbic  paralysis,  During  iiHiincy  or  early  childhood  it  h  noticed 
that  the  child  is  very  easily  fatigued,  walks  unsteadily,  falls  fre- 
quently, and  coutiniially  jiupporls  himself  by  clinging  to  chairs 
or  other  furniture.  He  »ooii  begiD:^  to  go  up-titaire  with  difficulty^ 
drags  hiiuiM^lf  along  by  the  batui^leni,  mid  fiuully  uinnot  ascend  ex- 
cept on  his  hands  atid  kueut.  He  in  aho  uflected  when  walking  on 
the  levrl  ground :  the  feel  are  held  widely  apurt ;  the  gait  becomes 
atruddling.  lu  sleppiug,  the  active  foot  its  raided  fi-um  the  ground 
by  an  elevation  of  the  pelvis,  and  the  trunk  is  bent  towards  the 
passive  leg.  Lordoeir^  \&  apiiarent,  both  in  stimding  and  in  walk- 
ing. The  iibdoiueii  is  thrust  forward  and  the  shoulders  liackward, 
00  that  a  vertical  line  drop{ied  from  between  the  flhoulder$  passea 
behind  the  sacrum.  In  the  a<lvauoeiI  f<tage»  the  child  is  unable 
to  rise  from  the  lluor  or  the  chair  in  the  crdiuary  munner.  He 
drags  hiniwlf  up  with  hJH  hands ;  or,  if  he  be  lying  down,  and 
no  supi>ort  l>e  fortbr-omiug,  lie  gets  upon  his  hands  and  knees,  and 
then,  grasping  each  thigh  alternately,  is  able  to  raise  himself  suf- 
ficiently from  the  floor  to  get  first  one  and  then  the  other  foot 
upon  its  sole.  He  then  lays  hold  of  his  tJiigbs  with  sucocseive 
grasps,  one  aljove  tlic  other,  and  thus,  as  it  were,  climbs  up  them 
to  a  iitaudiug  position.  This  mt'tliml  of  getting  on  the  feet  is 
pathognomonic  of  peeii do- hypertrophic  paralysis.  A  test  which, 
in  the  young  child,  is  alnioftt  diaginistic,  even  at  a  time  when  the 
changes  of  the  muscles  are  not  visible  to  the  eye,  is  the  inability 
of  the  standing  child  to  raise  himitelf  upon  his  toes. 

S<»oueror  later  in  paeudo- hypertrophic  pHmlyais  the  affected  mu8- 
cles  become  larger  and  firmer,  with  abnormally  rounded  outlines, 
Occasionally  some  of  them  undergo  atrophy.  The  ortler  of  de- 
velopment of  the  paralysis  is  usually  first  in  the  calves,  then  in 
the  ghiteal  monies,  then  in  the  muscles  of  the  back,  Uien  iu  those 
of  the  Uiigli,  and  finally  iu  tliinie  of  the  arms.  This  pn)gre8sion  is 
not,  however,  invariable.  The  electro- contractility  of  the  muscles 
may  for  a  time  be  normal :  Inter  it  Ls  diminished  to  the  faradie 
current,  abnormal  or  increased  to  the  galvanic  current :  finally, 


PARALYSIS. 


66 


it  is  Inst  to  hnth  ctirrenta  Tlieiv  alterations  are,  however,  de- 
veloped verv  dlnwly.  In  the  advanced  Htagcs  ttie  knee-jerk  is 
aholi^hetl.  There  w  no  paralysis  of  the  bIa<Uler  or  of  tlie  rectnnij 
■ltd  DO  disorfler  of  HensaiJDii.  Cliniiicterisiio  changes  will  be  (^een 
in  fragments  of  muscles  withdrawn  by  cutting  trocars. 


LOCAL  PAKALY8I8. 

Loral  parnlj-ses  may  be  either  centric  or  peripheral.  In  the 
large  majority  of  ca-ses  they  are  perlplieraJ.  The  iliagooaia  of  the 
nature  of  a  local  palay  is  to  be  raatic  in  exactly  the  same  manner 
m^  with  monoplegias  and  multiple  palsies,  and  it  does  not  seem 

[neoesaary  to  repeat  what  han  been  already  itaid. 

In  order  to  facilitate  the  recognition  of  the  muscles  and  nervea 
which  are  affected  in  any  individual  case  of  [xiralyiiiu,  I  propwe 
to  consider  succinctly  tlie  paralyses  which  r»4idt  from  a  loss  of 
power  in  the  various  nerves  and  their  tribnt^ir)-  muscles. 

Oculo-motcr  Paralyaifi. — Dilatation  of  the  pupil,  ptosis  or 
dropping  of  the  U|i|mu*  Ud,  paralysis  of  acxxitnciioilution,  squint 
with  consequent  double  vision,  are  symptoms  of  los^  of  power  of 
the  oculo-motor  nerve,  whose  auperflcial  origin  in  from  the  inner 
Iwrder  of  the  crus  cerebri,  the  deep  origin  being  in  the  locus  niger 
of  the  peduncles  and  the  gray  nucleus  in  the  fluor  of  the  aqueduct 
of  Sylvius  slightly  below  t]ie  tulK-rculse  quadragemini.  Partial 
ptmlyBis  of  this  nerve  is  frequent.  In  such  ctuiics  the  symptoms 
vary  a<-cordinf;  to  the  portion  of  the  nerve  affeeteil.  The  functions 
of  the  eye-muscles^  are  as  follows :  to  turn  the  eye — superior  oblique, 
downward  and  outwanl;  inferior  oblique,  upward  and  ouLwurd  ; 
saperior  rectus,  ujiwiird  and  inwarrl;  inferior  rcctu.^,  downwiird 
and  inward  ;  internal  rectus,  directly  inward  ;  externa!  rectus,  di- 

Frecdy  outward.  All  thew  muscles  are  supplied  by  the  oculo- 
motor uerve  except  the  superior  oblique  and  the  external  rectus. 
When  one  of  these  muscles  is  pnnilyzetl  a  squint  rcsullii.  lu  order 
to  determine  which  nmt^clc  la  alfeutt^l,  it  is  only  netrcsHnry,  at  least 
in  cases  of  fretsh  paralysis,  to  note  the  position  of  the  head.  The 
rule  is,  the  head  is  so  deflected  that  the  chin  U  carrUd  in  <t  direa- 
Hon  0OTTt»pirtuUng  to  ihf  adiim  of  the  paralyzed  muscle.  Mcgulop- 
sia,  or  macropsia,  is  a  oouditicu  of  visiou  in  which  ohjeets  look 
larger  than  normal.     Tt  is  m'lti  to  indicate  paraly^ut  of  the  e.xtetaa.\ 


m 


DiAOKoffrro  HKrBor.ooy. 


rectus.  Micropsia,  in  which  objects  look  smaller  than  normal,  is 
said  to  indiratc  pnrcsis  of  the  internal  ret'-tiia  mn-sole.  ThcBc  two 
fiyinptoma  nre  very  rare.     1  have  never  se*n  either  of  thera. 

Oeulo-motor  palsy  is  in  the  majority  of  instances  peripheral, 
due  to  pressure  u|toti  the  ucrvc  liy  haml  exutlaliiins.  Tlie  com- 
mon cause  in  adultu  is  a  syphilitic  meningitis,  in  children  tubercu- 
lar or  ra<'hitic  meiiini^itis;  but  it  may  be  produced  by  a  cancerous 
or  iKMiign  tumor.  For  other  details  upon  oculo-motor  palsy  as  a 
symptoni  see  page  41. 

Fourth  or  Troohloor  Nerve. — 1jOs»  of  jwwer  of  the  Huperior 
oblique  ranseie  of  the  eye  is  diof^nosed  by  the  fixedness  of  the  eye 
when  the  head  is  moved,  or,  In  other  words,  by  the  moving  of  the 
eye  with  the  head.  Double  visLUN  occuns  whenever  the  subject 
attempts  to  look  straight  downwurd,  or  at  objeoCs  aituatcd  towards 
the  panilyzcd  aide;  but  the  second  image  disippeant  when  the 
head  ii^  turned  to  look  towards  the  soiiud  side.  The  distortion  uf 
vision  is  eiipceially  manifested  when  any  attempt  in  made  to  pick 
an  object,  as  money,  olT  a  table.  The  nerve  Itivolve^l  is  the 
fourib,  trochlear,  or  pathetic,  whose  apparent  or  superficial  origin 
is  in  the  superior  peilnncic  of  the  cerebellum.  Its  fibres  have 
been  traced  iulo  the  ]>eduncle  to  the  valve  of  Vieussens,  near  the 
tubercular  quadragemini,  where  they  decusiiate  with  coiTesponding 
filaments  of  the  opposite  side. 

The  fourth  or  injcbleur  nerve  and  the  sixth  or  aUducena,  like 
the  oculo-motor,  are  frequently  itarnlysted  by  basal  meningitis,  but 
loss  of  power  tn  them  may  be  due  to  centric  lesion,  such  as  a  clot, 
a  tumor,  or  a  degeneration  of  the  nucleus. 

Fifth  or  Trigeminufi  Nerve. — Loss  of  |Miwer  in  the  mnaoleB 
of  mastication,  ix.,  the  temporal,  massetcr,  and  pterygoids,  and 
in  the  mylo-hyoid,  digastric,  tensor  palali,  and  tensor  tympani, 
indicate-s  paralysis  of  tlie  motor  root  of  the  fifth  or  trigeminus 
nerve.  This  root  has  it'4  apparent  origin  in  the  side  of  tlic  (mns; 
its  deep  origin  is  iu  a  nucleus  jui^t  tielow  the  lateral  angle  of  the 
fourth  ventricle,  immediately  in  front  of  the  nucleus  of  the  facial 
nerve. 

Sixth  or  Abducens  Nerve. — Paralysis  of  the  abiluceiis  nerve 
causes  loss  of  power  in  the  external  rectus,  with  consequent  in- 
teniftl  strabismus,  or  squint,  double  vision,  and  sometimes  mo- 
cropsia.      Internal   squint  do«t   not,  however,  always   indicate 


the  sixth  nerve,  because  the  weakness  of  the  external 
rectus  tnuacle  is  a  very  frequeut  rtisuU  of  iiuperfecLiou  of  vtsiou. 
The  apparent  origiu  of  tlic  abdueens  nerve  '\s  from  a  groove  be- 
tween the  anterior  pyramid  of  themedulU  aiul  tlie  posterior  border 
of  tbe  pons.  There  are  usually  two  roota,  one  from  the  medulla 
and  the  other  from  the  pons.  The  fibres  have  been  traced  to  a 
nucleus  which  lien  underue«th  the  faseiciiliis  tcre»  in  the  floor  of  the 
fonrth  ventricle.  A  few  fibres  are  believed  to  pasa  from  this 
DQcleiifi  ujiwanl  and  across  to  join  the  third  nerve  of  the  opposite 
side.  In  thii*  way  are  t'xplainwi  certain  rare  cases  of  ctinjugate 
pandysis  involving  the  internal  rectUH  of  one  side  and  the  ex- 
ternal rectus  of  tlie  o(her  .side,  and  aasimpaoied  by  atrophy  of 
the  nucleus  of  the  abduoens  nerve. 

FaciaJ  Nerve. — Of  all  the  nerves  of  the  body  the  facial  or 
eeveuth  nerve  is  most  frequently  paralyzed.  The  superficial  origin 
of  this  nerve  is  in  a  groove  between  the  olivary  ami  restiforra 
bodies  of  the  medulla.  Its  deep  origin  w  probaMy  in  the  iippr 
portion  of  the  pons,  although  its  Bbres  have  not  been  distinctly 
Irat-ed  farther  than  a  nocleus  in  the  upper  half  of  the  floor  of  the 
fourth  veiitrii-le  near  the  postero-nitilian  lissure.  It  .supplies  nil 
the  mosnlcs  of  the  fac«,  except  thoite  of  mastication,  also  the  levator 
palatf  and  the  tensor  tympnni. 

Centric  paralysis  of  the  facial  nerve  is  common.  It  is  never 
complete,  and  almost  invariably  affects  the  muaclcs  about  the 
ourner  of  the  mouth.  It  is  revealed  by  the  slight  drawing  of 
the  month  to  tlie  opposite  side,  hy  lo.<!s  of  power  of  whistling  or 
of  fine  articulation,  aud  by  a  little  flabbiucss  of  tbe  atfected  {>art. 
In  deep  ooma  this  {nilsy  can  ollen  be  recognizee]  by  the  peculiar 
puf^ng  out  of  the  corner  of  the  mouth  during  expiration. 

Peripheral  palsy  of  the  facial  nerve  is  very  frequent,  constituting 
the  affection  nonietimes  known  a»  Jiell'it  pnl^y.  The  paralysis  is 
always  oompteLu,  or  nearly  so.  The  face  is  strongly  drawn  ti»- 
wurds  the  oppoTiitc  side.  Tlie  |H»wer  of  oorapleU^ly  closing  the 
eye  w  lout,  betnuse  the  orbicular  mu.wle  Is  not  able  to  raise  the 
lower  lid.  The  wrinkles  in  the  forehead  and  the  various  folds  of 
the  skin,  to  which  the  face  owes  so  much  of  its  expression,  entirely 
disappear  or  are  greatly  flatteneti  out.  The  saliva  is  with  diffi- 
culty retained.  Articulation  is  distinctly  impaired.  During  the 
prooeas  of  cliewing,  the  food  is  very  apt  to  accumulate  between 


88 


DIAGNORTIC  NETJKOT.OOV. 


the  teeth  and  the  cheek,  nu  account  of  the  floccndit}'  of  the  buc- 
cinator nni^le.  Miwtlcntion  h  not.  otherwise  inlerfored  with,  be- 
cause the  muscles  of  ranstication  are  not  supplied  by  the  facial 
nerve.  Bilateral  facial  paralysis, /oci'a/ Jrpfeywi,  w  simultaneous 
palsy  of  both  facial  nerves,  is  exceedingly  rare,  (hough  it  is  some- 
times produced  hy  a  I<mg  transverse  lesion  crossing  the  anterior 
half  of  the  pons,  or  by  a  similar  transverse  lesion  encroaching  upon 
the  facia)  nerves  after  their  emergence.  It  is  characterized  by 
a  fixed,  immovable,  espressioiiIcsB  countenaooe,  a  peculiar  drop- 
ping of  the  angles  of  the  mouth  aud  «)lla(iBeil  appearam*  of  the 
nostrils  during  iosplralinn,  and  a  marked  flapping  in  and  out  of 
the  cheeks  during  respiration.  The  voice  is  usually  nasal,  and  the 
articulation  very  bad  owing  to  an  impossibility  of  prouuuuciug 
labial  oonsononls.  Tiicrc  is  exccHsive  difficulty  in  retaining  the 
food  between  the  teeth,  and  the  saliva  in  the  mouth. 

There  are  tliree  distinct  positions  at  wbicii  lesions  of  the  facial 
nerv&-trunk  may  occur  and  produce  characteristic  symptoms.  The 
Brst  and  roost  frequent  \s  that  in  which  the  jwlut  of  paralysis  is 
at  or  immediately  after  the  cscajiR  of  the  nerve  from  the  tcm|>f>ral 
bone.  Under  these  circumstances  the  paralysis  is  limited  to  the 
musolet!  of  expression. 

TliG  second  form  of  facial  palay  is  that  in  wbicli  the  lesiou  is 
situated  above  the  origin  of  the  chorda  tympiuii  nerve,  but  on 
the  dintal  side  of  the  petriisal  nerve.  Under  these  circurastanoes 
to  the  paralysis  of  expression  is  added  great  diminution  of  the 
aeose  o{  taste  in  the  anterior  two-thirds  of  the  tongue. 

In  the  third  variety,  the  lesion  ta  behind  the  ganglionic  en- 
irgemcnt  which  gives  origin  to  the  third  petrosal  nerve.     There 

now  loss  of  power  in  the  muwles  of  expression,  lo.*  of  taste, 
iralysis  of  the  soft  palate,  as  revealed  by  a  depression  of  the  arch 
of  the  palate  upon  the  nSbcted  side,  ond  a  loss  of  power  in  the 
tensor  palati  muscle,  so  that  the  soft  palate  is  drawn  towards 
the  normal  side.  At  the  same  time  the  sense  of  hearing  is  gen- 
erally abTiormally  acute,  and  the  secretions  of  tbe  parotid  and 
submaxillary  gland  are  deficient. 

Paralysis  of  the  facial  nerve  may  he  duo  to  tumors  at  the  base 
)f  the  brain,  to  disease  of  the  petrous  portion  of  the  temporal  bone, 
or  to  simple  rheumatic  neuritis.  Owing  to  the  exitosed  position 
of  the  nerve  and  the  Jiabitual  nakedness  of  the  face,  this  paralysis 


i 


PARALYSIS. 


fe 


18  freqaeotly  produced  by  exposure  to  coM  drauf^lits  or  wimls, 
especially  after  heating  of  the  body.  Paralysis  frora  expcwure 
o^nally  involves  only  that  portion  of  the  n?r\'e  which  is  external 
to  the  )>ony  canal,  though  ^mctinies  the  inflamruation  oiay  extend 
bsckward  ioto  the  caual.  C^^mplete  peripheral  paUy  of  the  whole 
nerve  Is  in  the  great  majority  of  cases  due  to  (Usease  of  tlie  bone, 
or  to  tnberculnr  or  syphilitic  bnsal  meningitis. 

OloaBo-Pharyn^eal  Norve. — Paralysis  of  the  glosso-pharyn- 
g«il  nerve  is  revealed  by  difficulty  of  svpallowing,  with  great  ten- 
dency to  regurgitation  of  food  through  the  nostrils,  and  the  loss 
of  taste  in  the  posterior  third  of  the  tongue.  The  ttu[)erficial 
origin  of  the  nerve  is  in  the  groove  between  the  lateral  tract  and 
the  reeiiform  body  of  the  meflulla  oMoiigflta.  Its  libreA  have  been 
(raced  to  a  nucleus  in  the  Qoor  o(  the  fourth  ventricle. 

Spinal  AccesBory  Nerve. — The  spinal  accessory  nerve  is  com- 
poftpd  of  fihrfls  Hpringing  fnmi  the  lateral  rolunitm  of  the  mwlnlla 
oblongata  and  of  fibre**  whicli  rise  between  the  anterior  and  pos- 
terior roots  of  the  dnt  and  fifth  cerviotl  nervea,  the  two  parts 
being  united  in  the  cmnitim  anil  e^-a[>iiig  ax  one  nerve  through 
the  jugular  foramen.  The  ^pinnl  aoces-soiT  nerve  sends  commu- 
nicating fibres  to  the  pnenmognstnc,  which  appear  to  reach  the 
laryngeal  muscles,  »ince  in  jmralysis  of  the  (tpinal  aooetwory  the 
voice  becomes  hoarse  and  umiataral;  the  act  of  deglutition  is  also 
aomewhal  afl'wtetl.  Tl  alfordH  the  <:hief  but  not  the  only  supply 
of  the  stcmo- mastoid  and  ira}>pzius  musolcs. 

Stemo-maatofd  Muscle. — Paralysis  of  the  stern  o- mastoid  mii9- 
clea  causes  slight  elevaiitm  of  the  clitn,  with  rotation  towanls  the 
paralyzed  side,  «msing  an  oblique  position  of  the  head.  There  is 
difficulty  in  depressing  the  head  towfirds  the  paralyzed  muwle, 
whose  normal  outline  in  the  neck  is  also  softened  down.  If  botli 
miucles  be  affected,  the  head  is  held  straight,  and  is  rotated  with 
great  difficulty;  great  difficulty  inalrio  experienced  iu  depressing 
the  chin. 

Trap«zlus  Muscle. — Paralysis  of  the  trapezius  muscle  is  shown 
by  sinking  of  the  ]>oint  of  the  shoulder,  drooping  downward  of  the 
scapula,  tlic  inferior  angle  being  in  the  relation  of  adduction  to  the 
apiue  as  coni|)ar(H)  with  it^  fellow,  and  pnuninencc  of  the  clavicle 
and  supraclavicular  space.  If  there  is  also  difficulty  in  raising  the 
scapula  and  davicle.  and  in  elevating  the  arm,  the  up^r  &bT^ 


• 


90 


uiAQNoerrio  necrologt. 


of  the  muBoIe  are  especially  involved  ;  while  if  the  scapula  is  not 
€iunly  approximated  to  the  spinal  ooltimn,  the  middle  and  tower 
fibres  are  chiefly  affected.  If  after  oomplete  [taralysis  of  llie  trape- 
zius there  is  absolute  inability  to  draw  the  scapula  towards  the 
Bpine,  palsy  of  the  riwmboidcite  vuijor  and  rfutmboidaui  minor 
muscles;  may  lie  inferred.  Under  tiimilar  circumstancca  loas  of 
the  power  of  elevattu^  the  scapula,  aud  of  moving  the  neck  af>er 
fixation  of  tlie  scapula,  indicates  paralj'sis  of  the  levator  auffulas 
gcapula: 

Lonf;  Thoraoio  Nerve. — If  the  scapula  is  drawn  upward 
with  its  lower  nngle  approximated  to  the  spine,  and  if  during  the 
act  of  elevating  the  arm  the  luwer  angle  of  the  boue  does  not 
describe  ou  arc  outward,  as  it  normally  should  do,  hut  appruichee 
still  nearer  to  the  spine,  while  the  vertebral  border  stands  out  in 
a  wing-like  manucr,  leaving  a  well-marked  depreasion  between  it 
and  the  thorax,  then  there  is  pai-alyt^is  of  the  srrrntm  magnua, 
which  is  Bupplitd  by  the  posterior  thoracic  or  long  thoracic  or 
external  rtspiratory  uervc  of  Bell. 

Subscapulaj-  Nervos. — Difficult  Jidduction  of  the  arm,  with 
loea  of  the  normal  power  of  deprei»iug  it  and  drawing  it  back- 
ward, especially  in  llie  act  of  placing  the  hand  in  contact  with  the 
buttot'k,  shows  paralysis  of  tlie  laiissimnn  dortti  muHcle,  which  is 
chiefly  .supplied  by  tJic;  subscapular  nr-rves. 

Inability  to  ])erform  properly  inward  rotation  of  the  humerus, 
diminished  |Kiwer  of  pronation,  excessive  outward  rotation  of  tlie 
upper  arm,  and  cou»ci]ueut  faulty  [loeitloa  of  the  hand,  denote 
paralysis  of  the  suhawpu/aria  and  teres  iwijor  muscles,  which 
receive  their  nerve-.supply  from  the  subacapnlar  nerves. 

Supra-scapular  and  Ciroumflex  Nerves.— Tmpaire«!  jwwer 
of  outward  rotation  of  the  humerus,  and  consequent  difficulty  m 
performing  such  at^ts  as  writing,  dniwing,  and  csfwcially  sewing, 
in  which  this  movement  is  ea^ntial,  together  with  excessive  in- 
ward rotation,  even  to  the  point  of  turning  the  ulnar  bordej  of 
the  hand  uppermost,  iudicaU*  ]>anilysi8  of  the  important  external 
rotator  of  [he  linmLTiis,  the  infrn-ifpiwitfig  muscle,  as  well  as  of 
its  .xssistnnr,  the  (frrji  unnor  muscle.  The  former  is  .supplic<l  by 
the  supra-scapular  nerve,  and  the  latter  by  the  circumflex. 

When  the  arm  cannot  be  directly  elcvatetl, — i.e.,  brought  at 
right  angles  with  the  trunk, — but  huiigs  helpless  close  to  the 


PARAI-T818. 


I 


thorax,  ami,  later,  when  a  definite  space  appears  between  the  head 
of  the  humeruH  and  the  acromion,  titere  U  paralysis  of  the  dtUoid 
mtMi^,  which  is  supplied  by  the  circumflex  nerve. 

Anterior  Thoracic  Nerves. — Inability  to  ad<hict  actively  tho 
arm  i»  as  to  draw  it  acmss  the  chest,  or  to  place  the  hand  on  the 
Of^Mssile  shoulder,  abnormal  prominence  of  the  v\\y»  and  inter- 
costal spaces,  aofl  losa  of  tetii«ioii  of  the  anterior  border  of  the 
axillary  space,  arc  tlie  Hymptonu  which  show  paralyftie  of  the 
pedoratis  iru^or  and  pedortiliM  minor  museles,  supplied  by  the 
anterior  thoracic  ner\'cs. 

Muacuto-Ciitaneous  Nerves. — Absence  of  the  greater  part  of 
the  power  to  tlex  the  forearm,  with  io-ss  of  some  of  the  power  of 
supination,  and  [mrtial  luck  of  ability  to  draw*  tlie  htiniorus  for- 
wani,  inward,  and  townrds  the  .scapuln,  point  to  paralysis  of  the 
:p  of  muM-Iefl  supplied  by  the  inuiKnilo-outaneou-s  nerve, — viz., 
itk9  M?^  ovbitis,  the  coruco-ifracJiiaiis,  and  part  of  the  bracJiialis 
antfimt*. 

Musoulo-Spirol  Nerve. — If  the  hand  han^  at  right  angles 
to  the  forearm  (wrist-drop)  and  the  power  of  extension  nt  the 
wrist-joint  and  clbow-joiut  is  absent,  with  the  hand  in  pronation, 
Uic  fiagvrs  lieni,  and  the  thumb  flexeil  and  HtJducied,  tlieileftinnity 
ia  charaeteristic  of  the  j^roup  of  muscles  su})p|{ed  by  the  niuseulo- 
Kpiral  nerve  and  its  iwsterior  interosseons  branclt, — viz.,  the  ^itV^mi 
and  oTiconetu,  tlie  tniphutior  tongue,  the  exUiwor  cttiyi  i-adlnlU 
tongior  and  brevior^  and  all  the  extensor  muscles  of  the  superficial 
and  deep  [Ki»terior  bnurhinl  rc:gionK,  Other  prominent  syniptotn» 
■re  that  the  eflbrt  at  extension  of  the  tingers  is  ptiasible  only  in 
the  second  and  end  phalanges,  while  the  first  phalanges  are  more 
flexed  (the  tnteroK5tii  flexing  tlit!  Bnit  phalangvs  ami  extending  the 
otiicre).  The  hand-grip  is  wtakcucil  u^Il■^*.s  the  wrist-joint,  Iw  put 
into  extension,  and  when  the  hand  and  forearm  ore  put  prone 
uiMsn  tlie  table  there  is  diminishc^d  power  of  abtluction  and  addiie- 
tioD.  The  forearin  cannot  be  brought  midway  between  prona- 
tion aud  supination,  ami  when  it  is  in  this  position  the  ability  to 
perforin  ellmw-Joint  flexion  \a  impaired.  Finally,  the  forearm 
cannot  be  extended  upon  the  arm. 

Median  Nerve. — Loss  of  tiie  power  to  flex  all  the  second 
phuhingiH  and  the  end  phalanges  of  the  index  and  ntiddlc  flngem; 
pmicrvation  of  this  motion  in  the  first  phalanges  (i[iterossei^,aiid 


« 


DUOKQflTIC  HECBOLOQY. 


its  partifl!  prcacrvation  in  the  two  outer  fingers;  inability  to  flex 
the  (.btiuib  or  bring  It  in  appositloQ  with  tlic  little  finger;  (limin- 
ifilietl  [lower  in  ilextng  the  wri.sl,  which,  when  this  ie  attempte<), 
throm-a  the  hand  into  »  marke^I  addttrtinn  ;  nnd  impaired  pronation 
with  lessened  sensibility  of  the  first  two  fingers  and  radial  side  of  i 
the  ring  fingei',  indicate  paralysis  of  the  median  nerve.  This  nerve 
supplies  all  thejicxor  and  pronator  niu!4cle>^  uf  the  (lee|i  and  sujKr- 
&via]  anterior  brachinl  region,  with  the  exception  of  the  ,/Zerorj 
Cftrpi  ttJiuirin  artd  the  nlrar  half  of  the__^rtrw  })rofiinf1»j>  diffUomm, 
which  are  snpplletl  by  the  ulnar  nerve,  and  also  all  the  muscles  of 
the  thiinil)  except  the  addxtdor  and  one  head  of  ihcjlexor  brevit 
pollicij^,  and  fiiiiilly  tliP  two  cmt-fT  Inmhricnlex.  ^ 

Ulnar  Nerve. — Imperfect  flexion  of  the  hand,  which  is  towards" 
thft  radial  side;  impaired  power  of  adduction  of  the  hand  ;  lea*- 
ent-d  ability  to  separate  the  fingers  (abduction)  or  to  bring  them 
together  (addnotion) ;  absenoe  of  the  power  to  flex  the  first  row  of  _ 
the  phalanges  and  ext«nil  the  last  two  rowH;  almost  entire  immo-  | 
bilily  of  the  little  finger;  difficulty  in  attempting  to  oppose  the 
thnmb  to  the  metacarpal  bone  of  the  index  finger,  with  disturbed 
sensation  of  the  entire  little  finger  aral  nliiar  side  of  the  ring 
finger,  conatitutc  the  symptoms  of  paralysis  of  the  muaclca  Bup- 
.plied  by  the  uhmr  nrrvr.      These   muscles  are  the  jlexor   enrpl 
^Wnom,  }yart  of  ihejrffiror  profundus  tliffilorum,  the  iiiiero^xet,  and  ^ 
the  two  iauer  lumbricaicg,  all  muscles  of  the  little  finger,  and  thofl 
addnriur  i»f  the  tJinmb  and  one  liend  of  ihisjiexor  brrr'ui  -jnillicis.     ~ 

When  the  intorossei  and  lumbriealfts  are  no  longer  able  to  flex  J 
the  first  row  of  the  phalanges  and  extend  the  other  two  rows,  but^ 
the  extensor  communis  <ligilornm  excwwively  extends  tlie  first 
row  of  the  phalanges,  while  the  flexor  museles  bend  the  second  and 
third  row,  the  condition  of  "claw-hand"  is  protluoed,  which  may 
lean  paralysis  of  the  ulnar  ner\*G  Just  above  the  wrist,  so  that 
the  innervation  of  tlie  interossei  and  Inmbricales  alone  is  affected. 

Spinal  Nervea. — If  the  head  hang  forward  and  cannot  be  ex- 
tended, or  at  least  can  be  extended  only  by  the  aid  of  a  swinging  fl 
motion,  there  is  paralysis  of  the  extensors  nf  the  rervirai!  vertebne, 
— i.f.,  the  rec^jw  cupiiin  po^ticwf  truyor  and  minor,  Uie  upper  portion  ^ 
of  the  trapezius,  and  the  itplc7m.  H 

When  the  spine  tentls  to  a-^snme  a  posterior  curvature,  most 
marked  in  the  dorsal   region,  and  the  patient  presents  the  ap- 


PARALYSL'*. 


03 


peanutce  of  "old  man'a  back,"  in  which  he  cannot  voluntarily 

■itrai^hten  the  curvature,  nltliough  thU  may  be  done  by  passive 

^%rtioo,  there  ia  paralysia  of  the  ftriffn*//-  muscJeg  of  the  back,  chiefly 

the  tongiegimus  dorsi  and   muTO-tumbdlig,  and   the  cunditiun  of 

foralytic  eyphariit.    The  produo-tiun  of  lateyal  curvature,  or  para- 

h|(to  KoHosUy  means  that  the  paralysis  is  limited  to  one  side  only. 

When  a  patient  carries  the  body  with  the  upper  portion  bent 

Inekward,  so  as  to  throw  it  behind  the  centre  of  gra^'ity,  and 

wbai  tlie  body,  if  inclined  too  far  anlenorly,  falls  furwani  and 

I       cannot  again  asAumc  the  crfct   posture  until   the  hands,  hcing 

placed  Dpon  the  legs,  help  the  arms  by  a  sort  of  climbing  process 

tpbrlitg  the  body  again  to  it^  baokwurd  [H^Kture,  tlie  condition  of 

ponlystsof  the  extent^or  muHc](%  of  the  lumbar  region  obtains, — 

lA,  the  erector  gpina:  and  its  divisions.     In  this  condition  the 

patient  further  stands  with  the  htsd  bent  forward,  walks  with  a 

nrajriug  uiotiou  of  the  trunk,  and  when  he  sits  down  ihe  upper 

pan  of  the  body  apparently  sinks,  6o  that  the  dorsal  e»])iiie  is  bent 

(cvpbusis),  while  there  is  a  deep  concavity  of  the  luinbur  .spine 

(lordosis).     The  nerves  ooncerned  in  these  jKilsiea  of  the  back  are 

a.     He  posterior  branches  of  the  spinal  nerve*,  cervical,  dyn«al,  or 

^B  lumbar,  aocordiog  to  the  region  involved. 

^M  DiO'Hypoirastric — nio-Ingninal — InteroostaJ  NorveB. — Tii- 
^V  ability  to  comprww  proi>crly  the  coiiteni^  of  the  alxiominal  cavity, 
u  that  such  acts  as  urination,  defecation,  and  vomiting  are  per- 
foriiie*!  with  difficulty,  and  diraiuished  jwwer  in  the  effort  of  rea- 
ptniioii,  (ogctJicr  with  a  tcudcocy  to  fait  backward  when  the  upper 
part  of  the  trunk  is  inclineil  [Hjnteriurly,  show  jiaraiysis  of  the 
oLdcnmnal  muaJfsi,  which  are  supplied  by  the  ilio-inguinal,  iUo- 
iypogastric,  and  lower  intercosta.1  nerves. 

Aoterior  Crural  Nerve. — Ixiss  of  the  power  to  Ilex  the  thigh 
upon  the  alMlonien  and  extend  the  leg  at  the  knee,  and  impaired 
ability  to  raise  the  body  fmm  the  recumbent  posture,  and  to  perform 
the  acts  of  walking,  running,  going  up-i^tairs,  and  the  like,  arc  the 
nnptooid  which  indicate  paralysis  of  the  group  of  muscles  6up- 
jlied  bv  the  anterior  crural  nen'c, — vi/,.,  tlie  iliacm,  pecimens,  aud 
the  mitsderi  on  Uxe  anterior  mLr/aoe  of  tfie  th'ujh  except  the  tcn-tor 
pn«  femoris. 

Obturator  Nerve. — When  the  act  of  pressing  the  knees  firmly 
together,  or  of  crossing  one  leg  over  the  other,  cannot  be  ^iro^ierly 


DIAONOenC  SEOROLOOy. 


perrormcd,  and  whpo  there  is  impainxl  power  of  external  rotation 
of  the  tliigh  w]iil«  in  tlie  silting  p(Wtnn',  the  intltealions  are  that 
tht're  is  paralysis  of  the  gracilis  and  adductor  niiisclcft  of  the  in- 
ternal femoral  region  and  of  the  extenxal.  ol>turati»r  muscle,  whiuh 
group  is  siipplitnl  \>y  the  ol>lura(<^ir  m-rve. 

Superior  and  Inferior  Gluteal  Nervoe. — Unrortninty  in  tlie 
act  of  walking  or  stftntHng,  tc^ther  with  absent  power  of  internal 
rotation  of  (he  thigh  and  impaired  |)Ower  of  external  rotation; 
difficulty  in  abducting  the  thifi^h,  with  disturbed  relation  of  the 
thigh  to  the  pelvi!?,  and  incliuHtion  of  the  latter  to  the  opposite 
side  dnring  attempted  action  on  the  imrt  of  the  affected  limb,  are 
the  syaiplouie  which  point  to  paralysis  of  the  musolee  supplied  by 
tlie  »u|R'rior  and  inferior  gluleal  uerve;-.  The  inferior  gluteal 
nerve  \h  distributed  to  the  gfvJeug  inaxtmua,  which  niudcle  can 
forcibly  extend  the  thigli  on  the  pelvit*  nml  perform  outward  rota- 
tion of  the  thigh.  The  sii|>erior  gluteal  n»rrve  pa-ssen  to  the  taisor 
vtigime /emoris  and  to  the  glitlem  mediiis  aud  miviintut.  The  an- 
terior ^bres  of  these  latter  miiscles  rotate  the  thigh  inward,  while 
their  posterior  libres  rotate  it  outwanJ.  This  grf>up  (gluteal), 
when  taking  their  fixed  |>oint  from  the  pelvis,  are  ab«'uctora  of 
the  thigh;  when  they  take  their  fixed  point  from  the  femur, 
they  support  the  jiclvis  on  thy  femur.  The  tension  of  the  fascia 
lata,  which  may  be  slackened  in  palsy,  is  usiibIIv  maintained  by 
thp  gluteus  maximus  and  thir  tensor  vaginie  femoris. 

Sclatio  Nerve. — Inability  to  flex  or  bend  the  knee,  to  oppose 
resiatitnoe  to  paseive  extension  of  the  knee,  and  to  raise  the  heel 
towards  the  butiotik,  would  show  loiwof  {Hiwer  in  thi^  nemimfmhra- 
nosus,  ganUendtnosvSj  and  biceps  fenuyris  muscles,  a  group  supgdied 
by  [he  great  sciatic  nerve-  This  is  a  possible  form  of  i^iralysis; 
but  more  ueual  are  the  palsies  which  occur  from  afiections  of  the 
principal  branches  of  its  distribution,  and  consist  in  loss  of  the 
extension  and  flexion  of  the  foot  and  toes  and  abduction  and 
adduction  of  the  foot 

External  Popliteal  Nerve. — Tf  the  foot  cannot  I>e  flexed  or 
alxlucted,  nor  completely  adtlucteil,  and  hangs  downivard,  so  that 
tiie  patient  in  the  act  of  walking  raises  the  foot  by  flexing  the 
bip-joint  and  tlien  places  it  again  upon  the  tloor  in  such  a  manner 
that  tlie  point  of  the  toes  aud  the  outer  border  of  the  f(x>f  touch 
the  ground  first,  the  symjitoms  are  diameter istic  of  paralysis  of 


the  muiioleB  Rupplicd  by  the  external  poplitcfll  or  jwroncal  nerve. 
Tbis  nerve,  through  its  two  branches,  the  anterior  tibial  and 
moficulo-cutaDeous,  t^upplies  the  muscles  of  the  anterior  [jurtJon 
of  the  I^  and  tlie  eilenaor  brevis  dif^itorum  on  the  dorsum  of  the 
foot 

Internal  Popliteal  and  Post-TibiaJ  Nervee. — Tf  the  foot  can- 
Dot  be  eitended,  Qor  the  toee  be  flexed  or  moved  laterally,  and  if  the 
patient  cnnnot  stand  npoii  hiB  toes  or  {im|M!rIy  addtict  the  foot  and 
raise  its  inner  border,  parolyaiB  of  the  group  of  muBclea  supplied  by 
the  internal  popliteal  nerve  and  its  continuation,  the  pi-isterior  tibial 
nerve,  may  be  inferred.  This  group  consists  of  the  muscles  of  the 
calf  and  of  the  deeper  posterior  leg-region,  and,  through  the  ex- 
ternal and  internal  plantar  nerves,  of  those  of  the  sole  of  the  foot. 
Id  thia  palsy  the  great  toe  can  neither  be  flexed  nor  moved  from 
Bide  to  side.  The  foot  may  assume  an  apjH'aracice  similar  to  the 
"  claw-liand"  described  undtir  palsy  of  the  ulnar  nerve,  aud  for  the 
BBOie  reasons. 

NoTS. — I  detlre  lo  Acknowledge  tlic  u^tUtnce  derived  from  Dr.  K.  H«ller'ti 
Art.  und  TAerap.  der  Krank/i.  der  periphtr.  Xeretn  (Wien,  1879)  in  the 
,  prvpkrfttioi)  at  U)e  account  of  IiocilI  Paliiim. 


CHAPTER   II. 


MOTOR   EXCITEMENTS. 


DiSTTRBANCES  of  inutility  whiub  are  aooomimiieU  by  un 
excess  of  motion  may  be  well  divided  for  clinical  study  into 
CoDvulaioiiB,  Spasiiiw,  Clioreit!  Movwnenty,  Tremors,  and  Auto- 
matic  Movcmciita,  to  wliicli  1  aliall  add,  for  convenience  of  de- 
scription, Couti-actores,  altlioiigh  the  latter  condition  of  the  muscle 
miglit  be  very  ]>FOi^rIy  considered  as  essentially  diverse  from  the 
other  motor  disturbances. 

Convulsions. — A  convtilsiuu  is  a  condition  io  which,  on-ing  to 
an  excessive  di^tcharge  of  motor  im|>ulacii  from  the  nerve-oentree, 
there  is  disturbance  of  the  uervoui*  t^ysteoi  and  usually  a  wide- 
spread exeefisive  muscular  luiit ruction, — citiier  a  BucoeBSton  of  vio- 
lent momentary  contractions  und  relaxations  or  a  maintained 
contraction.  When  there  is  un  alternation  of  contraction  and 
relaxation,  the  convulsion  or  epasra  is  said  to  be  clonic.  When  the 
contraction  Is  maintaiucil  for  a  time,  the.  convulsion  or  spasm  is 
ttmie.  ConvulsiuuB  are  further  chiinictenzcil  by  being  temporary 
States.     They  arc  naturally  divtd&l  into  general  and  partial. 

In  order  to  bring  a  case  into  the  category  of  general  cohvul- 
sions  it  is  not  necessary  that  the  whole  of  the  muscular  system 
Bhould  be  involved,  but  only  u  sufficient  pruportion  of  it  to  make 
a  wide-spread  genenil  disiurbatice.  A  partial  convulsion  is  one 
vhich  involves  bat  a  limited  portion  of  the  muscular  system. 

BptmmB. — A  apaxm  U  a  muscular  cvninictiun  involving  only  a 
narrow  territory,  and  not  conncctwl  with  a  general  involvement  of 
the  nerve-eentre&.  The  division  between  convulsion  and  spasm  is 
to  some  extent  arbiirary.  In  many  coses  the  nature  of  the  spasm 
18  at  once  ajtparent.  In  the  so-called  Jacksonian  epilepsy  the 
convulsive  disorder  may  for  a  time  tteeui  to  be  a  local  sjiesmj 
but  its  more  serious  nature  is  sooner  or  later  shown  by  its.  con- 
nection with  loes  of  (»nsclou^ne:i<s.  A  spasm  is  a  local  phenome- 
non ;  and  in  any  case,  so  long  as  there  is  no  disturbance  of  other 
nerve-functions,  a  localized  muscular  c^mti'accion  must  be  looked 
fid 


M 


^ 


upon  OR  a  spasm.  It  muet,  however,  not  be  forgotten  that  an  ap- 
purentlr  simple  loca!  spasm  may  be  the  outcome  of  an  hysteria, 
and  be  therefore  the  momentary  expression  of  a  geueral  ueunwitt. 

Choreic  Movement. — A  choreic  movement  is  one  in  which 
irr^ular  and  more  or  !e*.^  violent  oontnuTlinrw  nconr,  either  in 
ingle  muscles  or  in  muscles  which  are  associated  in  groups,  80 

at  a  certain  amount  of  re»embtance  exJBts  between  the  dkeased 
movement  and  the  voluntary  motion. 

Tremor. — A  tremor  is  a  to-aml-fro  vibratile  raoveraent  whieh 
is  produced  bj'  more  or  less  rhythmi<'al  ^uoi-cssive  omtraetioDS  of 
aniagontstic  muscles.  It  docs  not  in  any  way  simulate  voluntary 
movementjt. 

Automatic  Movementa. — The  term  antomatic  movements  is 
nsed  to  signify  those  motions  which  oocur  independently  of  the 
will  of  the  person,  but  in  which  some  voluntary  act  is  closely 
simulated.  An  automatic  act  often  involves  au  elaborate  series  of 
movementit,  such  aa  occur  in  bowing,  getting  out  of  a  chair,  and 
tbe  like.  Cases  of  this  kind  belong  in  the  clasa  of  cAorm.  twyor 
of  some  German  writers,  but,  as  there  is  no  relation  between  these 
motions  and  true  choreic  movements,  I  have  preferred  the  term 
automatic  movcmcut£. 


^ 


CONVULSIONS. 


1         K. 


Convulsions  are  divided  into  rpilepHform,  hygftrcidat,  and 
Monte.  In  the  epileptiform  and  liysteroidal  convulsions  there  is 
a  disturbanoe  of  couBciousncss.  In  the  tetanie  convulsion  the 
nervous  dtiK^harge  comes  solely  from  the  spinal  uoni,  and  oon- 
aciousnest!!  is  undisturbed.  In  the  epileptiform  convulsion  the 
isturbaut^of  consciousness  amounts  to  a  complete  suspension  of 
whilst  in  tlie  hysteruidal  convulsion  there  is  a  peculiar  condi- 
tion in  which  eonftciouaness  is  aeemingiy  Inst,  although  after  re- 
covery tbe  jiatient  rememt;er^  alt  tliat  liaij  happeniKl  during  the 
convulsion,  or  in  which  the  patient  during  the  convulsion  appears 
to  be  oousdoos,  but  after  recovery  has  no  remembrance  of  ocour- 
naioes  during  tbe  fit. 

Bliileptifonn  Convulsion. — In  the  typical,  ful  iy-developed  epi- 
leptiform convulsion,  the  first  symptom  is  a  peculiar  sensation  6rst 
felt  in  some  part  of  tbe  body,  and  rising  from  its  ifeat  of  origin  up 
jo  tbu  head,  to  be  lost  iu  uuoonticiouaness.     This  eo-ctJled  aura  is 

7 


DtAONOBTIC  NEtTBOT/WV. 


succeeded  ut  UD<.-e  by  the  ]>ecnliar  soreum  known  as  the  epileptic 
cry, — a  wild,  liareh  cry,  prolrahly  due  to  a  TonnDg  i)f  air,  by  imnvul- 
stve  contractions  of  the  thoracic  and  abdominul  muscles,  through 
the  glottis,  narrowed  by  il  rigid  EtpatttD  of  the  vocal  cords.  With 
the  iirst  iiiic»u»<^^ioiisiiettK  a  general  tonic  spiisiu  comcH  on,  pro- 
ducing rigidity  of  the  whole  body,  and  violent  distortions  of  the 
head,  liml»,  anil  face.  The  muscles  of  tlic  trunk  and  abdomen 
are  rigidly  contracted.  Often  a  turning  of  the  head  and  eye*  to 
one  aide  is  the  fir^t  evidence  of  this  condition,  and  in  some  ouws 
not  only  the  hL>ad  but  the  whole  Ixjdy  ro(»U3s.  The  facta!  mus- 
cles ore  violently  contracted,  Ui^ually  mo^t  markedly  on  the  side 
towards  which  the  hea«l  turns;  the  jaws  are  fix<?d,and  often  drawn 
tu  oue  t)ido;  the  arms  arc  almost  always  flexed  at  the  ell>ow,  and 
still  more  etrongly  at  the  wrists,  whilst  the  fingers  are  flexed  at 
the  metacar[)o-ph;Llangcal  joint>!  luid  nitLendcd  at  the  othert^  the 
tliumb  being  adducted  into  the  jyalm  or  preyed  against  the  first 
fioger.  The  iMwition  of  the  fingei-H  is  similar  to  tliat  of  grwtping 
a  pen,  and  is  due  to  conjoint  sptumodic  voutrac-tioits  of  the  iDteroe- 
aeous  aud  Eesor  muHcles,  as  in  the  so-called  athctosb.  The  legs  are 
extended  and  the  feet  inverted.  The  position  of  the  arms,  legs, 
hands,  and  feet  is  usually  that  which  is  assumed  in  a  cHse  of  uni- 
versal tonic  spasm,  the  members  being  drawn  always  In  the  direo- 
tion  of  the  mum-leH  of  superior  power ;  but  in  Home  e])ilcptic  con- 
vulsions tliis  isdc{Mirte<l  from,  showing  ihatccrtaiu  of  the  muscles 
are  more  affected  than  others.  Thiw,  the  fist-s  may  be  clinched,  or 
the  IcgH  may  be  violently  flexi^  und  drawn  up  on  tLe  abdomen. 

The  stage  of  toitic  spasm  is  usually  accompanied  by  marked 
pallor  of  the  face,  and  laatB  fn>ni  a  few  Bec«n<l8  to  ime  or  even 
two  minutes,  when  it  is  3uccec<lcd  by  tlic  stage  of  clonic  spasm. 
Usually  the  coming  on  of  this  is  marked  by  vibratory  tremors 
passing  into  vibrations,  which  conliiiuatly  gn>w  butli  slower  and 
more  severe  until  the  iutcrmissions  become  long  and  complete, 
and  the  limlie  are  alternately  relaxed  and  jerked  in  move- 
ments a»  wild  and  bizarre  as  they  are  violent.  During  the 
period  of  clouic  spasm  the  face  becomes  red,  congested,  eveo 
bloated,  and  often  livid.  The  cxprei^ion  changes  coutintially, 
since  the  Hpasm  involves  all  the  muscEes  of  the  faoe,  including 
those  of  mastication  aud  of  the  tongue,  the  soft  palate,  and  the 
larynx.     Owing  to  the  violent  working  of  the  muscles  of  maati- 


UOTOB   EXCITEMENTS. 


99 


eatioD,  tb«  saliva  U  forced  from  the  moutti  lu  tlie  lurin  of  frotb. 
The  toDgae  is  oontiQusily  thrust  id  and  out  by  the  spasm  of  ita 
muscles,  atid  is  a]>c  to  be  i^iiglit  iKtweun  the  convulsively  moving 
iaws  and  severely  bilteo.  If  the  tongue  happeiM  to  be  between 
tb«  teeth  during  the  period  of  tonic  spasm  in  an  epileptic  couvul- 
noti,  it  h  bitten  in  the  fii>it  &tage  of  the  lit. 

The  blood-stain  winch  is  so  characteristic  upon  tlie  froth  is  due 
to  hemorrhage  from  the  tongue.  Tlie  pnpils  at  the  beginning  of 
tiie  fit  are  sometimet*  coutracteJ  ;  aI>solutely  immovable  dilatation 
occurs,  however,  very  early,  if  iudeetl  it  be  not  present  from  the 
onset,  and  is  the  uharacteristtc  condition  during  tlie  whole  fit. 
The  return  of  the  pupils  to  the  normal  state  is  often  one  of  the 
carlifeit.  evidencts  that  tlie  paroxysm  has  eibaasted  itself.  In 
some  caseH  after  tlie  fit  the  pupilM  undergo  remarkable  os^^Illations. 
During  the  height  of  the  attack  botli  the  pupillary  and  the  con- 
,  Junotival  reflexes  are  alwlinlieil.     The  splilmiters  aw  in  the  raa- 

rity  of  epileptic  convulsions  not  relased,  but  it  ia  not  rare  for  the 
Qriue  and  fieceg  to  be  passed,  and  Gowers  affirms  that  this  is  more 
apt  to  occur  iu  uocturmd  Gin.  The  pulse,  feeble  or  uuufieute<l  iu 
the  beginnii^,  during  the  height  of  the  paroxysm  is  greatly  in- 
oreoMd  in  frequentn'  and  in  force. 

The  stage  of  clonic  convulsion  lasts  from  three  to  four  minutea, 
when  it  mei-ges  iuto  tlie  condition  of  quiet  coma,  and  this  in  turn 
pa^es  into  a  heavy  t^leep,  which  may  continue  for  a  few  moments 
or  for  hours.  After  the  waking  the  jiatient  sufiTera  from  heaxlache 
and  general  muscular  soreness. 

Tb«  deiicrtptjoil  which  baa  just  been  given  represients  the 
epileptiform  convulsion  as  it  is  seen  in  what  may  be  considered 
typical  epile|xsy;  but  even  in  tiie  majority  of  ca^es  of  epilepsy 
some  of  the  phenomena  are  wanting,  and  almost  any  of  them  may 
be  abeent.  The  essential  or  central  idea  of  the  epileptiform  eou- 
vulston  h  the  occurrence  of  complete  unconsciousne»H,  with  ner- 
vous disdiargc  taking  the  form  of  a  clonic  spasm,  In  which  the 
movements  have  no  relation,  appari'oL  or  real,  to  those  of  ordinary 
life.  The  terra  epileptiform  is  nscd  to  represent  any  variety  of 
moh  oouvulsions,  becaitse  such  convulsions  occur  most  frequently 
'in  epilepsy;  and,  in  a  similar  manner,  the  term  liysteroidal  oun- 
valaion  is  used  to  express  a  convulsion  of  the  general  character 
in  hysteria.    The  distinction  Is,  however,  a  somewhat  arbi- 


100 


>IAOXOSTIC  XEUROLOGY. 


jpar-       1 


trary  one,  since  ever)*  grfldation  Iwfwecn  the  two  forms  exists,  and 
an  hyjtteroiJal  convulsion  may  wcur  in  true  epilepsy  an<l  an  epi- 
leptifunu  ounvuI)iii>n  in  liveleriu. 

HsTBteroidal  Convulsion. ^-lu  tlie  hvfiteroidaJ  conviilBion  the 
tendency  is  in  n  prolongc<I  tonic  contraction  of  tiie  muscles,  giving 
rise  to  the  a&suinptiun  of  pusitioirs  wliich  bear  more  or  lesia  re- 
seuiUIunce  to  tlioec  that  may  be  talccn  in  health.  In  the  typical 
hvHteniidal  i^invnli^iDn  iwnsciousness  is  im|Kiired,  but  is  not  en- 
tirely set  aside.  Thiirf,  a  patient  apjinpcntly  unconscious  <luring 
the  fit  narrates  after  recovery  all  that  has  occurred  during  the 
oxysni ;  or,  in  other  aises,  what  U  knt'wu  a»  tiiUtmmik  corvfcioi 
is  present,  iti  which  the  [intit-nt  during  the  fiaro.\vsm  socnis  to 
Herstand  all  that  is  said,  but  nevenhele^  after  the  paroxysm  lias 
no  rtmenibranMof  what  has  ixicurrcd.  The  hysteroidal  convulsion 
of  the  most  highly  developetl  and  niu»t  prououuced  tyi»e  is  usually 
preceiled  by  some  waraing, — by  a  special  feeling  of  malaise,  epi- 
gastric ^eiiisation,  pal[iitation  of  the  heart,  giddini«s,  ooni^lriction  in 
the  thniat  (the  so-called  f/fobjis  h/strrh'us),  or,  frequently,  by  an 
aura  whirJi  ajipears  to  arise  from  the  ovary,  which  nnder  such 
circa mstant^C})  Is  almotit  always  liyiienetithetie.  The  [laticnt  falla, 
but  usually  gently  and  not  with  the  suddt-nness  of  true  epile|>By' 
Not  mrely  there  ih  at  this  lime  an  initial  scream,  whic-h  may  be 
repeated  during  the  |>aroxy8tn8.  The  pallor  of  the  face  may  now 
be  miirhed.  A  simple  tunic  spasm  develops,  lasting  two  or  three 
miiniitM:  in  it  thi.'  limbK  tire  u»;nally  rigid,  with  chu  toes  pointed 
downward,  and  the  arms  extended  or  lyiog  nt  the  side  of  the 
patient.  It  is  at  this  time  that  the  respiration  becomes  arresi 
and  there  is  dL^veloped  the  stage  of  asphyxia  of  some  writera. 
The  face  is  swollen,  with  turgid  veins,  and  suflpncation  seems 
imminent.  This  wiidirinn  may  pass  into  the  characteristic  stage 
of  opisthotonos,  or  may  be  followed  by  a  fnrioos  clonic  convul- 
sion, in  which  blootly  foam  gathers  about  the  mouth,  aUhongh 
the  movements  preserve,  to  tsome  extent,  the  appearance  of  wil- 
fulness, so  that  the  head  or  the  arms  are  struck  violently  against 
the  floor  or  dashed  against  pieces  of  furniture.  Following  these 
donic  convulsions,  or  not  rarely  replacing  tlieni,  Is  the  charaoler- 
istic  stage  of  opiathotonosi,  iu  whicli  (be  person  lying  upon  the 
back  is  lient  violently  into  the  arc  of  a  circle,  so  that  the  body 
restii  upon  the  head  aud  feci,  with  tlic  central  portion  arched  from 


the       , 
tecH 


1 


MOTOR    KXCITEMENTO. 


the  ^rotmd.  The  moscular  contractions  may  be  so  severe  that 
the  head  l<«  drawn  coniplotely  Iiackwan]  and  Ihn  ii|)|K;r  portioiifl 
of  the  body  rest  opon  the  face,  which  looks  towards  the  floor, 
whilst  the  lower  eod  of  the  arc  is  supported  on  the  toes.  This 
condition  of  opiMhoionos  may  lafit  for  some  minutes.  In  some 
laucs  it  is  interrupted  or  replaced  by  violent,  purposive  clonic 
sfiftsnis,  the  pntient  .inddrnly  lenping  from  the  bed,  or  fitting  into 
a  sitting  (KKiition,  and  as  quii^kly  falling  back  again  in  opistholo- 
lUM.  This  to-and-fro  movement  may  lalte  plate  with  extraurdi- 
naiy  velocity.  In  sunic  raseti  \hv  Ixxly  in  bent  viulcnlly  lati.'rully 
instead  of  backward.  The  opisthotouic  stage  may  be  interrupted 
by  various  emotional  actions,  or  it  may  gradually  subside  into 
what  may  be  calk-d  the  emotional  r^tage,  when  the  ]>atiL'ut  a^uuiea 
some  attitude  of  intense  rniolion,  aud  not  rarely  the  so-railed 
pOBtore  of  the  crucifix.  In  the  latter  attitude  the  .subject  lies 
npon  the  back,  absolutely  qniot,  with  the  legs  strctehcd  out  side 
hy  side  and  the  arms  firmly  extended  at  right  augles  to  the  body, 
in  the  position  of  the  crtjss.    The  widely-ojiened  eyes,  with  dilated 

iiiii,  appear  Lo  be  looking   Into   indefinite  distance,  whilst  a 

ilific  smite  is  seltletl  upon  llie  face:  so  that  by  the  ignorant 
the  coavulsant  is  oflen  believe^l  to  be  seeing  visioua  of  heavenly 
I  Joy.  Usually  tite  emotion  chatigCH  from  time  to  time;  the  light 
of  religious  beatitude  upon  the  countenance  deepens  ititu  an 
inteose  voluptuousn<'jut,  atten<l<xl,  it  may  be,  with  gcsttin's  and 
wonli  full  of  venereal  desire;  or  terror  becomes  supreme,  and  is 
manife»^ted  with  equal  intensity;  ur,  in  a  paNfion  of  peniteui'e, 
the  cr>nvul«inl,  with  80I16,  hitler  criert,  and  broken  words,  liegfi  for 
ra«w.  Again  the  scene  shifts,  and,  now  singing,  now  weeping, 
reproacjiing  alternately  herself  and  her  care-tukcrs,  the  woman 
paaaes  on  to  a  slowly-perfected  couscioiisitees. 

Hallucjnations  oceur  during  and  after  the  fit,  and  are  abvays 
correlated  to  the  emotional  >;tate:  thuR,  during  Itie  terror,  the 
sohject  sees  rats  and  other  disgusting  objects,  whicli,  according  to 
Charcot,  are  usually  ui>on  the  side  that  is  an«evithetic  between 
the  paroxysms. 

The  hysteroidnl  convulsion  does  not  neocaaarilycoinprrgo  all  the 
stages  or  phenomena  which  have  been  just  narrated.  Indeed, 
oonvnlsions  which  approximate  the  descriptiou  just  given  are 
ezceeflingly  rare  in  tlie  United  States,  and,  aoeordiug  to  the  ^aiHr 


I 


■ 


:o2 


DIAGNDSTIC    SEUROLOOV. 


mente  of  Knglish  autliow,  also  in  Great  Britain.  The  writing 
trf  the  scluml  of  Charcot  Jmlk-ute  that  tliey  tire  frequent  in  France. 
The  difference  appears  to  be  oonnectetl  witli  race,  li_v»teria  being 
more  mild  io  the  cald-bloode<l  Anglo-Saxon.  Dr.  John  Guit^nm 
informs  lue  that  at  Key  West,  where  the  inhabitants  are  generallv 
of  pure  Latin  blood,  hysteria  oouforiQB  with  the  descriptionB  of 
the  Frciicli  writers. 

Charactoriatics  of  Hystoroidal  ConviilBion. — The  varieties 
of  hystoroidal  cfinvnision  as  they  occur  in  hystoria  in  the  UnitM 
States  will  be  diwiisse*!  in  detail  later  in  the  chapter.  Suffice;  it 
for  ihe  prtsQut  to  state  that,  as  contrasted  with  the  charactcnstics 
of  the  epileptiform  convulsion,  thnsc  of  the  hyKtt'-rtndal  iimvul- 
sion  are  the  peculiar  disturljanoes  of  oonaciousneas;  the  presence 
of  emotional  disorders ;  and  the  tendency  of  the  niiisciilar  contrao- 
tioDS  to  simulate  in  an  exaggerateil  form  natural  uiuveuieut»  and 
to  become  Ivtanio.  Persistently  clonic  spasms  i>ertain  cspeeially 
to  the  epileptiform  convulsion,  whilst  tetanic  rigidity  is  inditattive 
of  the  hysteroidal. 

Tetanic  Convulsion. — In  tetanic  convulsion  motor  diMharge 
arises  from  the  spinal  cord  alouc,  the  bruin  not  being  invnlvi-d; 
consequently  there  are  no  distnrlanceH  of  consciousnesH.  The 
convulsion-i  may  I*  clonic  or  tetanic:  tliey  are  evidently  produced 
by  irritation  of  the  peripheral  sensory  nerves, — touching  of  the 
skin,  draughts  of  air  over  the  fatx,  loud  noises,  or  otiier  feeble  sur- 
face-irritations producing  at  once  violent  outbreaks.  According 
to  the  cause  of  the  tetanic  convulsion  is  the  amount  of  the  mus- 
cular titstue  iuvulved. 


EPrLEniFORM    CONVULSIONS 

The  epileptiform  eouvuhlou  may  bo  due  to — 

Mrd.  Idiopathic  c|>iIeiJ3y. 

Second.  Peripheral  irritations. 

77tir*i.  Cardiac  failure. 

FoniiU.  Organic  disease  of  the  brain. 

F^jfh.  The  action  of  certain  poisons. 

fifjitfi.  Unoraifu 

ScveiUh.  Hvsteria. 


i 


MOTOR   EXCTTEMESTS,  103 

Idu^tathic  SpilepifT/. 

It  is  necessary  to  prec«<k  the  diwnuKian  of  the  diagnosis  be- 
I  tween  tb«  etiologi<:aI  varieties  of  epileptiform  coavulsions  by  a 
Btady  in  detail  of  the  convuLsIoDs  as  they  occur  in  idiopathic  epi- 
lepey. 

Epilepsy. — As  seen  in  this  country,  the  aura  is  wanting  Id  a 
very  large  proportion  of  cases  of  true  epilepsy.  In  the  majority 
of  cases,  when  pn»ent,  it  is  connected  either  with  oueexti-emily  or 
with  the  stomach,  ahhouj.'b  psychical  and  special -sen^c  auras  do 
occur,  and  in  siime  caaeB  warniiigH  are  given  by  bilai(>rat  tremors 
or  starts  Jn  the  limbs,  or  by  wide-spread  indeOnable  sensations, 
which  may  perhajie  be  looked  upon  as  generalized  auras.  Variona 
as  tlie  auras  are  in  difiereut  individuals,  they  are  remarkably  ood- 
Stant  in  the  one  sufferer,  each  epileptic  paroxysm  conforming  to 
these  that  tiave  preceded  it. 

An  aura  which  commences  in  an  extremity  is  usually  first  felt 
ID  the  hand,  but  ic  may  Ix^in  in  the  foot.  From  the  Imnd  it  rises 
up  the  arm  as  an  iude^Tihuble  neniaition,  and  tx  not  rarely  traced 
by  the  patient  to  the  neek,  where  it  disa])pcars  in  the  development 
of  nnconsciouBneas.  The  gastric  anra  la  very  frequent.  It  is  va- 
riously de^ribed  as  pain,  3B  burning  or  &>i  a  »en»e  of  cotdnei^,  i 
as  trembliug,  but  more  often  as  an  indefinite  distress.  Usually  i' 
there  is  no  sensation  of  rising  connected  with  it,  but  in  some  cases 
thifl  occurs.  An  anm  may  be  first  felt  in  the  chest,  and  asoend  to 
the  throat,  when  it  gives  rise  tn  choking  sensations.  It  may  also 
begin  in  the  faoe,  tongue,  larynx,  pharynx,  or  indeed  in  any  part 
of  the  body. 

In  psychical  aura  the  emotion  in  almost  always  that  of  alarm  or 
excessive  terror.  In  very  rare  cases  a  very  peculiar  idea  uslii^rn 
ID  the  epileptic  convulsion,  conHtituting  a  true  intellectual  aura. 

Special-sense  auraa  are  rare,  but  do  owur  in  oounectiou  with 
sight,  hearing,  oraell,  and  taale.  Of  these  special-sense  auras  the 
gu.'^tatory  is  the  roost  infrefjueiit,  the  ocular  the  mo^  frequent. 
The  ocular  aura  may  consist  in  seeing  colors;  in  an  apparent  in- 
crease or  lessening  in  the  size  of  objects  j  in  ind&**Tibable  visual 
eetumtions;  in  double  vision,  or  in  loss  of  dii^tinctnes^  of  sight, 
deepening,  it  may  he,  into  conijdcte  blindness.  In  a  few  cases 
there  are  actual  visions,  either  simple  or  complex.     When  once  a 


104 


PIAOKOenC   KKDRGIAXiY. 


eertaiii  persoiwlity,  as  tliat  of  an  old  woman,  or  of  a  man  with 
liaumKir  iu  hand  striking  a  blow,  has  ustierni  in  a  paroxysm  uf] 
epilepsy,  the  smme  form  ushers  in  subsequent  altacks.     lu  thoi 
auditory  aura,  abnorninl  sounds  are  heanl,  such  an  hissing,  or  the-' 
vrhvzz  of  ru^hitig  Mt«am,  or  intennittent,  pulnating  noiA«s,  i^uch  &$' 
bcotiog  of  drums  or  rau.«ie,  and,  in  very  infrequent  cases,  even  a 
spoken  wonl.     The  olfactiir)'  aura  seems  always  to  take  the  form 
of  a  bad  siuoll. 

There  are  cases  in  which  two  aurag  coexist.     Usually  one  c^j 
theee  is  connected  with  the  special  seuaeo. 

Sometimes  the  warning  preceding  an  epileptic  paroxyeni  takes 
the  form  of  a  localized  spaani,  which  may  occur  simultaneously 
with  the  sensory  aura  or  without  it.  Usually,  nntJer  such  circum- 
atauoes,  the  patient  is  suffering  from  organic  braiu-diseuw. 

A  very  remarkable  fatrt  iji  connartioti  with  auras,  espedally 
those  nrigiiialing  in  the  extn^nutic^^,  is  ihat  in  many  canes  thdr 
upward  passage  can  be  arrested,  and  the  fit  aborted,  by  oircalarly 

jCom]»r(ssing  thf  limb  above  the  aura.  When  the  senRntion  reaches 
the  |K)iut  of  compretisiou  it  ceases,  and  the  patieut  escapes.  I 
have  seen  a  similar  oocurrenoc  in  an  epilepsy  which  commenoes 
with  a  motor  contraction  involving  the  throe  fingers.  If  this 
local  spasm  be  immediately  overoome  by  violently  opening  the 
clinched  fingers,  the  further  development  of  the  paroxysm  will  be 
preventetl.  The  arit-st  of  the  aura  in  MiIb  miuiner  would  seem  to 
indicate  that  the  starting-i>oint  of  the  epileptic  jiaroxysm  is  in 
the  periphery,  where  the  aura  h  first  felt;  but  even  in  some 
in  which  the  epilepsy  has  lx«a  due  to  coarse  lesion  of  the 

"brain  it  has  been  foiiitd  possible  to  prevent  tlic  pnroxyKm  by 
chft^Uiiig  the  u]iwurd  patwagc  nl'the  aura.  To  my  mind,  however, 
this  does  not  absolutely  prove,  as  seems  to  be  believed  by  most 
recent  authorities,  that  the  6t  doe*  not  really  commence  in  the 

.peripheral  uerve-endings.  Fur  it  is  |)OBsibEe  that  in  these  rare 
of  organic  ppilc])6y  the  jiamxysms  arc  due  to  secondary 
changes  which  have  been  prmhiced  in  the  peripheral  nerve-fila- 
ments. In  the  famous  exiwriment  of  Dr.  Brown-S^uard,  sec- 
tion of  the  sciatic  nerve  in  the  gninca-pig  produixid  structural 
alterations  of  tlie  skin  of  the  face  and  ati  epilepsy  which  evidently 

;aroae  from  the  altered  aurfare,  and  was  cured  by  remm-ing  the 
Itseased  fkin.     With  tlieae  experiments  and  facts  it  socins  not  at 


MOTOR   EXCJTEMESTS. 


105 


* 


all  inopowible  ihat  a  di.aease  of  the  brain  may  produce  an  alu-ration 
in  the  peripheral  ijerve-6laiiienta  of  a  distant  part. 

CoDvolsive  Stages. — A  brief  tonic  f|>asm  may  coiiMiLute  tUe 
whole  of  the  (Convulsive  seizure.  The  clonic  spaitni  of  true  epi- 
lepey  is  especially  characicrized  by  its  lieing  universal,  although 
One  aide  of  the  body  i«  often  more  strongly  convulsed  than  the 
other.  According  to  the  elaborate  studies  of  M.  V.  Magnon 
(L'^Hlepitie  iMnili/tujufj  1881),  during  the  clonic  stage  of  Uje  epi- 
leptic eonvnUion  the  arterial  tension  and  ])nlsc-ratc  are  greatly  in- 
rreft^,  but  during  the  tonic  convulsion  the  pulse-rate  falls,  and 
the  rhythm  is  altered  su  that  a  complete  tiy^tole  and  diastole  may 
occupy  six  times  the  normal  pcrio«l.  Aflerward?  the  pulse  gradu- 
ally approache.'i  the  normal,  or  posi^fH  into  a  state  of  exaggerated 
fon<e  ami  frequenc)'.  During  the  clonic  convuUton  the  respira- 
tion is  ooI«y,  stertorouj^,  «low^  or  even  irregular  ;  often  the  paiideB 
between  the  acts  are  ho  long  that  the  jmtient  e^tems  to  have  stopfied 
breathing,  and  when  death  occure  in  a  fit  it  ia  by  the  pcrRistence 
of  such  arrest  of  respiration. 

Petit  Mol. — AlDi{«t  any  of  the  fitagefl  of  the  epileptiform  con- 
vuUion  may  be  alKitrnt  in  epilejisy.  To  the  lighter  paroxyi^m  of 
the  disease  the  name  of  petit  mal  has  been  given.  In  its  mure 
ordinan'  form  petit  mal  consists  of  a  momentary  loss  of  mnsoious- 
tw^  accoin{ianied  by  jmllor  of  the  face,  which  is  not,  however, 
invariably  present.  The  sufl'crer,  in  the  midst  of  a  couversationj 
suddeidy  Rtop6,  is  quiet  for  a  few  eecondti,  and  tlum  takes  np  the 
thread  of  discourse  as  though  nothing  had  happened,  being  in 
fact  uDcon-cioug  that  anything  has  happened.  Sometimes  the 
period  of  conscion.''ne«  is  followed  by  a  Mtatc  of  confusion  of 
thought,  and  in  other  eanos  some  peculiar  sc>ni<ation,  or  some  more 
or  lese  indistinct  sensory  or  jwychital  auni,  gives  the  (uitieut  waru- 
of  the  attack. 

The  attacks  range  in  degree  of  violence  from  the  mildest  |>etit 
Otai  to  tlic  moet  severe  convulsions.  Sometimen  a  slight  un- 
BODBCloospeea  ta  accompanied  by  a  single  hiud,  piercing  i^crcam, 
without  further  motor  disturbonce.  Sometimes  the  epileptic 
paroxysm  is  comprised  in  a  brief  loss  of  consciousness,  with 
irregular  i!«>nvulEiive  movements,  or  with  just  enough  tonic  con- 
tractiom*  to  cause  the  ptitiem  to  fall.  So  variable  is  the  epileptic 
attack  in  its  manifestations  that  manv  authorities  consider  the 


106 


DTAONOSTtC  SBOIIOWKIT. 


«wen 


tial 


oonvulflioii  an  m^cnnclaty,  aud  tbe  unooiiscvousnesA  m 
portion  of  tlie  paroxysm. 

Not  only  the  ooiiviilsive  symptoms,  however,  hut  even  the 
cotirtcriouHiteff  itflclf,  may  be  absent  in  an  opileptit' attack.    Ina< 
whicli  wns  prohably  ooe  of  epilepsy,  and  in  which,  m  long  as  I 
had  opportunity  for  watching  tbe  symptoms,  there  was  no  change,  ^ 
the  patient  Iiad  a  diHtitict  aum  in  the  hand,  rlning  up  the  arnaH 
in  llie  usual  manner,  hut  sutierinj;  arrest  in  the  neck,  at  which 
time,  without  any  loss  of  consciousness,  there  were  \'inlenl  tjon- 
vulsive  movements  of  the  rnuccles  below  the  position  to  which 
liie  aura  had  rcaclieil.     vVllicd  to  this  case  arc  thoae  described  byfl 
Dr,  S.  Weir  Mit^:hell  in  his  work  on  Nervous  Diseases,  in  which  ^ 
the  whole  paroxysm  vsoa  sensory.     In  the  most  pronounced  of  Dr. 
Mitchell's  calces  an  aura  beginning  at  the  feet  pa-used  up  to  the] 
head,  when  it  M'as  hwt  tu  the  heu»ation  of  :i  loud  Bound,  like  that  oi 
an  explosion  or  of  a  pistol-shot,  followed  by  a  momentary  sense  of| 
deadly  fear.     Dr.  Milt'lielt  stfltei^  that  in  men  he  has  never  seen[ 
these  paroxysms  occur  except  in  the  border-land  between  vrakingj 
and  sleeping,  but  that  in  hysteric  femalns  the  attacks  may  t-ike  place] 
at  any  time.    In  some  cwses  instead  of  the  aura  lieing  loot  in  a  londj 
noise  it  diHapjioars  in  a  flash  of  light,  or  in  an  excessively  badj 
smell,  or  occasionally  simply  in  a  sense  of  a  blow  or  of  a  shock] 
on  or  in  the  bead,  or  of  a  rending  or  bur¥ting.     It  may  be  oou- 
sidered  umiertuin  how  far  these  ca&vs  ought  to  be  ranked  as  epi- 
leptic.    They  seem  to  me  to  lie  very  close  to  epileiwy,  and  also] 
to  liy.steria.     Whatever   hesitation  there   may   lie  in  classifyingj 
these  cases,  no  doubt  exists  in  regard  to  several  cases  that  I  havfli 
,  Been  in  boys,  in  whitih  the  paroxysms  for  a  length  of  time  c<m-] 
fliated  sim|)ly  of  a  gastric  aura,  bnt  firially  dfivcln|»ed  into  a  cora-i 
plete  epilep,«y.     Thus,  a  child  eight  years  of  age  would  cry  outJ 
with  a  sudden  pitinfitl  sensation  in  hU  stomach,  liecomc  excessively 
pitllid,  run  to  lii»  mother  and  be  held  for  a  moment,  when  th«' 
whole  attack  woulil  be  over.     In  some  of  his  6{>ells  he  hud  tonioj 
cantractioiis  of  tbe  feet  and  neck.     According  to  the  mother,  tbeyi 
were  not  acoompanied  by  loss  of  consciousnes!*,  but  were  followed 
by  heavy  sleep.     Cases  of  this  character  j-liow  that  we  cannot  con- 
8ider  loss  of  consciotisut^si;  as  et^ential  to  a  |mroxysiu  of  idio]>uLliic 
epilepsy. 

As  already  stated,  the  especial  character  of  the  epileptic  convul- 


MOTOR   EXCITF-MESTS. 


107 


is  the  absence  uf  apparent  purposiveiiess  in  its  movements: 

thii^  chnrarl^riftti'C  may  lie  wanritig;  tliiis,  in  the  frcquciitlj- 

^|ooterl  case  rcportpd  by  Professor  Trousseau,  a  PaHfiian  master^ 

builder  vrvLi  Iiahituaily  ^ized   witli  attacks  in   wliich,  iiUliotigh 

entirely  uni!onscion«,  he  would  run  frniu  scalfold  to  scaffold, 
I  gprlogin^  rrom  plank  to  plank,  but  never  falling.  Ii>  a  negro, 
'  long  noder  my  onre,  the  epileptic  pantxysm  would  hcgin  with  a 
I       vcreem;  then  the  man  wonld  be  seen  running  furiouely;  wheu 

Hued  Bud  held,  he  would  fall  in  a  general  eonvuUJou.  He  him- 
I       kK  Slated  that  if  he  were  [lennilttHl  (ti  have  hii^  run  out,  after 

Koiitga  quarter  lo  half  a  mile,  lie  woiihl  wake  up  wiLliiiut  falling. 

Various  maniacal  outbreaks,  or  emotional  distnrlmncGB,  accom- 

paaied  by  automatic  muvemeuli;,  may  also  replace  an  epileptic 
^^parwxysm.  (See  Disturlmnees  of  Intellection.) 
^B  For  the  reasons  which  have  beeu  assigned  in  the  lant  few  para- 
^■Waphs,  and  which  might  be  much  more  claborntei]  withonC  adding 
^"  lo  their  force,  it  may  be  concluded  that  the  essential  character  of 
r      i£opaiJue  epUepny  ia  a  tauiencif  lo  an  iJmorfnal  discharge  of  nene- 

ftrrcf  id  irregular  iniervafa,  nnd  wUhoul  obvious  caunc,  bid  tifjtend- 
I      fnt  upon  9omt  persistent,  edmcat  irremediabU:,  state  of  the.  ■nervoxis 

tijlttem, 
I  Prriph^al  IrriUdirmit. 

A  reflex  convulsion  is  one  which  is  due  to  some  peripbernl  irri- 
tation. It  ifl  almost  invariably  epileptiform  in  its  general  symp- 
tmiFi,  and  may  conform  exactly  iri  the  typical  epileptic  attack.  In 
the  majority  of  cases,  however,  the  convulsion  ia  more  prolonged 
mH  more  purely  clonic  in  its  manifestations. 

In  some  wwes  the  supposed  reflex  convulsion  takes  npon  itself 
the  hysteroidal  form;  but  under  these  circumstaiuies  It  ia  exceed- 
ingly difficult  lo  decide  how  far  tlie  convulsive  seizures  are  really 
I  reflex,  and  how  far  they  are  duo  to  a,  hysteroidal  (miiditiiin  pro- 
j  daced  by  the  irritation.  This  Is  es|KM:ially  true  of  the  numeroua 
Loses  of  the  so-called  reflex  spx^ms,  paralyses,  and  convulsions  in 
^Biildrcn  which  are  connected  with  irritatlnn  of  the  gcuital  organs, 
^■ui  my  own  exjierieuce  in  young  children,  hysteria  is  mure  fre- 
^^nent  in  the  male  than  in  the  female  sex :  it  is  also  very  gen- 
erally connected  with  an  eariy-acquired  habit  'vf  masturbation. 
Even  when  no  such  babJt  exists,  reflex  disorders  M^ni  \o  \n 


108 


mAONOCTIC  NEUROLOOT. 


produced  by  elongated  prcpuws,  and  are  relieved  by  oircum- 
daion.  I  lje!i<'ve  that  not  rarelv  tlie  disease  is  of  an  livsterifml 
nature,  and  is  relieved  in  great  part  by  the  moral  effect  of  the 
o|>eratioD.  I  have  seea  also  a  general  hysterical  stole  acoom- 
imnied  by  severe  epileptiform  and  hysteroidal  wmvulsione  audfl 
diatinet  hysterical  disorders  of  oonBclousnosa,  imitation  of  aniinal  ^ 
movements,  etc.,  produced  in  a  boy  by  an  injnr)-  W  the  head, 
and  cured  by  removal  of  the  cleatrli.  Of  course  it  18  very  diffi- 
cult to  say  how  far,  under  these  circumstances,  there  was  some 
irritation  vC  the  }>enpheral  nerve-etidin;^  In  the  cioitriji ;  but 
there  was  nn  tenderness  or  other  local  manifestation,  and  all  the 
gymptoniB  partook  of  the  hysteroidal  type.  We  must  conclude 
either  that  reflex  epileptic  attacks  take  on  tlie  hvHteroldal  form,  or 
tliat  hysteria  may  be  produced  by  genital  irritations  in  young 
children,  and  by  the  moral  or  physical  effects  of  injuries. 

There  are,  on  the  other  hand,  convulsions  wliii-h  conform  to  tha^ 
epileptic  type,  and  which  are  the  result  of  an  organic,  peripheral 
irritation.      Under  these  circuni.Klan(<i.-s  there  is  of^n,  but  nutj 
alwayfl,  an  aura  arising  at  the  point  of  Irritation.     In  Fomc  cases 
there  is  tenderness  at  this  jwint,  or  pressure  npon  it  may  produce 
an  aura  followed  by  an  epileptio  attack.    The  effect  of  ovarian 
pressure  in  some  hysterical  subjects  shows  how  eloHily  even  this 
true  reflex  epilepsy  in  related  to  hysteria.     In  this  so-called  reflex      i 
Gpile]ifiy  the  irritiiting  lotion  may  l>e  in  the  extremities,  or  in  the^J 
trunk,  but  In  the  majority  of  cases  it  is  in  the  head.     Wlien  the 
latter  is  the  case,  it  is  always  doubtful  how  far  the  couvidttive  at-^ 
tacks  arc  reflex,  and  how  far  they  are  produced  by  direct  pressurtt'H 
or  irritation  of  the  nerve-contrcs.     There  is  nothing  in  the  reflex 
epileptic  attack  which  points  out  its  true  character,  except  when  ^ 
there  Is  a  localized  aura,  or  when  the  flt  may  be  cau^  at  any  time  ^ 
by  prLs.sure  upon  the  diseased  ]*orlphery.     The  diagnosis  is  usually 
to  be  made  out  by  the  history  of  the  owe  and  the  discnverj-  of  the 
point  of  irritation.    In  every  ease  of  apparently  causeless  repeated 
convulsive  attacks,  it  is  the  duty  of  the  practitioner  to  March  care-  \ 
fidly  for  any  imssihle  point  of  irritation,  anil  if  any  depre&don  of 
the  skull  be  foun4l,  the  o]>cration  of  trejihluing  should  be  per- 
formed, nnleas  it  can  be  clearly  ascertained  that  the  convuUtve 
attacks  preceded  the  injury  of  the  ekull.     In  children,  es|)ecial]y 
in  boya,  it  Is  in]j>erative  to  examine  carefully  tlie  genital  organs. 


MnrOR    KSCrTKMENTS. 


10ft 


ConvulBionjs  of  Childhood. — A  variety  of  reflex  convulsions 
are  iht?  onlSiiary  roiivtilsioiw  of  children  due  to  tho  Irritation 
caused  bv  teething,  or  by  indigestible  }<tt balances  in  the  (^stro- 
intestinal  tract.  In  all  cases  of  convuUive  beiziirt^  occurring  in 
young  children  in  w)iit>h  there  is  uo  rcaf^on  to  suspccr.  hemorrhage 
inlo  the  brain,  epileptic  disease,  or  an  acute  fever,  and  in  which 
there  is  no  pf>int  of  irritation  in  (he  gumn  or  elsewhere  upon  the 
sarface  of  the  body,  an  emetic  should  be  at  onoe  administered. 
The  symptoms  of  ga-itric  convulsion  are  not  peculiar,  bnt  usiialty 
there  is  no  difHculty  in  arriving  at  a  probable  diagnosis  if  iJie 
following  paints  are  attended  to : 

Firnt.  The  eonvuUion  U  not  one  of  a  series,  and  is  general,  and 
oot  ac>.t)tui)auied  by  paralysis. 

Second.  It  oocurs  in  young  children. 

Third.  There  is  no  history  of  exposure  lo  the  contagion  of 
scarlet  fever  or  other  similar  disease,  and  no  fever,  excessive  vital 
depression,  or  otiier  symptom  of  a  developing  malignant  fever. 

Fijurth.  A  history  of  over-eatJug,  or  of  the  use  of  indigestible 
food,  such  as  stale  cream-puOs,  green  fruit,  candy,  etc.,  may  Ijb 
attsinahle. 

RetaiioM  htbctai  the  Cbnrtdtions  qJ  Qiildhood  and  EpUepsy. — 
The  quefftioD  of  the  relations  between  epile|M»y  and  the  cnuvul- 
sions  iif  i;liihlliood  i.s  one  of  great  inijmr ranee.  As  alnaily  staled, 
[-1  do  not  believe  that  the  diagnosis  between  these  two  nt!ections 
Is  to  be  made  out  by  the  symptoms  of  a  single  fit.  Moreover, 
lit  seems  to  me  positively  eslubliahed  by  clinical  experience  that 
Ithe  tendeocy  to  convalsioDS  in  the  child  is  closely  associated  with 
[the  epileptic  diathesis,  and  that  in  many  casw  ntridental  convul- 
I  lions  are  the  commenccrueDt  of  a  life-long  epilcjwy.  In  »  very 
large  pn.«portion  of  the  cases  of  epilepsy  there  is  a  history  of  rw- 
peated  coovulsiuus  during  early  childhood,  aitd  there  must  Ik  iu- 
bcTCDt  diflereuces  in  the  nervous  constitutions  of  children  living 
under  exactly  similar  conditions,  some  of  whom  frequently  ticiiler 
from  convulsions,  whilst  others  pas^  unscathed.  Some  children 
are  evidently  I>orn  with  tlie  <»uvulsive  tendency,  which  in  many 
eases  is  so  lirinly  fixed  in  the  nervous  system  that  it  ninnot  be  af- 
fected by  any  mode  of  life  or  treatment:  its  possesBor  is  doomed 
birth  to  a  hopeless  epilepsy.  I  believe  that  there  is  a  second 
of  cases   In  which  the  epileptic  tendency  exists,  but  in  so 


niAGN09nO  WBOHOLOGY. 


slight  a  degree  hs  to  be  ooutrollublu  by  hyglenh  und  medicinal 
treatinent.  Under  ihcM>  cirt^umslaiiccs  the  child  may  kuOlt  from 
repeated  attacks  of  accidental  convulsions  and  become  epi< 
leptic,  or  by  great  care  the  early  convulsions  may  be  prevented, 
and  the  nervous  sytit«m  allowed  to  harden  into  the  normal 
mould. 

Pleuritic  Epilepsiee. — Among  the  elasfl  of  reflex  convulsions 
must  at  preeunt  be  plautxl  the  aSeolion  sometimes  known  as  pleu- 
ritic epilepsy,  or,  in  some  of  its  forms,  as  pleuritic  hemiplegia. 
Cases  of  this  ootulitioii  were  first  reportwl  l>y  M.  Maurice  Ray- 
naud in  Paris  in  1875,  since  whieh  time  a  number  of  records 
have  api^eared  lu  me<lical  literature.  The  attacks  have  been 
cauf^ed  by  the  iujvutiun  of  various  substaxic-es  into  the  pleural 
cavity  for  the  relief  of  chronic  pleuritic  aflections.  They  have 
followed  the  use  of  very  weak  sohnions  of  iodine,  chloral,  eart>olic 
acid,  etc.,  and  have  not  bton  dui>  to  abi^orptiou  of  the  medicament. 
After  the  iujection,  suddenly  the  face  becomes  very  pale,  the  res- 
piration is  suspended,  and  the  pulse  is  ver}'  small  and  scarcely 
felt.  Geuorally  rlic  spasms  are  first  confined  ui  the  face  or  arm 
of  the  side  in  which  the  injection  has  been  practised,  but  soon  they 
become  general,  and  are  aucompauied  by  profound  uncunscious- 
neKs.  At  first  tonic,  they  almost  always  in  a.  very  short  time 
become  clonic.  The  pupils  iu  the  beginning  of  the  attack  con- 
tract, but  nfterward-s  dilate  largely.  The  pallor  of  the  face  gives 
way  to  cyanosis  h.s  tlic  respiration  re-establishes  itself  and  becomes 
stertorous.  The  urine  und  fvetxa  are  often  involuntarily  dis* 
charged,  and  the  |>atient  jmishck  into  a  condition  of  epileptic  coma, 
which  may  go  oft'  in  half  an  hour,  or  may  continue  many  bout^ 
and  in  some  canet*  has  ended  in  ileath.  A  fatal  reiinit  is  tisually 
preceded  by  a  true  epileptio  status,  with  repeated  ulooio  convul- 
sions and  even  opisthotonos.  A  partial  hemiplegia  {see  Vnitm 
MfyH,,  1876)  has  followed  pleuritic  injei^tioiifi  without  tlie  occur- 
rence of  convulsions:  less  rare  is  it  for  a  partial  hemiplegia  to  be 
present  after  recovery  of  the  patient  from  tlie  epileptic  paroxysm. 
The  side  in  which  the  injection  is  pructii>ed  Is  the  one  commonly 
affected.  All  the  recorded  c-nses  of  pleuriuc  hemiplegia  have 
finally  recovered.  In  the  fatal  cases  of  pletu-itic  epilepsy  no 
lesions  of  the  brain  have  been  found. 


SIOTOB   EXCTTEireUTS. 


Ill 


OartUae  FaUurf. 

Cardiac  EpUepey. — ^There  ie  a  dasfi  of  «isps  in  wliioh  epilep- 
tiform convulsiona  occur  connected  with  marked  disturbances  of 
tlie  otrcolatiOD.  The  mcett  proinineiit  symptoms  are  attacks  of 
miconsciouaiess,  which  arc  spokcu  uf  hy  mmc  observers  as  apo- 
plectic, and  by  others  as  epileptic,  and  a  remarkable  slowing  of 
th*  pnl«. 

The  habitual  rate  of  the  pulse  has  in  the  reported  cases  varied 
from  twenty  a  cuiuute  up  to  fifty  ;  usually  it  is  between  twenty- 
five  aud  thirty-tive.  At  the  moment  of  the  altark  of  uncon- 
acionsn^s  the  pulse-rate  diminishes  to  ten,  twelve,  or  even  five 
per  minute ;  and  in  ihe  tase  reported  by  Dr.  P.  Thornton  {Th-ans. 
iCUn.  Soe.,  Loudon,  vol.  viiu  p.  95)  it  wae  proved  by  slethoecopic 
examinattoD  that  in  the  tinit  stage  of  the  attack  the  heart  ceased 
to  l)«ti  for  many  Re4Y)nde.  In  other  (ia£c»)  the  fltctho8ix)]>c  haa 
shown  that  the  heart  is  acting  feebly,  although  the  pulse  has  been 
lost  at  the  wriKt.  Th«>  n*piration  is  at  first  iisually  quickened, 
and  may  become  laborc<f  and  stertorous.  The  fa**  is  very  pale, 
hnt  afterwards  bewmes  congested  and  livid.  Tlie  temperature  is 
prnhnbly  in  most  of  these  coAes  I>c!nw  the  normal  point,  and,  at 
least  in  some  instance)!,  falls  very  decid(Klly  during  the  attack.  It 
ie  quite  common  for  the  |»ttieat,  directly  before  the  epiteptifurm 
attack,  to  complain  l>itlerly  of  intense  mjdiiet^;  and  any  t-unc  of 
allied  epilepsy  in  which  the  body  during  the  attack  is  exccsively 
eold  is  prolmbly  not  idiopathic,  hnt  (lardiac  epilepsy. 

Umally,  during  the  stage  of  nnconsciousness  the  patient  lies 
quiet,  hut  there  may  be  very  dLslinct  general  convnlsinns,  or,  more 
frequently,  [larlial  eonvulsionr' ;  and  biting  of  the  tongue  wa.s  note*l 
I  «vcn  bv  the  earlier  olwervors.  (See  W.  Stokes,  Diseases  of  the  Heart 
and  Arteries^  p,  310.)  In  wnie  of  the  reix»rteil  ca.ses  the  parox- 
ysms have  been  ushered  iu  by  a  distinct  aura.  On  aeeount  of  the 
f «)njoint  occurrence  of  unoonsciousness  and  convulsive  inovcmcnta, 
as  well  an  of  llieir  irregular,  persisti^nt  reapjiearaniic,  these  attarks 
are  epileptic  rather  than  apoplectic.  In  most  instanoes  the  patient 
finally  dies  in  a  poroxysni. 

It  has  been  shown  hy  tlie  autopsies  reported  by  W.  Stokes  and 

'  Dr.  A.  R.  Blondcau  {Etudes  cHniqiies  «*r  fc  Pouh  f,ent pfrmanfTU, 

n»,  1870),  and  by  other  physicians,  that  cardiac  epile|)8y  is  con- 


112 


UIAUNOSTIC  KEUltOMmV. 


nectej  with  fatty  degeneraiion  of  tiie  Iioart.  Tlie  close  relation" 
of  the  [Hiroxysius  to  synfope  is  further  cvitu'ed.  by  tlie  fact  that 
in  one  of  Dr.  Stokes's  <'a*»e«  the  &iiai-k  conld  t^e  aborted  by  t!ie 
patient's  getting  upon  hi»  hands  uod  knce^,  with  his  head  downward. 
Further,  in  a  considerable  number  of  the  casca  valvular  murmurs 
Iiavc  beeu  heard.  Cliannit  wtalt^  that  he  lias  seen  slow  pulse  in 
several  old  people  hi  whom  the  heart,  ailer  death,  was  found 
to  Iw  normnl ;  and  oases  were  reported  by  Dr.  Flalberton  {ifed,~ 
Chir.  Tnim.,  vol.  xxiv.,  1841)  la  which  the  affection  folloned 
an  injury  of  the  neck,  ap[»irently  as  the  result  of  a  lesion  in  the 
medulla  oblotigaia.  It  is  piu^sible  that  in  some  noses  cardiac 
epilepsy  ia  due  to  irritative  Icsiona  of  the  mt-dulla. 

Otyfanie  Digerw  of  the  Brain. 

Almost  any  forai  of  chronic  or  oi^nic  brain-disease  may  pro- 
duce epileptic  attacks,  but  clinical  experience  ahow^  that  the 
paroxysmR  arc  mueh  more  apt  to  be  severe  and  pronounced  when 
the  up]>er  brain  is  afTecled,  and  especially  when  tlie  disease  is 
uituated  in  or  near  the  motor  region  of  the  brain-cortex.  Every 
variety  of  attack  which  cxxMirs  in  irUo|Hithic  epiieiMy  i»  simulated 
in  organic  brain-diseii^e.  From  (he  simplest  verii^:)  up  through 
petit  mal  to  the  mij»t.  typical  and  violent  epileptiform  convul- 
sions an  iinbruki?!!  series  uan  lie  im<^.  Usually,  however,  certain 
features  in  the  organic  epileptiform  attacks  indicate  the  true  sig* 
nificance  of  ihe  convulsion. 

At  least  ill  my  experience,  an  aura  connected  with  the  special 
senses  is  in  the  majority  of  co^s  associated  with  some  ot*ganic 
disease  of  the  centres  Miiineeted  with  8iich  aenm.  When  the  or- 
ganic brain-disease  affects  excluavely  the  motor  region  the  con- 
vulsive |>aroiysm  is  not  usually  usherefl  in  by  a  distinct  aura,  butJ 
in  many  eases  both  the  sensory  and  the  motor  regions  of  the  brain 
are  implicated,  and  uudur  these  circumfiUniccs  the  spasm  which 
Wgins  the  paroxysm  is  freijuently  asscwiiited  with  feelings  of 
numbness  or  other  pnrasthosia  in  the  affected  part.  Moreover, 
ill  some  cases  an  aura  occurs  at  a  distant  part  of  the  body,  and  a 
true  aura  of  the  special  senses,  or  even  a  |>sycl]ic»l  aura,  may  usher 
in  an  epileptic  attack  due  to  organic  brain-diiiease. 

The  characteristic  pheoonienou  of  the  JftckMtnian,  or  organic," 
epilepsy  is  a  conliDuuUy-recurring  tonic  or  clonic  sptisni  of  a 


MOTOIt    EXCITKMENT8. 


113 


group  ofrauades.  Almost  any  group  of  niusolus  uitiy  be  a0«crtMl, 
but  the  various  paroxysms  in  the  same  «L<ie  always  bc^ln  in  the 
mme  way.  In  studying  an  iiitlivldiia]  cam  it  Ib  neoettsary  to 
obeerve  especially  the  starting-point,  the  march,  and  the  rang;e 
of  the  Bpttam.  Tha%  are  three  points  at  which  it  is  not  rare 
ibr  a  fipasni  to  ori^natc.  Tiie  mu^t  frequent  ih  protiably  the 
Iwuid,  then  ihe  foot,  then  the  face  and  tongue.  The  range  or 
i^ivad  nf  the  rotiviilfiirm  vane-*^  from  the  Kllghtest  spasm  con- 
fined lo  (he  thumb  and  index  huger,  and  not  }u:-oon)panie<l  with 
loes  of  consciousness,  up  to  the  violent  general  epileptiform  toq- 
vuIfiiuD. 

According  to  their  range,  attacks  are  well  divided  into  mono- 
Cpasm^, — I'.r.,  fijia-sm  of  the  arm,  fat*,  <»r  leg, — henuRpasnis,  corre- 
spooding  iu  range  to  hemiplegia,— «ud  general  ootivuhfjong.  lu  the 
beinif<pB.-im>i  the  cDaviiIt-ions  may  be  confined  to  the  face,  arm,  and 
leg,  but  often  there  ia  in  addition  a  turning  of  the  eyee  and  hvsd 
to  the  convulsed  side,  with  more  or  less  contraction  of  the  mpi- 
nUtry  mnscles  of  both  sidfs.  Tliis  tendency  of  the  respirat-ory 
muscleB  uf  the  two  sides  to  undei^  cousenlaneoua  itpuKm  in  evi- 
j  dentJy  etiolf^enlly  connected  with  the  fact  that  in  hemiplegia 
^Bchey  UHUally  e»ca}>e  paralysis.  In  amml  with  the  theory  of 
^^&roadl)ent,  which  was  explained  in  the  chapter  on  Paraly«ii*,  one 
^Pbmin-heniispherc  is  evidently  able  to  affect  the  i-espiratory  mus- 
r      eles  of  each  fude. 

Usually,  if  a  gpEe;!!!  becomes  general,  afler  having  affect»I  the 
band,  it  in  by  ninrching  up  Uk  arm  and  down  the  leg,  or  up  the 
leg  »ad  down  the  arm,  and  then  crossing  to  the  other  side. 
There  are  cai-et?  in  which  tlie  s|>a.sm  begins  not  in  the  hand  or 
foot,  but  in  the  cihouldcr  or  thigli,  when  the  march  of  the  8paf>m 
is  down  the  limb.  The  relation  of  the  spoHins  in  these  cases  to 
seat  of  the  lesion  Is  itimilar  to  the  relation  of  paralysis  to 
nic  disease  of  the  brain.  This  relation  has  beeu  fully  dis- 
oiUBed  in  the  chapter  on  Paralysing,  aud  I  shall  not  otxiipy  more 
spaoe  witli  it:  contenting  myself  with  the  statement  tliat  an  irri- 
tative lesion  in  the  motor  region  of  the  hrain-cortex  will  pnxluce 
M  spwDM  of  those  muitcles  which  would  be  |>aralyzed  by  a  totally  de- 
^■ctruciive  Icnion  of  tlic  same  brain-oeutrcit.  A  lenion  may  |Mirtinlly 
^B  destroy  the  functional  jHiwer  of  a  centre  and  thereby  cause  a  ])ar- 
^Wal  local  palsy,  and  at  the  same  ttmc  irritate  the  remaining  nerve- 


cells  ai)<l  BbreH,  so  that  h  Jacksoiiiaii  epilepsy  not  rarely  oocxJstB 
with  partial  paralvflis. 

In  Jacksoiiiaii  epilejtsy  ouiisctousness  may  or  may  not  b«  lost. 
Usually,  although  not  iuvariably,  the  tlegree  in  which  conscious- 
ness is  affbetctl  is  iu  dirwt  jiroportioii  to  the  severity  iiud  range  of 
the  coDvulsiciJ)^:  it  will  be  oAen  noted  that,  whilnt  cortsciouBneis 
sfl  preserved  in  the  early  portions  of  the  paroxysm,  it  is  finnlly 
lost,  Wlien  the  portion  of  the  brain  affected  is  situated  near  the 
speech K-ent res,  a  temporary  partial  aphasLi  not  rarely  follows  tJie 
fit.  Indeed,  as  shown  in  tlie  case  reported  by  Dr.  Allen  Stai^ 
{Trans.  InirrmU.  Mai.  Cmig.,  London,  1881),  a  sudden  complete 
aphasia  may  form  the  most  iDarkefl  jiheiiomenon  in  the  organic 
epileptic  attack,  and  may  develop  with  the  firdt  convulsive  move- 
ments, or,  ]w6sibly,  even  precede  them.  More  common  still  is  a 
partial  loss  of  |H>wor  in  tlie  oonvulned  extremity,  continuing  for 
some  hours  after  the  passage  of  the  paroxysm.  When  the  con- 
vulsive seizure  lit  narrow  in  its  range,  the  weakne^w  is  apt  to 
amount  to  a  partial  paralysi*  in  the  restricted  region  of  the  con- 
vulsion. When,  however,  the  epileptiform  seizure  has  been  a 
very  wtde-8pread  ami  aevcrc  one,  a  hemtplegic  weakness  not 
amounting  to  a  jmlsy  is  often  noticed. 

Severe  general  epileptiform  convulsions  often  usher  in  an  acute 
in  flam  I  nation  of  the  bruin.  Under  tht^e  ciretiuiKtanoes  tJie  deli- 
rium, ihe  hmdacbe,  the  intolenmce  of  li^ht  and  sound,  the  fever, 
and  the  tendency  to  coma  indicate  the  exi^tcnct^  of  a  nicrunt^iti.''. 
CouvuUious  may  also  be  a  part  of  an  attack  nf  sunstroke.  Thoy 
are  frequently  present  iu  tubercular  meningitis.  Whenever  tliey 
are  priKliu'iwl  by  a  geucniiizcd  diseane  of  the  brain  they  do  not 
take  on  the  Jaeksonian  type, — i.e.,  they  do  not  affect  especially 
any  group  or  a^Miciated  j^roups  of  muiwle^  but  are  themselves 
generalized.  Their  causation  is  to  l»e  made  out  by  paying  atten- 
tioo  to  the  symptoms  ussociutcd  with  them. 

Diagnmia  beiweeti  Tdiopathie  and  Orgttnie  EpUeptfy. — The  diag- 
nosis of  an  organic  epilepsy  can  be  usually  made  out  with  a 
fair  degree  of  cerlainty  by  a  study  of  the  convulsive  seizures. 
Before  giving  a  [K)i^it!ve  opinion,  however,  it  is  usually  wisest  to 
wait  for  other  manifestations  of  organic  bmin^disease.  In  idio- 
pathic epilepsy  the  convul^iivc  movements  very  i-arely  b<^n 
babitualiy  in  one  extremity,  and  whenever  convulsions  have  euch 


i 


p 


p 


origia  ibey  are  probably  due  to  oi^nic  fotal  braiii-diseasc.  This 
pmhahility  apprndchtB  a  cerlainty  if  the  convulsive  movements 
be  entirely  confined  to  one  limb,  one  side  of  the  face,  or  any  other 
narrow  muscular  territory. 

The  age  at  which  the  epileptic  paroxysm  has  first  appeared  is 
a  natter  of  vital  ini|M)rtniiee  in  rlic  diaginK^if^  iM'tweeii  ii)io|iiithio 
add  organic  cpilcpt*y.  The  statement?  of  Gowers  and  of  Hasse, 
Including  between  them  about  two  tliousand  five  handre<l  cases  of 
■ui^xwed  idiopathic  epilepsy,  show  that  in  weventy-five  per  pent. 
tlie  dtfea^  commeuocd  under  twenty'  ycar.t  of  age.  Id  Gowers's 
Bfleen  bnndred  coses,  only  about  two  per  cent,  began  after  the 
fortieth  year,  and  about  five  ppr  flcnt.  after  the  thirty-fifth  year. 
I  beli«ve  that  thei^e  small  percentages  would  tnuSTer  Mill  further 
reduction  if  there  could  be  u  rigid  exclusion  of  organic  cohcs; 
and  it  may  l>e  laid  down  as  a  rule  of  sufficient  accuracy  for 
practical  diagiiosia  that  an  epilepsy  wkick  devehpn  ajlfr  ihe  thirty- 
fifth  year  of  arje  is  not  idiopathic,  but  in  due  to  »ome  organic  hrain- 
dvKOtt,  to  the  t^nse  of  aicohol,  rrftex  irritation,  or  othar  cautes, 
which  m  Kftne  cowji  may  be  so  htdtten  as  to  be  exoeedingly  ilijtcull 
oj  rfeoffniHon.  An  cpilcjwy  which  first  appears  after  the  thirtieth 
year  should  be  viewer!  with  great  suspicion.  In  ray  own  experi- 
ence, epilepsy  occurring  after  the  age  of  ihirty-five,  not  dependent 
u|ioD  assignable  causes  unconnected  with  organic  braiu-discafie, 
has  in  at  least  eighty  per  cent,  of  the  cages  been  due  tu  syphilitic 
kbions  of  the  brain. 

ConTUlsions  from  Cerebral  Hemorrhage. — An  epileptiform 
convulsion  maybe  prwluced  by  a  cerebral  hemorrhage.  Under 
these  oiruumstanccs  the  convulsive  movements  very  frequently 
lake  on  the  form  of  a  Jacksonian  epilepsy,  and  may  be  confiued 
to  a  group  of  muscles,  to  one  extremity,  or,  more  ooninionly,  to 
one  half  of  the  bwly.  The  [-rue  nature  of  such  a  case  can  a»ually 
be  made  out  without  diflicntty  by  attention  to  the  evidences  of 
local  palHV.  Thus,  the  face  is  drawn  to  oivc  side,  or  an  ineqtialiLy 
of  the  pnpila  or  of  the  movements  of  the  eye  can  be  mode  out,  or, 
etill  more  frequently,  a  distinct  hemiplegia  cao  be  discovered,  even 
thrmgh  the  jKitient  be  uomatose.  (See  Apoplexy.)  The  a|x»plcctic 
attack  also  usually  occurs  in  advanticd  adult  life,  and  is  either 
tbe  first  convulsion  the  patient  has  had,  or  \xtts  been  preceded 
by  previous  attacks  of  apoplexy,    A  cerebral  UcmoTiU&^  m^.*^ 


[e 


DIAONOSnC  KEVROLOGY. 


hap|>en  during  an  epileptic  fit.  Under  those  eircumstanees  the 
.diagnottis  call  scarcely  l>e  made  out  until  the  recoverj-  of  con- 
^Bciou'tnt'Sf',  when  the  persistent  paralysis  will  rt*veul  the  lesion. 

Epileptiform  Convulsions  in  €)«nera]  Paralysis. — Epileptic 
oonviilsinns  are  a  very  pommon  sympton)  of  (he  disease  known 
aa  (reneral  paralysis  of  tlie  iii^ne.  They  usually  occur  in  the 
eeooad  or  maDiaoal  stage  of  the  disea-^e,  and  ere  still  more  fre- 
quent ill  the  jinal  fit:i^  of  dementia.  Many  yeare  ago  Eeqiiirol 
called  BttentloD  to  the  fact  that  a  sncression  of  epileptic  fits  very 
frequently  elnses  the  scene  in  general  ]mraly«is.  Epilejrtic  con- 
vulsions may  occur  in  the  beginning  of  a  general  palsy,  awl  niay, 
indeed,  usher  in  the  disease.  Under  sudi  circumstnocos  their 
Bignificnm-*'  may  readily  lie  overloiikoii.  This  la  c«]H3cially  the  ca« 
when  the  major  attacks  are  replaced  by  or  associated  with  petit  mnl, 
in  which  the  only  symptom  of  the.  seizure  may  he  a  sudden  pallor 
with  umutai  confusion  or  a  momentary  UDconsciousneBB,  or  a 
dilatation  of  the  pupils  with  drawing  of  the  head,  or  a  auddcu 
fixation  of  the  countenance  with  an  outpouring  of  cold  perspira- 
tion, or  an  automatic  repetition  of  coherent  or  incoherent  phrasea. 
Such  paroxysms  are  apt  to  be  interpreted  as  Bvneopal.  Not  rarely 
epilepsy  in  general  paralysis  takes  u|)on  itself  the  Jacksonian 
form,  the  convulsion  being  limited  to  isolated  gniups  of  muscles, 
or  to  one  side  of  the  face,  one  leg,  or  one  srm,  or  being  hemi- 
pl^io.  Usually  the  attack  begins  with  an  aura,  which  is  e»- 
specially  apt  to  be  vertiginous.  Sometimes  the  convulsion  is  prc- 
'oeded  for  several  ilayw  by  excew^ive  restlessness,  tinnitus  aiirium, 
and  great  psychical  excitation.  In  other  casc»  it  begins  with 
vomiting. 

Very  frequently  there  is  a  aucoesaiou  of  convulsive  attacks, 
producing  a  true  epileptic  status.  In  this  condition  the  8ucce?«iva'l 
oonvulflions  may  be  very  different  from  one  another,  one  being 
complete,  the  next  partial,  in  one  the  head  l>eing  dmwn  to  the 
right,  in  the  next  to  the  left,  aud  so  on.  Frt-quently  after  the' 
piiroxysms  tjonvulsive  tremblings  persist  in  the  single  muscles,  or 
in  gn>ii|»of  muscles,  for  many  hours,  and  are  followed  by  a  more 
or  less  pronounced  partial  jiaUv.  To  use  the  words  of  Dr. 
Nielroll,  paralysis  follows  the  convulsion  or  spasm  as  the  shadow 
follows  the  boily.  During  the  more  severe  jmroxysuis  oonseious- 
neos  is  always  luet,  but,  especially  when  the  convulsive  movementa 


I 


» 


are  more  or  less  local,  it  may  be  perfectly  maintained ;  occasionally 
it  Lb  uSected  fus  in  hysteria,  Afler  wevere  seizures  the  iiieutal 
ouuditioo  of  the  pa(ieDt  is  almufit  always  (lietitielly  a^ravated. 

It  U  affirmed  I>y  many  aiitlior<i  that  tti  general  {Ktralysin  the 
tem]>eralure  rises  during  and  imiiKKliately  nHer  the  epileptic 
pikrozysms,  aod  sometiracs  also  immediately  before  them,  and 
that  tlic  elevation  ixnttinues  for  >mmc  houra,  and  may  Ik;  vgij 
oDDfiderable  after  severe  fits.  This,  however^  does  not  eeem  to  be 
universally  the  am:,  sim*  Mendel  (Parafifm  elcr  Irren,  pK-rlin, 
1880)  affirms  tli:it  lie  W^n  re]>catedly  stitdied  the  tem[>eratiire  tn 
cades  in  which  there  was  a  prolonged  convulsive  attack,  and  in 
which  no  elevation  of  tcn]|icrauirc  occurred.  In  a  single  case 
Meadel  found  that  the  temperature  fell  very  decidedly  as  the 
resDit  of  an  e|)ileptic  status  which  had  lasted  three  houra.  He 
also  states  that  M'^e»Cphal  h[i8  uotlcetl  the  same  thing.  Usually, 
however,  a  distinct  sinking  of  the  tem]>erature  in  the  coutve  uf 

.       an  attack  of  uticons>tiinii4ner«  during  general  paralysis  marks  tlie 

^k  devetopmcnt  of  a  true  apoplexy. 

^H  Thxamia. 

^H  Epileptiform  convulntona  may  be  produced  by  a  very  targe 
^^number  of  potaons.  The  nature  of  such  attacks  is  to  be  made  out 
by  a  hiijtory  of  the  case,  aud  by  the  presence  of  nllier  liymptoins 
of  tlie  poisoning. 

Convulsions  in  Pever. —  Among  the  toxpemie  oonvulrtions 
are  to  be  placed  tho)*  which  nsher  in  scarlet  fever  and  other 
malignant  diseases.  The  diaguogii^  iu  these  eases  rests  u{>od  the 
recognition  of  the  febrile  diwea-w.  Exce-'*iive  vital  deprei^sion, 
with  lowered  or  elevated  bodily  temperature;  the  absenoe  of  evi- 
deuces  of  the  convulsion  being  reflex,  due  to  acute  or  chronic 
braiu-diseaae,  or  unemie;  the  age  of  the  patiunt,  and  the  history 
of  ex  [insure  to  the  cause  of  an  acute  febrile  diwrder,  are  tlie 
principal  Incts  which  .should  lead  to  a  correct  diaguoHi-s. 

AlcohoUo  Epilepay.— There  are  two  distiiiot  epileptic  con- 
ditions produced  by  intoxicating  drinks.  In  one  of  thcAC  the 
convulsions  are  symptoninlir  of  acute  poisoiiing,  and  come  od 
during  an  oncv,  or  immediately  aflter  a  sincrle  excessive  dmu 


¥ 


ing  an  orgy, 


ight 


of  liq 


uor. 


In  the  second  form  the  convulsions  are  apparently  not  the  !m- 


118 


PtAONOSTIC  SECROtOOY. 


mediate  rt-autt  of  alcohol  in  the  blood,  but  arc  developed  at  a  time 
when  the  system  is  not  profoiimlly  under  the  direct  infliieuce  of 
the  [mtBOu.  Tliwe  epileptic  c-onvgUitms  may  Buiwrveue  durtug 
delirium  tremens,  when  tlicy  arc  accompanied  by  ballucinationa; 
during  the  mental  enfeehlerncnt  of  profonnH  chronic  alooholisni, 
wlieti  they  are  aHStx;iatetI  with  deuieiitia,  paralysis,  or  stupor ;  or  ^ 
at  a  time  when  the  general  symptoms  of  chraaic  alcoboliam  are  H 
not  pronouiKvi].  In  the  alw>bolir  convulsion  the  Kymptoms  may 
dosely  rcticmble  those  of  true  epilepsy,  and  not  rarely  the  attack 
is  ushered  in  by  headache,  gastric  embarrassment,  troubles  of 
vision,  excessive  cremora,  or  some  HimSlar  prodrome  which  may 
be  looked  upon  as  ]>artiiking  of  the  nature  of  nn  aura.  The  con- 
vulsiona  usually  occur  in  paroxysnin, — two,  three,  four,  or  more, 
one  fifrer  the  other,  at  intervals  of  a  few  minutes.  ^M 

Not  only  may  major  epilejisy  be  closely  simulated  by  the  alco-  " 
holie  affecttou,  but  simple  epile])tic  vertigo  or  true  )>etit  lual  may 
exist,  either  alone  or  associated  with  the  major  convulsious. 

Alcoholic  epilefwy  is  often  aa^iciated  with  hallucinations,  es- 
pecially of  terror,  and  the  convulsion  is  not  rarely  followed  by 
teiupurary  mental  dcmngemeat,  which  may  last  only  for  a  few 
minutes  or  may  amtinue  for  hours  or  daj-s.      The  mental  de- 
rangement may  take  the  form  of  an  acute  dementia,  in  which  the  ^ 
uit«llectual  functions  seem  to  be  in  alwyance,  and  the  subject  is  ( 
reduced  to  tlie  condition  of  an  automaton,  obeying  immediately 
and    mechanically  all   commands    and   impulses   from  without. 
This   stale  of  j>erverteil   twnsiciousueeB   has,   in   some   inetaiiceai       i 
lasted  for  days.     Suicidal  impulses  are  very  frequent.  ^M 

Tliere  is  uotliing  diagnostic  in  the  convulsion  of  alcoholic  epi* 
lepsy,  and  it  in  especially  im])ortant  to  remember  that  if  under 
the  prolonged  use  of  the  stimulant  the  epileptic  paroxysms  have  H 
occurred  re(jeatedly,  they  may  continue  even  if  the  patient  cease  to 
use  intoxicating  liquors.     Under  these  circumstances  it  must  be   ^ 
cuuisidereil  that  an  idioi>aLhic  epilepsy  haa  been  prodnoed  by  alco*  ^ 
hoi.     In  every  case  of  apparently  causeleKS  epilepsy  occurring  in 
middle  life,  the  ]iogaihility  of  its  licing  altHiholic  must  be  borne  in  h 
mind.  B 

VrXEmia. 

Ursamio  Convulsions. — A   very  frequent   cause  of  epileptic 
oonvulaions  is  uraemia.     In  this  disease  the  convulsive  phenum- 


MOTOR   EXCITKMENTH. 


119 


em  tasv  be  altogether  wanting  Huring  tlio  attacks  of  coma,  nr 

my  appear  only  in  the  shape  of  twitchings  nf  vflrioiia  groups 

<if  muscles;  but  severe  coiivul«ioua  ol*  tho  (Epileptic  Iv|>e  are  fre- 

qnent    In  thew  there  are  u.tuftllv  complete  insenHibility,  rotutory 

■wvements  of  the  eyes  nn<l  head,  violent  clonic  eontractionTt  of  oil 

tlie  miKcIes,  biting  of  the  tongue,  foaming  at  the  month,  and 

AbIIv  coma :  so  that  it  is  not  rarely  imptw^ible  from  the  oon- 

rnlsioo  alone  to  decide  that  the  attack  is  not  true  epilepsy.     Even 

wljeo  disease  of  the  kidneys  has  not  l»een  previously  wii«iwftecl,  a 

history  of  prolonged  dysprpsia,  freqnent  vomiting,  occasional  at- 

laoks  of  asthma,  failure  of  general  health,  etc,  may  genemlly  be 

obtained,  and  an  examination  of  the  urine  will  usually  reveal  the 

nature  of  the  ca^;  bul  Mnnetimes  such  ojiaminatioD  must  be  made 

repeatedly  before  evidences  of  kidney-disea'tp  can  be  found.     The 

danger  of  overWiking  the  serious  uaturc  of  urtcmic  eclnmpsia  is 

especially  great  when  the  convulsive  seizure  takes  on  the  liys- 

teroidal  type.     So  long  ago  an  1840,  Dr.  Bright  descrilwl  caseB  of 

anemia  in  which  there  were  furious  nonvuUinus  without  loss  of 

ooRsciooanesa ;  and  Dr.  Roberts  has  reported  similar  inHlanoes. 

I  have  seen  the  diaguosis  of  hysterical  coiividsiuns  {}er4ii«te<l  in 

by  practitioners  of  large  experience  until  within  a  few  hours  of 

desth.      In  all  cases  nf  coiivnlBions  occurring  for  the  first   time 

during  adolt  life,  a  very  carefnl  study  of  th.('  urine  is  essential. 

Moreover,  fatal  uraemia  may  occur  with  a  urine  that  if>  appar- 
eutly  normal,  and  in  a  large  proportion  of  c:ise»  of  contracted 
kiduey  albumen  b:  aluwnt  from  the  urine  for  long  peritxls.  The 
stady  of  the  3pe<^'iRc  gravity  of  the  urine  is  of  the  utmost  impor- 
tance, and  in  doubtful  ca-ie?  the  percentage  of  urea  flhould  1)« 
determined.  Unless  dialwles  insipidus  exists,  a  specific  gravity 
habitually  1)e]ow  1010  is  almust  proof  of  the  existem^e  of  chronio 
Rright'a  disease.  In  doubtful  caaa'^  a  number  of  examinations  of 
the  urine  taken  at  different  periotls  nf  the  day  should  Ik  made. 
Fajiting  urine  may  befouml  to  l>e  of  abnormally  low  siwcifif:  gravity, 
and  urine  voided  three  or  four  hours  after  a  heavy  meal  to  contain 
albumen.  The  jjower  of  elimination  of  the  iodide  of  potassium 
ha*  been  prop^vsct]  as  the  means  of  tc-sting  the  renal  secreting  sur- 
face. It  18  affirmed  that,  after  a  full  dosso,  this  drug  can,  !n  an 
hoar,  be  readily  recoguize^l  in  the  urine  by  adding  nitric  acid  and 
Ihim  starch,  but  that  when  contracted  kiilney  exists  the  iodide 


I 


DIAONOenC  NEUROLOOT. 


fails  to  appear,  or  names  over  io  only  very  small  quantitits  and 
after  a  ver)*  long  intervnl. 

HYSTEKOIDAL  CONVULSIONS. 

The  svmptoma  of  hyfitero-epilfliwv  have  l>een  sufficiently  de- 
tailed ill  ihe  discussion  on  the  hysttroidal  convulsions.  It  was 
there  ohowo  that  the  attack  is  usually  ushered  in  by  an  aura,  and 
is  made  up  of  pei^uliar  diKlurbaiiL'eii  of  uonsciousuf:^,  of  emotional 
storms, and  of  ulonlu  and  tonic  convulsions^simulatiug  toa  greater 
or  less  degree  purfmsivc  movements. 

The  major  hysterical  convulsion  variej  almost  Jnde6nitely.  The 
ordinan-  hy:jtericat  attack  which  we  see  habitually  in  the  United 
StatfH  luiiy  1m>  well  spoken  <if  as  minor  liysteria. 

Minor  Hysteria. — Into  minor  hysterical  paroxysms  enter  all 
the  elements  of  ilie  major  affection  ;  but  usually  sf>me  of  the 
symptoms  are  wanting  in  individual  attacks,  and  not  rarely  a 
single  stage  oonstitutes  the  whole  paroxysm. 

The  aura  is  not  ii-iiually  prewent,  tmless  the  so-calle*!  fjtobm  hj/s- 
Uricitm  be  considered  to  represent  it.  The  globus  is,  however,  B 
local  convulsion,  and  is  not  necessarily  prodromic.  Jt  is  described 
as  a  fettling  of  a  l>all  in  the  throat,  or  of  something  rising  in  the 
throat,  and  is  the  result  of  spusiu  of  the  muscles  in  and  around 
the  larynx.  In  ordinary  minor  hysteria  the  emotional  state  is 
usually  well  developed,  and  is  especially  prone  to  express  itself 
by  uncontrollable  laughter  or  equally  luiicoiiLrollable  sobbing  or 
ci'yiug.  A  very  clmructeristic  {H;rfunnuiiire  wliicli  I  have  seen, 
especially  in  young  hoys,  is  that  which  may  be  termed  bfogt' 
■mimiri'ii,  in  which  the  patient  bites  or  snajv*  or  snarls  like  a  dog, 
or  crows  like  a  cock,  or  in  some  other  way  imitates  the  movements 
and  the  vocal  acts  of  the  lower  animals.  Among  these  cases 
belong  tlu'  not  nii-e  attacks  of  itjnmtnt*  hyiirnphaiiiay  in  whirh, 
either  with  or  without  severe  general  convnl^ion,  the  subject  shows 
profound  dreiid  of  water,  givat  emotional  distnrbam-e,  often  crying 
out  to  be  held  lest  iie  bite  some  jwrson,  and  L-ontinuully  snarls  and 
barks  and  attem])tu  to  bite.  These  symptoms  do  not  closely  re> 
scmblc  lhn?*e  of  true  hydrophobia,  in  which  diseiL<ae  the  subject 
never  oflere  to  bite,  and  does  not  make  any  noises  resembling  those 
of  the  dog  or  any  other  lower  animal.  Beast-mimicry  may  he 
Considered  a^  diagmistii!  of  hysteria. 


UOTOB   KXCrTBMF.NTB. 


121 


The  convulsive  syiii|)tonis  of  minor  hysteria  are  tonic  rather 
than  clonic.  Mure  or  1(!ms  |>ersiHU-iit.  rigtility  is  very  frequent  and 
vety  characteristic.  It  may  Imt  for  hours,  or  may  pass  by  io  a 
few  moments.  The  tlisturljances  of  wosciousness  take  the  form 
whirli  lia«  alreatly  Ixwu  fiilly  <l«MTibei]  in  Hpt>akiii<;  of  the  major 
attacks.  Occasionally  the  abolition  may  beoumplcte,  but  almost 
invariably  at  .wme  stage  of  the  attack  the  chararteristic  alterations 
of  eODSciousness  can  I>e  diaeoveroj.  The  diagnosis  between  fnlly- 
furmed  bystcroldal  epilepsy  and  idio|}a(bic  epilepsy  is,  of  course, 
tarn,  but  I  have  seen  tii  private  and  liinpcuriiin,-  pnictioe  |iiitieJit8 
suHenng  from  recurrent  irregular  attacks  whose  nature  remained 
Very  doublful  for  months.  One  great  tllfficulty  in  these  ca^^s  is 
that  the  phvdiciau  is  usually  unable  Io  bce  tlie  patient  during  the 
paroxysm.  A  further  complication  arises  from  the  fact  that 
aovere  liyMtericnl  manlft^intiong  nmy  follow  immediately  u)Hni  an 
epileptic  fit,  and  that  hystcritad  convulaiona  may  alternate  with 
tbo«e  of  true  epilepsy.  The  only  safety  ia  to  be  found  in  a  very 
cautious  diuguosis  and  prt^oats,  especially  wheu  the  ttubject  is  a 
yoQDg  woman.  In  sucli  patients  I  have  several  tinier  Keen  "spells" 
which  [  had  Iwlievtil  to  lie  epileptic  yii^d  to  careful  treatment. 

Temperature  (u  an  Aid  to  Diaffni>m.-~-Aid  in  the  diagnogig 
between  urEemic  convulsions,  hystero-cpilepsy,  and  epilepsy  can 
sometimes  be  obtoiocii  by  a  Btudy  of  Uie  temitcrature.  In  18(io, 
Dr.  Kien  (6'<u.  MM,  de  Sinuboury,  1865,  p.  12)  i-alled  attention 
to  the  fact  that  oven  when  the  unrndc  <'onvuIi*ioiis  are  very 
violent  liiey  are  a<«ompanied  by  a  marked  fail  «)f  teinpn-rature, 
which  increases  until  death.  This  has  been  confirmed  by  Roberts, 
of  Manchester,  by  Hiriz,  Hutt-hinsoii,  Clian*ot,  Toitiurier,  and 
Bourneville.  (See  {duties  din.  et  ilierm.  aur  fcs  Maladies  du  %s/. 
iterveux,  Paris,  1873.)  In  the  severe  isolated  attack  of  epi!e|wy 
there  is  usually  a  distinct  elevation  of  lempeniture.  In  the  severe 
isolated  hystcroidal  convulsion  the  temperature  also  rises,  but  not 
w  distinctly  as  in  true  epileiirty.  In  tlie  epileptic  suite — 1.«.,  in 
tliat  condition  in  which  there  is  a  prolonged  series  of  fits,  con- 
by  coma  and  o^vurring  at  short  intervals — the  temperature 
dily  thniugliiiNi  llie  whole  niridiiion,  tfiis  rise  of  tem- 
perature not  being  preceded  or  interrupted  by  a  fall.  On  the 
other  band,  when  the  series  of  convulsions  are  the  ex])re-ssion  of 
a  hystero-epilepsy,  tlie   temperature   falls   very   rapidly   imme- 


122 


DIAONOenC   NEtniOI/K>Y. 


diately  after  eacli 


convulhion,  itnd  docs  not  id  the  suooeesive 
attankfl  reach  rlistin<;tly  higher  thnn  in  tlio  flnit  cotivulnion.  Tn  a 
(supposed  hystero-cpilp[isy  a  continuous  elevation  of  tempcnitarc 
is  sufficieiit  to  e!>tabli^h  the  presenoe  of  some  other  disorder,  or  at 
least  of  a  very  threatfiiing  condition  of  th«  iierve-wntres.  Thus, 
in  a  curious  case  rcjwrted  bv  Quincke  (,'ircA.  der  Halhtnde,  186-1), 
after  a  seriM  of  apyrettc  hyfllerlform  convulsions,  oonvalsions  oo 
currwl  witli  an  elevaiion  of  t^ni[)eralure  10  43"  C,  and  soon  ended 
in  death.  Puer|)tir&l  convulsions  arc  usnally  supposed  to  be 
uraemic,  but  aoconling  to  the  riisearches  of  Bouruevitle  they  are 
distinctly  s^^parated  from  urnrnia  by  the  fant  that  the  tenip<>rature 
rise*  almost  brusquely  in  the  begiiuiiug  of  the  convulsions,  and, 
when  the  latter  are  fre([uei)tly  repeatct),  maintains  itself  at  an 
elevalf^d  po»4ittnn  M'ith  great  steadiness.  Eaoh  pamxyam  is  marked 
by  a  slight  increase  of  heat,  and  if  the  attack  is  to  end  fatally  the 
temjwratur*'  finally  bfoonies  very  high;  if  recovery  occur,  the 
tei«[>erature  gradually  falls.  I  am,  however,  doubtful  whether 
the  tetniKniture  altoat/g  falln  in  true  urieniia.  I  have  certainly 
seen  it  rise  in  coma  oocurring  in  persons  suffering  from  contracted 
kidney,  and  apparently  urfemic.  The  subject  is  one  of  much  in- 
terest,  and  needs  further  clinical  study.  It  is  alwo  complicated  by 
the  frequcuoy  of  serous  or  true  a|>oplexy  in  uroimia.  CHniiul 
studies  of  the  temperature  should,  as  far  as  possible,  he  checked 
by  post-mortem  results. 

TETANIC  CONVULSIONS. 

The  tetanic  convulsion  h  one  in  which  the  cerebrum  does  not 
participate,  and  in  which,  therefore,  rtjnsciouaness  is  not  di^urbed 
exoept  secondarily  us  the  result  of  asphyxia. 

It  may  be  due  to — 

1.  Hysteria. 

2.  Tetanus. 

3.  Poisoning, 

4.  Tetany. 
Hyetoria. — Hysteria  may  produce  convulsions  which  conform 

to  the  tetanic  type,  but  usually,  sooner  or  later,  the  cerebrum  is 
involved,  and  the  clmracleristics  of  the  hysterical  convulwoas  ap- 
p(rar,  The  diagnosis  of  hysterical  tetanus  is  fully  discussed  on 
page  126. 


Tetanus. — Telaiius  Is  cltaracterized  by  tonic  contractions  of 
many  nf  the  mnsclffl,  a-ssociateti  with  violent  paroxysms  of  reflex 
DvuLsion«  affecting  the  whole  Inxly.  There  are  two  (llttinct 
iological  varieties  of  it, — tiie  trauotatic  and  the  idiopathic. 
The  traumatic  (Hsea.ee  is  ilue  to  a  Iraiiinatism,  usually  a  laoera- 
tioD^  althonjjh  it  may  follow  a  blow,  or  may  occur  after  child- 
birth. Idio|>9thic  tetautis  in  many  instances  comes  on  without 
obvioDN  cauiw,  bat  not  rarely  follows  exposure.  There  are  do 
distinctive  ayraptoms  separating  the  two  varieties,  except  it  be  in 
that  the  idio[»thic  di5eat«  is  ]ms  violent  and  ItfHs  fretjuently  fatal 
than  iR  the  traumatic  aSbction.  The  diagnosis  between  the  two 
vsrifties  must  rest  upon  the  history. 

Teluuus  usually  begins  with  mild  symptoms,  which  gradually 
increase,  although  in  rare  esses  the  attack  i»  sudden  and  the 
course  of  the  disease  very  short:  thus,  in  a  patient  of  Gnietziier, 
the  convuhiionfi  »et  iu  the  moment  a  ligature  was  tied  around  the 
crural  oervc,  and  proved  fatal  in  six  hours.  Jaccoiid  speaks  of  a 
case  reported  by  Bardeleben,  tn  M'hich  a  negro  dietl  of  tetanus 
fifteen  minutes  after  receiving  a  wound.  On  the  other  hand,  tet- 
anus may  uot  appear  until  long  after  the  reception  of  the  injuiy, 
and  may  run  a  ven,'  prolonged  coun»e,  with  active  tirmptoms 
lasting  for  four  or  five  weeks. 
^^  The  first  manifestation  of  the  disorder  m  usually  a  stiffnet*  of 
^■be  muscles  of  the  lower  jaw,  of  the  ccsophagua,  and,  in  a  little 
^Hvbilc,  of  the  neck.  At  firat  the  jaw  can  still  be  opened,  bnt  in  a 
^Obort  time  the  ma»»eters  set  so  Qrnily  in  tonic  Hpa-sm  that  the  up[>er 
and  the  lower  teeth  are  immovably  pressed  together.  At  the 
same  time  the  spasm  of  the  cesophagus  increa'ses  so  that  swallow- 
ing becomes  very  difficult  and  fatiguing.  The  speech  is  altered  in 
distinctness  and  in  tone,  not  only  because  the  lips  and  the  tongue 
are  rigid,  but  also  because  the  muscles  of  the  larynx  are  inipli- 
rared.  The  facial  mu.wl(«  nf  expression  are  very  rapidly  in- 
volved; the  forehead  is  wrinkled;  the  eyebrows  are  drawn  up- 
ward, with  the  eyeballs  staring  and  raotionlcAs  and  the  pnpila 
generally  contracted  ;  the  corners  af  the  mouth  are  pullwl  out- 
ward and  downi.^'ard,  and  the  lipR  parted  so  that  the  teeth  are 
expofied,  whilst  the  na.>Mi-Iabial  folds  are  exaggerated.  As  the 
spasms  jwrsist,  the  face  sets  itself  into  an  anxious,  frightened, 
,wildly -excited,  half-Iaughing,  balf-cr^'ing  expression,  to  N<V\\^Vi 


124 


DIAQKOariC 


tJie  name  ri»iM  ivtrtlonicuti  han  liecti  given.  Spasm  of  the  nituach 
of  the  aeck  soon  succeeds,  if  it  doea  uot  unvmpaoy,  the  firat  evt- 
dvncett  of  the  dJMsi&e,  and  Id  a  very  short  time  the  whole  erector 
spiiiffi  group  are  involved.  Somewhat  later  tiie  mnsoles  of  tlie 
legs  and  of  the  nrm^  are  affected,  the  tootc  spasms  being  more 
marked  in  the  legs,  ami  id  some  coses  the  forearms  and  the  hoada 
entirely  escaping.  Painful  8|)a$moJic  ereelioiis  of  the  i»euiB  may 
now  occur. 

When  the  tonic  spflAins  are  thoroughly  eHtabllshtd,  the  bod) 
a«sunie«  a  characteristic  jxvsition :  the  bead  is  drawn  back ;  the 
trunk  arched  into  opisthotonos ;  the  belly  hard  and  spasmodicallr 
retracted  ;  the  legs  rigidly  contracted.     Paroxyems  of  violeut  ii 
crease  of  the  tonic  spasms  now  occur,  or  brief,  furious  diwhar 
of  nerve-force  give  the  appt'arance  of  mpidly-repeated  clonic  cod 
vulntions.      During  the  paroxysm  the  distorted  position    of 
body  is  greatly  increased.     With  a  sudden  shuddering  tlic  optsthot 
onoR  bcKnniea  mnrkeil,  the  liend  \r  fort^]  hark  Into  the  pillow,  tl 
fiiittened  abdomen  is  thrown  forward,  and  the  feet  are  driven  iut 
the  lictl,  Ko  that  tli^  hcKly  rit^eN  until  it  ai^unici^  the  form  of  a  boi 
renting  u|>ot]  the  head  and  the  feet.    The  spoAin  of  the  nKpiraim 
muficles  and  of  the  pharynx  and  glottic  arrests  respiration, 
cauflcs  not  onlv  a  sense  of  suffocation  but  an  alKolute  cvanosli 
which  may  continue  until  uncon»ciouMnt.>M  and  even  death  r«sut| 
UBually  during  the  attack  the  thorax  is  spasnioditially  Ixjund  ii 
the  {HJMltioij  of  insjiiration  and  tlie  diaphragm  is  rigidly  dra\ 
downward.     The  respiration,  arrested  during  the  paroxysm,  ma 
be  rapid  l>etween  the  convulsions;  the  pulse  is  sometimes  notaf<^ 
focteil,  but  utiually  Irecomes  more  and  more  rapid,  and  the  arterij 
pressure,  at  first  high,  es|M«iully  during  the  convulsion,  falls 
exhaustion  uets  in.     The  skin  is  lialhed  in  sweat,  whilst  frc 
the  bronchial  mucous  membrane  there  is  usually  an  outpourii 
which,  as  coughing  is  impossible,  may  accumulate  in  (he  broa^^ 
oliial  tubes  ami  l>e  a  very  distinct  factor  iu  the  production 
sitffbeatinn. 

The  tem|)er;iture  in  some  cases  of  tetanus  dixs  not  rise  dtstinotlj 
but  very  frequently  it  steailily  mounts  upward;  and  in  fata! 
as  death  a]>proaehes  this  rise  may  suddenly  l>ocorae  extreme, 
sionally  reaching,  awonling  to  the  observations  of  Wutiderlichji 
113*^  F.      A  remarkable  but  woll-authcnticuled  phenomenon 


UOroB   EXClTEUIv^fTB. 


125 


S'^-t  aflfr  deatti  from  tetanuii  the  temperature  of  the  body  often 
dnoes  to  rise  for  a  time, 
Hie  paroxT»nis  of  tetanus  are  ix'flex,  and  nre  provt^litxl  by  the 
sli^te^it  periphL-ral   irritation:    a   Intn]  <;ntiml,  a  bright   light,  a 
draught  of  air,  a   new  contact   witli  the   b»1clotbc8,  intestinal 
peristaltic  movements,  an  irritation  so  sliglit  m  in  heahh  not  to 
DOticcdf  may  cau^  aii  icumedtatc  furiiiUK  ct^nvulsive  uutbtvak. 
The  sufferings  during  an  attack  of  tttanus  are  extreme.     During 
.■whole  course  of  the  disease  there  is  usuollv  excessive  slecp- 
.,  and    the   patient   ie  tormented    not   only  by   pain,  but 
ileo  by  di6tFessiDg    thirst,  and   in  some  cases  by  a  very  acute 
banger,  buth  ihe  thir»t  and  the  Initiger  Wing,  in  a  measure,  due 
tsthe  difficulty  of  o|»ening  the  month  and  of  swallowing.     The 
crunp-pain  is  horrible,  is  more  severe  during  the  iiaroxysnis,  and 
is  in  direct  proportion  to  the  seventy  of  the  wutractious.     The 
tflwts  of  these  sources  of  distrfss  arc  increased  by  the  character- 
istically clvar  mental  state.     In  Hranvly  any  other  disease  ie  there 
so  much  anxiety  and  dread.    Retention  of  urine  is  frequent,  but, 
I     specially  in  children,  involuntary  niictiirlttun  may  ooenr;  rarely 
^^e  urine  ts  [la-ssed  in  lurge  (pmntiticH,  usually  tn-lng  diHtinetly 
^Helow  the  average  amount ;  It  is  of  high  spci'Ific  gravity,  and  of  a 
^Rirk  brown  color.     Sngnr  and  albumen  are  exccptionallv  present. 
^     Trigmu*  Neonatonnn. — A  variety  <if  tetanus  very  ran;  in  this 
eounlry  is    the  so-called  trisoius   neoaatorum,  which  occurs  iu 
ite«-[)om  babes.     In  it  the  spasmic  ar-e  eonlined  chiefly  to  tlie 
mastics  of  the  jaw.     Some  authorities  Iwlieve  that  it  is  a  trau- 
Butic  tetanus  due  to  irritation  of  nerve-filaments  in  the  stump  of 
umbilical  oord ;  othen!,  that  it  is  produced  by  preisNure  upon 
Bcdnlla  (luring  lalmr;  others,  that  it  is  due  to  phlebitis  and 
pyaemic  manifestations.     Like  olher  fornw  or  varieties  of 
los,  it  is  connected  with  epidemic  intiuences,  and  is  notably 
'Tom  io  extremely  hot  or  extremely  cold  weailier.    It  i:*  probable 
^  tbe  starting-point  varies  in  dilferunt  cases,  and  that  the  epi- 
dmifi  nr  aimospiicric  iiifluencoii  act  as  strong  predisposing  causes. 
iHfrraituJ  Diagnrais  of  'IWanoid   Affivfionn. — The  only  dis- 
««e  which  could  possibly  be  confounded  with  tetanu-s  are  tet- 
ayjiDeDiugitis,  strychnia -poisoning,  and  hysterical  convulsiong. 
Cenibro-spinal  meningitis  is  dititiugulehcd  at  once  by  the  cerebral 
^Uptons;  whilst  in  a  pure  spinal  meningitis  the  ladialiug  \mm 


128 


DIAGNOSTIC   NEtmOLOOY. 


along  the  ncrve-oords  ought  to  reveal  the  nature  of  the  afiectioa. 
The  diagnnsis  betweeu  tetanus  aiicl  tetany  is  given  on  ]iage  128. 

About  Bfteeii  years  ago,  in  a  very  important  mcdioo-Icgal  case, 
there  was  pronounced  disagreement  between  the  medical  experts 
iu  regard  to  the  nature  of  certain  cHmvult^iutih.  Th«  following 
table,  whiob  I  pabliahed  shortly  ufterwnnl^,  wom  based  ii^mn  the 
experiences  of  that  trial.  Time  ha-s  confirmed  its  correctness.  E 
have  since  seen  one  tase  in  which  a  broker,  after  prolonged  ex- 
citement on  a  very  hot  day,  wus  buddenly  seized  with  nausea, 
directly  followed  by  general  eonvuhiions  closely  eonforoiablc  to 
those  detailed  iu  the  second  column.  Thcise  couvulsions  were  un- 
doubtedly hysteroidal,  provoktd  by  exhaustion  and  gastric  irrita- 
tion. 


TvrAitvc. 


0*«n*DMdwlUi  UlndntM  ud 


MoMatar  fjupionM  umtlly 
wmunaoca  wllb  gsln  iwcl  iilff' 
U(B  of  tfaa  bwk  tiT  UiK  nwrk, 
■OmaOBUI  irith  lllBhC  mUMQ- 
lar  twi  lub  lap  ;  oom>  ou  frmii- 

Jk<r  oa*  of  lb*  «*iU«il  para 
altacltKl ;  rliUly  viil  ■■rnUI- 


MUKnlarf  jiDpUsmt  coakDiMictd 
witli  lit^dUj  or  th«  dkIl, 
vhlcb  it>*<li'>11f  "  ntopt  nvr 
lb«  bodf,"  aflocUni  till  •>' 
InnltiBi  ImL 

Jtwi  liglCBj  Ml  trtTor*  t  Miml- 
iliiii,  aiiil  rnnalunl  K>L*tir*e[i 
III*  [wji  uau. 


»TIiri'1IM«-PWH<i«l<C. 

fi*cii»  with  •zliilustlaa  aad 

WlllMIIMI.  itiBifsclalmwM 
Iwlng  naiullr  macb  •huti- 
n«d.  DtmaMtorTWokaky 
In  una  o«a  b*  maalialad 
laCar,  ■TUr  lb*  teirslapMaal 
ot  «th«r  (TinptuiM,  bni  naa 
than  II  1(  cmra. 

MuecuUr  •ynrploiM  4«T*l<rp 
T>rj  lapldlf ,  oammaaclaB  Id 
Ilia  •xtrarniila^  oi  Uia  <«•• 
TDWon,  whcD  lh«  40M  It 
lirsa,  lolMa  Uin  ■but*  botf 
•ItnallaJiaoualj. 

Jkw  Ui«  lul  t«rt  or  111*  tKi4j  |9 
l«  aRKlaJ  i  ila  oiuxJna  nlk* 
Dial,  anil  afHi  alian  diirtD(  ■ 

MTtn  mDnUluiB  II  li  Mt.U 
ilrota  ■■  *u(iii  aa  III*  latlM 


PttnUlant    mutonUr   rlcidlcj, 

■•rF  ganatalljt  vltb  a  (nKkfoi 
at  lc«a  <l«i;r*«  of  parouoaoi 
opIitboLinai^MIiIiroalbolixHMa 
pIcumlhuloDuo,     or    ortbot. 


Oonaclaiunra  praawTed  nntll 
aaar  dmtb,  •*  In  aUyebnl^ 
pfiwiLliiB. 


P*niiUDt  opiitboUno*  knd  Id- 
l*DM  rifldlljt  lwl>*iMi  tb« 
ODiinilalniw,  and  afCar  tin 
eoEiTublcu  had  MtMd  Uia 
ofditliutLiiiix  anil  liilcriM  ri- 
BI1MI7  laalail  toi  lioun. 


OoDMlonanMB  lost  M  the  *MODd 

ooaraliioii  mnip  CD.  aoil  WL 
wltb  fvrj  otbot  ronTulaiim, 
Uia  Jlalurbanca  of  eon^ciulU* 
naai  anil  nmlllll;  bcln^dmul- 
lutaoua. 


Miwrular  nUutloa  (nnl7  k' 

■light  Hclilltf}  btCiiMii  ih* 
OnitTUlalnna,  thapallant  M»( 

•■buiii«d  uid  amiMtmg.  U 
nsotTj  occu,  th»  cooTvt 
•IMM  RnulDallx  etm*v.  trt,timg 
air«l>aiu*rular*i)iMiSHkaDd 
•omrtitnM  ■tISrm  llko  thai 
Tall  aftiir  *lul*ol  aitrdat, 
n>ii*dauaii*«  hlwaja  pruaenad 
diiilns     roniuUlntii,     CKMft 

whan  lb*  UciN'  liacofii*  n 
intoDM  tbat  dt^Ui  U  Im- 
cTiln<-nl  rnim  mfTiKatton,  to 
irblob  Dua  ■onatlKiM  lb* 
(Ktlent  IwiooiM  InaoMlbte 
tmm  Btph.Tila,  which  eooiM 
oa  dnrtnf  tba  latter  part  ol  k 
oocYuUon.  and  La  ^fau^t  a 
Mttala  iTMTttraor  of  tiMlk. 


-Mfab^      vlotanllr-      an  J 
I  «11h  caoTaUnAa. 


Tha  apaan  tn  1a|   rniut    haia 
bMD  ]WKUi,  W  tb*  IMt  wot* 

cmaaad  and  tuaa  InT*ri*>l, 
wliUb  cualit  uol  liafpan  irall 
ika  raaaclM  wtn  laaolvail, 
baeaoM  Iha  mioiiclR*  nf  nar- 
■lon,  baltig  Tpr/  luucli  Ilia 
•Ironcar,  iro-oM  nt  bvuhIIj 
oTamsma  tha  an  laguolatlG 
■maelai,    and    Uia    faat    ba 


PttltDt  BMT  KTauD  wlib  |M[n, 
or  nay  ripnat  [rval  a|ipn^ 
liaDffou.  1<ul  "crTtnrapallt" 
vnalil  appivi  lo  bo  Impoaai* 
bta. 

Ej««  itralebad  Kid*  opce, 

I^a  atlOlj  astaiiilK),  wttll  bet 
•atrtad,  w  U)«  iiiuiiu  alTtct 
kll  Uia  miuolaa  ol  lb*  Icf , 


^ 


Tetany. — TTmler  the  name  of  Infermltlent  Tetana-*,  Danoe 
originally  described  tlic  convulsive  disorder  now  usually  known 
by  the  title  given  to  it  by  Corvisart, — i.e.,  tetany.  Tt  is  a  disease 
of  cliildhood  aud  early  adult  nfi.',  aud  is  exceedingly  rare  in  tins 
country.  If  the  various  writers  u|»«jn  the  milijeot  are  to  be  credited, 
tetany  may  be  produced  by  excessive  lactation,  by  the  puerperal 
state,  by  exposure  to  cold,  by  prolonged  fatigue,  by  exhaustion 
from  diarrbcea  or  other  cause,  by  the  irritation  of  intestinal  worras, 
by  exposure,  and  even  by  the  rbeutnatiodialhcaia  or  the  infec^tious 
fevcre.  Further,  it  h  afiirnied  that  it  may  result  from  pxof?aaive 
emotion,  and  spread  from  patient  to  ptati>rat  a.H  nn  epidemic, — facts 
which  would  indicate  an  hysterical  nalure.  It  consists  esxenlially 
of  gacoessive  tetanic  convulsive  attacks,  separated  by  intervals  of 
qoiet  and  repow.  Thf  panixvrirns  may  <H>iitiiHit'  for*  sume  minutes 
or  for  many  houre,  and  may  cease  gradually  or  abruptly.  Ar- 
thralgic  pains,  formiration«  or  nnmbncAS  in  the  bandit,  radiating 
paio!?  in  the  fiugert),  tem[X)rary  partial  blindiiestj,  heudaehe,  seiiKe 
of  fatigue,  etc.,  are  assigned  as  occasional  prodromes.  Usually  the 
gpasms  are  most  markeil  in  the  upper  extremities,  and  nometimea 
are  confined  to  them  ;  the  fingers  are  drawn  together  so  as  to  form 
a  ooDe  like  the  hand  of  the  Accoucbfur  when  he  is  aWut  (o  in- 
troduce it  into  the  vagina.  Rarely  there  is  a  more  ac(%niuate<I 
flexion  of  the  fingers,  and  still  more  infix-queutly  the  hand  and 
tlw  Biigers  are  stiffly  extended. 
The  feet  may  be  altacke<) ;  sometimes  cramps  of  the  calf  occur 


128 


DrAGNOSTIO    NECROIXKiY. 


without  distortion,  but  in  other  cases  the  feet  are  violently  ex- 
tended, witli  the  toes  pointing  downward,  or  very  raraly  they  are 
flexed.  The  thigh  usually  ef^capes,  but  spasm  of  the  abductors 
and  crossing  of  the  feet  have  been  notitwl.  It  is  affirmed  that 
tlie  spasms  may  be  confined  to  the  arta«,  but  that  t!ic  logs  are 
never  the  only  portion  of  the  Ijwly  altucked.  Only  in  the  eeverest 
caFc«  are  the  trunk-ratiRclcs  aflfected;  but  opixthotonos  and  men- 
acing dysiniceu  do  uc^ciir.  Even  more  exceptional  than  thet<e  are 
spasmodic  closures  of  the  jaw  and  distortions  of  the  face.  The 
course  of  the  disease  may  be  painless ;  sometimes,  however,  neu- 
ralgic paiuti  run  along  the  nerves,  and  usually  crauip-paius  are 
present  in  tlio  iiflVntted  muscle.  Ana?.t[]icsla  and  analgesia  are  or- 
dinary phenomena,  Acninling  to  Erh,  the  farailic  excitability 
of  all  the  rauaeles  of  the  body  is  increased.  The  course  of  ihe 
disease  is  often  slow,  may  continue  for  months,  and  usually  ends 
in  rwovery.  A  diagnostic  sign  first  discovered  by  Trousseau  is 
that  during  the  periods  of  relaxation,  and  in  some  cases  even  as 
long  HH  three  days  afiiT  the  mxjiirrence  of  a  (xiiivnlsioti,  the  latter 
can  1)6  brought  on  by  presaure  upon  the  principal  nerve-trunks 
or  blood-vessels.  By  this  eymptom,  by  the  complete  relaxation 
between  tlie  attacks,  and  by  the  |Htriial  character  of  the  oonvulsiou, 
tetany  ia  at  once  distinguished  from  tetanus. 


I 


LOCAL  SPASMS. 

For  the  purposes  of  diagnostic  study  local  spasms  are  usefully 
divided  into  thiwe  winch  affect  the  muscles  of  ot^nic  life  and 
tliose  which  attack  Ihe  voluntary  muscles. 

SpfiJiTTUt  of  the.  Muscles  of  Orvjania  Life. 

<Bsopha{jreal  Spaam. — In  spasm  of  the  a2sophagus  the  diagno- 
sis of  the  nature  of  the  striotiire  can  usually  be  made  out  without 
trouble ;  but,  if  there  be  a  reasonable  doubt,  the  patient  should  be 
etherized,  when,  if  the  stricture  be  spasmodic,  a  probang  can  be 
[»ssed  into  the  htomach  without  the  rtwintaniw  wliidi  would  be  met 
with  in  organic  diaeuse.  The  spasmodic  affection  develops  rapidly, 
and  usually  without  a  history  of  the  causes  which  produce  o?so« 
phageal  lesion:  it  is  mostly  paink**,  varies  excessively  fn.>m  time 
to  time,  and  is  apt  to  disappear  suddenly.     It  ia  usually  accom- 


UOTOB    EXCITEMENTS. 


129 


panied  by  distinct  hysterical  or  neurotic  syiiiptouiK,  or  occurs  in  a 
person  who  has  such  a  histor}*. 

Rectal  Spasm. — Rectal  strictnrc  in  occa.tinnally  so  closely  coun- 
terfeited that  the  diagnosis  can  be  made  out  only  by  physical  ex- 
ploration. Under  tiieae  ciroumBtauces  the  flattening  ol'  the  stools 
mod  the  other  evideixx's  of  organic  diHea^w  an;  pnKluced  by  a  epa^ra 
of  the  sphincter  ani.  Spasm  of  the  rectum  and  of  its  sphincter  is 
very  prone  to  bn  associatwl  with  vaginismus  and  spasmodic  dys- 
meoorrlioefl.  It  also  i»  uocasioiialiy  produced  by  the  pressare 
of  a  misplaced  uterus  upon  the  sacral  nerves. 

Urethral  Spasm. — Urethral  h|Kti^ni  L-^  iiHually  caused  by  some 
irritant  substance  in  the  urine,  such  as  cantharidcs,  but  in  some 
eaaes  is  hysterical  in  its  origin.  It  is  to  be  re<:ognized  by  its  sud* 
den  develupnieut,  and  by  the  absence  of  a  history  of  guDurrhcca. 
Etherization  will  alwa\-5  decide  a  doubtful  cstae. 

Vomiting. — A  symptom  which  niny  he  (XHwiilered  as  a  form  of 
local  spasm  is  vomiting.     Vomiting  of  course  accompanies  many 
acute  fevers  or  disorders,  but  in  its  chronic  form  it  is  usually  either 
doe  lo  d'maue  of  the  stomach,  liver,  or  kiduei'Sr  or  of  tlie  bmiuj 
or  is  hysterical.     In  any  caac  of  chronic  vomiting  it  is  essential  to 
determine  at  once  the  condition  of  the  stomach,  liver,  and  kidneys. 
Uremic  vomiting  h  accompanied  by  dyspeptio  symptomSj  ia 
9ttj  olwtiuate,  and  gi-oerally  ts  associated  with  headache,  asthma, 
OT  other  unemic  manifestations.     Its  diagnosis  rests  chiefly,  how- 
ever, upon  the  detci'tion  of  the  dii4?asc  of  the  kidney. 

The  cause  of  chronic  gastric  vomiting  is  sometimes  diffirult  of 

detmnination.     It  is  neoettary  to  examine  for  the  existence  of  a 

'"B^or,  or  of  [lain  and  tenderness,  or  of  bltiod  in  the  matters  vom- 

"*'i     In  ulcer  of  the  stomach  the  [win  is  habitually  referred  to 

^  liack,  between  the  shoulders,  or  sometimes  as  low  down  as  the 

niiatmr  region.     In  liyMerical  vomiting  there  is  frequently  pain 

*"  ^>«Be  parts,  and  not  rarely  blood  will  be  found  in  the  vomit. 

*^*     practitiooer  is  es|K>oially  liable  to  be  deceived  when  along 

*"**     these   manifestations   there  are   gastric  tenderness,  excva- 

sively  fool  tongue,  and  pronounced  dyspeptic  symptoms.      The 

''^'■^tvrrical  pain  in  the  back  is  usually,  if  not  always,  associated 

""wVx    marked  superflcial    tenderuesa,  or   hypcriostfact'ia,  which  is 

**i»t.inK  ''*  *l'C  organic  dUease.     In  cases  of  hysteria  the  diagnosis 

(4  ^iMrio  uber  should  be  made  with  reluctance. 


ISO 


DIAONOBTIC    NBUBOLOQY, 


Tumors,  iiij!amiuatiot>s,  and  olher  diseaais  of  the  brain  may 
prcH)u<3c  voniitiug.  There  is  nothing  in  the  vomitiag  whtcli  is 
tilianic^^rietiCf  iinlc^a  it  be  itA  nppar(!nt,  (iiu~S(!lei»ii»«t,  and  the  fact 
that  in  many  cases  it  is  affected  by  rapid  change  of  posture :  thus, 
vomiting,  which  is  not  present  so  long  a-s  a  horizontal  position  is 
quietly  iiiaint.'iiiKtl,  uiay  Imalont-c  prtivMiUal  by  tJie  Bubjix^'a  rising 
suddenly  from  the  bed.  The  dtngnosiB  of  nervous  vomiting  ia  in 
most  cases  to  he  reacliwl  chiefly  by  the  process  of  erchimon,  and 
by  the  discovery  of  symptoms,  other  tlian  the  vomitiug,  pointing 
to  disease  of  the  brain. 

Nervous  Coueh. — A  form  of  repeiitetl  rhythmical  spoBtn  whioli 
18  espwiially  seen  in  peraons  suffering  from  minor  hysteria  is  ihe 
ao-called  nervons  cough,  which  may  exist  independently  of  ca- 
tarrhal or  other  organic  irritation  of  the  reepirutory  tract,  or  may 
be  asaoeiated  with  such  irritation. 

The  cough  iw  iibtmlly  ringing,  dry,  and  very  loud,  often  rasping, 
and  apparently  excessively  annoying,  and  is  prone  to  occur  in 
violent  paroxysms.  Tt  must  not  be  forgotten  that  uot  rarely  the 
catarrhal  and  ncrvoutf  elenjents  are  associated.  Under  Huch  cir- 
cumstances the  treatment,  to  be  successful,  must  be  directed  to  each 
element  of  the  condition.  The  diagnosis  of  nervous  cough  is 
arrived  at  cliiefly  by  ejtclusion, — i.e.,  by  finding  that  cough  in 
a  neurotic  subject  is  entirely  disproportionate  to  tlie  amount  of 
catarrhal  disease.  4 

Phantom  Tumor. — A  phenomenon  wlitch  may  l>c  considered  " 
the  result  of  a  conjoint  spasm  of  muscles  of  voluntary  and  invol- 
untary life  is  the  so-called  phantom  tumor.  This  occurs  almost 
exclusively  in  ncnroLiu  wnmen,  and  cnnKistA  of  an  npparent  local 
swelling  and  hardne-S^  in  the  alxlomen,  which  on  palpation  gives  to 
the  liand  a  sensation  like  that  imparted  by  a  true  abdominal  tumor. 
Its  true  elmracter  js  usually  at  ouce  ivvealed  by  the  absence  o( 
pcruug&ion  duliieiiH;  but  it  is  said  that  organic  percussion  dulnesa 
may  bo  simulated.  Abdominal  section  ha«  been  practised  for  the 
relief  of  a  phantom  tumor  due  simply  to  a  local  spasm  of  the  ab- 
dominal walls,  and  probably  also  of  the  intestines,  la  all  cai>«s  of 
allege<i  or  apjiarenl  abihmiinal  tumors  in  hysterical  women  sus- 
picion should  be  aroused,  and,  if  there  be  any  doubt,  the  jKitient 
should  be  etheri7ed,  when  the  nature  of  the  alleged  growth  will  be 
revealed  by  itd  disapjiearauoe  or  its  permanence. 


MOTOR    EXCITEMENTS. 


131 


S}M»ni8  of   VotunUiry  ifuaolai. 

ras  Stridulus. — A  verv  iini>ortdDt  form  of  local 
ISO-called  tijKisin  uf  tlie  glottitfi,  or  laryDgismus  strldn- 
Ina,  which  it  prohahlr  the  result  of  contraction  of  the  two  thyro- 
■rytenoW  ami  the  two  laleral  crico-nrytenoid  muscles  and  the 
arytenoideutt  niuifcle,  and  is  due  to  an  irritation  of  the  recurrent 
larrngral  nerve  Laryngisnius  stridulus  Eh  a  very  rare  affection 
in  adults,  and  when  it  oa*tirH  in  women  m  ummlly  hysterical. 
lo  men  it  is  of  very  serious  import,  as  in  moat  cases  it  depends 
npon  dangerous  organic  disease.  The  attacks  cnme  on  without 
warning,  and  may  occur  during  either  the  night  or  the  day.  In 
Ibe  mildeet  form  the  child  throws  itseSflwpkwardjjrrows  pale,  and 
makes  uneasy  movements  witli  its  extremities.  In  a  few  seconds 
liie  attack  is  over;  the  child  is  \e(t.  irritable,  and  is  sometimes  pnn- 
bheil  for  naughtiness.  Tn  the  more  violeut  paroxysms  there  is 
whistling  or  crowing  inspiration,  preceded  by  irriigiilar,  lalwriouB, 
and  audible  expiration,  or  even  by  a  momentary  arrest  of  respi- 
ration. In  the  severest  [wirdxysms  the  closure  of  the  glottis  is 
complete,  ho  that  the  thonix,  diaphragm,  ami  atiterior  alMlomiual 
ranaclea  remain  immovable.  The  child,  exceedingly  pale,  and 
with  a  wild  cxpreenion  of  anxiety  in  ttH  countenance,  throws  its 
,head  buck,  with  the  mouth  wide  o|icti,  and  tlie  nostrils  dilated. 
(The  face  now  rapidly  becomes  nyanolic  ;  a  cold  sweat  covers  the 

jrefaead,  and  the  blue  lipsi  puirse  out  in  a  manner  almost  path<^- 
'Domonic.     If  the  spasm  continue,  unconsciousness  and  convulsive 
symptoms  rapidly  ilevelop. 

The  muscfilar  contractions  may  take  the  form  of  tonic  cramp 
Tof  the  lower  legs  with  ab^luction  of  the  big  toe,  or  other  distor- 
tions about  the  feet ;  eonietinie.^i  the  aruiti  are  similarly  contorted. 

Id  rarely  general  tonic  and  clonic  convulsions,  with  involun- 
[taiy  discharges  of  urine  and  faeces,  occur.  This  condition  of  un- 
<Dn8ciousnes.s  and  coiivuli^ionB  may  la^it  from  a  few  seconds  to  two 
oinutee,  and  occasionally  ends  in  death.  Usually  crying  or 
whistling  inspirations  mark  the  beginning  of  (he  relaxatimi  of  the 
■paum ;  the  Irni^ular  inspirations  become  rapidly  normal;  the 
feeble,  quick  pulse  regains  its  ordinary  character,  and  the  general 
cyaDoeis  passes  off.  Very  frequently  after  lite  jiaroxytim  the  child 
gocB  to  sleep.     If  it  does  uot>  it  is  invariably  peeviah. 


132 


DIAOKOHTIC  KKUROLOGY. 


Lflrvngi'smns  8trk1ulii8  can  hardly  be  confounded  vntfa  anj 
other  dUcaso.  It  U  to  be  distinguished  from  catarrliftl  croup  by 
the  sudden  beginning  of  the  attack  ;  the  whittling  or  crowing  in- 
spiration ;  the  noisy  expiraiiun  ;  llie  increiiaing  cyanosis ;  the  fre- 
quent loss  of  conBcioiisness,  and  Kcrmral  oorivulsivo  plipnomcna; 
the  feverlfss  course;  the  short  duratinn  of  the  paroxysms,  and 
their  terniinatioo  through  convulsive  crowing  inspiration;  and 
eA{M!cialIy  by  the  absence  of  cough  and  other  evidences  of  catar- 
rhal inflainntatiot)  of  the  larynx  l>etween  the  paroxvani^.  In  the 
majority  of  oases  the  disease  ia  connected  wilii  rachilifi,  and  it  in 
closely  allied  to  rachitic  epilepsy.  In  some  caae«  the  spasms  seem 
to  be  due  to  ri'flex  irritation  from  teelliing;  or  they  may  he  ihe 
result  of  irritation  of  the  nerves  by  enlai-ged  glands ;  and  cs|iciniLlly 
ID  adults  it  IB  neccHsary  that  the  larynx  be  explored  for  evidences 
of  local  ulcerations.  In  extremely  rare  cases  the  symptoms  are 
said  to  have  been  dependent  upou  local  disease  of  the  medulla 
oblongata. 

Occupation  Neurosea. — Under  llie  name  of  oam)>aiion  neu- 
roses may  Iw  asnociateil  diseases  wliicli  are  connected  with  the 
excessive  u!<e  of  ItK-iilized  gn>up»  of  mu!?clei  in  business  or  pro- 
fessional occupation.  Itecausc  the  symptoms  ara  most  fmjnently 
aeen  as  the  result  of  the  exice^iiive  use  of  the  pen,  the  disease  is 
typified  in  the  soKullcd  writer's  cramp;  but  it  also  occurs  among 
tel^raphers,  dancers,  pianists,  workers  in  metal,  etc.,  when  it  is 
known  as  telegrapher's  cramp,  dancers  palsy,  hammer  palsy, 
etc 

The  symptoms  are  iindonbtedly  produced  by  the  excessive 
repetition  of  movements  requiring  exeefidingly  fine  co-ordination, 
and  diSer  from  the  simple  muscular  exhaiistiou  which  oouuiou- 
ally  is  produced  by  severe,  gross  mui^'uiar  efforts.  In  1H68, 
Moritz  Itenedicl  stated  tliat  there  were  three  forma  of  oocupt- 
tlon  neurones, — the  paralytic,  the  spasmodic,  and  the  treraulous. 
These  varieties  undoubtedly  exist  in  nature,  although  not  abso> 
lutely  separated  fmm  one  aDOtber,^the  dlstiuctiou  between  them 
being  simply  thut  in  some  casfs  the  panilytio  symptoms  are  most 
jnarlicd,  whilst  in  others  the  spasm  or  the  tremor  is  the  most 
pronounced.  According  to  my  own  obser\*ation,  the  paralytic 
form  of  the  affection  is  mncli  the  most  frequent,  although  some 
aiilliorities  assert  that  the  s[>asmodic  is  the  ordinary  variety. 


* 


I  shall  take  the  trrtfA^*  cramp  as  a  type  of  lh«  occupation  nea» 
Keen.  lu  Uie  paralytic  form  of  it  the  Hi-»t  syiuptoni  its  usually  a 
paiofal  feeling  of  fatigue  in  the  arm,  which  is  often  associated 
with  formications  and  nnmbness,  bnt  usually  not  with  true  anses- 
ibesia  or  hypenwthesia.  Only  in  rare  cases  can  tenderness  be 
found  over  the  ner\'e-trnnks.  The  pain  is  always  increased  by 
writing,  and  at  last  it  grows  ho  intolerable  jih  altogether  to  forbid 
the  use  of  the  pen.  With  this  fatigue  and  pain  there  is  usually  a 
tense  of  stiffiMSS,  and  often  ii  distinct  museular  resistance  when  the 
eflbrt  is  made  to  grasp  the  pen.  At  fir^t  no  pain  is  felt  when  the 
arm  is  not  used,  and  dui^ng  use  the  pain  is  confined  to  the  arm 
itaelf ;  but  by  and  by,  if  efToris  l>e  pereisteil  in,  the  Mcnse  of  fatigue 
beoomcs  more  or  less  permanent,  and  oxtendi"  upward  from  the 
'arm,  and  may  often  be  felt  as  a  distinct  pain  between  tlie  shoulders. 
Dunng  all  iliis  time  the  power  of  the  uiusclw  for  (.-oarne  work  it* 
in  most  eases  not  sensibly  impaired,  but  the  execution  of  any  form 
of  fine  wr»rk  is  usually  interfered  with. 

Even  in  the  paralytic  form  of  writer's  cramp  there  is  a  certain 
nt  of  irregular  spasmodic  contraction  of  the  muscles  during 
act  of  writing,  as  iB  csi«Hiially  ehowit  by  the  stiffness  and, 
OGcaatonally,  by  the  cramp  of  the  fingers  around  the  pen ;  but  in 
spasmodic  form  of  the  affection  irregular  muscular  contrac- 
are  the  dominant  symptom.  At  first  tliere  are  only  simple, 
slight  spasmodic  movements  of  the  thumb  and  first  Unger,  so  as 
to  produce  an  invgular  struke  in  the  writing,  but  after  a  time  the 
epoBins  become  stronger  and  more  wide-sjirend.  By  a  sudden  ex- 
temion  of  the  finger  the  |>en  Ls  drojiped,  or  by  a  spasmodic  action 
>f  the  opponens  ]x>lUcis  with  abductiou  and  coincident  flexion  of 
le  index  finger  the  pen  is  rapidly  moved  from  the  ])apcr,  ur  ou- 
>casioually  a  violent  spa^^nitHlic  flexion  of  all  the  cunivnied  fiiigera 
loMs  the  pen  as  in  a  vice.  In  extreme  cases  all  the  maseles  of 
(he  forearm  are  involved;  and  it  iii  a.<serted  that  the  muscles  of 
['tile  ana  and  shoulder  may  be  uficcted,  ultliuugh  I  have  never  seen 
lao  instance  of  this. 

Much  tlie  rarest  form  of  writer's  cramp  is  that  Iti  which  tremors 

lire  the  most  prominent  manifestation.      When  any  atleiupt  to 

Iwrite  is  made,  Irenibliogs  in  the  hand  and  forearm,  and  in  extreme 

instances  in  the  arm   itself,  iitnic  on.      The  ]>cu,  following  the 

tremora  rather  than  the  eflbrt  of  the  will,  soon  makes  nothing  but 


DlAOSOSTtC  XBUROLOOY. 


irrq^iilnr  uudulating  or  angular  ntrokot,  in  which  not  even  the 
vestige  of  n  letter  atii  ite  made  ont.  I  have  never  seen  a  case  in 
which  tremors  existe*!  a»  the  mU  ttymptnni,  bul  I  have  seen  thtm 
very  marked  in  the  8)uisiuo()tc  form  of  telegrapher's  crarap,  and 
have  noted  their  (wreLsteiice  during  almost  all  forms  of  voluntary 
movement,  even  after  the  occii|)ation  bad  been  abandoned  for 
months. 

The  symptoms  of  writer's  cmmp  naturally  lead  to  the  sappo-l 
sition  Uiat  it  is  a  |>cripheral  afleetion;  but  llmt  it  h  intimately 
connected  with  a  dtscntered  condition  of  the  nervc-oeutrcs  is  indi- 
cated by  the  fact  that  when  the  victim  atteinpbt  to  subHtitntc  the 
left  band  for  the  right  the  cramp  appears  iu  that  member  ako; 
and  also  by  the  ciroumstaoce,  which  I  have  repeatedly  noticed, 
that  it  may  be  the  flntt  symptom  of  a  general  break-down. 

Cortica]  Spaems. — Any  of  the  muHclos  of  the  extremities 
of  the  trunk  may  l>o  atfct^ted  with  a  lof-al  spa»m.     Snoh  ttpasms' 
may  be  due  to  disease  of  the  cerebral  cortex.     The  nature  of  soch 
attackN  IK  to  be  recognized  by  the  oecasii>nal  o<xrurrence  of  Jack- 
sonian  epilepsy,  or  by  tlie  prcsenoe  of  other  indieatious  of  disease 
of  the  cerebrnm. 

Hystericai  Spasms. — Localizeil  s{)asmis  are  frequently  hysteri* 
cal.  The  nature  of  such  a  gpasni  is  to  be  recognized  by  its  appar- 
ent cantwleBsnei<H,  by  its  sudden  onset  and  departure,  and  by  the 
prespjico  of  other  hyslerical  manifestations,  and  the  abscnoe  of 
evidence  of  organic  dJM'iuK  of  the  brain,  spinal  cord,  or  nerves. 

Inflammatory  Spasms. — Localized  spinal  meningitis  and 
spinal  tumors,  by  irritating  nerve-roots,  may  give  rise  to  tonic  and 
clonic  spasm  of  the  muscles  tributary  to  such  nerve-roots.  The 
cause  of  such  contractions  is  to  be  recognized  by  the  presence  of 
pain  and  vertebral  soreness,  either  ujxtu  direct  or  indirect  pressure, 
or  of  other  symptoms  of  diseiuie  of  the  spinal  membrane  or  of  the 
vertebnc.  Again,  rheumatic  coiitnictions  of  the  muscles  may  be 
mistaken  for  true  local  spasms  :  the  diagnosis  under  these  circuro- 
stances  in  to  lie  made  out  by  ol^erving  the  presence  of  exceeuve 
pain  u[K>n  pasuive  or  active  motion,  tenderness  upon  pressure, 
achiag  pains  in  the  part  when  at  rest,  and  otiier  evi'deiiceH  uf  rheu< 
matic  disease,  either  in  the  present  or  the  |ML<<t  hlttory  of  the  case. 

Beflex  Spasma. — Someliiues  local  spasm  Is  of  reflex  origin. 
~'he  rect»gnitiou  of  these  retiex  spasms  is  often  a  very  important 


aid  to  the  pmotitiouer  in  diagn*ising  .siiliacute  disease  of  the  joints 
or  of  tlie  vcrtclirul  rolmiin.  In  any  riase  of  fltiepwtel  joint  or 
Tcnebral  diaease,  a  close  examination  should  be  made  m  to  the 
power  of  motioD  in  the  part:  thus,  the  patient  in  whom  inuiptent 
caries  of  the  r^pinal  txird  ia  flnKpix-tet]  niioult]  he  fitripiHxl,  Ktood  np 
with  the  feet  close  tf^ether,  and  then  required  to  bend  forward, 
backward,  and  laterally  a.4  far  ax  poiwible.  If  it  be  found  that  the 
muscles  of  the  back  are  thrown  into  Bpasm  by  any  of  these  move- 
ments,  the  existence  of  local  disease  of  the  bone  is  ven,-  probable, 
The  preftenoe  of  the  niiisctilnr  fi|juut[ii  mn  sometimes  be  iimile  ont 
whcQ  otberwiae  it  might  be  overlooked,  by  noticing  that  the  move- 
ments in  some  one  direction  are  ver)-  miicli  more  restricted  than  is 
Qoruial. 

Apparently  Caueeless  Spasms. — A  localized  spofim  in  the 
trunk  or  extremities  which  is  not  hyMleric-nl,  and  for  which  no 
definite  cauKc-  can  bo  assigned,  should,  if  persiatont,  be  viewed  with 
great  suspicion,  as  it  may  be  a  manifestation  of  a  hidden  incipient 
centrio  disorder.  There  are,  however,  oisea  in  which  no  cause  for 
a  lotal  spaam  can  be  made  out,  although  the  spasm  may  be  abso- 
lutely intractable  to  treatment.  Thus,  I  have  seen  a  robust  man, 
without  discoverable  disease  of  the  genital  or  other  organs,  and 
without  history  of  sexual  or  other  excesses,  iu  whom  the  testicles 
were  frwjueutly  drawn  u}>  Ijy  spasm  of  the  crcniaster  muscle  with 
80^  force  as  to  cause  iiickness  of  tlic  stomach  and  syncopal  sensa- 
tions from  the  violence  of  the  patn. 


1  shall  not  occupy  space  with  details*  of  Lhe  various  distortions 
or  irrc^lar  movements  produced  by  spasms  of  the  extremities. 
The  reader  who  is  desirous  of  tra<>ing  a  iipa<tm  in  any  individual 
case  to  the  afi*ected  oerve  and  miiscle  is  referred  to  the  pages  upou 
local  palsies. 

A  spasm,  of  course,  causes  phenomena  which  are  the  reverse  of 
those  prodw«d  by  the  correspondiug  palsy:  thus,  a  spasm  which 
prodm-es  abduction  of  the  hand  is  due  to  an  irritative  lesion  of 
the  muscle  and  nerve,  wJiose  palsy  muses  loss  of  the  power  of 
abduction. 

There  are,  however,  certain  muscular  territories  belonging  to 
cenbraJ  nerves  in  which  spasm  is  so  frequent,  so  severe,  and  80 
tudden  in  its  causes  as  to  require  special  notice. 


136 


DlAOSOSnC  yETROLOOY. 


Facial  Nerve  Spaam. — First  araon$^  tlic^c  f^phalic  spasmodic 
affections  U  that  wliicli  affects  tlie  distribution  of  the  farial  uerve. 
Wbea  tipabm  uf  the  oiuR-les  of  tiie  fais  i6  at'<:'Oinpanied  Uy  paia, 
it  is  spokon  of  aa  tia  douloureux  ;  when  there  is  no  pain,  the  spasm 
is  known  simply  as  (w. 

Tlie  contntiL-tioi].s  of  a  tic  may  aEEect  all  the  muscles  of  expres- 
BiOQf  or  may  be  limited  to  a  very  few  of  tbem.  lu  the  violent 
tyjw  of  the  disorder  there  is  &x\  itiL'^B^antly  repeated  clonif  spasm 
of  the  mtisclea  of  one  nide  of  the  fat'c,  <^using,  in  i^crpctual  sno- 
oession  and  alteraaltun,  winking,  wrinkling  of  the  forehead,  move- 
ments of  the  uose,  and  even  of  the  ears,  drawing  upward  and 
downward  of  the  angle  of  the  mouth,  etc.  Usually  the  (5t>nvul- 
aivc  movements  occur  in  paroxysms,  lasting  from  a  few  seconds 
to  as  many  minutes,  then  gradually  subsiding  into  quiet,  which 
persists  fur  a  greater  ur  lesss  length  of  time.  Sometimes  the 
periods  of  relaxation  are  very  brief,  or  may  seem  altogether  want- 
ing. The  paroxysms  vary  in  number  from  two  or  three  in  the 
twenty-four  hours  up  to  thirty  or  even  forty  an  hour.  They  are 
tisually  mild  during  the  night,  aud  soiuetimes  disappear  entirely  ^ 
when  tlie  patient  steeps. 

Grassct  asserts  tJiat,  aceonling  to  .laocoud,  sueh  eesRation  is  a 
proof  of  the  retlex  origin  of  the  spasm  ;  but  I  believe  that  this  is 
not  (x)rreut.  Although  almost  any  of  the  mustles  supplied  by  the ' 
facial  nerves  may  l)e  affected,  the  spasms  are  especially  prone  to 
attat-k  the  orbicularis  pal}>t'brarum,  the  levator  labii  superioris 
alGcque  nasi,  tlu:  z)'goraatici,  and  the  <^rrtigatnr  ^upeiT-ilii:  more 
rarely  the  frontalis  or  the  platysma,  and  still  less  frequently  the 
muscles  of  the  ear,  are  attacked.  The  stylo-hyoid,  the  digastric, 
and  the  velniii  pnlali  are  very  rarely,  if  ever,  affected. 

In  some  cases  (in  my  ex|>crience  especially  when  the  attack  \s 
hysterical)  the  motor  disturWnt^  involves  the  various  neighboring 
nerves.  If  the  motur  root  of  the  trigeminus  sympathize,  the 
muscles  of  mastication  are  violently  convulsed,  so  that  the  jaws 
an-  jamnipd  togirlher;  and  If  at  the  same  time  there  exists  a  uni- 
lateral spasm  of  the  pterygoids,  the  teeth  are  violently  ground  on 
ouc  another.  If  the  hypoglossal  nerve  is  affected,  the  tongue  is 
thrust  in  and  out  of  the  mouth,  and  may  bo  caught  and  sevei-ely 
bitten. 

Id  a  proportion  of  the  cases  of  facial  spasm  certain  points  can 


*: 


be  fotind,  premure  upon  whicli  will  itnoiedialcly  rause  cessation  of 
the  spasm.  Those  points  usually  oorrespond  to  the  situation  of  the 
Valleix  points  in  trigerainal  neuralgia.  Thpy  may  oa-ur  in  every 
brmnrh  of  the  Irigeuiinus,  on  the  nkin  of  the  fuoe,  and  in  the  cavity 
of  the  moath.  Kemak  has  called  attention  Uj  tlie  fact  tliat  prwB- 
npe  a|)on,  or  galvanic  irritation  over,  the  transverse  processes  of 
Uiecer\'ical  spinal  (.'olunin  will  sotnetintes  arrest  the  !«pasm.  Occa- 
aiooally  these  pressure- points,  which  should  be  diligently  searched, 
for.  may  be  found  in  more  remote  part^  of  tlie  body.  The  actioo 
of  preasnre  upon  the  points  of  arrrat  is  much  more  pronounced  in 
blepharo8pA.4m  than  in  the  more  difiiiHed  cases.  Under  these 
drcuminances  the  eyes  will  fretjueutly  fly  open  a&  tliough  a  spring 
had  been  tooched  liberating  a  slmtcer. 

The  facial  fonvulaions  are  in  some  tau^s  limited  to  isolated 

moaclea;  the  orbieularia  palpebrarum  is  especially  prone  to  suffer^ 

giving  rise  to  the  affection  known  as  htepharogpami,  whose  history 

ms  so  elaborated    by  Von   Graefe.     The  contraction   is  tonic, 

caosing  a  complete  closure  of  the  eye,  and  consequent  blindness, 

This  is  accompanied  by  innumerable  bizarre  grimaces,  due  to  tlie 

vflorttt  of  the  antagouislic  muscles  to  overcome  tlie  force  which  is 

dosiug  the  lids.     The  tonic  spoem  may  lost  for  but  a  few  mo- 

entfi,  or  it  may  conlinne  nltmwt  without  relaxation  for  wcyks. 

;  is  prone  to  be  excitetl  by  sudden  exposure  to  light,  by  loud 

loiscs,  or  by  any  emotion.     Blepharospasm  is  usually  ofiincidejit 

with  photophobia,  and  is  generally  reflex,  due  to  Borao  local  in- 

tion  of  the  eye,  or  more  rarely  to  carious  teeth,  to  ulcero- 

in  tlie  mouth  or  throat,  or  to  Home  other  local  irritation  at  a 

point  distant  from  the  eye. 

Aootlier  form  of  local  spasm  of  (he  orbicularis  ocnli  is  the 
BO-nUled  niditatiiit/  yptum.  It  differs  from  blepharospasm  chiefly 
in  being  clonic,  so  that  the  eye  is  rapidly  o|iened  aud  shut,  instead 
of  being  held  firmly  closed. 

Vaso-motor  and  trophic  changes  very  rarely,  if  ever,  aoeompany 
fadal  spa&m. 

^K  Tonic  spaf^m  of  all  the  facial  muscles  is  spoken  of  by  some 
^B  «rriter<«,  but  in  the  majority  of  case^  hucIi  alleged  touic  spasm  has, 
^■in  all  probability,  been  doe  to  contractures  following  paralysis. 
"  (See  Contractures.) 

In  any  case  of  facial  spasm  it  is  the  duty  of  the  practitioner  to 


DtAONOHOTC  SEITBOtOaV. 


endeavor  to  dteoovpr  the  caiiRc.  It  may  he,  Sret,  rcilex;  secondly, 
rlieumatic:  thirdly,  due  to  hysteria,  or  to  a  general  neurotic  con- 
dition of  the  system  ;  fourthly,  the  expression  of  a  cenlrio  di»f&-se. 
The  reflex  spasm  lia»  lieen  noted  as  being  produoeil  hy  fiieial  sur- 
gioal  trnuniatisnis,  hy  tumor*  and  disease  of  the  bone,  by  enlarged 
lymphatic  ghimls,  jtarotid  alisccsses,  diseases  of  the  teeth  and  jaw, 
and  various  irritations  of  more  disCanL  portions  of  the  body,  such 
as  nterine  disease,  intestinal  worms,  etc  In  nmny  of  these  cases 
the  spoi^m  slicuild  perhaps  \k  [:unFiidered  as  due  tu  a  dirGct  irrita- 
titm  of  the  iaeial  nerve  rather  than  as  reflex.  The  nature  of  a 
reflex  facial  siiosm  is  to  \ye  rccfygnixcd  by  finding  the  point  of 
irritation  and  noting  the  efTec-t  of  !t«  removal. 

1  have  used  ihe  term  rheiimatie  to  cover  the  class  of  cases  in 
which  the  spasm  is  prei^i [iltatetl  by  exiHieure  to  ould  and  wet.  It 
is  prolfflble  that  under  these  rireumstanccs  there  is  a  neuritis,  and 
that  the  nerve-trunk  would  be  found  sensitive  on  j)ressure.  I 
have,  however,  no  periional  evidenoc  to  o0er  ou  this  point,  and 
have  not  been  able  to  find  any  In  literature. 

The  liysterical  furm  of  the  disorder  is  to  Iw  recngnised  by  tlie 
presence  of  a  neurcUc  or  hysterical  temperament  and  the  ah^euee 
of  other  cause.  As  already  stated,  this  form  of  the  spasm  is  par- 
ticularly apt  to  involve  contiguous  muscles,  and  it  is  eyi)«'ially 
character Utie  that  at  times  s|>asms  of  these  muscles  should  re- 
place those  of  the  facial  territory. 

Spasm  of  the  facial  nerve  due  to  oeotric  disease  is  the  result  of 
an  irritating  legion  cxistiug  either  in  the  ucighborbfHKi  of  the 
facial  nucleus  or  in  that  of  the  nerve-trunk.  It  is  especially  apt 
toocH'iir  in  syphilitic  dlsca-se.  Theserioa'*  nature  of  organic  facial 
spasm  ia  UMtally  recognized  without  difficulty  by  its  beiug  asso* 
ciated  with  ootusioual  epjleptiu  attacks,  or  with  other  evidences  of 
cerebral  implication.  Not  rarely  tlie  <>eniriu  facial  sfiasni  ought 
to  l>e  looked  on  as  part  of  a  Jacksonian  epilepsy. 

Finally,  there  Li  a  residuum  of  oases  of  farsial  Rjuutm  in  which 
DO  cause  can  be  assigned  for  the  spasm.  Under  these  circum- 
staneas  there  is  probably  some  degeneratiim  uf  the  facial  nucleus. 

Spinal  Aoceeeory  Spasm. — Spasm  of  the  muscles  supplle<1 
by  the  spinal  a4':ce^^^ory  nerve  constitutes  the  Tie  rotatoire  of 
French  and  the  Tic-h-ampf  of  German  writers,  and  is  not  ex- 
tremely rare.     In  the  majority  of  cases  it  is  unilateral,  but  not 


MOTOR   EXCITEMENTS. 


139 


infrequenlly  it  ie  b!lalei-at,  ami  iniplical«8  the  musolcfl  of  each  mle 
of  tli«  net'k.  The  8ternu-cleitli>- mastoid  ruuBcle  may  be  affwted 
eiihcr  alone  or  as  a  co-sufferer  witli  the  trapezius  muscle.  By  the 
'oontToriion  of  the  stern o-oleirli> mastoid  of  one  alric  the  occiput  is 
drawn  bai^kward  aud  tuwardti  the  affected  muacle,  so  that  the  chin 
is  throwD  upward  and  towards  the  normal  side.  At  the  same  time 
tlie  head  U  Iwut  over  so  that  the  ear  is  brouglit  ueiirer  the  chivide. 
When  the  trapezius  is  alone  affected,  the  head  i^  drawn  backward 
and  towarilii  the  mntrnctof]  muscle  without  i-otation  of  tlic  chin, 
whilst  the  slioulder  ia  raiiml  and  the  scapula  brought  nearer  to 
the  vertebral  oolamn. 

Contraction  of  the  trapezius  without  impllialinn  nf  the  sterno- 

idodo-maatoid  is  unusual,  but  it  is  common  for  the  trapedus  to 

Icscftiw  in  part  or  entirely.     When  tlie  mu.scles  are  fitmnltaneously 

oonlracteO,  the  movements  produced  by  each  of  them  are  combined 

in  various  proportions,  aocording  as  one  muscle  or  the  other  is 

more  violently  affectetJ. 

The  spasms  come  on  in  frequently-repeated  parox)'8ma,  which 
often  frightful  in  their  violence.  They  u.sually  WJise  during 
>,  aud  are  inient^iltetl  by  euutMoi)  or  any  kiml  of  diKturliacic^. 
In  the  severest  cases  the  patient  is  disabled  during  the  parusysin 
from  Lilking  or  performing  any  notion.  There  m  almost  invariably 
more  or  less  suffering  duriug  the  paroxysm,  and  in  some  cases  the 
pain  is  terrible.  It  seems  to  me  that  there  are  as  clearly  two  forms 
of  tic  roiatoire,  a  painful  and  a  nnu-|minful  spinal  aocegaory  spasm, 
u  there  are  of  tie.  It  is  very  rare  to  Hud  |>uint<4  uputi  which 
pressure  will  arrest  the  paroxysm ;  on  the  other  hand,  I  have 
noted  painful  points,  pressure  upon  which  induL'ed  [paroxysms 
of  horrible  intensity.  There  is  a  very  distinct  tendemy  for  the 
spinal  accessory  H[K)Bm  to  overflow  into  the  spinal  <-crvi(-Al  region; 
ind  in  a  ease  in  which  I  had  both  spinal  acoessory  nerves  cut  tbo 
a»nvulsions  continued,  although  In  a  touch  modified  form,  evi- 
liently  thruugh  tliespiniil  uerves. 
The  causes  of  spinal  Bccest<ory  spasm  are  usually  extremely 
mdite.  It  probably  may  lie  reflex,  and  it  certainly  may  be 
meal,  but  in  the  great  majority  of  cases  no  point  of  irritation 
cut  be  found,  and  no  evidences  of  centric  disease  cau  be  discov- 
The  extreme  ohwiinacy  of  the  affection  indicates,  however, 
liat  it  is  due  to  aomc  obscure  degeneration  of  the  nerve-centres. 


WAGs-oerrc  yEuaoLoov. 

Wry-Neck. — Tonio  »pnam  nf  the  sternft-ckido-niastoid  muscle, 
aiifl  con&etnient  fixeJ  toiticullis,  or  wry-neck,  la  usually  rbeunoatic. 

I  have  .seen  a  severe  tcrtioi)Ilis  produced  in  childixm  by  enlarge- 
ment of  the  cervical  glauils,  probably  as  the  reMittof  a  direct  irri- 
tiition  of  !lie  nerves.  In  some  of  these  cases  care  ie  necessary  to 
avoid  being  mi!(l«<l  into  believing  th&t  a  centric  dlisease  exists,  be- 
cause the  pupil  upon  the  diseased  side  may  be  alfcctcd  by  press- 
ure n|Kjn,  or  by  irritation  of,  the  Byinpotbettc  nerve  fibres,  which 
accr)nijMiny  the  carotid  artery  and  its  branches  through  the  skull 
and  orbit  into  the  eye. 

TREMORS. 

TremorB  may  be  defined  to  be  involuntary  oHcillatory  inove- 
mcuta  which  are  produced  by  somewhat  rhytliraica!  ultefnate  con- 
tnirtioDs  of  antagonistic  nui^w^Ics  and  do  not  prevent  voluntary 
QAtiond.  They  are  normally  present,  to  a  certain  degree,  in  niauy 
oenrudc  peraous,  iu  wbum  they  are  iucruased  by  exuessive  luental 
or  plivsiciil  work,  by  tlio  frcp  nse  of  tobacco,  coffbe,  or  tea,  and  by 
any  other  ot^tiun  or  agency*  wliich  tends  to  increase  "  nervousness." 

Pathological  tremons  may  be  due  to  wrtain  poisons,  to  ibe  al- 
teratious  of  old  age,  lo  the  so-tallcd  Parkiuaoo's  disease  or  |>araly- 
sis  agilaus,  to  multiple  cerebro-spinal  sclerosis,  to  general  paralysis 
of  the  iuBani',  and,  i[i  rare  cases,  to  focal  diseases  of  the  brain. 

Senile  Tromora. — Senile  tremors  usually  are  developed  at  an 
advanced  age,  alibough  in  some  cased  they  are  manifested  in  early 
middle  life,  particularly  under  au  hereditary  influence.  Their  or- 
dinary development  is  gmdnal.  In  most  cases  they  are  first  seen  in 
the  muscles  of  the  nook,  or  in  the  arms,  from  which  tbcy  slowly 
spread  to  other  portions  of  the  Ix)dy.  During  absolute  repoee 
they  are  naturully  absent ;  but  even  the  elfort  of  extending  or  sup- 
portinga  lirab  causes  them  to  reappear.  They  are  nsually  ioereasod 
by  excitement,  mental  or  physical.  The  most  characteristic  symp- 
tom is  the  oscillation  of  the  head,  which  ts  often  accompanied  by 
trembliugsofthetongue  and  of  the  lower  jaw.  In  advanced  cases 
the  muscled  of  respiration  participate  so  that  the  speech  is  affected. 
Senile  tremors  arc  usually  aocomjtaiitcd  by  a  very  gradual  failure 
of  muscular  power,  but  there  is  no  true  palsy. 

Toxic  Tremors. — According  to  Lafout,  kad-pouonmff  is  some- 
times avoouipanieU  by  tremors,  whose  origin  Js  indicated  by  their 


I 


MOTOR   EXCITEUEKTS.  141 

;  Wing  much  worse  at  the  end  of  the  da^.  It  is  affirmed  thaC  in 
BOtne  oases  these  iiaturuine  tivmont  arc  exccc(]ing]y  violent  and 
acute.     Muscular  oDiilractility  is  said  to  remain  intact. 

Tremors  are  said  also  to  lie  a  markisi]  phenomenon  in  chronio 
vtereurial  poi«oning.  HalIo]»cau  slates  that  in  workers  in  mer- 
cury they  are  a  very  constant  symptom,  and  are  transmitted  to 
the  children.  Tbey  usually  begin  as  a  very  fine  tremor  of  the  lips, 
tongue,  and  extremities,  gradually  becoming  more  intotiiie  until 
they  are  excessive.  In  some  cases  they  have  come  on  suddenly. 
During  repoRC  the  afiecte^l  tinibn  are  quiet,  but  tlie  moment  any 
attempt  is  made  towards  voluntary  movement  the  tremors  appear : 
90  that  there  is  a  sioiuhition  nf  multiple  C(rrebro-t«piiial  solerofiis. 
Tbo  tremulousiicKfl  of  the  tongue  it;  said  to  be  exceedingly  eon.stui]t, 
land  to  produoe  a  peculiar  staccato  and  hesitating  speech.  The 
h«ad  is  quiet  until  very  late  iit  the  disorder.  There  is  usually 
insofunia;  eometimcs  there  are  true  clonic  convuhiionij.  The 
diagnosis  must  rest  chiefly  upon  a  knowledge  of  exposure  to 
mercurial  vapnrR. 

Tremors  are  constant  and  characteristic  in  chronic  alcohotlmi. 
They  resemble  somewhat  those  of  old  age,  but  their  true  nature  is 
revealetl  by  their  being  markcfily  woree  in  the  early  morning;  by 
their  being  increased  by  al)stinence  from  drink  and  qnletixl  by  a 
potation ;  and  by  their  ac<'omj>anyiDg  other  symptoms  of  chr<inic 
alcoholism.  (See  page  27,)  They  are  commonly  worse  in  the  hands 
than  in  any  other  portion  of  the  body.  In  old  drunkards  the  alco- 
holic ti«mor  mcrj^cs  insensibly  into  tho  phenomena  of  senility. 

Paralysis  A^tans. — The  eliaracteriatic  phenomena  of  pa- 
ralysis agitans,  or  PHrkins(in'>i  diiiease,  are  tremci*s,  progreftsive 
failure  of  jiower  in  the  ailocltflJ  muscles,  slowly-developed  moder- 
ate rigidity,  and,  in  the  mo.st  ndvamied  stages,  peculiar  alterations 
in  the  habitual  [KisitiotiH  of  the  l>ody  and  in  the  gait. 

Paralysis  agitans  usually  comes  on  insidioa^ly  and  gradually, 
although  in  some  ca«es  the  symptoms  have  developed  at  once  after 
a  suddeu  fright  or  other  emotional  storm.  The  attention  of  the 
patient  is  first  attracted  hy  a  tremor  in  (he  hand  or  foot,  or  even 
in  one  Bnger  or  toe.  This  tremor  at  first  is  tmnsitory,  can  be 
controlled,  at  least  temporarily,  by  an  effort  of  the  will,  and  is 
suspended  by  voluntary  movement.  Little  by  little,  without  any 
fixed  method  of  progression,  it  involves  more  and  more  of  the 


J 


143 


DlAGNOfiTIC  SEDBOLOQT. 


body,  beoomes  more  and   more  settled,  and  at  last  coDtiDaMJ 
thratighout  iill  the  waking  liuui?,  during  repose  els  well  as  during 
action,  and  cannot  Ihj  ormtnillod  at  ail  by  tlie  will.     It  often  [>af«QS  j 
up  the  arm  first  invaded,  and  then  descends  to  the  lower  limb  of  ^| 
the  same  side,  TOnstitutinig  the  liemtpleglc  furra  ;  or  it  may  com-  ^^ 
mence  in  a  leg  and  pass  across  the  l>ody  to  the  opposite  le^,  and 
produce  H  para|ilegic  variety.     Finally,  alt  portious  nf  the  Iwdy 
are  affpctod  excopt  the  head.     The  fat*  is  very  rarely  attacked 
by  the  tremors,  nlthongli  in  tlie  later  stages  it  puts  on  a  peculiar 
fixed,  immovable,  usually  nieUncbolic  expression.     Aooonling  to 
Charcot,  the  head  \a  never  affected, — any  ap]>urent  tremblio;;  of 
it  heing  dne    to  the   tmnaraission  of  motion    from    the   trunk. 
Tlitfl  al»olute  assertion  is,  however,  not  correct,  as  I  have  tsccQ 
typical  cases  of  paralysis  agititus  iti  which  the  muscles  of  the  neck 
and  the  liejui  were  in  constsint  tremor;  and  Westphal  {ChanU 
Ann.,  1877,  p.  405)  is  said  to  huve  reported  Rtmilar  cases.     Loss 
of  power  in  the  lipe  seems  to  be  not  infrequent  in  the  advanced 
I,  ao  tliat  there  is  a  tendency  to  dribbling  of  the  saliva,  a 
"tendency  which  is  also  in  part  due  to  the  peculiar  prone  ]>03ition* 
of  the  head.     The  speech  betwmes  a  little  slow  and  laboretl,  but  is 
not  profoundly  affected  :  neither  eating  nor  swallowing  is  inter- 
feretl  with. 

The  tremors  themselves  are  short,  very  niptd,  and  in  some  cases 
diRtinctly  rhytlirnical,  C8|>ccially  in  tlie6ngers,  where  they  may  as- 
aume  somewhat  the  appearance  of  voluntary  actions,  as  though  the 
patient  were  nilling  Bomething  Iwtwoeri  the  digits.  1  have  noticed 
in  some  cases  a  distinct  tendency  of  the  tremors  to  alter  their 
rajiidity  in  accordance  with  any  rhythmical  sound,  so  llial  tlieir 
rapidity  could  be  regulated,  without  the  patient's  being  conscious  of 
it,  by  altering  the  rate  oi'  vibration  in  the  interrupter  of  a  faradic 
battery.  A  |)ec-uliar  rigidity  of  the  rauscies  is  characteristic  of  the 
advanced  stagt?-.  There  are  uo  violent  contractures,  but  a  char- 
acteristic fixation  uf  the  part.  To  tliiti  statiie-like  rigidity  is,  at 
leaAt  in  some  meaijiire,  due  the  portion  of  tlic  palient.  In  stand- 
ing the  trunk  is  inclined  forward,  with  the  face  loi^king  obliquely 
dowuwar^l ;  the  forearms  usually  Hexed  somewhat  ujwn  the  arms; 
U)i;  hands  a  little  bent  upon  the  forearnts,  and  the  Sngcrs  partially 
closed,  so  that  the  hands  assume  a  position  similar  to  tJiat  in 
which  the  pen  is  held  :  hence  the  term  of  "  writing  hand"  as  given 


MOTOR  EXCITEMENTS. 


by  OioTcot.  The  Bome  tendency  to  flexion  of  the  legs  exists,  so 
Ui»t  in  standing  the  knees  are  bent.  Ococasionally,  peeiiliar  dis- 
tortions of  the  liaud^  or  other  tortious  of  itie  body  niuy  be  met 
with.  On  attempting  to  restore  the  normal  position  of  the  parts, 
the  mti^icle  usually  offem  but  little  reRijitance  until  the  refttomtion 
is  nearly  perfected. 

The  power  of  njakioj;  momeutary  muscular  eflbrts  diminiBhes 

very  slowly  in  [wiralysis  agitana,  but  even  early  in  the  difieaHe 

fildj^c  follows  moderate  exertion,  so  that  there  is  soon  a  g:rcat  loss 

of  endurance.     In  not  rare  camen  there  is  a  market]  teiuletiny  to 

fmthhathnin  the  walk^— 1.<.,  toa  progressive  increase  in  the  rv 

pidity  of  tlie  ^it.     The  man  seems  to  be  in  eontinual  danger  of 

falling  fonvanl  when  attempting  to  walk,  .^iO  tliat  the  h^  has  to  \ie 

thntst  forward  more  and  more  quickly  in  order  to  prevent  top- 

pling  over,  and  the  walk  lierameA  more  »nd  more  rapid,  and  in  a 

little  while  brcttkit  into  a  run,  which  growg  faster  and  faster,  unUl 

.      the  patient  either  falls  or  arreHts  his  course  by  seizing  hold  of  some 

^ktationary  object.    Thi>  peculiar  iKisilion  of  the  iKxly  would  appear 

^■ko  be  the  cause  of  the  accelerated  gnit,  the  head  being  thrown  so 

Vfiu-  forwonl  as  to  bring  the  centre  of  gravity  beyond  the  line  of 

the  feet.    Thattlie  festination  dejwnds  upon  sonierhiiig  mor»  than 

thii«  is,  however,  shown  bv  the  fact  that  there  are  cases  in  which 

the  tendency  is  to  run  KickwaiY]  instead  of  forward.      Moreover, 

a  very  markedly  bent  jwsition  is  not  inoomjiatible  with  a  normal 

gait. 

Seoaation  is  not  profoundly  affected,  and  in  some  cases  there  is 
very  little  sufTcring.  Usually,  however,  especially  as  the  disease 
advances,  there  is  a  perpetual  eense  of  fatigue  in  the  affectetl  mus- 
cles, which  may  amount  to  a  severe  aching.  Very  frequently  the 
patient  complains  of  an  habitual  feeling  of  exceesivu  heat,  which 
also  may  lie  mantfcHled  by  a  continual  sweating.  This  sensation 
of  heat  docs  not  depend  upon  any  elevation  of  the  central  bodily 
temperature,  which  is  of  normal  intensity.  The  studiei  of  GrDxaet 
aud  Apollinario,  however,  indicate  that  there  is  an  elevation  of 
iht^  tera[»entture  of  the  external  surface  of  tlie  IkhIv.  These  oli- 
servers  found  that  whilst  the  temperature  of  the  surface  of  the  fore- 
arm in  the  normal  individual  was  33.6°  C,  in  a  case  of  paralysis 
agitans  placed  under  similar  conditions  of  clothing  and  exposure 
the  temperature  was  36.^'^  C 


Tlie  urine  lias  hcen  chemically  analvKed  by  Regnard  (Proffrit 
M(*I.,  1877),  who  fouod  the  urea  uomml,  tlie  sulpbaUe  l«e»  lliau 
normal.  Acconling  to  Clieron  {Progria  Mfd,,  1877,  No.  48), 
there  is  a  constant  incnnsc  in  thequantity  of  thephwi|)hatefl,  which 
is  characteriRtic,  and  may  even  jji-ecede  the  development  of  the 
trcmon.     This  imiwrtniit  uhservation  ueed»  confirmation. 

The  course  of  paralrsis  agjtans  requires  many  years  for  its  fall 
development,  but  if  the  [mtient  does  not  die  of  an  intercurrent 
dixorrler  he  parses  into  a  condition  of  hy[)ocltondria>^i.<),  great 
depre^ion  of  spiritn,  lass  of  intellectual  power,  general  failure  of 
Qutritton,  markt^d  vmaci&tion,  loss  of  digestive  power,  and  ^neral 
mamfltiiu»,  and  at  last  dies  uf  exhaustion,  tlio  end  often  being 
hastened  by  bed-sores  nr  other  local  ailments. 

Multiple  Cerebro-spinal  ScleroBis. — The  tremors  whicli  are 
pre«eut  in  Diultipie  cerebro-^ipioal  sclerosis  are  characterized  by 
their  complete  alKience  not  only  during  sleep,  but  also  during 
repoac.  fn  mo^l  cases  the  quiet  sitting  with  the  hands  in  tlie  lap 
aufltcca  to  puta-jideall  trembling,  but  in  other  instances  it  is  ueccfr- 
sary  to  put  (Jie  patient  to  bwl  in  order  to  get  a  muscular  rest  suffi- 
ciently abBolute  to  allow  complete  cessation  of  the  tremors.  When 
anv  movement  is  made  the  treniora  appear  first  in  the  jrart  that  is 
in  action,  hut  in  most  oists  they  in  a  little  time  spread  throughout 
the  body,  so  that  the  simple  effort  of  writing  may  produce  trem- 
blings in  every  part  of  the  organlem.  In  contradistinction  to  or- 
dinary cases  of  paralysw  agitaus,  the  tremors  especially  affect  the 
head.  They  are  alway»4  nsi^uoialed  with  a  niort;  or  less  pronounced 
palsy  of  the  affoctcd  part. 

In  roost  cases  tliere  are  some  indications  of  disturbance  of  cere- 
bration, such  us  lutw  of  memory,  or  of  the  power  of  Bxing  the  at- 
tentton.  As  lhesym])toms  depend  upon  the  existonoe  of  isolated 
patches  of  chronic  inflammatinn  or  sctero^tis  in  the  brain  and 
spinal  cord,  it  is  apparent  tliat  the  cei-ebral  and  spinal  symp- 
tomi(  which  accompany  the  tretnora  must  vary  almost  indefinitely 
according  as  the  exact  seat  of  the  sclerotic  [xitdies  varies.  The 
degree  of  mental  impairment  ts  in  direct  projHirtiou  to  the  amount 
of  inva-^ion  of  the  upper  brain-<*ntres.  Mental  symptoms  may  be 
very  slight,  or  even  altogether  absent,  but  hallucinations  and  other 
BympLoms  of  insanity  have  been  noticed.  The  usual  tendency 
is,  however,  towards  failure  of  tho  mental  powers,  ur  even  oom- 


I 

I 

I 
I 


I 
I 


Mtrroe  excitements. 


145 


plete  amentia,  ratlier  than  towanls  active  insanity.    Cliarcot  states 
that  in  about  th roe-fourths  of  the  cases  of  cerebro-spiiial  soleroais 
vertigo  is  present.  Usually  olyccla  seem  to  be  whirling  around  with 
great  rapidity,  and  the  individual  himself  feels  as  though  he  were 
revolving.    Not  rarely  the  vertigo  h  so  severe  Uiat  the  patient  has 
to  lay  hold  of  «jmuthing  iu  order  to  maintain  theslaii(lin<;  position. 
Closely  allied  to  the  vertigo  are  the  apoplectic  attacks,  whi<-h  are  in 
advanced  cases  quite  freqnetit.     Thi>»e  attack?  usually  come  on 
Boddenly  withoutaura  or  nther  warning.    Sometimes  there  is  com- 
plete I068  of  couaciousuc6s,  iu  other  cases  there  are  couvuHvc  seiz- 
arBs,  which  may  resemble  those  of  major  epileps^y.    Commonly  tlio 
patient  recovers  rapidly  from  such  attacks,  Imt  occaflion.il!v  a  par- 
tial hemiplegia  is  left  for  a  few  hours,  or  even  a  few  days.     DeiUh 
may  take  plnce  during  a  paroxyi^ra,  when  00  lesion  will  be  found 
in  the  brain  to  account  for  the  acute  symptoms.     At  the  time  of 
liie  attack  the  pulse  is  usually  auoelerate^l,  and,  according  to  the 
1     rascttrchea  of  Wcstphal,  there  is  a  rapid  and  characteristic  rise  of 
^piilie  central  temperature-     In  the  hours  following  the  6rstapopleo- 
^  tic  invasion  a  temperature  of  102*  F.  has  iK'eu  noticed,  and  twenty- 
fonr  hours  later  lO-I*  F.,  the  patient  finally  rcoovei'ing.     It  is 
aaserted  that  when  the  temperature  passes  above  106°  F.  death 
almost  inevitably  occurs.     Charcot  affirms  that  the  congestive 
attack  of  diBscraioated  sclerosis  can   be  diagnosed  from  a   true 
apoplexy  oocurring  in  this  or  any  ottier  aflection  by  paying  atten- 
tion to  these  temjwraturcs, — in  cerebral  hdmorrhnge  anv  rise  of 
the  bodily  temperature  lieing  always  preceded  by  a  fall,  which  is 
J      wanting  iu  congestive  apoplexy. 

^m     Ocular  symptoms  are  very  frequently  pre-sent  in  multiple  oere- 
^^bral  sclerosis.     Nystagmus  has  been  noted  In  a  number  of  cases. 
Diplopia  occasionally  exists;  but  amblyopia  is  a  much  more  fre- 
quent and  persistent  sympiota. 

In  many  cases  »yiuptuias  due  to  invasion  of  the  pons  or  medulla 
are  present.  A  peculiar  euunciatiou  is  almost  characteristic  of  the 
disease,  tlie  jjotient  hesituting  in  the  articulation,  alibongh  not 
distinctly  stammering,  and  having  siwclal  trouble  with  the  con- 
^- sonants  I,  p,  and  g.  The  words  are  praiiouuced  in  a  low,  heal- 
^Btating  manner,  with  a  <%rtain  regularity  of  ncccut  and  juiusc,  some- 
what after  the  method  of  school-boys  in  reading  Latin  poetry: 
mce  this  jjeculiar  speech  has   been  spoken  of  aa  "  sc&nmu^" 

10 


146 


DIAOKOenC  NEDBOLOOV. 


TTCmuIoiLtnesB  of  the  tongn<^,  with  wasting,  has  been  noted  in 
some  in8tuuce«:   id  other  cases  all    the   paralytic  autl   atrophic  i 
ByinptoiDs  nf  the  Bu-c«illed  progressive  bulbar  ]>aUy  are  present.     ' 

The  Rpiiial  8y[nptotn>i  may  Rimulate  those  nf  auy  form  of  chronic 
sclerosis,  or  loay  consist  of  a  (iia^  of  oominingled  types.  Thus, 
if  the  sclerosed  piitcbes  lmp|>eu  to  be  Jii  the  poi^terior  root-zones, 
the  fulgumnt  )>ains,  diKturt>am^es  of  co-onli nation,  loss  of  the 
knee-jerk,  and  the  other  symptoms  belonging  to  locomotor  ataxia 
may  be  pre-eent.  When  the  lateral  columiis  of  the  cord  arc  in- 
volved, contractures  of  tlie  rauBcle^  with  resultant  deformities,  ex- 
aggerated reflexes,  and  the  other  symptoms  of  lateral  sclerosis  may 
be  well  develoixsl.  If  the  patches  Itave  involved  l>oth  the  lateral 
columns  and  the  contip;uoua  gray  matter,  the  symptoms  resemble 
those  of  amyotrophic  lateral  sclerosis.  Mu«cular  contractures, 
heightened  rellexes,  and  wasting  of  the  afiected  muscles  are  pres- 
ent. The  gait  varies  according  to  the  spinal  din^rrtbution  nf  the 
sclerosed  foci.  It  may  be  that  of  locomotor  ataxia,  it  may  be  that 
of  lateral  sclerosis,  or  it  may  be  a  grotesque  combination  of  the 
two. 

The  course  of  multiple  cerebro-spinal  sclerosis  is  usually  slow. 
Five,  flii,  or  even  eight  years  nmy  Iw  require*!  for  the  wearing 
out  of  the  prodromes.  The  inieilectnal  disturbance  6na1ly  deepens 
into  dementia,  the  general  loss  of  ]>ower  into  profound  paralysis, 
the  diHicuUy  of  speech  into  au  uuintoUigible  grunting,  the  mus- 
cular wasting  into  excessive  trophic  disturbances,  with  abscesses, 
ulcerative  destruction  of  the  inl^mal  mucous  coats,  and  perhaps 
death  from  seplic«mia.  In  the  great  majority  of  cases,  however, 
the  patient  perishes  of  some  intercurrent  disease,  specially  of 
pneuiiioiiia,  phtliisis,  or  dysentery. 

The  diagnosis  of  multiple  cerebro-spinal  sclerosis  is  generally 
to  be  l>ru*d  ii]>on  the  app^jiran<«  of  tremors  during  action  and 
tlie  slow  failure  of  uiuiscular  power,  since  years  may  elapse  before 
the  occurreooe  of  any  other  symptoms.  When  the  patches  of 
solenwisare  confmeil  to  the  npinal  (Mini  (here  are  no  tremors:  i.e.f 
in  multiple  spinal  acierosis  tremors  are  not  present. 

OnOREA. 

Choreic   movements   may   be  defined  to   be   irregular    more-' 
ments  produced  by  independent  contractions  of  single  or  associated 


groups  of  muscles  not  vibratory  In  character,  and   more  or  leas 
I    sttDulalin^  puriKKtive  movcmetilA,  but  never  Tormiitg  acomplicatAd 
eeries  of  apjtarently  purposive  actionti.     Tbey  may  vary  in  inten- 
sity from    the  sligbtest,  irr^ular  niuveruentii  uf  (be  fnigvnf  or 
to(»,  or  even  a  mere  oundition  of  excee^ve  muBcular  activity  re- 
sembling restlesgnesH,  up  tu  llie  most  seveiv  and  violeut  motions. 
^ITiey  may  Im;  C30ti6ti»l  t«>  a  single  group  of  mii.sclcs,  under  which 
^■eircumstAnocs  ibey  may  be  considered  an  forms  of  local  spasiu,  or 
^Hhtf  may  involve  a'wociated  groups  of  imtscltis,  or  the  entire  mus- 
^VHvr  syj^teni  of  the  urguuism.     When,  however,  Llio  whole  liody 
IB  aflected,  the  muscular  oontructions  do  nob  uike  place  regularly 
or  coDiientaneouely,  but  momentarily  here  and  tli€re.     They  are 
oAeo  under  die  I'ontrol  of  the  M'ill  for  a  short  period  of  time,  but 
always  assert  itiemiieLves  in  a  few  minutes,  and  in  many  cuecs  can- 
not be  controlled  at  all. 

The  choreic  movonictit  is)  usually  irr^ular  and  not  at  all  rhyth- 
mical, but  in  »K>nie  ca>ses  is  more  or  te>M  n-gidar,  and  it  iiiav  be 
entirely  rhythmic^.  Uliytlimieal  choreae  more  or  1ce»  closely 
re^mble  trenior»,  difleriiig  chiefly  in  that  the  roovements  ore 
.much  slower  an<l  more  exft-asive. 

When  the  choreic  movements  iuvolve  all  parts  of  the  body  the 
it  amy  be  said  to  be  suffering  from  general  chorea.*     When 


'       in 

lb 


*  Tbe  DAinea  of  St.  Vltut't  Dftnc«,  the  D«ntJ6  ot  St.  John,  OhorCK  Mintw 
iail  Citnrett  Major,  and  Churen  (terronnoruni,  have  been  so  tntich  used  and 
with  Rucb  dilTvrsot  miwuingi'  tlut  jt  kkciii*  rie^-wvary  to  »ty  n  fow  wordi  tier« 
lo  regard  to  the  ti^iflcotion  with  which  ibcy  wilt  be  empbyLM)  in  this  book. 
IttppeHn  tliuctbe  Pbryg:lan  BDCchantcji,  in  their  wIM  worship,  wrrft  affACtcd 
with  furioiu  unconlniiliLbte  autoiuaUi;  movementa,  uccompaniod  by  mure  ur 
l«M  dti>turhanc<>  of  conMmoiiitnRiui,  and  it  i*  oertniii  that  thn  tttvt  nf  Ibo  titifll, 
in  Persia,  shortly  aft«r  the  orifiiD  of  HobBTuniBijaiiisni,  were  nooustonied  in 
llipir  aacred  ccroinoninti  to  paiH  into  a  c>oiidit!(in  of  ratting  oxcitt-mcnt,  with 

hou»  dancing,  conruUive  trcTDblinga,  and  eri>n  gBiitral  conTuUions.  About 
the  yoar  1000  a  sect  of  ihc  Siiffi  fuimd  TuimtTOUs  follower!  and  imitatcrs 
IhnmglK'Ul  Asia  Minor,  Persia,  and  Ej'ypl.and  ev«n  in  Greece.  luChriiliao 
bada  the  itc>-(«lUd  Danci.- i>f  Ht.  Ji^hn  wnH  iilri<ac]y  at  Ili«  timv  of  ihn  C'riiKnilee 
BB  ob««rTed  custom  ;  and  when  the  influance  of  the  Suffl  spread  llaelf  by  the 
rciuroini;  wave«  of  tha  Oru«ad«,  the  cpidotnics  of  rclit^ioiis  oxcilemcnt  and 
aulotnalit^  dancing  b«!amo  more  and  more  violent.  It  wan  noi  until  itie  DUt- 
brvslc,  in  H18,  of  a  freali  «pid<?mic  in  Slnwibiirg,  that  the  term  Dunce  of  St 
Tail  b<KHn  to  bo  frrcly  ■pplliid  tu  thoic  rttli^ioii*  di*ordur«,  a  niimo  whi(;h 
appCkra  to  hare  had  ib  origin  largely  in  tbu  fact  tital  in  tb«se  Ut«r  epi- 
Aataica  children  wer«  Mpeclall/  «Airct«d.    St.  Vclt  wu  a  boj  «Uo,  V)ot%  Vit 


T>lAOK0OTrC  KEtniOtOOY. 


the  uliuroic  moveraeats  are  fixed  in  one  part,  t)ie  terra  local  clioi 
may  be  uBetL 

GENERAL  CHOREA. 

Acnte  general  chorea  is  nsiially  cine  to  St.  Vitns's  danee. 

St.  Vitua's  Dance. — St.  VitUf'jt  <lance  Is  a  non-f«brile  (HseaM, 
generally  twciirriug  in  children,  which  is  oharactcrized  by  the  pres- 
ence of  cliorei«  niovements  usually  involving  all  portioiw  of  ihe 
body,  altlioiigh  liable  to  uffect  especially  one  extremity  or  one 
half  of  the  hndy,  aissnciatefi  with  a  eondition  of  general  lack  of 
tone,  and  often  with  a  distinct  loss  of  muscular  power.  The 
invasion  of  this  disea-se  may  be  sudden  or  nradual.  The  attaoi 
may  come  on  in  the  midst  of  appaifnl  liealtli,  hut  ordinarily  it  is 
preceded  by  languor,  irregular  action  of  the  gastro-intcstinal  tract,] 
and  8  protioiinced  nervous  irrlt-iUMty.  The  motor  di8iurban< 
may  bo  finit  indicated  by  a  jieciiliar  nwtlcsaness  of  the  child,  wl 
18  not  rarely  punished  for  fidgeting.  The  true  dioreic  movements 
usnnlly  apiienr  firot  in  the  flngfi-i!,  and  shortly  aftertvardn  in  the  fare, 
and  spread  until  they  involve  the  whole  body.  In  severe  attacks 
the  arms  are  in  almost  constant  movement,  the  fingers  openin;^ 
and  closing,  ihe  wrii^ig  flexing  and  extending,  aud  tlie  ellK)W-joint8 
in  alnioit  incessant  activity,  so  that  every  imaginable  [losition  of 
the  hand  and  arm  i^t  rapidly  taken  and  ]n<it.  Dnring  the  violence 
of  the  disease  it  i&  impo^ible  for  the  child  to  control  the  move- 
ments of  the  arm  sufficiently  to  drees  or  feed  himself,  or  to  performj 


the  island  of  Sicily,  siifTvred  tniirtji-rdurn  in  tho  ycht  30:^  during  tile  |irtn«eutiaa 
of  DioclolitTi,  and  whom  body,  curried  liiLlior  and  Ltiitliar  Tdf  h  considerabli 
Imif^tb  of  timfl,  fdund  its  Onal  r©»ting- place  in  ihe  claistur  of  Kwrvey. 

Bjr  Pn.riii.'clitui  tlife*o  <!pidi)in[c*  wur«  t;ul]ud  Cborou  Saiicti  Viti,  und  Cfaoroa 
Lucira  Tbo  disBuso  of  childhood  now  known  oe  St.  Yilua's  dance  has  no  coa- 
Doction  cither  ctiMogicaHj*  or  in  it«  niiturc  with  th^uc  epidomlcj,  but  modem 
Cu*torn  enfurces  the  nppliculion  of  the  namci  to  it  ns  used  in  this  book.  By 
many  Oonnan  writurn  th«  aiftKition  of  ohiMlidod  is  knuwii  a*  Chorua  minor, 
wbiUt  thtt  term  Clioneu.  luitjor,  or  Chorea  Gerntanorucn ,  is  uied  to  exjiroa 
affections  more  or  Ins  c-losDly  rcsumbling  in  tlivir  pLonDmima  thoM  of  tlia 
(tpidoiDtc  fairies  nf  the  Middle  Ages.  By  som«  German  wricen  any  rery  bad 
OMe  of  ordinary  chorda  i«  spok«n  of  as  C'boreA  loap^na.  In  the  preaent  work 
tbs  Uirni  Cburca  major  Is  used  with  its  moro  1itnit«d  stKnificatioa,  at  expresa- 
Ing  a  discaafl  in  wblch  occur  paroxysms  of  tnovenienu  that  are  automBtlc  and 
beyond  ihc  Itnmitdliite  control  of  the  will  of  the  pikticnt,  although  cloaoly  t«- 
sembling  voluntary  acts  in  Ibeir  apparent  purpoisivenesa  and  la  tb«ir  BoquaiiccL 


any  act  requiring  precisioD  of  motioii.  At  this  time  the  legs 
■re  similarly  affected,  no  that  walking  \n  gradually  interfered 
vith,  or  may  be  remjered  imjjossiblt.  The  steps  are  irregular, 
jerking,  often  with  lateral  movements,  now  rajtid,  now  slow,  aud 
if  progreMioD  oocnr  at  all  it  is  xigKtig  and  unu^rtaiu.  The  face 
and  head  are  do  less  affected :  there  is  a  constant,  ever-changing 
distortioo  of  the  oouDteoance,  giving  rise  to  fleeting  exprettsioDs 
of  B8du<»6,  terror,  grief,  rage,  etc.,  and  to  grimaces  innumerable^ 
The  mouth  is  opened  and  shut,  the  cornera  jerking  up  and  down: 
the  tongue  is  protruded,  or  sometimes  move<I  raptdiy  in  the  mouth 
BO  as  to  produce  a  peculiar  clacking  )K)uod.  Articulation  grows 
iudistinct,  the  child  speaUe  irregularly  and  badty,  ptirtiups  only  in 
uionoeyllnblcs,  and  Hnally  llii>  voice  may  Im  eonverted  into  a  ruc- 
eHBion  of  irregular  unintelligible  sounds.  In  very  bud  cu^e^  mas- 
tication becomes  almost  impossible,  and  even  the  muscles  of  deglu- 
tition are  iavolved,  60  that  the  child  Is  unable  to  swallow  at  llm 
proper  moment,  and  the  food  is  spluttered  and  spilled  about.  The 
bead  itself  is  moved  rapidly  to  and  fro,  backward  and  forward, 
sometimes  laterally,  sometimes  in  per|)etii!d  rotation.  In  the  most 
violent  cases  all  the  muscles  of  the  body  are  iu  a  condition  of 
furioos  action.  The  rolling,  twisting  movomciit  of  the  trunk,  and 
the  perpetual  beatings  and  tlira;>hings  of  the  extremitieii,  render 
it  almost  impossible  fr>r  the  patient  to  lie  in  bed  unless  fti.<tcned 
down,  and  the  utm<jst  cart?  i^  iieces,sary  to  pi-event  sevei-e  bruises 
and  excoriations  of  the  skin. 

Tlte  nspiratory  mui^^^les  are  the  last  to  be  a^'e'etixl,  bnt  coses 
have  been  reported  in  which  hiccongli,  crowing insplrniion,  irrcga- 
lar  respiratory  rhythm,  and  otiier  evidettces  of  choreic  action  of 
ihe  rea|firatory  muscles  were  abundantly  present.  The  eliureiu 
movements  cease  at  night,  or  at  least  during  sleep,  but  in  the 
moat  severe  cases  liy  keeping  the  imticni  awake  they  proiluce  an 
insomnia  which  constitutes  an  additional  factor  in  the  rapid  n-ear^ 
ing  out  of  the  .ntreugth  and  the  bringing  al}out  of  a  fatal  result. 
That  tlie  brain-cortex  does  Dot  entirely  escape  is  shovvu  by  the 
peculiar  nervous  irritubllity  which  forms  an  almost  I'ssential 
symptom  of  the  disease.  The  grncrut  tntelligLnce  is  ordinarily 
well  preserved,  but  there  can  often  be  notc<l  a  temporary  weakness 
of  memory,  and  tbe  loss  of  the  |)ower  of  fixing  the  attention  upoo 
any  one  sulgect  fur  a  len^tti  of  time  is  usually  very  dm^vded. 


150 


DIAOKOenO  KKtmoiXJOT. 


Hallucinations  are  very  rare,  and  usually  indicate  that  a  ob 
is  li^vsterical.  Tbey  may,  however,  occur  in  typical  St.  Vitasl? 
danoe.  In  fatal  cosca  the  mental  diflturhniicesarc  vqtv  |>ranouncerl ; 
there  may  be  even  an  acnte  dementia:  sometiraea  the  patient  19 
seized  wttli  maniacal  tielirium,  which  is  always  of  exceedingly 
serious  inijwrt. 

The  muHcles  uf  urganiG  life  may  participate  in  the  choreic 
disturbonoc.  This  is  i^fipeoially  tnie  of  the  heart.  Chronic 
valvular  lesions  are  frequent  among  choreic  patients,  and  au 
acute  endocarditis  occai^ionally  iHKuni  during  uo  attack  of  St. 
Vitus's  dance;  but  caacs  are  not  rare  in  which  mitral  or  evea^f 
aortic  ninrmurs  are  heard  during  an  attack  which  arc  not  due  ^^ 
to  any  oi'ganio  leition  of  the  heart  and  are  not  btemic  in  their 
origin.  This  is  shown  by  the  fact  that  these  murmurs  occur 
wlien  theru  In  no  anromia.  that  they  vary  from  day  to  day  and 
from  hour  to  hour  and  at  times  may  l>c  abKimt,  and  that  when 
the  chih]  recovers  from  the  chorea  the  murmur  disappears  en- 
tirely. 

Further,  fatal  cases  have  been  reported  in  which  00  x'alvular 
leeion  was  found  at  the  autopsy,  although  marked  canliac  mur- 
murs had  existed  during  life.  (See  Rti'ur  mrmi.  dra  MaltuUf*  de 
PJ'SnJance,  1884,  ii.  421.)  The  most  rational  explanation  of  these 
murmurs  U  that  they  arc  due  to  the  irregular  contractions  of  the 
chordae  tcndintiffi  ])reventing  the  pro|}er  closure  of  the  valvea.  It 
is  the  dutv  of  the  practitioner  always  to  auscult  the  heart  of  the 
choreic  <-hi  Id,  and  if  mnrnturs  l>e  present  to  decide,  If  popwible,  their 
siguiScance.  If  the  fiistory  of  a  ]>revious  endocarditis  or  of  pr»^| 
vious  chronic  valvular  lesions  can  be  obtained,  the  probnbiliiieg 
arc  alwayr^  that  tlie  murmur  is  due  to  an  old  legion.  The  absence 
of  such  history  is,  unfortunately,  no  proof  of  the  previous  non- 
existence of  cardiac  dJsea;**.  Supposing  that  the  niurniur  is  re- 
cent, it  is  often  a  very  diificult  matter  to  decide  whether  it  is 
neurotic  or  inflammatory.  The  neurotic  murmur  rarely,  if  ever, 
manife{>t8  itself  in  irregularity  of  the  ptdse;  it  is  not  associated 
with  cardiac  pain,  nor  wiih  elevation  of  the  general  temperature. 
If  these  exist,  the  (liagnosis  of  acute  endocarditis  may  be  eou- 
sideri'd  niaile  out.  The  presence  of  even  one  of  Uiese  &ym[>tom8 
should  lead  the  practitioner  to  treat  the  case  as  one  of  cndocai 
ditis. 


MOTOR    EXCITEMENTS. 


161 


Wbeoever  a  cardiac  murmur  b  heard  in  a  choreic  patient,  ud- 
\em  ti«  nature  Iw  very  apparPiit  great  wire  should  lie  exercised  in 
tbe  treatment  of  the  case,  and  a  guarded  prognoais  should  be  given, 
because  a  murmur  wbieh  is  apparently  ucurotic  may  fail  to  disap- 
pear after  the  child's  re^wvery,  aud  because  the  rapid  and  tK)raplete 
di^appcaranoe  of  a  murmur  winch  vms  apparently  organic  may 
J       prove  It  to  have  been  neurotic. 

^K     JVo/wre  and  LirmtaUona  of  Clivrttt. — The  St.  Vitus's  danoe  or 
^H.^ona  of  childhood  is  a  very  frc<)uciit  disorder,  having,  as  al- 
^1  ready  staleil,  clearly -deli  ued   elioical   chamcLeristics,  and   wuuld 
^H  acsem,  ihercforo,  to  deserve  a  distinct  place  in  nocuilog}'.*     Choreic 
^^  movemeula  may,  howevur,  be  prwlucud  by  peripliei-al  irritatioua, 
ood   in  some  eases  these  movements  have  been   unjven^t,  and 
BO  severe  as  eveu  to  threaten  life.     Dr,  C.  Fit^cher  rejiurts  {Zeit- 
tthnft  fur  WunddrzU,  1S63.  vol.  vl.  p.  89)  the  case  of  a  young 
peasant  girl,  in  whom  a  futile  attemjit  to  remove  a  tnotli  was  fol- 
lowed by  the  formation  of  au  abscess,  aud  by  marked  uuilateral 
chorea,  which  lasted  two  years,  until  Dr.  l''igclicr  removed  the 
^m  root?)  nf  the  tooth,  when  the  movenieiit»  ceased  at  onoe. 
B      Dr.  R.  Fiacher  {OoiUr.  Mfd.   Wochemcknjt,  1841,  p.  46)  re- 
ports a  case  in  which  a  general  chorea  ceased  at  once  upon  tlie 
exptUsion  of  u  taiwwurm.     Dr.  Efhnond  Ceusicr  recoixls  a  49lso 
amilar  to  this  in  the  (Jtiz.  MM.-<'hir.  de  Toukni^e,  1877,  p.  -13, 
The  chorea  wn.<  no  violent  as  to  threaten  life,  and  had  (icrsiflted 
several  montlis,  notwithstanding  treatment.     Amelioration  began 
five  days  after  the  expulsion  of  the  parasite,  waa  very  rapid,  aud 
resulted  in  (.naiplcte  cure.     In  tlie  Journ.  de  M£d.  d  de  Chirurg., 


* 


*  I>r.  L.  Koojuc,  in  bia  TheaU  { Pane,  tKti6,  Ka,  26£),  atBrnie  that  in  ordinary 
cboKA  of  childliixKl  poinu  of  pflin,  upon  pi^jiiure,  c«n  bo  found  in  titirvc- 
trunlu  where  tiny  become  very  superSciul,  or  where  the  ii«rv«-trutiki 
iaierg«  fpom  bony  plaow,  or  wtior^'  tlm  n«rvoHliitiii>nU  travvricj  k  rnmcli-  tu 
FMcb  ihe  skin,  or  vrfaere  tbe  &net  filamenl«  cume  near  tbe  aurfuce.  Tbe  pals 
ii  staled  to  be  quilo  ravero.  IIl-  luierU  tti«l  tlifi  noumlgic  puinUof  Valldz 
kK  wait  mnrtiH),  imd  he  finds  in  the  h«ftd  four  cdfiocial  choreto  [laln  points,— 
III*  occi|>ttal  point  just  below  tho  occiput,  and  ccrvicftl  BuporJIcini  pointu  \a 
til*  middle  of  th«  uuck,  u  liltia  boluw  tho  uitddlo  of  tho  ucck,  mid  upon  the 
posterior  ed^  of  the  slerno-cleido'iniLfitoid,  corresponding  to  the  maetoid 
point  upon  the  mutoid  proci-«H.  I]c  further  givM  a  Inrgo  niimbLT  nf  polatt 
found  in  connection  with  t>(her  putLiunft  of  the  body,  urixl  i-orraa ponding  to 
the  generslisatiane  which  b«  makee  d«  detailed  abore. 


1S2 


DIAON06TIC    NEUROLOaY. 


Paris,  1841,  yn  rccordc-d  tJte  immciliatc  arroRt  of  a  chorea  nf  one 
moDth's  duration  by  the  expulsion  of  lutubricoid  worma. 

M.  Borelli  repoptu  {liullrtin  de  la  Soc.  de  Chirxirgie,  1852,  p. 
292)  the  cuMj  of  a  boy  thirteen  yea»  old,  in  m'Iioiq  a  violent 
chorea  which  had  resisted  nil  treatment  for  six  montha  was  cored 
hy  the  removal  of  a  neuromatous  tumor  from  beneath  the  foot. 
The  inoveraent^  became  less  the  day  after  tlie  operatioD,  and  by 
the  fourth  day  had  ceased  catirely.  In  the  Revae  dt  Mfd.,  1834, 
p.  568,  T)r.  E.  Weill  rejHirtw  ii  very  iiUensiliiig  case  iii  which  a 
decided  hemiohorea  was  produced  by  intrapleural  injectiona,  the 
movements  being  upon  the  same  side  of  the  body  as  the  pleorisy. 

Further  citallona  of  uaues  might  readily  be  made,  and  especially 
an  ahundaiiec  of  opinion  mi^rht  be  obtained  from  rccogni&ed  au- 
thorities, showing  the  occasional  deiiemleuoe  of  chorea  ujMjn  the 
presence  of  intestinal  worms;  but  I  think  enough  has  l>ecu  here 
said  to  prove  the  existence  of  a  refiex  ch)rea. 

A  large  number  of  auto])eieti  have  been  made  upon  children 
and  adulttj  dead  of  St.  Vitus's  dance,  and  the  results  have  given 
rise  to  much  diacusaion.  In  my  opinion  the  older  autopi^ietj  ought 
to  be  dlan^rded.  The  raeana  of  luveHtigatiou  were  eto  iin|)erfect, 
and  were  so  imperfectly  used,  that  tlie  danger  of  lieing  mielcd  by 
these  observations  is  greater  than  the  chance  uf  receiving  enllgbt* 
enment.  Ncvertheleas,  it  seems  to  me  that,  after  throwing  over- 
board much  rubbish,  (here  remain  certain  cases  in  which,  after 
pro]>erly-couducted  autoiisies,  no  appreciable  lesion  could  be  fouud. 
The  jHKiittve  rcHult^  whii>li  have  been  i-escbed  in  other  cases  com- 
priae — first,  brain-alteration ;  secondly,  alteration  of  the  spinal 
cord. 

Among  the  mijat  remarkable  papers  upon  the  brain-lesions  of 
chorea  is  that  of  Dr.  Bruadbeiit,  who  hus  dumunstrated  that  the 
coq)n»8triatu(u  and  tJiahiTiitis  opticus  un-  in  some  cases  the  location 
of  the  lesion.  Dr.  liroadbont  states  that  a  variety  of  morbid  con- 
ditions of  these  ganglia  may  pnxlnee  chorea,  but  the  most  frequent 
alleraliou  in  his  caaes  was  a  capillary  embolism  of  the  corpus  stri- 
atum, thalamus  opticus,  and  their  vicinage.  A  number  of  autop- 
sies  have  l>een  made  confirming  the  existence  of  cjipillury  emlKtlisni 
iu  the  brain  in  fatal  chorea,  and  it  would  seem  as  though  there 
wera  an  iutimatc  relation  betweco  chorea  and  this  condition  of 
the  brain.     The  associatiuu  is  too  frequent  and  too  pecultai'  to  be 


I 


HCrrOB  EXCITEMENTS. 


153 


p. 


p^ 


mereJv  the  result  of  chance.  On  the  otli«r  liaud,  it  is  evident 
that  ill  many  cases  of  chorea  no  such  lesion  exists.  It  is  absurd 
to  suppose  that  the  chorea  vrhich  \s  prixluceil  in  a  few  houra 
by  a  fright  and  is  cured  in  a  few  days  by  arsenic  is  the  result 
of  eo  serious  an  organic  lesion  as  that  indicated.  Moreover, 
there  has  been  an  abundance  uf  auto[,isiu8  in  which  cufiillary  em- 
bolism did  not  exist.  Again,  as  in  the  case  reiMJi-ted  by  Tuck- 
well,  other  cluuiges  in  the  brain  have  been  notc<]  bc!«idrs  tlin^  of 
emljolisni.*  It  must,  therefore,  be  concluded  that  an  acute  chorea 
may  b<;  intimately  ai^oeiated  with  luiuutc  cerebral  embolism,  and 
also  with  other  lesions  of  the  bmin  ;  among  which  lesions  may  be 
especially  nieutionol  the  |>eculinr  alteration  of  the  ganglionic  cells 
of  the  brain  noted  by  Meynert  as  pervading  the  whole  organ  in  a 
of  chorea. 
In  regard  to  the  spinal  <»ril,  the  followini;;  |Ntragmph  from 
c  article  of  Von  Ziemssen  in  his  Cyclopfledia  sums  up  the  evi- 
dence to  the  date  of  its  writing,  1877  :  "  In  the  spinal  cord  alter- 
ations have  been  repeateiUy  found, — namely,  hy|»nemia  of  the 
medulla  and  die  membmnes,  softening  of  the  cervical  and  utso  of 
the  dorsal  raethilla  (RtMuljerg,  Ogle,  Gray,  Golgi,  Dc  Biamvais, 
Hme,  Brown-S&iuard,  Lockluui-Clarke)  ;  inleretitial  proliferation 
nadei  and  hyperplasia  (llokitansky,  Sbeioer,  Meyncrl,  Elis- 


In  llie  c«5««  collected  by  A.  Koucherand  {La  Choritt  Lvoiu,  1888),  in- 
flunnutorv  l«iton  of  tlin  cnntrnl  ipingli*  (opCo^triiite  bodiet ),  and  porioncepha* 
litU  with  Ki>d  witbflut  di>eai«  of  tho  ceDtral  giniKli*,  urt  raprecoDted.  Dr.  J. 
KudlleodurflTrfporte  (DtuUeh.  Arehiv/iir  Med.,  1990,  vol.  xl.  p.  909)  a  fttal 
VMeducto  dbeBM  of  tbesplianuld  bone,  wilb  oomproaeion  and  c)igbl  Bofleo- 
itiK  of  lh«  pom.  Dr.  Bughlingi-jKckioik  detAJI*  (Itrit  M<d.  Joitm.,  1H76, 
Tol.  !.  p.  R36]  a  cu«  in  wliiuh  th«  symptutoi  fur  a  cuntidemble  time  exactly  rfr- 
unibted  tboMof  tho  SU  Vitus'«  dnticti  of  childhood,  and  in  which,  after  dcnth, 
th«r«  wai  fcHiitd  a  luborcuicMU  afTecting  ibe  surface  af  the  [x>n9,  modutin,  ocre- 
b»llum,  and  tbc  whole  bue  of  tho  brain,  bI<u  Clio  inland  of  Koil,  and  nuigh- 
\itttiag  convolutioDi,  wblch  w<>re  toftened,  as  Witll  lUi  ihe  gfrm  fornicalus.  Tba 
pMUirior  cerebral  artorics  w«rfl  ioTolved,  but  not  tho  vns«1j  of  tlio  cnrpom 
lUiata,  and  no  tim Wli  could  bs  daledod.  I>r.  H.  M.  Tuukwatt  roportii  (St. 
Borifi.  Uo*p.  Hfpvrt,  1869,  p.  87)  a  oau  of  cborea  in  whicb,  iifUr  dvath,  thora 
wat  found  Hoftvning  of  tbo  righl  cctrobrnl  middle  lube,  involrlng  iha  deep«r 
lajrer  of  tbe  «(irt«x  and  tbe  subjaceut  white  aubitanco,  and  extending  into  tb« 
neigbborbood  of  the  oorpu*  utriatum  and  optic  thnlumtu.  Thf>  coqiui  itriaUim 
WM  ivemlnicly  not  affected ;  tbe  optlo  thnlaniui  waa  ■llt^hlly  atTerted  in  its 
upper  and  outer  stpcvt.    The  corraaponding  nigion  in  ibe  lofl  bemiiphoro 

likawtse  toft. 


154 


mAONOffriG  XEUROLOOY. 


cher),  and  Bometiraes  serous  exudation  iu  the  c^utrul  caoul,  prolif- 
eration of  nuclei  in  the  advcntitin  of  the  vessels,  and  i^ressive 
mefaiuorphosU  in  tlie  f,»anglion-oells  (Elischer)."  Since  tliU  {lara- 
gnph  was  [>cniie(i,  spinal  leaton^  have  been  found  in  chorea  b; 
Dr.  Dickinson,  by  Dr.  Bury,  and  by  Dr.  James  Ross.  Accord- 
ing to  Dr.  Dickinson,  tlic  part  of  the  oord  eopecially  afTuiTt^il  in 
the  disease  is  "  the  central  portion  of  each  lateral  mass  of  gray 
matter  romprisiiig^  tlie  root  of  eaph  piwferior  horn.*' 

Dr.  RtKw  Ki_v«  of  a  case,  "  I  was  struck  with  the  alteration  pre-i 
sented  by  the  accessory  cells  of  the  anterior  ^ray  horns:  they  ap- 
pcuroil  Hlirivellefl,  their  prtitoplasm  was  grantilnr,  their  nuclei  were 
obaenred,  and  mrniy  of  their  processes  were  indistinct  or  absent." 

Without  in<Iu1ging  in  further  quotations,  it  may  he  slatet!  thac 
we  have  the  evidence  of  at  least  five  or  six  diOerent  observers  aa 
to  the  alterations  of  the  spinal  ganglionic  oclls  in  acute  human 
ehofCA,  and  that  in  numerous  other  cases  these  alterations  in  all 
probability  existed,  bm  were  overlooked.  I  do  not  mean  to  assert 
that  an  apprft:iable  let^ion  of  the  gpiiial  cell«  is  always  to  be  found 
iu  St.  Vitus')^  dunce;  indeed,  I  am  confident  tliat  the  disease  may 
prove  fatal  without  such  lesion.  Nevertheless,  I  am  well  assured 
that  such  alterations  arc  very  frequent  in  fatal  cases,  and  that  in 
not  a  few  iiirtlanoes  they  have  been  overlooked  because  not  ap- 
preciated and  sought  for. 

There  is  a  form  of  chorea  which  is  not  unconniion  in  the  young 
of  certain  of  our  carnivorous  domestic  animals.  I  have  never 
seen  a  case  in  herbivora;  but  Professor  Ilnidekopcr,  of  the  Vet- 
erinary Department  of  the  University  of  Pennsylvania,  informs 
me  that  he  has  treated  the  disease  in  calves.  The  relations  of 
animai  rJiorea  With  the  chorea  of  cliiklhoiHl  have  Ijeen  considei^ 
ably  discuKtcd,  with  difference  of  conijlusions.  £xccpt  in  the  cose 
of  ooi)tagioii9  diseases,  it  is  iin[>o8sible  to  determine  with  alisolute 
poeitivencss  tlmt  a  certain  disease  in  the  animal  repreeeuls  a  oer- 
taiu  disease  in  man ;  but  to  my  mind  it  is  plain  that  if  canine 
chorea  be  not  the  same  disonler  as  the  St.  Vitiis's  danoc  of  child- 
hood it  is  very  closely  allie<l  to  it. 

It  is  true  that  the  movements  iu  canine  chorea  are  usually 
rhythmical,  whilst  the  niovemenls  in  the  child  are  ordinarily  not 
so,  and  much  has  liesn  made  out  of  this  ditltrcnce.  I  have,  how- 
ever, seen  dogs  in  which  the  movements  were  not  rhythmical,  but 


* 


Id 


HrVTOR    EX0ITEMEXT8. 

hwl  all  tbe  gauoherie  of  tlie  chorea  of  chihliiixxt,  and  in  some  cases 
of  children  the  choreic  raovements  approximate  the  rhythmiaal 
type.  The  points  of  reeeraWaiice  in  llie  two  affections  are  cli>se 
aod  striking.  In  each  (lisease  it  k  tlit;  young  tiiat  are  especially 
attacked;  in  each  the  cliicf  gymptonis  are  tho!!c  of  disordered 
motioD  ;  esicli  affection  is  (wnnecteil  with  a  conBtitiitional  disorder 
(rheumatism  in  the  ehild,  and  distemper  in  the  dog);  in  each 
the  movements  can  be  temporarily  inhibited  by  the  will,  are  not 
BOoompaDied  by  diwnler  of  sensation,  and  are  associated  Avitb 
lois  of  |Kiwer  and  lowered  general  ndTve-tone;  finally,  in  each 
diseajse  ar>enic  is  recognized  ns  the  standard  remedy. 

The  important  point  in  this  matter  is  that  it  is  proved  (.see  paper 
by  author,  TTierapeulic  Gazette,  May,  I880)  that  the  niovemeuta 
in  animal  chorea  originate  in  the  spinal  cord.  My  own  studies 
of  the  spinal  cords  of  choreic  dog^  have  shown  tliiit  tlio  Uam\  legion 
is  a  peculiar  condition  of  the  ganglionic,  or  multipolar,  cells, 
Qowersand  Sankey  have  noted  an  inliltratioii  of  the  gray  matter 
with  leucocytec,  esiwi^ially  in  the  neigliborho«Kl  of  the  vessels,  and 
a  similar  conriilion  Uas  been  seen  by  M.  Pierret  (Foucherand,  Im. 
Cfior^f,  Lyons,  1863),  hnt,  for  reasons  given  in  detail  in  my  paper, 
it  seenu)  to  me  that  the  cliangv  in  tliv  celU  is  the  maiti  lesion,  and 
ID  this  I  have  been  recently  confirmed  by  ProfefiBor  Horslcy,  of 
Loudon.  Further,  this  is  in  accord  with  the  previous  obHervalioa 
of  Proft'ssor  Putnam,  of  Boston. 

When  the  animal  was  killed  in  the  very  b^inning  of  the  attack, 
the  cells  showed  uo  change;  a  little  later  the  only  alteratjoriM  in 
the  rclls  were  the  ver)'  frpfjuent  ahsencx;  of  the  ouelei,  the  failurn 
of  granulations  in  the  protoplasm,  the  loss  of  power  to  take  stain- 
ing fluidit,  and  mrcly  the  occurrence  of  sharply-defined  vncuolesi. 
Then  the  processes  began  to  drop  off;  and  (inally  it  was  found  that 
the  places  of  the  cells  were  occupied  by  irrt^ular,  globose,  crtiin- 
plwl-looking  raaBW*!,  without  sharp  outline,  nnd  taking  tarmine 
staining  very  faintly.  Nn  granulalioos,  no  nuclei,  no  procesyea, 
were  ap[>ar«>nt.  These  masse?  reprca^^nt  the  celk  in  the  last  stages 
of  degeneration. 

There  is  probably  at  first  only  a  fumrtioual  disturbance  of  the 
spinal  cell.  The  distinction  between  functional  and  organic  dis- 
ease is  a  purely  arbitrary  one.  Functional  movements  are  the 
Rsnlts  of  nutritive  change?,  and  a  functional  disorder  h  one  ia 


DiAONoarrc  neurology. 

whi<;h  the  Dtitritive  cbangce  have  oct^urred,  hut  have  not  suf- 
ficitnily  advanow]  to  Ue  rceognizod  by  our  comparatively  groas 
methods  of  study.  The  slrncliire  of  the  giinglionic  nerve-ceils  is 
Bu  complex  in  its  ultimate  nature,  and  yet  so  simple  io  ita  niiuro- 
sciipic  appoarancia,  that  ii  may  be  permanently  and  very  scfiously 
alwred  without  leaving  a  physical  trace  which  we  can  recognize. 
The  firet  change  lo  canine  chorea  i»  an  altered  nutrition — ue.,  fuoo- 
tioiml  excitement  (or  depression) — of  the  multipolar  cells  of  the 
spinal  cortl.  This  altei-ei.!  nutrition  may  cunltniie  until  tlie  strao- 
turc  of  the  colls  is  entirely  dcRtroyod,  but  it  may  never  go  beyond 
a  condition  of  change  so  non-apparent  as  to  be  unappreciablc  to 
us.  The  studies  of  Dr.  Putnam  show  that  in  the  kitten  tb«  braiu- 
oells  Huffer  like  tliosc  of  the  spinal  cord,  and  it  is  moiit  probable 
thnt  in  animal  chorea,  the  movement^i  originate  in  the  altered 
nutrition  of  the  ^ipinal  cells,  but  that  throughout  the  ncrvoufi 
system  the  gauglionic  nerve^maeses  suSer,  ho  that  the  disorder 
is  really  a  condition  alTecting  nut  merely  tliu  spinal  but  ratlier 
the  whole  nervous  system. 

The  bearing  of  wliat  has  just  been  said  upon  the  question  as 
to  the  nature  of  St.  Vitus's  dance  is  very  obvious. 

The  marked  tendency  of  the  choreic  movements  to  affect  one  side 
of  the  bmty  or  uii't;  lliub  has  led  inuny  observers  to  confine  their 
careful  examinations  tit  the  brain,  thiit  hcmiplcgic  or  monoplegic 
tendency  being  believed  to  show  that  the  movements  originate  in 
the  brain  and  not  in  the  spinal  cord.  A  clinical  study  of  the 
variuLiti  liunmii  afieolioug  of  the  motor  ganglia  of  tlie  cuni  f^hows, 
however,  that  iu  such  disorders  spinal  monoplegias  are  not  at  all 
uncommon,  and  that  in  some  ca.»es  hemiplegias  may  be  seen.  In 
many  cases  of  chorea  of  the  dog  this  localizatiou  of  tlie  move- 
ments In  one  limb  or  in  one  side  of  the  body  is  quite  pronounced; 
indeed,  this  was  the  case  m  dogs  in  which  I  positively  detcniuned 
the  apinal  oord  to  be  the  source  of  the  moveraents:  it  cannot  ihera- 
fore  V>e  considered  that  a  hemiplegic  chorea,  much  less  a  mono- 
plegic  one,  is  necessarily  of  brain-origin. 

The  simllariiy  of  tlie  lesions  which  have  been  recently  noted 
in  the  ganglionic  c«lls  of  the  spinal  cord  in  fatal  cases  of 
human  chorea  to  those  which  I  have  found  in  the  dog  is  very 
appuivut,  and  Increases  the  probability  that  the  two  afieelions 
arc  esbcutially  the  same  disorder.     Whether  this  be  so  or  not, 


I 


J 


UOTOB   EXCITEMENTS. 


157 


it  M  proved  that  choreic  movements  in  the  dog  tn&y  originate 
from  a  diseased  condition  uf  the  gunglionic  spinal  cells,  and  it  is 
contrary  to  all  knon'ii  physiological  laws  that  whnf.  in  t\m  respect 
is  true  of  the  dog  should  not  be  true  also  of  the  human  being. 
That  a  purely  spinal  chorea  may  exist  in  mau  is  further  shown 
not  only  by  what  has  already  been  jmid,  hut  aUo  by  the  ua->=e  re- 
ported by  Fouclierand,  in  which  in  ii  chronically  choreic  child  the 
brain  was  found  to  be  healthy  but  the  cord  full  of  minute  infbm- 
natory  foci.     Fnriher,  since  a  dii^ensed  condilioii  of  the  spinal 
gwigUooic  cells  baa  been  found  in  several  coses  of  St  Vitus's 
dance,  it  must  be  allowed  iliaL  euch  diH^ased  tiMe  m  at  leoi^t  one  of 
the  fundamental  pathological  alterations  of  human  chorea.     It  is 
perfectly  clear.on  the  otlier  liaiid,  tliat  the  disorder  U  not  confined 
to  tbeae  multipolar  cellu.    Tiie  retnearches  of  Dr.  Putnam,  already 
quoted,  show  that  in  the  cat  alterations  may  be  found,  at  Iciist  in 
Rome  cases,  in  the  hmin  ganglioniccells,  and  every  clinician  knows 
that  the  cerebral  functions  are  often  profoundly  aflectcd  in  tlie 
jreio  child.     The  will,  the  intellect,  and  the  emotional  facul- 
ilieB  are  all  prone  to  iiiliow  the  pruMrnee  of  uri  abnormal  influence 
I  in  chorea;  and  it  seems,  tiierefore,  that  we  must  consider  that  in 
lihe  choreic-  ehUd  the  gangUonic  celig  in  tJie  wkafe  cerebrospinal 
tgwtem  vuJfTf  and  Uiat  Ihim  uUrraiion   (V  the  base  of  the  diVtwe; 
in  other  wonls,  the  pathology  oj  ihc  iS(.  Vitua^a  dance  of  childhood 
may  be  said  to  be  a  disrujteif.  condition  of  Ihe  gamjlitmlo  gtni>ctiirea 
of  the  cerebro-npinal  axig,  which  abnonaal  etaie  may  crint  without 
aUtratiofu  of  slrwiure  gitffieicni  to  be  determined  by  the  microscope, 
or  may  go  on  unfit  it  is  accompanied  by  marked  )slrudural  lesiong. 
Furtlier,  this  condition  must  be  looked  upon  as  one  of  lowered 
tone,  and  it  must  be  allowed  that  it  may  be  proflueed  by  various 
caoses,  but  h  not  likely  to  occur  in  ]>ersons  of  robust  nervout 
sjTfttem.     The  vital  choreic  depression  of  the  nerve-cells  may  be 
the  result  of  emotional  disturUnice,  as  in  the  chorea  pnHlu(H.Hl  by 
fright.     It  may  be  the  result  of  the  influeoce  of  the  rlicuraatio 
diathesis  or  poison  upon  the  affecteil  tissues.     To  the  greatly  de- 
preaeed  oonditiou  of  the  Bpinal  ganglionic  cells  is  due  the  fact  that 
ia  almost  all  nevere  ca.'^es  of  St.  Vitus's  dance  in  cbildreu  some 
degree  of  general  or  local  muscular  weakners  exists.    This  in  many 
cases  amounts  to  a  partial  palm',  which  may  take  the  hemiplcgic, 
paraplegic^  or  monoplegic  form.     The  paralysis  is  never  complete 


168 


DIAONOSTIC  SEUROLOOY. 


tinless,  ini^cod,  the  chorea  l>e  aitsoctated  with,  or  dependent  upon, 
some  organic  lesiou  of  the  nervous  system,  aud  it  ahuost  invaria- 
bly 15  recovered  from  without  difficulty  m  the  choreic  in'iuptoius       . 
subside  ^H 

On  the  other  hand,  it  is  very  oertaio  that  minute  braiD-embo-^^ 
lisms  and  other  lesions  exclusively  of   the   brain   will   produce 
a  chorea.     Not  only  does  this  rcFit  upon  au  ahnndamre  of  clinical 
evidence,  but  IM.  Kayinond  has  produced  chorea  in  dogs  by  in- 
juring the  |K)flterior  part  of  the  foot  of  the  corona  radiftta  in  the 
brain.     It  would  ap|)ear,  therefore,  that  iestojui  of  any  of  the  gam-        j 
ffHonie  odls  connected  with  the  direct  cerebral  or  jnframtdal  trad  may        , 
aiuse  diorm ;  and  that  fhere  are  various  forms  of  acute  chorea,  or, 
to  state  it  more  correctly,  that  there  are  various  acute  diitcases  in 
which  chorea  is  a  prominent  symptom. 

We  must  conclude  that  chorea  is  uo  more  uniform  in  itssiguifi- 
oanoc  than  is  paralysis,  and  that  it  may  be  due — 

Fir^  to  the  chorea  of  childhood,  or  St.  Vitus's  dance. 

Srocmdly,  to  reflex  irritation. 

Thirdly,  to  organic  disease  of  the  uerve-oeatreg. 

Fourthly,  to  pregiiamg". 

Fijihiy,  to  hysteria. 

SixUilif,  probably  to  conditions  of  the  nerve-centres  not  as  yet 
made  out. 

Sufficient  has  been  said  ia  regard  to  choreas  of  the  first  Uirae 
classes. 

Ohorea  of  Pregnancy. — A  form  of  chorea  the  immediate  cause 
of  which  is  uncertain  is  that  which  occasionally  occurs  during 
preguancy.  It  is  fri-([ucntly  a  yuTv  severe  aSection,  in  which  the 
movempiitti  ait*  so  executively  violent  and  incEssant  that  tliey  de- 
prive the  sufferer  of  sleep  and  rapidly  cause  n  fatal  exhanstion. 
There  seems  to  be  on  th<-  |(art  of  obsietric  authorities  a  tendency 
to  believe  that  this  chorea  i»  a  t-ellex  ueurosis  j  but  tlie  cliuiml  his- 
tories of  the  coses  show  that  a  remarkable  proi>ortion  of  ibe 
patients  hud  KiiRVred  fnim  rhorwi  during  c!iil)ll»xKl,  that  aome- 
timea  the  symploms  ure  mild,  closely  resembling  those  of  the  St^ 
Vitus's  dance  of  childhood,  and  that  they  are  often  acoompauied 
by  the  [leculiar  muscular  weaknesyw  Keen  in  that  ditioitler.  {Cases, 
Dr.  Fchiing,  Arcltw/ur  Ui/tmecol.,  IST-I,  vol.  vi.  p.  137.)  More- 
over, in  a  number  of  instances  distinct  organic  lesions  of  the  brain 


have  consisted  of  sliglit  hypurieiula  uf  the  brain  aud  vvty  great 
effusion  in  tlio  right  ventricle  {(Jbslet.  Jotim.  of  Great  lirilain, 
»ol.  iv.  I*.  80) ;  of  softening  of  theoorpiis  cnllostitn,  inodulla  ob- 
longata, and  ixreheWam  {Obstet.  7^^)i«.,Loiid.^  vol.x.  p.  159);  and 
of  Koflening  of  the  cord  {U/id.,  pp.  163,  101,  etc.).  Farther,  if  tho 
symptoma  of  cliorua  uf  pregnuuvy  were  purely  rellex,  removal  of 
the  fretus  shmild  bring  quiet.  Yet  in  six  of  the  seventeen  fatal 
eases  colletrted  by  Dr.  Barnoa  (Ohtffi.  TVotw.,  18G9)  no  effect 
was  produced  by  emptying  the  utvrus ;  also  in  the  case  reported 
by  Dr.  Gooddl  {Amer.  Joum.  of  Obstet.,  1869)  removal  of 
the  chiUi  w^  without  influence.  The  facts  that  are  at  present 
known  concerning  Uie  causaLion  of  cliorea  of  preignancy  may  be 
Himiui-d  up  iu  a  uiugle  eeoleuce.  There  are  usually  a  predispo- 
BJtion  to  chorea,  inherited  or  accpiircd,  inanition  of  ttie  ucrvouA 
system  incident  to  thi^  hydrseniit-  tnn\/c-  of  the  hhxHl  during  prcg- 
naocr,  and  varioos  potential  peripheral  irritations,  e3)M>ciaIly  in 
eonnectton  with  thet«ext:al  organa.  The  mo^  ralinnal  explanation 
of  the  chorea  yf  pregnancy  is  that  It  varies  in  its  imiiiediat«>  jHitho!- 
ogy,  the  prcguancj-  simply  producing  a  condition  of  the  nervous 
system  \vhich  predisposes  it  to  be  thrown  into  an  active  chorea  by 
various  exciting  eamcw. 

HsTBterical  Chorea.— A  general  or  local  chorea  may  be  pro- 
duced by  hyBterta.  The  movements  may  be  limited  to  a  ftinglo 
limb,  or  they  may  be  lieniiplegtc  or  paraple^c,  ami  not  rarely 
they  involve  the  whole  body.  They  are  of^en  disorderly  and  ir- 
reg;alar  aud  closely  Himulate  tli'we  of  ordinary  St.  Vitus's  dance. 
Under  such  circumstances  their  true  nature  is  to  he  recognized  by 
the  existence  of  marked  concomitant  l^ymptonls  of  hysteria,  and 
eapeeially  by  the  occurrence  of  occaitional  or  |>cr(ii9tent  rigidity  of 
the  affected  muscles.  The  true  choreic  neurosis  may,  however, 
,  euexidl  with,  or  perhajK;  depend  upon,  the  hysterical  neunifiir),  so 
that  it  would  often  be  eipmlly  correct  to  siM-ak  of  a  patient  as 
suffering  from  hysterical  chorea  or  from  choreic  hysteria. 
^K  it  is  especially  in  liysteria  that  the  peculiar  brusque,  rapid  mus- 
^■eular  contractions  occur  to  which  the  name  eleciric  dwvta  has  bees 
H  given  by  the  French  writers.  (See  Tbms,  F.  Colancri,  Paris, 
~  1884;  also  A.  Guertin,  Paris,  1881.)  In  this  disorder  the  whole 
body,  or  any  portion  of  it,  is  tJje  seat  of  more  or  lew  t»^\4\^ 


160 


DIAONOSnC  !(EUB01X)0T. 


repeate<1,  violent  miisciilar  spasms,  resembling  those  prodaoed 
a  siiddtn  Kevere  electric  lOiuok.     It  is  asserted  thEt  electric  ch«re»^j 
may  be  a  symptom  of  chronic  olcoholUra :  thus,  in  the  case  ra^| 
porte»)  by  M.  Landouzy  {Sop.  dt  Bint.,  1873,  May  31),  an  Inibitual™ 
drunkard,  ageil  tbirty-«even,  siiQeretl  from  manife^tatioim  of  this 
fwm.     When  the  man  was  tying  on  his  back  the  legs  would  he 
flexe<l  upon  (he  ttilgh,  and  the  thigh  upon  the  pelvis,  witJi  eilifht 
abduction,  then  audclcniy  would  bo  violently  extended  with  a 
rhythmical  movement  at  the  rate  of  sixty  or  sixt^'-five  times  a 
minute.    Similar  caaes  are  on  reconl ;  but  I  am  inclined  to  beltere 
that  they  are  simply  iusfanccs  of  hysteria  occarriog  in  personsj 
who  have  RbuBed  alcnhol. 

Rhythmical  Spasms. — Choreic  movementft  of  hysteria  are  v( 
prone  to  lake  on  the  form  of  vibratory  spasms  and  to  become  moi 
or  let*  rhylbniical.  The  vibrations  may  be  very  rapid.  They.J 
frecpiontly  ntta«rk  extreniiriea  dintorted  by  hyaterinal  oontractui 
Thu.-»,  in  a  Ip^;  violently  flexed  by  conirnctures  I  have  seen  the 
knees  vibrate  laterally  over  a  considerable  arc  at  the  rate  of  one 
huudreil  and  twenty  tliue^  a  tuiiiute.  By  traciug  a  series  of  oBsea 
it  will  be  seen  that  disordei'ly  choreic  niovemeots  insensibly  pass 
into  vihmtionfl,  and  ihfw  into  true  rhythmic  -tpasms.  Rhythmic 
spasms  may  affect  auy  ]'<>rtio»  of  the  b«tdy.  The  limbs,  uorraal 
or  dIslortetJ  by  contractures,  may  be  agitated  with  regular  move- 
ments. The  face  may  be  attackwi  rliythniit«lly,  and  facial  gri^J 
maces,  with  or  without  the  conaoiitnneous  thrusting  forwanj  of  th^H 
tongue,  occur.  Occasionally  the  miisclwi  of  the  larynx  and  of 
respiration  are  alsu  alTccted,  so  that  each  s{>asm  is  accompanied 
by  H  quick,  strange  utterance.  This  rhythmio  chorea  again  paaees 
by  inHCusible  degrees  into  tho  purposive  movements  of  hysteriatfj 
thus,  the  rhythmic  movements  of  the  legs  may  give  rise,  when 
patient  is  slanjiijg,  to  a  scries  of  rapid  changes  of  poatnre  resem-< 
bUug  the  mazourku  or  other  dance. 


LOCAL  CHOREAS. 

Paralytic  Chorea. — Of  the  various  htcal  choreas,  I  shall  &rst 
s[>eak  of  liuitic  which  arc  connected  with  hemiplegia  or  mono- 
plegia of  cerebral  origin.  In  some  casen  the  movemeula  precede 
the  cerebral  hemorrhage,  constituting  tho  so-callotl  pre-bcmiplfgio 


MOTOK   BXClT£MBNTe. 


161 


^ 


lu  ottwr  cases  they  come  on  after  hemorrhage,  and  are 
af  as  poet'hemiplegic  chorea.  Not  rarely  they  fail  to  de- 
elop  until  the  pamlysis  is  distinctly  growing'  less,  and,  it  may  he, 
almoBt  entirely  paf»ed  off.  They  may  come  on  gradunlly  or 
mddeoly,  and  are  uaually  raodt  marked  in  the  hand  and  arm, 
next  in  the  face,  and  only  in  rare  cat^es  in  the  leg.  The  uius(;]is 
wliidi  are  employed  in  delicate  and  complicated  movements  are 
cBpecially  prone  to  be  attacked.  The  inlerossei  muscles  of  the 
hand  are  very  frwjnently  affected  simnltaneoti-^ly  with  iheir  aseo- 
taated  muscl<»  of  the  forearm.  Almost  everj-  variety  of  motion 
may  occur.  Sometimes  the  fiDgers  are  rapidly  opcn«l  anil  shut. 
Agpin  they  are  in  ]>eri>etiiai  flexion  or  extension.  The  hand 
itself  is  often  folded  and  opened  out.  The  wrist  may  be  alter- 
nately flexed  and  extended,  the  forearm  pronated  or  supiuated,  and 
bent  or  straiglileued  at  the  elbow ;  not  rarely  the  whole  arm  swings 
with  an  incessant  pendulum  movement  from  the  shoulder-joint. 

In  many  cases  the  movemeuts  of  paralytic  chorea  are  incessant 
duriog  the  waking  period,  and  cease  only  when  the  Kuhjecl  goes 
to  sleep.  Yet  in  not  a  few  in&tancea  they  can  be  purliully  coii- 
tzoUed  by  placiug  the  hand  in  some  {leciiliar  position:  thus,  in  a 
ease  under  my  own  care,  when  the  arm  was  put  Iwhiiid  the  body 
partial  qniet  was  obtain^vl ;  and  by  fixing  the  hand  ajfainst  the 
froDt  of  the  body  iuiniediately  umler  the  breaut,  the  woman  was 
able  to  control  the  movements  sufiicieutly  to  do  crocheting.  In  a 
reported  by  Ross,  putting  the  hand  in  the  pocket  was  suf- 
sient  to  obtain  rest. 

In  some  instances  the  contractions  arc  much  more  marked 

daring  voluntary  movement  than  <lurring  rest.    Indeed,  someLimes 

poei-hemiple^io  chorea  ia  reprewnted  simply  by  a  lack  of  power 

of  co-ordination  and  control,  so  that  during;  qutct  there  19  no  move- 

ineni  of  the  part,  but  whenever  a  voluntary  act  is  attempted  the 

muscles  are  thrown  into  irrvgukr  e)>asmodic  action.     As  pointed 

oat  by  Dr.  S.  Weir  Mitchell,  who  apjiear^  to  have  been  the  first 

oltnician    to  study  post -jiara lytic  chorea,  there  are   some   cases 

^Lin   which   the   movements  simulate   purposive  acts.     Thuii,  in 

Booe  of  Dr.  Mitchell's  cases  the  patient,  after  an  attack  of  right 

^ftfaemiplegia,  so  iiiueHHiintly  rubbeil  at  the  right  leg  with  the  right 

hand  as  to  wear  out  the  pantaloons.     In  another  case  the  arm 

alternately  pronated  and  .stipinated,  and  in  a  third  Xjast  ftjia 


^< 


162 


DIAOSOSnc   NEaROU^Y. 


wan  swung  ncn^m  the  body  only  during  walking,  at  each  step  the 
fingers  being  firmly  flexed. 

The  movements  of  the  face  may  affect  the  whole  dietributioD 
of  Iho  fuinal  riei*ve  of  the  afTecled  »i(le,  or  may  be  locatf^  einiply 
in  certain  parte  of  its  territory.  They  give  ri.se  to  all  sorts  of 
grimaces  and  disturbances  of  expression. 

A  very  curious  a.s<fOciatioa  of  movements  in  sometimea  seeo  ia 
post-hcmiplegir  cliorea :  thus,  in  a  mm  iindf  r  my  own  i»re,  when- 
ever the  woman  winked  a  very  peculiar  spasm  occurred,  involving 
only  a  few  fibres  of  the  fecial  nerve,  and  causing  a  peculiar  dimple 
in  the  chin.  lu  this  caee  the  <.kcu]o-inotor  ganglion  harl  become 
linked  to  a  few  cells  of  one  facial  nuclcuit,  so  that  a  simultaneous 
nervous  di-sitfiarge  from  two  centres  wan  provoked  by  one  periph- 
eral irritation,  or  by  one  effort  of  the  will. 

One  form  of  local  chorea,  which  is  usually,  if  not  always,  oon- 
neoteJ  with  chronic  braiu-let}iotis(eiipeciully  ticleroe^is  alter  infantile 
cerebral  hcmori'hage],  is  that  to  which  the  name  aihetoaut  hatt  been 
given.  In  this  the  fingers  or  tww  coiitinuotisly  and  slowly  assume 
varioiLs  distorted  jxxsilion.s,  and  are  only  partially  under  llie 
control  of  tlio  will.  Tiie  gpasms  of  the  m utiles  of  the  forearm 
change  so  slowly  that  they  might  well  be  descrilied  as  slowly- 
shifting  tonic  spa.sm<j.  Athetrwi.s  i.<t  simply  a  iiympt^itn,  not  a  dU> 
ease,  and  indeed  aa  a  symptom  scarcely  deserves  a  name,  since  it  is 
only  one  of  an  ianuiuerable  variety  of  post-hem iplegic  spasma,  and 
is  never  exactly  the  name  in  two  cases. 

A  condition  which  occasionally  follows  a  cerebral  paralysis, 
and  to  which  the  name  of  haniaUixia  ha.-*  Iwen  applied,  may  be 
considered  simply  as  a  very  mild  form  of  post- paralytic  chorea. 
In  this  affection  (liaorderly,  irreguUir,  spasmodic  movements  occur 
when  voluntary  actions  are  attempted,  although  there  are  no  mus- 
cular contractions  at  other  timM,  Speftking  of  such  a  caac,  Dr. 
Mitchell  says,  "Tliis  patient  had  no  involuntary  or  spontaneous 
iDovements,  no  motor  disLiirbamw  until  voluntary  acts  were  at- 
tempted, wlien  they  at  oni*  became  irregular.  Those  of  the  hand 
were,  as  I  recall  them,  so  striking  that  they  possessed  every  clinical 
peculiarity  of  the  chorea  of  childhood."  Other  observers  attribute 
Uie  irregularity  of  movement  to  the  loss  of  the  power  of  co-ordina- 
tion ;  but  that  this  ia  probably  not  correct  is  F^hown  by  the  fact 
noted  by  Dr.  Mitchell,  that  the  movements  were  as  well  performed 


UOTOR    EXC1TEMBMT8. 


163 


the  dark  as  in  the  light.  (See  also  Gowers,  Medko-Chirvrg, 
f.,  1876,  vol.  Jxs.  p.  321 ;  Gnisset,  Protjrix  Mid.,  viii.,  1880.) 
M  Dr.  Miteholl's  case  nil  the  cxtrciuiticf^  noeni  tn  have  been  some- 
what affected,  but  the  right  hand  was  the  inf»st  so.  At  the  ailtojwy 
there  \Tas  found  very  pronounced  genernl  atheroma  of  the  cranial 
blood-vessels,  and  a  spot  of  softcuiog  in  the  right  cms  cerebri, 
^^Iso  one  ill  the  left  corpun  Htriatiiin, 

^M    Very  generally  post-paralytic  chorea  is  associated  with  a  luore 

or  less  marked  disturbiince  of  sensibility.     This  honiianresthesia 

may,  however,  alaio«it  oc)mplete!y  disapiwar,  although  the  choreic 

movements  continue  as  violent  as  ever.    The  clinical  reports  seem 

H^  show  thai  heniianiesthesi!!  is  not  8o  absolutely  emeniialj  even  to 

^^the  post-hcmiplegic  chorea  of  adults,  as  is  stated  by  some  writers. 

The  acrumulafiiig  clinical  recorrU  confirm  the  original  guppoai- 

rtaon  of  Dr.  Mitchell,  tliat  |Hnst-paralylic  chorea  is  most  frequent 
wheu  the  attack  of  heniij)le);,'iii  comes  an  in  early  life:  hoiuv  the 
disease  is  espi-cially  marked  in  childrt-ii  sntTering  from  paralysis 
the  result  of  sclerotic  patches  in  the  brain,  such  os  has  been  fully 
discussed  in  the  chapter  on  PaUy.    {See  p.  75.)    It  should,  how- 
ever, he  distinctly  umlen^tood  that  this  foriu  uf  local  chorea  nay 
develop  at  any  age. 
H     The  particular  seat  of  the  lesion  in  post-hemiplegic  chorea,  as 
"first  states!  by  Charcot,  and  especially  developetl  in  the  thesis  of 
his  pupil,  Itaymond,  is  in  the  posterior  part  of  the  iiitcrual  cap- 
sule, iu  the  ininiediabe  neighborlHJtid  uf  the  leniiculur  nueleus  aod 
Optic  thalamus.     The  immediate  hand  of   fibres  of  the  corona 
radiata  especially  involved  is  in  frout  of  that  connected  with  and 
ooveriag  the  [xwtenor  end  of  the  uptio  thalamus.    This  region,  it 
will  be  rcmemlienxl,  is  a  very  distinct  one,  having  its  own  arleiy, 
the  posterior  optic.     Although  in  many  cai^es  of  ]K«t-licniiplegto 
chorea  the  lesion  is  located  in  the  spot  designated  by  the  great 
French  neurologist,  such  location  is  not  invariable.    M,  Demauge 
^^{Hev,  de  Mid.,  March,  1U83,  p.  877),  after  rvporting  a  case  with 
^BCharoot's  Icstiui,  rcc!ords  one  in  wlndi  there  was  violent  post- 
V^  bemtplegic  chorea,  and  in  which  the  lesion  was  situated  in  the 
ooovolutioos.     It  is  a  very  interei^ting  feature  io  this  case  that  the 
choreic  movements  were  preccdcil  by  cpilt-ptiform  crises^  which 
ceased  when  the  choreic  movements  developed.    The  choreio 
movements  themselves  a,)ao  disappeared  before  death.    \n  t«(i 


164 


DIAGKOBTIC  NKDROLOOY. 


casee  of  cerebral  syphilis,  with  presumably  cortical  tesioD,  I  have 
seen  a  violent  clioreiform  spasm  of  the  face  replace  epileptiform 
oonvult^ions,  and  there  is  a  e\mc  analogy  bettvoen  post-hemiplegie 
chorea  and  Jacksonian  epilep<iy.  Dr.  Demange  reports  a  case  in 
which  hemiplegia  was  atf^ociated  with  severe  tremblings,  liketho«e 
of  paralysifl  ^itans,  ami  the  Icstoii  was  situated  m  the  leniirnlar 
nucleus.  Tlii^  f(irm  of  tremor  mig-lit,  however,  be  BHisidercd 
distinct  fn>m  true poat-hemiplf^ifr  chorea,  but  in  the  Runrtinoflht 
AnafomifxU  SoeUttf  of  Pari$,  1879  (vol.  liv.  p.  748),  is  recorded  a 
case  in  which  a  true  post-paralytio  chorea  was  found  to  depend 
upon  a  Boftcning  of  the  brain  on  the  level  of  the  first  oonvolntton, 
involving  the  whole  thickneas  of  the  external  capsule,  as  the  sole 
lesion. 

Dr.  F.  Greiff  (.-ircA./iir  Pmfchiatrie,  1883,  xiv.  598)  reports  a 
case  where  the  only  lesions  were  in  the  eercbral  cortex  and  in  the 
pons;  further,  that  Itxal  ohorrei  may  lie  spinal  is  shown  by  the 
case  detailed  by  Eisenlohr  (quoted  by  Foucheraud,  p.  58),  in 
which  choreic  movements  had  existed  in  lx>th  arms  from  btrtb, 
and  yet  mreful  luierowMpical  exatninution  failed  to  detect  anything 
abnormal  in  the  brain,  but  revealed  sclerotic  nodules  in  the 
cervical  cord. 

The  evidence  seems  to  me  eufficnent  to  show  that  a  lesion  any- 
where in  the  pyramidal  tract — i.e.,  in  the  direct  line  from  tlje 
brain-cortex  to  the  motor  epiual  oell,'^ — or  in  the  motor  spinal 
cells  may  produce  a  localizcxl  chorea.  When,  however,  a  post* 
paralytic  chorea  is  associatetl  with  hemiaiijesthesia,  the  lesion  is 
prolmhly  at  the  position  designated  by  Charcot.  The  cases  re- 
ported by  Demange  se[>ara[e  tlietnselves  from  iIiohc  of  Charcot 
in  the  abaonoe  of  sensory  disturbance. 

Chorea  of  Stximps. — A  form  of  local  chorea  to  which  the 
name  Chorta  of  Stuni]w  was  given  by  Dr.  8.  W.  Mitchell  con- 
sists in  its  mildest  form  of  a  condition  of  unstable  i^uilibritim  in 
the  muscles  of  a  yiirgicnl  slump,  so  that  nndertlie  stimulus  of  voli- 
tion, emotions,  or  even  changes  of  the  weather,  they  will  contract 
irregularly  nnd  spasmodically.  In  the  next  degree  of  intensity 
spontaneous  twitdiings  and  movements  occur  without  any  per- 
ceptible immediflte  cause.  In  severe  cases  the  violence  of  the 
movements  is  surh  that  the  stump  is  pcr|)etually  rotated,  jerked,  j 
vibrated,   whirled    in   all   directions,  thrashed  about,  etc.     The 


UOTOR    EXCITEMENTS. 


165 


1  some  caites  are  entirely  irre^^ular,  in  other  inslanccK  they 
1  go  with  clock-like  monotony.  Ap|>caring  first  tn  the 
peripheral  muscles  iif  the  atiimp,  they  are  liable  to  spread  until 
they  involve  the  whole  limb,  or  eveu,aa  in  a  case  which  I  reported 
in  detail  in  the  Pfiiladelphia  Medicai  Times,  vol.  x.  p.  53,  one  side 
of  the  body.  In  thii>  c«se  Ihe  cluiiin  BjMwnis  of  the  fleKors  of 
a  li^-stump  were  at  the  rate  of  a  little  over  a  hundred  a  roinute, 
eacfa  drawing  the  end  of  the  stump  towards  the  thigh  over  an 
arc  of  from  two  to  four  inyhes.  Ot-catjiotially  there  were  also 
BpBsins  of  the  extcnsont,  and  more  rarely  chorcitr  H|)a8ius  of  (he 
glutei  and  other  muscles  moving  the  thigh.  In  the  forearm  the 
choreic  movements  occurred  from  eighty  to  ninety  times  a  minute. 
The  bioe|>s  muscle  of  the  upper  arm  even'  uow  autl  then  was 
(wized  with  spasms,  wliich  for  a  time  were  rapidly  repeated.  The 
muacles  of  the  shoulders  were  rarely  affViHeil,  but  (he  patient 
stated  that  sometimes  they,  with  the  lateral  muscles  of  the  truak, 
were  very  active.  There  were  ali*o  slight  choreic  twitclungs  of 
the  neck-mu9cle8,  and  occasionally  very  decided  clonic  spasms  of 
the  &oe.  The  right  side  of  llie  body  was  always  quiet.  Usually 
in  the  chorea  of  stumps  the  movements  cease  rluriiig'  sleep  ;  but  in 
the  case  just  spoken  of  the  stump  was  never  quiet,  and  the  patient 
always,  when  attempting  to  go  to  sleep,  placed  the  arm  under  hia 
head,  so  as  to  hold  it  still.     In  most  (sm-»,  when  stump  chorea 

|has  onoe  set  lo,  it  oontinues  indetinitely ;  usually  it  is  not  associ- 
alfti  with  pain  or  tenderness.  In  my  own  case  very  careful  inves- 
tigation was  made  of  the  nerve-trunks,  both  by  pressure  and  by 
the  electrical  current,  without  eliciting  any  abnormal  sensitiveness. 
Occasionally  a  neuralgic  stump  is  also  choreic.  The  jmlhology 
of  chorea  of  stumps  remains  uncertain.  After  amputations  the 
nerves  are  prone  to  undergo  iuflammaiory  changes,  which  may 
gradually  creep  up  nntil  they  involve  the  spinal  cord.  The  ab- 
sence uf  local  tenderne.<v(  in  many  choreic  stumps  indicates  that 
the  movements  are  not  due  to  neuritis;  but  the  only  recorded  case 
I  know  of  in  which,  by  section  of  the  nerve,  light  was  thrown 
opon  the  question  whether  the  spasm  is  or  is  not  due  to  a  [ler- 
ipberal  irritation  is  one  reported  by  Dr.  Lang&dorf  (quoted  by 
iVUicbell),  in  which  the  chorea  coexisted  with  evident  neuritis, 
OA  was  shown  by  pain  and   tenderness,  and '  was  cured   by  r^ 

.ampatatioD. 


166 


DUOK06TIC  NEITBOLOaV. 


I 

I 


Chorea  in  Internal  InflanunationB. — There  have  been  re- 
portwl  from  time  to  time  cases  in  which  violeot,  brusque,  wide- 
spread riiuscutar  cuutractioDs  have  been  developed  in  the  course 
of  acute  internal  iiiflaniinatiou,BUcli  as  a  plenrUy,  or  a  hronrhilJs, 
or  a  pnenmonta.  It  is  possible  that  the  choreic  tnovemeuta  in 
some  of  these  cases  were  reflex.  The  jjaramyodonus  multiplex  of 
Prof.  Friedreich,  of  Heidelberg,  apiicars  to  be  of  tlii«  eharacter. 

Habit  Choreas. — There  remains  a  eeriea  of  local  choreas  in 
which  no  defitiitc  cause  can  be  aasi|i;ncd  for  the  •tpasmodio  move> 
raeiits;  which  movements,  also,  in  a  great  many  casee^  oloeeljr 
simulate  pur|H><iive  acts.  It  i.s  probable  that  in  many  of  these 
cases  the  movements  originaitcd  during  ohildhoiHl  in  a  frequently 
repeated  pnrpoi?ive  act,  which  soon  gained  the  foroe  of  a  bad 
habit,  and,  not  being  corrected  by  the  will  of  the  child,  grew, 
in  a  neurotic  temperament,  into  a  fixed  custom  of  the  nervoua 
system  :  heuoe  the  term  Habit  Chorea  of  Dr.  3.  Weir  Mitchell. 
A  brow  may  be  lifted  at  intervals,  a  shoulder  shrugged,  an  eye 
winke<i,  a  jaw  dragged  forward,  a  trick  of  gesture  incessantty 
repeated,  even  a  cough  or  a  ftnnfHe  perpetually  indulged  in.  In 
the  beginning  these  habit  chorcaji'  are  not  purely  voluntary  move- 
ments, although  controllable  by  a  strong  effort  of  the  will,  but  are 
alli<'d  to  the  ordinary  St.  Vitns's  dance  of  childhood,  and  are 
greatly  benefited  by  hygienic  trGatmont  and  by  the  use  of  arsenit^ 
as  well  m  by  moral  means.  They  filially  become  mi  fixed  that  they 
are  entirely  l>eyond  the  control  of  the  patient  or  of  any  medicinal 
trcattneot.  Under  these  oircumstauoes  it  would  appear  as  though 
the  affcf'ted  nerve-centres  had  noqnired  the  habit  of  discharging 
themKcLves  at  regular  intervals  iudepeuduutty  of  any  control  of 
ttie  will.  The  habit  chorea  has  a  distinct  tendency'  not  only  to 
become  niorc!  and  more  uuamiiMlIable  with  years,  but  also  to 
increase  in  its  range. 

CONTRA  CTDRES. 
Contraefures  may  affect  one  extremity,  one  lateral  half  of  the 
body,  or  the  lower  extreniitieH,  when  lliey  are  spoken  of  re- 
spectively as  nionoplegic,  hemiplegic,  and  parapt^c.  They  may 
also  lie  ci)nfined  to  a  group  of  associated  (nusctcs,  or  to  a  single 
nerve- distribution,  or  liiey  may  exist  in  saittcL-eJ  unconnected 
groups  of  muscles:  in  a  word,  as  contractures  are  frequently  late 


HOrOB  BXCn'EMKNTS. 


167 


oDoditioos  of  paralyzed  muscle,  they  follow  imralyslf)  in  their 
distributioa. 

Tbo  axislouoe  of  a  contracture  is  so  apparuiit  that  it  is  reoog- 
nixed  at  oac«;  but  much  diagnostic  skill  is  ttoraetimes  required  to 
determiae  the  cause  of  it. 

CoDtraetures  may  be  clinically  divided  into  those  which  occur 
im]e|)en{ltently  of  moveinenl.^'iaHH  A, — and  those  which  take 
place  only  daring  voluntary  movenaent, — class  B. 

Cooti-aetures  of  class  A  may  be  due  to — 

1.  Cerebral  affections, 

2.  Complete  loas  of  power  in  ooe  of  two  seta  of  antagooistio 
tunscles. 

3.  Chronic  neuritis. 

4.  Irritation  of  the  motor  oervo-roota  by  oi^anlc  disease  of 
the  spinal  membranes  or  of  the  vertebrie. 

5.  Si^lcro^is  of  the  npinal  oonl,  ettpcciatly  aflecting  the  lateral 
oolumns. 

6-  Hysteria. 

Cuutracture«  of  class  B  are  represented  by  one  aflectioo,  Thorn- 
sen's  disease. 

OmtradureM,  Ciass  A. 

Cerebr&l  Contractures. — Contracture*  from  cerebral  hemor- 
rbage  may  be  clinically  divided  into  three  seta: 

Firri.  Thiiee  which  cotno  on  at  the  time  of  the  hemorrhage, 
and  which  may  be  known  as  immediate  rigidity. 

Second.  Those  which  appear  from  fifteen  to  thirty  days  after 
tiie  hemorrhage,  and  which  may  be  known  m  early  rlgidUi), 

Third.  Those  which  develop  after  the  lapse  of  some  months^ 
and  cuuHtitnle  Utle  riguUhj. 

In  each  of  these  forms  the  contracture  follows  the  position  of 
the  paralysis,  except  that  the  face  is  rarely  implicated,  and  that 
the  arm  is  usually  more  affectetl  (liuu  the  leg. 

Both  Iromcdiate  and  early  rigidity  ore  the  results  of  irritations 
of  fibres  of  tlie  pynimiilal  tpat-t.  In  their  lightest  form  they  may 
be  easily  overlooked,  but  they  are  to  be  recognized  by  the  sense 
of  resistance  experienced  whcu  ptiseivc  motions  of  the  a&ected 
parts  are  made.  They  are  always  associated  with  an  excessive 
faradtc  and  reflex  excitability  of  the  afTcotcd  muscle,  and  usually 
disappear  during-  sleep.     A»  they  are  the  indication  ot  \xAmb- 


168 


DIAONOOTIC  SEUROLOGY, 


I 


matorv  changes  occurrinfc  Bomowhere  in  the  pvratnidal   tract,  j 
they  are  of  serious  import. 

Late  rigidity  is  duo  tu  a  desveading  dc^^noration  of  the  fibna' 
of  the  pyramidal  tract,  aod  corresponds  in  its  manifcslntions  with 
the  contractures  of  lateral  Aclero^i,  from  which  it  is  to  be  ilintio- 
guishcd  by  its  hiiiCory,  and  by  its  being  hemiplegio  or  tnonoptegie. 
The  reflexes  are  always  exa^erated.     There  is  finally  a  progres- 
Rive  atrophy  of  tlie  riitiHcle^,  w}iich  in  the  (Miirw  of  yean^  may 
almost  entirely  disappear.     As  has  already  been  stated  in  the 
article  on  Paralysis,  the  so-called  Rpastic  palsy  of  childhood  ill 
often  a  form  of  cerebral  hemorrhage  with  secondary  degenerations  j 
and  consequent  late  rigidity. 

ContractureB  in  InftjitUe  ParalysiB. — In  acute  poliomyelitis 
the  contractures  and  consequent  deformities  are  very  slowly  de- 
veloped.     The  paralyzed   muscles  remain   limp  until  they  are 
couvertetl  into  fibrous  cords,  the  contractures  being  exclusively  in 
their  antagonists, — i.e.,  in  the  non-paralyzed  muscles.     Neurolo- 
gists differ  as  to  whether  the  flistortions  are  produced   by  the 
ehorteningof  the  muscles,  or  the  shortening  of  the  muscles  by 
the  distortions.     Some  believe  that  the  nuu-pai'alyzed   muaolcs 
meeting  with  no  resistance  gnuhially  undergo  alteration  and  con- 
traction, whilst  others  believe  tliat  tlic  shortening  and  contraction  ^j 
of  the  mu&cles  are  tlie  result  of  the  settling  of  the  limb  towardc^^f 
the  origin  of  the  rausule,  which  fausts  the  muscle  to  sliorten  itself     ' 
for  pur|)Oscs  of  adaptation.     The  praKlcal  point  is,  that  the  non-^J 
paralyzed  muscles  griulnally  atniphy  and  grow  shorter.  ^M 

Meningeal  Rigidity. — One  of  the  most  chfiracteriBtic  symp- 
touis  of  basal  cerebral  meningitis  is  stiffness  of  the  muscles  of  the 
neck,  due  to  spasm  of  the  muscles,  which,  in  extreme  cases,  may 
cause  marked  retraction  of  the  head.     In  the  mikleat  caaes  there  is 
merely  immovability  of  the  bead,  and  even  this  may  be  wanting ; 
but  when  the  head  is  raised  from  the  ])il]ow  by  the  hand,  a  marked  j 
sense  of  reHistanue  will  be  felt.     T}itd  form  of  tonic  spasm  is  QOl^fl 
strictly  speaking,  a  contracture,  but  in  chronic  spinal  meningitis 
the  persistent  rigidity  of  the  muscles,  esi>ecially  of  the  legs,  may^^ 
well  be  mistaken  for  an  oi^anic  contracture.     The  limbs  undaKi^f 
tliese  circumstances  are  drawn  up  on  the  body,  the  legs  are  beot 
upon  the  thighs,  and  the  feet  are  somewhat  extended.     Relaxation 
does  not  occur  during  sleep  or  ante>sthcsia. 


A 


Some  little  difficulty  may  be  experienced  ia  cUtigm»iug  between 
the  rigidity  of  chronic  apmal  meniiiffitin  and  other  oi^nic  or 
hyeterical  contractures.  The  symptoms  are  due  Ut  infJBmrnation 
propagated  from  the  spiiial  membraues  along  the  ncrve-sheaths, 
BO  that  the  spHms  are  extraordinarily  intense,  and  are  associated 
with  violent  pains,  caused  by  irrilation  of  (he  posterior  nerve-roots. 
In  rare  coaes,  when  the  disease  ia  located  about  the  caiida  equina, 
the  exudation  may  produce  sufficient  pressure  upon  the  nerves  to 
cauiie  |>aralytic  symptom*.  Under  such  circumstances  au  error  in 
diagnosis  ia  especially  liable  to  occur. 

In  both  organic  and  hysterical  contractures  pain  ia  produced  by 
an  attempt  to  straighten  the  legs ;  but  when  the  spasms  are  the 
resale  of  a  epinal  meningitis,  any  attempt  to  overcome  theiti  pr<.'>- 
<  dnoes  au  agony  which  ia  much  greater  than  that  cau»ed  iu  other 
coniracturt*.  In  one  or  two  cases  I  have  been  enabled  to  make 
the  correct  diagnosis  by  noticing  the  existence  of  an  excessively 
Hevere  girdle  pain.  In  simple  myelitis  the  girdle  BcnttatioD  may 
be  ven-  pronounced,  but  it  does  not  rise  to  the  poiut  of  agony,  as 
may  happen  when  it  is  the  result  uf  a  secondary  neuritis  of  the 
abdominal  nerves.  I  have  noticed,  in  cnsca  which  I  believed  to 
be  chronic  spinal  meningitia,  tenderness  over  the  large  nerve-trimks 
of  the  legs,  probably  the  result  of  a  de^cetiding  ueuritia.  In  a 
doubtful  cage  aid  in  diaguoHie  might  be  obtaiiietl  from  this,  as  iu 
loyelitiB  the  inSammatiuu  travels  down  the  nerve-truuks  very 
slowly,  if  at  all. 

Localized  chronic  spinal  meningitis  not  due  to  a  disease  of  the 
vertebrw  is  usually  syphilitia  The  diagnosis  between  it  and 
cancerous  tumor  must  be  carefully  made.     (See  pagc«  flO  and  SI.) 

Contracturee  of  Neuritis. — Contracinrea  do  not  appear  to  be 
A  marked  symptom  of  chronic  neuritis :  when  they  occur  their 
nature  is  to  be  recognized  by  their  biBtory,  and  by  the  existence 
of  tenderneas  over  the  affected  aervea.  They  may  exist  in  isolated 
groups  of  muscles,  or  they  may  be  symmetriwilly  arrange<l. 

Hysterical  Contraoturos. — Permanent  contractures  may  be 
caused  by  hysteria.  They  may  affect  one  or  several  limbs,  and 
may  be  nionoplegic,  heraiplegic^  or  paraplegic, — the  paraplt^io 
form  being,  on  the  whole,  the  mmt  frequent 

The  contractures  may  affect  only  single  groups  of  mnscles,  or 
may  attack  a  aeries  of  muscles  surrounding  the  joiutA,  and  in  this 


w 


DIAGXOfiTIC  XEDTtOLOGY. 


waf  an  hystcriral  club-foot,  or  an  Kyctertcfltl^  contracted  hand,  oi 
an  by8(«ric»l)y  6jc«0  and  apparently  iuflumed  juiat,  inay  be  pro-^ 
ducetL     In  the  wiole-i>pread  gcueml   contracture  paiu  is  a  rare 
sym|itam,  but  in  these  localiiuMl  contracture!;,  espedally  in   tb» 
neighborhood  of  joints,  it  is  verv  frequent. 

The  generaJ  cootractures  usually  develop  suddenly,  ofleo  fol-' 
lowing  a  hystero-cpileptic  or  otlier  violent  lij-sterioal  attack,  and 
may  remain  for  years,  to  disappear  as  suddenly  as  they  appeared. 
In  mast  m-vs  the  shortening  of  the  muscles  is  excessive,  and  the 
rigidity  absolute,  no  that  the  distortion  is  extreme:  thus,  in  a 
contracture  afiTecting  the  lower  extremities,  tlic  patient  usually  lies 
with  the  tegs  rigiidly  extended,  the  feet  inverted,  the  heels  drawn 
dp  to  the  greatcitt  extent  pitssible,  and  the  toefl  Hexed.  In  the 
early  periods  of  the  contracture  the  reQexea  are  distinctly  exag- 
gerated, the  faradic  contractility  of  the  miiiwles  is  increased  to  a 
greater  or  leas  degree,  and  the  nutrition  of  tlie  part  is  giKMl.  When, 
however,  the  contractures  remain  for  a  long  time,  the  muscles 
undergo  gradual  wasting,  and  lo»  gradually  tlieir  faradic  contnuv' 
tility. 

Unless  a  history  of  sudden  oocurrence  of  the  coDtractures  can- 
be  obtained,  the  positive  diagnosis  of  the  hysterical  contracture  is 
often  excewlingly  difficult,  even  in  the  earlier  stages  of  the  disease. 
It  has  been  asserted  that  the  occurrcace  of  ankle-ulonus  proves  Lba 
existence  of  oi^nic  disease  j  but  this  is  not  correct. 

In  many  cases  an  anjilgesia  and  an  anresthesia  oopxist  with  con- 
tractures. Undnr  tliase  circumstances  the  diagnosis  may  be  aided  j 
by  the  relative  positions  of  tb«  paralysis  and  aniesthesia :  in  ^M 
cerebral  organic  hemiplegia  the  eontraotures  and  licraianassthcsia  ^ 
are  usually  on  the  «atue  side ;  in  liysterical  ca^es  the  two  symp- 
toms may  coexist,  or  may  be  upon  oppccnitc  sides  of  the  body.  If 
contractures  are  associated  with  a  generalized  aoeasthesia  or  aoaU 
gesia,  they  are  hysterical. 

The  difticukies  of  diagnosis  are  well  illustraletl  in  a  case  which 
under  my  care  in  the  Philadelphia  Hospital.  The  woman 
Buffered  from  pronotmced  spinal  curvature,  due  to  organic  verte- 
bral disease,  with  (^)utracturcK  of  tlie  IcgK  and  gixiK»<  utikle-clunua. 
No  other  hysterical  manifestations  were  present,  and  there  was  no 
reliable  history  of  the  case.  The  dl.Tgnnsij*  wim  made  of  organic 
degeneration  of  the  apiual  cord,  secondary  to  an  original  trausvetiK 


I 

i 


IIOTOR    EXCITEMENTS. 


m 


myeliciji;  but  after  boin^  in  the  hospital  for  many  montha  the 
[MtKnt  recovered  in  a  few  days. 

The  question  of  dittfjnuBis  is  further  comiilicatetl  by  the  fact 
thai  oi^nic  contractures  may  super\'ciic  u[>oii  the  hysterical 
Tariety.  Charcot  reports  the  case  of  a  woman  in  whom  contrao- 
tureei  of  all  four  extremitittt  deveIo]>ed  puddenly  and  continued 
for  ten  years,  with  but  few  temporary  rciuissioofi.  Allcr  ihc  last 
aeimre  the  contraoturee  remained  until  death,  and  at  the  aiitoptiy 
syinroetrica]  st'Ieroais  of  the  lateral  columns  was  found  to  extend 
alnootit  the  entire  length  of  the  cord.  In  one  of  my  own  cases, 
oontmctures  which  had  appareully  been  originally  hj'Bterical  did 
not  relax  duriiiK  anasthcsia,  ami  were  afictjnipanied  with  much 
atrophy  of  the  affectetl  muscle.  In  a(Y.-urdHnce  with  the  nde  laid 
down  by  Charcot,  that  whenever  marked  airopfty  of  ihe.  mi«ofe» 
and  pcrsisfoicr  of  tht  contraciuret  during  amedhmia  are  present 
organic  deffcneration  of  tlie  t<pinal  conl  iiiui  probably  set  in,  the 
diaf^osis  in  my  ease  would  he  lateral  selerogis  following  an 
originally  hysterical  contracture. 

TosQm  lip,  hysterical  contractures  are  to  be  distiugui-thcd  from 

! their  oi^nic  prototypes  by — 
First,  Suddenness  of  development. 
Sftondly.  An  hysterical  history. 
Thirdly.  Presence  of  aneestlieeia  or  other  distinct  hysterical 
»yiziptom«. 
Foaiihli/.  Absence  of  wasting  or  other  changes  in  the  muscles. 
F\fVily.  Sudden  remissions  of  the  con tnict urea. 
^xUdy.   At)6ence  of  various  symptoms  of  organic,  spinal,  or 
oerebral  disease  sometimes  present  in  orijauic  coutractures. 
Seventhly.  Di.sippea ranee  of  the  contractures  during  unu^thcsia. 
Lateral  SoIoroBis. — A  very  onramon  form  or  cause  of  con- 
tractures is  scleroais  of  the  lateral  columns  of  the  spinal  cord, 
either  focal  or  continuous.     In  the  groat  majority  of  cases  th^ 
l^s  are  affected  solely,  giving  rise  to  the  so-called  «pastie  ptira- 
pUtjia,     But  sometimes,  especially  in  focal  disease  of  the  lateral 
columns,  the  sclerosis  may  be  so  limited  in  the  upjier  [iorl:i»jii3 
of  (he  cord  that  the  motor  symptoms  are  coofined  to  one  or  more 
of  the  upper  extremities.     The  diaguusis  of  lateral  sclerosis  rests 


(.  Slowness  of  development. 


172 


DIAOK'UBTIC   SEtTROLOOY. 


Secondly.  Gradual  loas  uf  power,  associated  wiUi  epasm  ac 
heightened  reflexes. 

Thirdli/.  Absence  i>f  ginlle  ttensation,  of  pain,  or  of  distiirljoiK 
of  sen^iiion ;  of  paralysis  of  bladder  or  rectum,  of  trophic  changes, 
and  of  disorder  of  co-ordination. 

As  lateral  Hclertttis  lia«  already  been  fully  ooiisidered  (see  p.  (16) 
it  IB  only  necessary  here  to  state  that  in  some  coaca  violent  treuiOE 
develop  in  t>iP  leg  during  walking  and  other  voluntary  move 
mcnte  of  the  feet. 


Can/raeturea,  CiasJi  B. 

Thomeen's  Disease. — In  ,4rc/itV  Jar  Psychtatrie^  1876,  vot. 
vi.  p.  762,  Dr.  Thomsen  dcs*ril»«d  in  detail  a  group  of  Byraptoma 
with  which  some  thirty-five  of  his  relattvee  were  afflicted,  a: 
which  are  now  belkve«l  to  Iw  character ii^tic  of  a  distinct  affecti 
commonly  knoM-n  aa  Thomsen'a  disease  (mtf{Uonia  eongtnUa^ 
Strumpcl),  Caaes  of  similar  character  were  described  by  Charles 
Bell  as  early  as  1830,  and  more  recently  by  Benedict  in  1868, 
by  Lieyden  in  1874,  and  especiaUy  by  Seeliguiuller  in  the  last* 
nairied  year.*  The  essential  symptom  of  the  affection  is  that  whra 
voluntary'  raovenncnt  ifl  attempted  the  muscle  in  thrown  into  a 
condition  of  tonic  spaam^  which  may  spread  to  the  entire  vol- 
untary mubcular  system,  and  last  for  several  minutes,  before  then 
is  sufficient  relaxation  for  Uie  [mtient  to  oominand  his  aoiiooa. 
In  some  of  the  cases  the  symptoms  have  dated  from  infancy,  in 
others  they  appear  to  have  developed  in  late  childhood  or  early 
manhood.  Almost  in\-ariably  the  subjects  are  healthy  men,  who 
are  apparently  extremely  muscular,  but  who,  on  trial,  possess  very 
little  endurance,  and  also  oomparatively  limited  muscular  power 
for  momcDtarj'  exertion.  The  afPcclion  is  markedly  hereditary, 
tind  in  most  of  the  reported  cases  clear  evidences  oould  be  obtained 


ma     I 

iooH 


*  Tho  lltGroture  of  itiU  lubjoct  up  to  th«  full  of  18B8  wu  vny  thoroughly 
collected  by  [>r.  Mobiua  {Sehmidt't  Jahrb.,  cscTiii.  2S«).  Kince  tbii  time  tba 
nott  important  pupert  known  tn  xa<t>  nre  ti>  bo  found  t»  follow*:  Union  M6d., 
1S88,  xxxTi.  9O0;  1886,  xxxix.  &0;  IUik  dt  Mid  ,  I9fi5,  iti.  1064 ;  Oaa.  a»M. 
de  Midtcine,  1884,  xxl.  18;  Brain,  vii.  10&-I81;  Canada  Lmtett,  Toronto, 
16&i-85,  xvil.  71;  Alienist  and  NeuroUiffurt,  t.  (>]»;  Centraiilalt /%ir  yer- 
vmiAeilhunde,  IS8fi,  viii.  V2'2,  193;  lieriin^r  Klin.  WoeKerueArife,  1868, 
xzil.  006t 


MCrrOR   KXCITKMESTS. 


173 


oT  Dear  relatives  of  the  pntient  liavtng  suffered  from  similar 
STiaptoras.  In  ThomsGn's  family  there  was  n  distinct  history  of 
attacks  through  five  generations.  Several  of  his  owu  children 
were  affected,  and  of  his  thirteen  brothers  and  sisters  seven  bad 
developed  very  decided  Rym|Jtoms.  In  a  rcniarkuble  proportjon 
of  the  cases  the  disea^  has  been  dctert^l  in  military  recruits,  who, 
at  firet  believed  to  be  excessively  awkward  at  drill,  were  fiually 
foand  to  be  really  imablc  to  control  their  muscular  niovcnients. 
Such  was  the  nature  of  the  case  rejMjrted  by  Seeligmidler.  Peters 
tclU  of  a  soldier  twenty  years  old  who,  when  coramnndod  to  raarfh, 
wonld  remain  immovable  for  a  length  of  time  as  if  rooted  to  the 
grouud,  then,  with  awkward  tstrug^cliug  movements  of  his  arms 
and  Icjjs,  he  would  free  himself,  and  after  staggering  a  few  paces 
would  be  able  to  go  on  regularly;  but, even  after  he  had  regained 
ooDtrol  of  his  moscIcA,  if  he  attempted  to  ran  he  would  directly 
I  fall  to  the  ground  in  a  condition  of  rigidity  which  involved  his 
I  irhole  muscular  synteiu,  tticludiiig  the  tongue  aud  face.  Wheu 
I  be  yd  hold  of  an  object  be  was  unable  to  let  it  go;  and  thus  it 
K  WMwith  almost  any  muscular  act.  In  a  case  whi:*!!  came  under 
^1  ny  care  in  this  city,  the  patient  complained  chieJly  tiiat,  when 
^H  going  Dp-6tairs,  afler  three  or  four  steps  bia  advancing  leg,  as  ha 
'  nittd  himself  on  it,  would  l>e  seized  with  a  [minlcas  but  irresistible 
tetniK  spasm,  whicli  would  for  several  moments  entirely  prevent 
pcogreesion.  The  tendency  to  tonic  contractures  is  invariably 
iocreaaed  by  fatigue,  often  by  emotional  excitement,  aud  usually 
bf  exposure  to  cold;  warmth,  the  frequent  repetition  of  movo- 
OKnts,  and  incxierate  exercise  tend  to  lessen  it.  Pressure  U|H)n 
lie  arteries  or  nerves  docs  not,  as  in  tetany,  produce  muscular 
MBlnrtions.     (Marie,  Iiei\  dc  MM.,  1883,  ill.  1069.) 

The  contractions  may  be  coulined  to  a  single  group  of  muscles 
inilirect  relation  with  those  which  are  primarily  caused  to  con- 
tnot  by  the  will.  Thus,  in  a  case  reported  by  Mobius,  the 
miBcles  of  the  leg  were  the  only  ones  that  ever  suffered  from 
CTunp,  which  first  appeared  after  exoeMive  fatigue.  The  case 
tkididcred  from  the  onlinary  one  in  the  lack  of  the  eulurgcment 
of  t!ie  muscles.  Nevertheless,  the  fact  that  the  patient's  father 
h«j  also  9uff*er0(l  marks  the  diseasf-  fui  the  herctlitary  afTection. 
Dt.  L.  Deligny  {Union  Mfd.,  1885,  vol.  xxxix.  p.  bO)  details 
a  case  in  which  a  brusque  turning  of  the  bead  would  give  rise  to 


DIAOSOSmC  NKUROLOOT. 


a  spasm  of  the  acting  gtcrno'inostoid  musde.  Maittication  would 
produce  stiffness  in  the  jaw-muscles.  In  some  casee  of  Thotiwen's 
disease  a  sudcleu  jiuwli  during  walking  is  sufEcient  to  bring  on 
absolute  universal  stiffne^ ;  in  others,  aneezinjf,  coughing,  swal- 
lowing, crying,  evpn  winking,  will  prodiioe  a  paroxysm.  A  con- 
traction wliich  involve*  the  wliole  body  h  affirmed  to  comnieoce 
usually  in  the  legs  themselves,  and  to  spread  to  the  arms*  and 
finally  to  thumusiileKor  thehip.  This Buoceesion  pnilmbly  de{>end8 
upon  the  fiict  that  the  ottacka  are  generally  precipitated  by  the 
movements  of  wnlking. 

Vixioli  studied  the  mut4cu]arcontra(.>tion  with  the  dynamograph 
(Alicni&t  and  Neurologist,  vol.  v.  p,  G2I),  and  portrayed  its  pecu- 
liaritii's  in  graphic  curves.  "  He  olwervwl  that  by  making  the 
patient  bold  the  liand  open,  and  ordering  him  to  close  it,  there 
passed  some  five  wconds  l»efore  the  movement  was  accomplished ; 
if  the  hand  was  partially  cloned  instead  of  being  widely  open, — 
ie.,  if  it  was  put  into  the  atatc  of  fiexion, — ^the  patient  on  being 
told  to  Hose  it  fully  did  ao  almont  iiiimeiliaiely,  without  the  voli- 
tion being  sensibly  retarded.  This  contraction  was,  however, 
marked  by  a  line  com|Mi5ed  of  many  ample  oscillations  {irtmor 
oedRatorixut).  The  patient  took  up  from  five  or  t>ix  to  ten 
eeoonds  in  o]>ening  the  hand,  when  it  liad  been  contracted,  and 
the  relaxing  of  the  fleior  muscles  was  not  miirkcd  in  the  graphic 
cairve  by  an  almost  right  line  a»  iu  the  normal  state,  but  by  an^^ 
oblique  line  with  irregular  oscillationa."  ^* 

In  (Ti}nie  cases,  aw  in  tlit  wddier  studied  by  Pelrone,  after  the 
first  contractures  have  passed  over,  there  is  complete  liberty  of 
action. 

In  a  great  majority  of  the  reported  cases  the  contractures  have 
been  painless,  or,  at  least,  aconrapanied  with  no  greater  disturb- 
ance of  feeling  than  the  sensatiou  of  elw^tric  currents  rnnning 
through  the  part,  a  sense  of  awelUng,  of  pricking,  etc.;  but  in 
the  case  already  referred  to  as  reported  by  M.  Deligny,  four  or 
five  1im«»  a  year  the  patient  would  »uQer  a  sort  of  "crisis,"  oom- 
posed  of  a  series  of  general  muscular  contractions,  which,  during 
the  period  of  from  twelve  to  twenty-fonr  hours,  recurre<l  at  short 
intervals,  repeating  themselves  upon  the  slightest  pmvocation,  aud 
were  always  accompanied  with  such  violent  jMiin  that  the 
would  roll  on  the  earth  iu  his  agony. 


* 

I 

■4 


patient  ^| 


HOTOB   EXCITEMENTS. 


176 


The  knee-jerk  and  the  true  reflexes  aro  usually  Dormal  in 
ThomBen's  disease,  but  in  sumo  (uses  u  direct  bluw  upon  the  muscte 
produces  a  (Kreistent  toiuc  contraction,  and  Yizioli,  and  aUo  Marie 
{Rev.  de  Mid.,  1883,  vol.  iii.  p.  1069),  have  noted  incrca^  knee- 
jerk.  Paseive  movementj?  are  at  l(;ast  in  some  cases  [wrforraed 
without  resislanee  {Arch,  de  KeuroL,  January,  1883).  To  inapec- 
tioo  the  muscles  almost  invariaKly  appeared  to  be  hypertrophled, 
bat  careful  exaniinations  made  by  Jacusiel,  Pyntick,  and  Petnjne 
Iiave  denioDStnitcd  that  their  structure  is  normal.  In  a  single 
case  Petere  found  evideti<»es  <if  alrophy  In  the  lower  portion  of 
'  the  deltoid.  The  integrity  of  the  muscular  structure  is  further 
shown  by  iheir  electro-contnirtility  being  normal,  save  that  tno- 
mentary  appli^-atiuu  of  the  faraOiu  curn;nt  pruducies  a  tetanio 
oontraction  which  may  last  Ave  and  one-half  seconds  (Svelig- 
mflller)  after  the  remo^Til  of  the  current.  In  one  case  Bigou- 
roux  believed  that  the  tetanic  contraction  of  closure  was  grewter 
at  the  anode  than  at  the  cathoile.  The  muscles  of  involuntary 
life  do  not  appear  to  suITvr,  ultliough  in  u  ease  reported  by  Bullet 
and  Marie  the  larynx  was  often  the  seat  of  the  s|ia«ni.  The 
pailhology  of  Thomsen's  di.sease  is  unknown.  No  autopsies  have 
been  reported. 


AUTOMATIC  MOVEMENTS. 


^H  Automatic  Movements  are  coniplicated  movements,  closely  re- 
f^  sembling  the  purposive  actions  of  ordinary  life,  which  take  place 
^^  indepcndf^ntly  of  the  will  of  the  patient. 

^B  Cii»ei}  of  automatic  movements  are  beat  studied  for  clinical 
~  purposes  under  the  headings  of— t5rst,  thosft  in  which  the 
actions  are  pixnluceil  by  an  impulse  arising  spontaneously  within 
a  person,  but  indepeudcutly  of  the  will  of  such  person ;  secondly, 
tho«e  in  which  the  movements  occur  in  rcsp<m&e  to  impulBes 
received  from  without  the  perM)u.  Cases  of  the  first  c]aafi  are 
instances  of  chorea  major.  Cases  of  the  second  clans  are  psy- 
chical. 

Cliorea  Me^or. — In  chorea  major,  or  chorea  Genuanorum,  the 
•outbreak  is  usually  prec^l^d  by  pru<lr(>ines,  such  us  melancholy, 
Apathy,  feeling  of  nausea,  malaise,  cramps,  or  tonic  convulsions, 
dijstnrhanoM  of  the  circulation,  palpitations,  etc.  The  paroxysms 
usually  come  ou  with  a  general  excitement,  which  perhaps  ought 


176 


DIAONOSriC  NEUROLOGY. 


to  bo  oonsidered  as  a  form  of  aura.  During  the  paroxysms  the 
affeotetl  person  dances,  sings,  springs  from  tlic  ground,  rolls  hltn- 
Rclf  from  sido  1o  aide,  hammers  violeotly  with  the  hands,  stamps 
with  the  feet,  or  in  a  fury  of  motor  excitement  nhirls  with  mad 
rapidity  until,  completely  exhausted,  he  falls  to  the  ground.  The 
cxnitcnient  is  not  confined  to  the  motor  sphere:  songs  are  suog, 
affairs  recited,  foreign  tongues  spoken,  in  a  manner  entirely  beyood 
the  normal  power  of  the  iodividual;  events,  languagei!,  ]>oet- 
ical  quofatioiis,  whioh  seenun^ly  never  have  been  engraved  upon 
the  memory,  are  recounted  or  recited  in  eloquent  or  incnhcrent 
ravings.  In  the  height  of  the  attack  con»:iousn€8s  is  nstially  lost, 
but  sometimes  it  ia  iu  a  measure  praserved,  especially  in  the  spo- 
radic case!*.  As  an  instance  of  the  sporadic  variety  may  l»e  men- 
tionefl  a  case  rejwrted  by  Robert  Watt,  in  which  a  girl  ten  years 
old  turned  herself  round  and  round  in  paroTysms;  later,  she  bad 
atta«.rkH  in  which  nhe  would  roll  from  eud  to  end  of  the  bed 
violently  hack^vard  and  forward,  then,  lying  upon  her  back,  her 
feet  and  head  would  be  forcibly  jerked  togetlier  ten  or  twelve 
times  a  minute.  A  single  parrtxysm  of  these  movements  uAea 
lasted  fourteen  hount  a  day.  In  a  more  recent  case,  reported 
by  Dr.  Bdowcnzcl  {Schmidts  Jahrb.,  1874,  dxii.  193),  a  young 
boy,  huving  wartiing  of  aii  attack,  woiihl  run  home  from  school, 
qiiic-kiy  throw  himself  upon  the  l>ed,  spring  up  and  down  sud- 
denly innumerable  times,  i^nd  upon  his  head,  cry  out,  jump  from 
the  bed,  and  run  as  though  in  terror  round  to  a  circle  to  the  spot 
from  whieii  he  had  staried,  not  rarely  in  his  fury  striking  his 
bead  severely  againiil  olHtacles,  ami  jierforming  many  other  move- 
nieutit,  until  exhausted,  when  he  would  sink  upon  the  bed  io  a 
deep  sleep,  to  awake  with  full  consciousnese. 

Meiitiuu  has  already  beeu  made  of  the  religious  epidemios 
of  thfl  Middle  Ages,  which  have  been  in  modern  times  repeated 
in  the  outbreaks  that  have  occurred  in  camp-meetings  in  the 
United  Stales  (especially  in  Kentucky  in  the  early  part  of  this 
century).  Of  somewhat  the  same  character  are  the  perform- 
anoes  of  the  howling  dervi&lies.  The  relation  of  these  attacka 
to  liyMeria  is  a  very  clear  one.  Undoubtedly,  in  many  cases  the 
paroxysm  ts  brought  on  by  an  effort  of  the  will,  precisteiy  as  the 
hysterical  paroxysm  may  be  induced;  but  without  the  hysterical 
excitemeut  tlie  individiuil  would  be  iucapable  of  perfuVuiiug  many 


MOTOR   EXCITEMENTS. 


177 


of  the  acts  which  he  rittt*.  Further,  in  some  cases  of  chorea  major 
the  attacke  are  r«all}r  epileptic,  being  comparable  to  8o-calIe<]  run- 
ning epilepsy.  (See  p.  107.1  There- appears,  however,  to  bo  a 
remnant  of  rases  which  can  scarcely  be  considered  hvstericiil,  uiid 
which  certainly  are  not  epileptic.  Seemingly  of  this  character 
are  the  so-called  salaam  convulsions  of  children,  in  which  the 
paroxysms  recur  several  times  a  day,  last  from  a  few  seconds  to 
some  minutes,  and  consist  of  a  bowing  forward  of  the  head  and 
body  perhap*!  as  many  as  two  hundred  times. 

Psychical  Automatism. — In  that  form  of  antomatism  in 
wbicb  the  movements  are  In  ol)e<lience  to  impulses  from  without, 
the  abwirnial  condition  is  a  psychical  disturbance,  which  is  to  some 
extent  illustrated  in  the  phenomena  of  artificially-induw^il  hyp- 
nou.<;m, — a  mental  condition  into  the  discussion  of  which  I  shall 
not  here  enter.  In  some  rare  cases  of  iDsanity  the  sufferer  will  do 
at  once  tliat  which  either  by  example  or  by  word  of  inoutli  he  is 
bidden  to  do,  and  will  remain  almost  indefinitely  in  any  position 
in  which  he  is  placed  or  which  heaasumesnt  the  wonl  ctfoommand. 
This  condition  may  be  misialccn  for  catalepsy,  but  is  to  be  dij>tiD- 
guifbetl  from  it  by  the  fact  that  consciousness  is  not  lost,  and  tliat 
the  assumed  position  ia  at  once  departed  from  when  a  sharp, 
quick  command  is  given.  I  have  seen  this  state  of  pliability 
under  command  extraordinarily  pronounced  in  a  scrofulous  child 
of  feeble  physical  orj^anization,  but  not  insane,  and  uf  fair  menial 
development. 

Miryachit — Latah — Jumpers. — A  very  curious  afTVction  op 

t  nervous  condition,  which  is  perhaps  best  classed  among  the  psy- 
chical  automatic  alTections,  has  been  noted  under  various  names  as 
occurring  in  Asia,  Kiin)i>e,  and  America.  The  essential  feature 
of  lIiIs  condition  seems  to  be  an  extreme  excitability  of  the  pa- 
tient, which  causes  tiim,  njnm  the  lea>ft  abrupt  excimtion,  such  as 
would  be  prodnoed  by  slapping  him  on  the  shoulder,  hallooing  at 
him,  slamming  a  door,  etc.,  to  jump  or  perform  other  violent  disor- 
derly acta,  conjoined  with  a  couditiou  of  the  oerebrul  nervous  systeoi 
which  necessitates  a  repetition  of  voices  or  soumls  [frhiiliitijin),  or 
the  ejaculation  of  some  word,  usually  obscene  (coprofaJffia).  In 
eonw  cases  the  impulse  of  imitation  is  so  great  as  to  force  the  vic- 
tim to  repeat  not  only  the  spoken  word  but  also  any  act  done  by 
a  by-Btander.     Vety  frequeuiJy  the  sudden  nervous  excitement  is 

12 


* 


178 


DIAUN08TIC    SEUIiOIXJOY. 


aocotu}>aDied  by  au  excessive  euotioD,  e«p«c-ially  of  fear^  altboagh 
tiiich  emolitJD  may  be  entirely  foreign  to  the  ordinary'  nature  of 
the  individual.     The  diHcane  apjieara  to  be  hei^liiary.     It  ofteo^J 
afl*ect9  various  members  of  several  generations  of  one  family^^^ 
According  to  the  eluljomte  description  of  M.  O'Brieo  {Journal  of     , 
(Ac  StrttiU  yii-arwh  nj'  Ote  HoiftU  Aitiaiio  Somfiy,  Singapore,  June, 
1883),  in    Sontlieru  Asia   ihe  aflbctiou  m  known    by   the  Malay 
name  of  IfUtiJi.     Mr.  O'Brien  maketi  fonr  claflses  of  cases: 

Oo^JiTst,  comprising  tbose  iiHlividtialiii  in  whom  an  nnexpeei 
noise  produces  great  alaroi,  with  au  irre^sietible  impulse  to  rush 
upon  the  nearest  object,  and  at  the  saine  time  forces  au  exclama- 
tion which  is  always  obscene. 

CM«»  ("^roW,  comprising  those  |»ersoiis  in  whom  oerbiin  wo 
wUeu  Kudiienly  pronounced  will  prwluce  au  exceiistve  paroxysm  of 
sudden  terror.  Thus,  in  an  individual  noted  for  his  couraj»e  and 
who  faced  the  living  ulligator  without  a  sign  of  fear,  the  stidden 
prononiidng  of  the  word  "buaya"  (Malay  for  "alligator")  pro- 
duced a  paroxysm  of  overpowering  terror. 

In  cUvsM  Utree,  the  individuHls  imitate  tlie  wonU,  gestures,  oT^ 
aayitigs  of  those  in  tlielr  ncighlxirhifiod. 

In  thefourih  class  the  iudividimU  become  completely  aband 
to  the  will  of  Hoine  other  irerson,  performing  every  act,  howev' 
ouiri  or  impniper,  whiuli  they  arc  oomraandwi  to  do  by  such 
dividual,  standing  on  their  heads,  attacking  a  spectator,  eti!.     In/ 
these  cases  the  person  who  suffers  from  latih  roflngnizcs  his  enslave- 
ment and  is  greatly  depi-esscd  thereby,  but  is  unable  to  prevent  it 

According  to  the  observations  of  Americuu  naval  officers  {Ob* 
Bervniiow  upon  Ote  Cbj-ean  Cbcurf,  Untied  Stoiett  Naval  Dejiartmenty 
Washington,  1883),  an  affbclion  nllied  to  latah  esists  in  Easi.^rn 
Siberia,  wiiere  it  is  known  by  the  Russian  name  of  miryachiL 
In  a  caw  seen  by  the  American  ofH^wni,  a  pilot  would  imitate 
against  his  will  with  aljsolute  esaotitiide  all  tlic  strange  gestures 
and  actH  which  wcrw  performed  in  bis  presence  by  accident  or  foci 
the  determinate  purpose  of  tormentiDg  him,  and,  even  when 
escape  his  persecutors  the  muu  had  locked  himself  up  in  iJie 
pihit'houit^e,  be  could  be  heard  i^tamping,  pt>ui]ding  on  the  sides  of 
the  wall,  etc.,  in  exact  repetitioo  of  acts  performed  in  bis  bearing 
by  persons  without.  This  case  plainly  represents  claaa  three  of 
O'Brien. 


MOTOR   EXCITEMENTS. 


17d 


The  "  Jumpcra,"  or  "  .Tamping  Freiichracn,"  of  Maine,  descrilwd 
by  Dr.  G.  M.  Beard  {Joumai  of  Nervoiu  and  Menial Dumaai,  vol. 
vii.,  1880),  seem  aUo  to  belong  in  the  present  caUrgory.  lu  these 
persons  th(^  h«iriiig  of  a  smUhm  voioy  or  tioUc  causes  a  repetition 
of  the  words  or  aonnds,  with  the  performance  of  Btrange  antics, 
whilst  a  loud  coromaiid  eMKcns  to  by  always  olwyed,  Thus,  a 
"jumper"  was  told  to  throw  a  knife  which  he  held  in  his  hand: 
this  he  did  instantly,  repeating  at  the  same  time  the  order  with 
a  cry  of  alarm,  not  unlike  that  of  hystoria  or  epilepsy.  Two 
"juDopers"  standing  near  each  other  when  commanded  to  strike 
each  other  did  so  with  z«il.  Dr.  Beard  tentetl  the  eclio-speak- 
ing,  or  repetition,  by  reading  portinna  of  Latin  and  Greek,  when 
the  untutored  "jumper"  repealed  the  soundB  of  tlie  wttrrls  m  they 
can3«  to  him,  in  a  quick,  Aharp  voi<-e,  at  the  same  time  jumping  or 
DiakiDg  some  bizarre  motion.  Tlie  slamming  of  a  door,  the  fall- 
ing of  a  window-Hash,  or  the  sudden  scream  of  a  steam-whiiitle 
prD(iw«<l  tiie  i^me  effect  as  the  liumiui  voice.  In  an  elaborate 
review  M.  Gilles  de  la  Tourctte  (Arch,  dt  Nexirot.^  vol.  vii!., 
1884,  and  vol.  Ix.,  1885)  has  collected  a  number  of  cases  occur- 
ring ill  an  isolated  nianncr  in  Europe  mure  or  lees  closely  oon- 
formlng  to  the  type  of  the  aflection  just  d&scribed. 


CHAPTER   IIL 


BBFLEXB8. 


TJynER  th(^  general  headtng  of  refloxes  I  propose  to  diacosB 

certain  raovemeots  of  portions  of  the  body  which  are  din»ctljr 
producwl  by  external  irritatictiii}.  Suiiie  of  tlieve  movemeitts  are 
prolmbly  not  of  the  nature  of  rcSex  acts,  but  the  term  reflexes  is 
for  our  present  puriKKW  convenient,  ami  is  used  with  the  under- 
standing that  itA  employinent  does  not  indicate  the  eorrectaefls 
of  any  theory  aa  to  the  way  iu  which  the  movements  are  produced. 
The  reflexes  Daturutly  divide  theuuelvett  iutu  two  varieties,  the 
BUi«*rfiriiil  and  tlie  deep, — i.e,,  those  movements  which  are  pn>- 
dured  by  irritations  of  the  skin,  ami  those  whicli  are  the  result  of 
irritation  of  dee]>cr  tissues.  ThU  division  is  not  only  suitable  foi 
the  purjjose'of  tJie  cliniciim,  but  appears  also  to  l>e  a  nalur»l  one, 
as  it  will  be  tihown  hereafter  that^  whilst  the  superOdul  reflexes 
are  probably  true  reflexes,  the  deep  reflexes,  so  culled,  arc  in  ali^ 
probability  not  reflexes  at  all. 

SUPERFICIAL  REFLEXES. 

The  superficial  reflexes  are  excited  by  irritationg  of  (h«  skin 
aBd  mucouE  membrane,  either  by  tickling,  prinking,  pinching,  or;, 
gently  w^nitirliinji  the  fiurfnce,  or  by  means  of  a  dry  eleelne  bnish. 
The  nature  of  these  reflexes  will  be  discussed  when  speaking  of ' 
the  so-called  deep  reflexes.  They  are  to  tlie  diagnostician  of  coto- 
porutively  miour  import,  because,  unless  it  ix!  the  plantar  reflex, 
none  of  them  are  alwaysi  pre^int  iu  healthy  imliviiluals,  whilst 
some  of  them  are  so  closely  siniiilatci]  by  voluntary  acts  that  it 
may  be  impossible  to  deoide  whether  the  movement  is  the  result 
of  volition  or  of  ii  reflex  irritation.  Thus,  on  tickling  of  (he 
sole  of  the  foot,  so  long  as  there  is  voluuturj*  power  and  sensation 
a  sudden  aemi-involuotjiry  and  yet  truly  cerebral  withdrawing  of 
the  foot  is  almoitt  sure  to  occur.  It  may  he  laid  dotfn  as  a  geaenJ 
rule  that  the  absence  of  a  skin-reflex  is  of  uncertain  diagnoatio 
import,  whilst  the  presence  of  the  reflex  shows  the  int^;rity  of 


^ 


REFLEXES. 


181 


ft-" 


the  nerve-arc  implicated,  anch  nerve-arc  being  oomposcri  of  the 
afferent  nerve,  a  section  of  the  spinal  cord,  and  the  efferent  nerve. 
Ill  eiiurneratiug  these  auperfacial  n;flbxi.>s  I  slmll  follow  closely 
the  work  of  Frot'essor  Ross.  According  to  the  classification  used 
by  him,  there  are  nine  of  the  Bliin-reflexcfl  ; 

First.  The  Plantar  Rejlexy  evoked  by  tickling  the  RoIe  of  the 
foot,  whose  pnseooe  proves  the  integrity  of  the  reflex  are  in- 
volving l]io  lower  mid  of  (he  cord. 

Setond.  The  (Jfuieai  RefUx,  eonaistiog  of  contractions  of  the 
ginfeal  nansclcs  prodiiow]  hv  stimiibting  the  skin  of  the  biitlocks, 
aod  depending  upon  the  integrity  of  the  an:  through  the  fourth 
and  Bftb  lumbar  nerves. 

Third.  The  fh-eauu^er  ftfjifx,  causing  the  drawing  up  of  the 
^testicle  when  the  skin  of  the  inner  side  of  the  thigh  is  stimolnted. 
[ts  presence  establishes  the  integrity  of  the  first  and  second  pur 
of  lumbar  nerves  and  their  spiciat  centres. 

fourfh.  The  Abdovtinid  Reflex,  causing  contracUous  of  the  ab- 
dominal mascles,  chiefly  the  rectus,  when  the  skin  of  ihe  sides  of 
Uie  abdomen  is  stroked  from  the  ribs  downward.  It  proves 
the  integrity  of  the  arcs  from  the  dghth  to  the  twelfth  doi-sal 
nerves. 
^H  Fifik.  The  KpigaMric  Rfjlex,  causing  a  dimpling  of  the  eplgas- 
Iruim  on  the  stimulation  of  the  same  side  of  the  che«l.  in  th&  sixth 
and  fifth  iDtervoi>taJ  Kpacea,  and  sometimes  even  In  the  fourth. 
This  probabSy  requires  the  integrity  of  the  &.rvA  from  the  fourth  to 
^Ltbe  seventh  pair  of  dureal  uervca. 

H     Sixtli.  The   Kreeior-fipinal  lieJUx,  canning   contraction  of    the 
Htorector-spiiim  muscles  when  the  skin  along  their  edges  Is  stimu- 
lated.    It  demonstrates  the  integrity  of   Uie  reflex  arcs  in  the 
dorsal  r^ion  of  ihe  spinal  I'ord. 

•Slfim/A.  The  Scapular  Rrfiex,  causing  oontrnction  of  some  or 
oenrly  all  of  the  snapular  muscled  on  i4U[)erficial  irritation  of  the 
Scapular  region.  It  is  evidence  of  the  integrity  of  the  arc  of 
the  upper  two  or  three  dorsal  and  lower  two  or  three  curvlcal 
nerves. 

Ei(/h(h.  The  Palmar  Rfftex,  producing  confraclion  of  the  flei- 
ora  of  the  fingers  on  tlckllug  the  palm  of  the  hand,  and  sliowing 
Ute  integrity  of  the  arcs  thniugh  the  cervical  enlargement  of  the 
Keord.     This  reflex  is  rarelv  present  in  healthy  adults. 


182 


DrAQNoenc  keubotx>oy. 


Ninih.  Ortmiai  lirjttxtt:,  such  as  contraction  of  the  palatal  mits- 
c1«8  by  uritatiouof  tlie  fuucee,  sneezing  hy  irntatioD  of  the  nasal 
mucous  membrane,  ooiigh  by  irritation  of  the  laryngeal  mocoas 
membrane,  closing  of  the  eyes  by  irritation  of  the  conjunctiva, 
movements  of  the  iris  by  light. 

A  complete  invcsligatioQ  of  these  cutaneous  reflexes  in  disease 
ap|i€ars  to  Ixj  ^till  a  ilu^ideratiim.  R^nnciibiich  afVirins  that  tlie 
abdominal  reflex,  and  Jastrowiteh  that  the  cremaster  reflex,  ore 
le»wned  on  the  paralyzed  side  in  disease  of  one  cerebral  hemi- 
sphere. It  18,  however,  a  universal  rule  that  the  withdrawal  of 
the  cerebral  influence  increases  the  activity  of  tlie  reflexes,  and  If 
the  Biiperficiat  reflexes  are  really  lessened  in  cases  of  cerebral  dis- 
ease it  must  either  be  in  Honie  indirect  manner,  or  (Aae  be  due  to 
the  fact  that  tlie  lesion  which  iuterrupts  the  motor  pathway  really 
irritates  the  white  matter  below,  and  through  tlie  white  matter 
the  inhibitory  cx-ntres  in  the  medulln  wliioli  control  reflex  acid. 


DEEP  EEFLEXE8. 

Deep  reflexes  consist  of  muscular  contractions  which  are  pro- 
duced by  blows  upon  .such  deep-sealed  tissues  as  muscular  tendons 
and  bonee.  The  most  widely  known  and  studied  of  these  myo- 
tatic  coutractioiis  are  those  whicii  are  produced  by  striUing  the 
patellar  tendon  or  the  AchilLi»  tendon,  the  w-calleil  knee-phe- 
nomenon  and  foot- phenomenon  of  Westphnl,  the  potellar-tendoD 
reflex  and  the  AchillcR-tendon  reflex  of  Erb.  The  nntric  of  Erb 
has  Im^cu  Hhurteiied  by  nuMt  writers  into  patella-reflex,  aud  for 
the  term  foot-phenomenon  the  name  aDklc-clonus  has  been  substi- 
tutCfl.  The  movements  of  the  anklf  differ  from  those  of  the 
knee  in  that  they  arc  repeated  several  times,  so  as  lo  give  rise  to 
a  succession  of  movements.  This  variation  is  well  indicated  hf\ 
the  employment  of  the  term  ankle-clounsi,  whilst  tlie  term  kne^ 
jerk  is  coniing  into  voguo  aa  preferable  to  potella-reflex,  as  not 
being  indicative  of  any  theory  as  to  the  nalnre  of  the  movcmente. 
It  is  ditScult  to  unden»tand  why  we  should  uot  have  these  con- 
tractioNH  in  any  muscle  whose  tendon  can  be  readily  reached  by  ■ 
blow  when  on  a  stretch;  but  in  the  ordinary  healthy  individual 
this  form  of  mnscular  contraction  is  not  readily  demonstrated 
except  in  connection  with  the  patellar  tendon.     Occasionally  the, 


I 


RSTLEXES. 


bioepa  of  the  ami  itself  may  be  thrown  into  movcmcot.  In  thoae 
diaCMcn,  however,  in  wliich  the  activity  of  iheae  so-called  reflexes 
^ia  exa^eratecl,  contractionH  are  jMissibitf  iu  many  muMiIes  which 
^krp  not  affected  in  hoalib:  thas,  it  is  not  rare  under  the  circum- 
stftD€«s  mentioned  for  tapping  of  the  tendons  of  the  forearm  to 
prodnce  coDtractions  with  movenienbt  of  the  fiiigeni.  The  no-called 
jow-  or  ehin-jet-k,  na  noted  by  Dr.  Morris  J.  Lewia,  ap|Kyirs  to  be- 
loug  to  tliis  rat^or}'.  It  m  liest  obtained  by  allowing  the  Jiiw  to 
hanf;  passively,  or  by  gently  rtup[Kirting  it  with  one  IiqiuI,  whilst 
with  the  other  the  blow  is  struck  on  the  chin  with  a  hamn^er  in  a 
downward  direction. 

To  the  tendon-jorka  which  are  not  usually  demonstrable  in  nor- 
mal individual  belongs  the  ankle-clonus.  It  seems  to  be  adirmed 
by  Mit<-hell  and  Trfwia  {ifed.  Nt^wn,  February  13  and  20,  1886) 
that  theelbow-,  ankle-,  and  jaw-jerks  may  he  oecaj*ionally  obtained 

tfrotn  normal  individual.  I  liave.  however,  rarely  been  ahle  to 
demonstrate  them,  and  the  reiuly  production  of  these  jerks  in  any 
individual  is  a  strong  in<llraition  of  the  existence  of  diaease. 

Ejiee-J«rk. — Of  the  various  nuiscular  eontracttons,  to  the  diag- 
owtician  the  knee-jerk  and  tho  ankle-clonus  arc  Bupreuic  in  im- 
portance, and  T  sliall  disoiias  them  in  detail.  The  cundition  of  the 
knee-jerk  can  f»e  roughly  cxaminwl  by  seating  the  palipnt  upon 
a  chair,  with  one  leg  crossed  over  the  other,  and  ttien  striking 

I  the  patellar  tendon  below  the  patella,  when  a  movement  of  the 
foot  will  take  place.  In  order,  however,  to  study  closely  ihe 
knee-jerk  it  is  necesaarj-  to  have  the  leg  of  the  patient  bare.  The 
blow  may  hf  delivereii  directly  on  the  tendnn  or  upon  a  robber 
bond  pluueil  across  the  teiiduu.  In  some  delicate  cases  the  use  of 
the  finger  laid  upon  the  tendon  for  the  reception  of  the  blow  may 
be  advaulageoiiH,  ha  eiiHliling  the  diagnoetician  to  juiige  of  the 
force  of  the  blow.  The  blow  may  be  delivered  with  the  e<lge  of 
the  liand,  witJi  the  Angers,  or  with  a  ^mAll  liaminer  having  an 
elastic  steel  handle  and  uii  india-rubber  head.  The  hammer 
oflcn  used  In  percussion  may  be  cmployerl,  or  preferably  an 
oblong  narniw  head  may  lie  given  to  it.  For  onlinary  diagno«tio 
parpowM  the  hand  is  all->iijfficient,  and  wlien  exaggerated  tendon- 
reficxcs  ore  to  be  judged  of,  a  very  slight  blow  may  be  delivered 
with  rtne  finger.  In  some  cast*,  iiisteail  of  walohiiig  (he  move- 
ment of  the  foot,  otic  hand  may  be  laid  upon   the  quadriceps 


184 


DIAONOOTIC  XEUROLOOy. 


feinorin  and  its  coatnLciious  felt,  Auulber  metLod  wbioh  is  occa- 
sioDally  userul  is  to  allow  the  patient  to  sit  in  aa  ordinary  positioD 
with  the  m)lc  of  tho  foot  tuiiiMrcly  upon  th<>  girmtidi  nnd  then  lo 
jadge  of  the  effect  of"  the  blow  by  the  movements  of  the  quadrioepe 
muscle  as  felt  by  the  hand  ur  sL'eii  by  the  eye.  Dr.  A.  Muney 
praclisGB  8till  Hriothei*  [dan  for  developing  the  knee-jerk,  with 
aaserted  ocuiHiunal  iidvanta^.  The  patient  being  in  a  sitting 
position,  the  centre  of  tlie  instpp  is  laken  in  the  hand  and  alloww! 
to  rest  upon  its  iiahn  or  surftiee  at  a  convenient  angle  of  flexion, 
and  then  the  blow  is  delivered.  In  all  eases  it  is  eijscDtial  to  see 
that  the  leg  be  not  loo  mnrli  hunt,  as  sevfji-e  flexion  abidislies  the 
knee-jerk.  In  1883  [Vattsehe  Archhfur  Kfin.  Med.,  vol.  xxziii.), 
Dr.  E.  Jeodniesik  disctjvert-tl  that  if  a  severe  nmncular  exertion  be 
made  at  the  time  of  the  Ktrikiug  of  the  patellar  tendon  tlie  efieci 
of  the  blow  is  distinctly  exaggerated.  This  observation  gave  rise 
to  a  very  elal)omte  investigatiun  of  this  mibjtx'C.  by  Drs.  S.  Weir 
Mitchell  end  Morris  J.  Lewis  {Med.  News,  February,  1886). 

These  observers  found  that  the  knee-jerk  varies  in  healtli,  and 
is  capable  of  exhnustion  by  too  much  use,  but  may  be  iuoreased 
by  habitual,  Dot-too-ofteM-rcjMaitfid,  exciiation.     They  farther  di 
covered  that  all  volitional  acts  inrrea^e  the  knee-jerk  of  either 
leg,  soch  reinforcement  lasting  for  an  appreciable  time  after  tlie^^ 
ocssatioa  of  volitioa.     If,  however,  the  muscular  exercise  be  suf-^f 
fiuiently  violent  and   lusiing,  the  knee-jerk  is  ncially  enfeebled. 
Although  the  eoiitnictiou  of  a  muscle  may  he  produoed  when  it 
is  in  ft  condition  of  relaxation,  njodemtc  tension  increases  the  re-      , 
action,  and  violent  (enaiou,  snuh  as  is  pnxlneed  by  folly  flexing  th^H 
leg,  <icstroyB  it.    The  reinforcement  of  the  knee-jerk  by  volitional^ 
act  is  tlie  immediate  riviilt  of  tlie  volition  itM;lf,  and  not  of  the 
act  which  the  volition  calls  into  being.     For  Mitchell  and  Lewis 
found    that  when  an    individual    who    had    lost    an   avm   willed 
movement  iu  the  amputated  part,  the  kuee-jerk  was  reinforced. 
Pain  and  other  r'utRcni'ntly'  powerful  sensory  impraMioni^,  such  9B 
are  produced  by  the  opplicaiion  of  heat  or  cold  to  the  skin,  or 
intense  light  to  the  eyes,  increase  the  knee-jerk.     It  is  probably 
owing  lo  the  pain  caused  that  faradiccurrenw  applieil  totlicbody,     . 
and  even  galvanic  currents,  have  a  stimalatiug  effect  upon  tbqH 
knee-jerk,  an  effect  which  is  extremely  pronounced  when  tho  wire 
brusli  is  employed  with  faradiatu  uu  the  dry  skin.     Galvanic  cur- 


p 


reots  applied  to  Uie  head  iiioreattu  ilic  kneu-Jerk,  a«  aiao  <lo  spinal 
galvanic  currcnte  of  sufficient  power.  Pressure  upon  the  sciatic 
nt'rve  sufficient  lo  pnxliiee  niiriibiRHH  of  the  leg  decreases  the 
knee-jerk,  as  does  also  pmfound  etlierizalion,  wliilst  iulialutiou,  of 
nitrite  of  amyl  has  no  eSect. 

Drs.  Miteliel!  mid  Alornw  also  foiind  tluit  a  midiciently  severe 
blow  u|Mjn  any  ]>art  of  a  muaeie  will  produce  contraction,  which 
follows  the  same  laws  of  reinforcement  as  does  the  tendon-reflex. 

X'lture  of  Om  Rrffej-tit. — The  knee-jerk  and  all  the  other  so- 
callctl  deep  reflexes  arc  apiMirently  not  reflex  movements,  but 
phenomena  whuee  immediate  causes  lie  within  the  muscle  directly 
implicated.  Without  discussing  the  evidence  in  ftill,  it  is  suffi- 
cient to  quote  the  statement  of  Dr.  Goes,  that  "  there  1:*  now  pretty 
general  agreement  among  ex|>erimenters  that  the  interval  uf  time 
between  the  blow  and  the  contniccioii  i^  uot  suitioiciitly  lung  for 
B  reflex  act  to  take  place."  The  contrary  to  this  appears  to  be 
true  in  regard  lo  the  suporBclal  or  i^kin  reflexes,  as  the  measure- 
tueuta  which  hav«  so  far  been  made  of  the  time  neeesi^ry  for 
their  development  coincide  with  the  period  required  for  a  reflex 
movement.  According  to  the  KXi>eriment"*  of  Dr.  de  Wiittcvillej 
about  three  timed  as  long  a  time  is  ruquired  fur  the  development 
of  the  CDtitraetioa  of  the  quadriceps  femoris  after  un  trritntion  of 
the  sole  of  the  foot  a£  for  the  production  of  tlie  same  contrac- 
tion after  a  tap  upon  the  tendon.  All  onr  present  evidence  tficems 
to  (dinw  that  the  onntraction  of  a  knee-jerk  arises  in  the  muscle 
itself,  as  the  reiiult  of  the  atretching  of  the  tendon  which  the 
blow  causcg.  It  isj  however,  necessary  for  the  development  of 
80-oalled  deep  reflex  tliat  the  muscle  be  in  a  certain  condition 
of  tone,  the  term  tone  being  here  used  to  express  a  degree  of 
muscular  contraction  and  irritability,  which  ap[>eai"s  to  be  ihe  re- 
ault  largely  of  impul&es  received  from  the  spinal  oord, — these  im- 
pulsee  beinj;  provoked  by  peripheral  irritations,  and  being  there- 
fore of  the  nalnn*  of  minute  reflexes.  In  accord  with  this  theorj', 
impniscs  o^pccially  arising  in  the  muscle  itself,  or  in  its  iramcdiat« 
neighborhood,  stream  up  to  the  spinal  cord,  and  by  acting  upon 
die  ganglionic;  cells  give  rise  to  a  ooiitinuous  series  oi  itnpulBea, 
passing  down  to  the  muscle  and  maintaining  it  in  a  certain  con- 
dition of  activity.  Volitional  acts  evidently  increase  these  raus- 
^■ealar  reactions  by  producing  a  general  excitement  of  all  the  motor 


I      blo^ 
Kfi 


186 


DiAosoenc  NEimoLoay. 


centres.  Tbe  impulse-wave  which  Icavra  tlie  brain  either  pots 
the  whole  spinal  cortl  in  a  condition  of  momentary  excitement, 
or,  what  is  more  proliable,  gives  rise  to  numerous  minute  impulses, 
an'siug  in  all  parta  of  the  spinal  cortt  and  flowing  tlown  into  all 
partA  of  the  Imcly.  A  theory  which  at  Bret  thought  fX}mmeadi 
itself  is  that  the  volitional  act  (1eprc»ie:t  the  cerebral  centres  whtdi 
inhibit  spinal  movement,  and  nonsequeiitly  iucreaaes  all  rcilexcft 
by  removal  of  an  inhibitive  influeiiee:  this,  however,  would  seeta 
to  be  disproved  by  the  discovery  of  Mitchell  and  Jjcwis  that  tbe 
akin -reflexes  are  not  reinforced  by  muscular  acts  or  by  paiiK 
TheBe  akin-reflexca  arc  now  believed  to  be  of  the  nature  of  true 
refleiei*, and  if  deei-eased  inhibition  occurred  diirin;;  volitional  acta 
they  ought  to  be  more  strongly  reinforced  than  are  the  myotitia 
contractions. 

Further,  the  aswxHated  movements  of  Westpha!  strongly  in- 
dicate the  truth  of  tJie  overflow  theory,  since  they  are  best  ex* 
plained  by  suppui^iug  that  in  a  certain  excited  slate  of  the  spinal 
ganglia  the  overflow  is  sufficient  to  ]>roduoe  definite  movcmeal& 
The  overflow  takes  plnee  in  liealth,  but  only  when  the  gangli- 
onic cells  are  sensitirefl  hy  di^eaw  does  it  produce  pronou»ceJ 
effects.  When,  by  diaease,  there  is  an  iuterruptioo  of  the  con- 
netniou.s  wliicb  pass  llinmgb  the  Hpiiial  (centres  from  the  a&pcnt 
nerve-endings  to  the  cflert'nt  nerve-endings,  the  tone  of  the  rons- 
ele  becomes  enfeebled  and  rayotfltic  contractions  mnnot  be  evolced. 
When,  on  the  other  hand,  there  is  irritation  of  tbe  afferent  tierve- 
endings,  or  of  the  uerve-fibre  tracts  ia  the  spiual  cord,  there  is  on 
exaggeration  of  the  toncf-iuipulses,  and  coiiscquetitly  of  the  mus- 
cular tonicity,  with  a  resultant  incrcflse  in  the  activity'  of  the 
myolatic  contractions.  It  in  a  matter  of  practical  importance  to 
know  whether  excitement  of  the  motor  nerve-trunks  is  able  to 
increai%  the  tone  of  the  muscle.  Suflicient  evidence  in  regard  to 
this  point  is  at  present  not  forthcoming,  and  even  with  regard  to 
the  sensory  filamcnlit  iu  the  nerve-trunk  we  have  not  an  established 
knowlttlge;  bat  my  own  studies  iooline  me  very  strongly  to  tbe 
opinion  that  irritation  of  the  seuMiry  nerve  does  increase  rausde* 
t«ne. 

Whether,  as  physiologists,  we  accept  or  refuse  the  explanation 
of  the!i«  niyotatic  contractions  whicli  has  jutil  been  sketched,  as 
pntotic»l  physicians  we  must  recognize   that    cliniiul  cxperienuc 


KEFLEX  BS. 


187 


bas  proved  that  the  knee-jerk  and  .similar  jerks  are  tests  in  dis- 
eaeea  of  the  nerve-tracts  Mviae  exact  cliniml  value  is  well  made 

H      OoMtancy  of  Knee-Jerk. — It  is  a  matter  of  vital  practical  im- 
^ntortaaoe  to  detemiine  the  coDBtancy  of  the  knee-jerk  in  normal 
individuaJa     Dr».  Mitcholl  and  Lowi»^  found  that  the  intcu-'ity  of 
tlic  knee-jerk  is  greatly  lessened  by  excessive  fatigue.     Dr.  W.  R. 
■Gowers  {London  Lancet,  November  7,  1886)  believen  that  it  is 
Bcver  absent  in  health.     This  is  certainly  contrary  to  the  general 
opiuidu  of  i)ljKirver>',  for  the  reaclimi  has  been  found  wanting  by 
Hafschtnidt  in  5  per  cent. ;  by  Eulenbcrg  in  4.20  per  a'lit ;  by 
Ber^r  in  1.56  per  cent.;  and  by  Feilkchenfeld  in  1.3  i>er  cent. 
^{Deutsche  Med.   \Vo<^^en.,  June  6,  1884),  of  eleven  liuudred  and 
l&fty  OSes  examint'd  by  him.     Dr.  Gowers  thinks  that  the  ap|)ar- 
cnt  aheem*  ha«  Iwen  due  to  an  ini[ierft>ri  exii  mi  nation  ;  but  Feilk- 
chenfeld's  investigations  Tverc   made  with  the  greatest  care,  and 
Mitchell  and  TjCwIs  In  one  of  their  cases  were  also  unable  rn  any 
way  to  get  the  myotatie  contraction.     At  present,  tlierefore,  we 
must  consider  that  the  knee-jerk  may  be  absent  iu  normal  iudi- 
Yiduttls,  although  snnh  absence  is  e3[cee<lingly  rare. 
B     Diseases  -which  ks^en  Knec-Jerh. — The  knee-jerk  is  diminished 
by  leaioDB  that  diminish  or  destroy  funetional  activity  in  the  per- 
ipheral nerves  or  their  rtwtrt;  in  the  [Kjeterior  region  of  the  npinal 
onrdf — !>.,  in  the  neighborhood  of  the  posterior  nerve-roots;  in 
Athe  ganglionic  cells  of  the  .spinal  cord, — i.e.,  the  motor  cells, — or 
^in  the  muM^Ie  Itiself:  conw^qiiently  the  knee-jerk  ia  diminished  or 
abolisherl  in  locomotor  ataxia,  or  disea»c  of  the  [josterioreoUimns  of 
the  Hpinal  cord  ;  in  diifu.'^ed  niyelifisjifTecting  the  posterior  regions 
or  the  central  portions  of  the  spinal  cord ;  in  acntc  central  myelil  is 
affecting  the  gray    matter  of  the  cord  ;    in    acute   polioniyelitis 
(whether  idiopathic  in  the  child  or  due  to  metallic  [Hjisiming,  a.s  it 
Dsually  is,  in  the  adult),  which  tauses  destruction  of  the  motor 
cells  of  the  ooni ;  in  diseases  of  tlie  motor  nerves,  such  as  tniuraa- 
tiama,  neuritis,  tumors,  etc.,  diphtheritic  paralysis,  which  interfere 
with  the  conducting  power  of  the  motor  or  sensory  nerves;  in 
i^pfwudo-niuwrular  hyjiertrophy  with  destruction  of  the  inu-%'ular 
inc ;  and  probably  also  in  fatty  or  granular  degeneration  of  the 
miucles.     In  the  first  .stages  of  some  of  the  diseases  which  have 
enumerated  att  destroying  knee-jerk  there  is  a  oondition  of 


188 


DIAONOeriC  NEtrROU)OY. 


excitation  of  the  tii«un  which  is  finally  to  lose  its  power,  and  oon- 
aeqneotly  a  condition  of  exa^erated  Icnee-jerlc.  This  is  notably 
t)i«  case  in  neuritis  and  myclitijii. 

There  arc  mrtaia  dihca^M  which  a  priori  mi|;ht  be  expected  to 
destroy  the  {Kitellar-tcndon  reaction,  but  which  do  not  do  so.  Tbe 
most  important  of  tlu'sf?  is  ciironic  poliomyelitis,  or  projfressjve 
moscnlar  atrophy,  a^  haliitually  seen  in  the  adult.  The  explana- 
tion of  the  preser\'atioD  uf  the  knee-jerlc  in  this  alTectioa  is  nott 
however,  difficult.  The  individual  eells  of  the  ganglionic  epinol 
groups  are  attacked  one  by  one,  and,  altliuug!)  a  muBcle  may  have 
greatly  wasted,  those  of  it**  fibres  which  remain  unaS*ected  are 
still  under  the  normal  in6ueuce  of  »pinal  cells  which  have  so  far 
e>#ctt]>tx]  the  (liscase.  In  .Hime  oiseH  of  elironio  poliomyelitis  a 
condition  of  excitation  pivcpdes  t\w  destruction  of  the  cells,  as  is 
espw.'ially  revealed  by  the  very  prononiioed  fibrillar)-  contractions 
of  the  wasting  luuscles.  TJndor  ih&te  circumstances  tlio  irritability 
of  llie  muscle  may  lie  sufficient  to  give  rise  to  exaggei-ation  of  tlie 
tendon-reactions.  I  have  uotivetl,  however,  that  in  such  cases  the 
mtiRcles  are  sooti  exhausted,  ko  that  wlieu  the  patellar  tendon  is 
repeatedly  tapped,  the  renction,  at  first  excessive,  rapidly  dimin- 
ishes in  intensity,  and  at  last  fails  to  appear. 

How  fur  the  tL>ndtin-jerk&  are  Io»t  iu  acute  diseases  from  the  loes 
of  muecle-tone  which  is  ]>art  of  the  general  dcgradatiou,  is  un- 
certain.  Kepeatetl  Htuditu;  of  the  condition  of  the  knee-jerk  in 
various  chronic  disorders  not  usually  attributed  to  diseases  of 
tJie  nervous  svstcm  are  at  present  wanting.  Tt  would  appear 
prt>t»ilik*  lliiit  when  iiuLMuiIar  ri':lax;iti(in  exi>«tK  the  teudon-renc- 
tion  would  be  feeble,  but  Ur.  A.  Money  {Lmted,  vol.  oclxzxv. 
p.  842)  finds  that  in  ail  cases  nf  ninrkpd  typhriid  fever,  and  also, 
of  pliihisis,  the  knee-jerk  i*  mufli  exaggerated ;  and  in  two  cases 
of  rheumatio  fever  a  similar  condition  existed.  In  all  thcae  dis- 
eases the  fiupcrftciid  or  cutaiicnu>ior  true  reflexes  were  also  grossly 
ex^lgerated.  It  is  affirmed  that  habitually  in  diabetes  the  tendon- 
reaction  \n  lost;  but  I  have  seen  it  exaggerated  in  that  disease. 
Withdrawal  of  the  inhibitory  influence  of  the  brain  from  the 
Spinal  ojrd  is  followml  by  increase  of  tbe  knee-jerk,  and  a  priori 
it  is  therefore  probable  that  the  knee-jerk  may  be  diminished  hy 
rare  lesions  of  the  brain  of  such  character  and  niiuation  as  to 
augment  it-^  inhibitory  reflex  functions.     1  know,  however,  of  no 


REFLEXES. 


189 


diaical  proof  tJiat  stimulation  of  the  motor  cortejE  of  the  brain 
UcBpable  (if  lowering  tlie  kiie<!-jerk,  iidIoas  ii  hf  the  fact  that  in  a 
k^  proportion  of  cases  of  general  paralysis  of"  the  insine  {twentj*- 
tlirw  out  of  sixty-five  cases:  Dr.  W.  Crump  Beatley,  Brain, 
Aphi,  1885)  it  is  dioiinishetl  or  abolislici^.  The  c\(tm  raunei^ioD 
betvecD  locomotor  ataxia  and  ^'oeral  paralysis  lead.s  to  the  hus^ 
pidon  that  the  loas  of  knoe-jerU  is  tine  to  [vosterior  Mpinal  sMilcrosis, 
irew  which  is  confirmed  by  Dr.  Beailey's  report  of  ihrec  cases, 
iavlitch  absence  uf  the  knee-jerk  during  life,  without  other  dis- 
turbing evidenu^  of  inipliaitioii  of  the  spinal  ct>rd,  was  found 
ifier death  to  have  bcea  dependent  u[)on  sclerosis  of  the  posterior 
wliiDDa  of  the  cord.  Further,  in  my  own  experipiioe,  otsefi  of 
pwml  paralysis  with  loss  of  the  knee-jerk  have  habitually  suf- 
fcwi  from  !*evere  [>aios  Jo  the  legs,  evidently  ataxic  in  character. 
A^iD,  Dr.  Beatley  found  in  two  cashes  of  general  paral>tii.s  in 
«hicli  exaggerated  knee-jerk  had  existed  during  life  pronounced 
l(t*fal  gclerosis  of  the  cord.  It  ap]>e{irs  tliaC  in  general  paralysis 
there  is  a  very  decidutl  tendeuey  to  s^pinul  scleiosis,  aud  that  tlie 
knee-jfrk  may  tie  absent,  exaf^gerated,  or  normal,  aceordinp  to 
lite  re|[ioD  of  the  spinal  con!  which  is  attacked  by  the  secondary 
deneis. 

Iij  diplillieritie  paralysis  the  knee-jerk  is  diminished  or  lost, 
Jliil,  aswas  pointeil  out  by  Bernhardt,  this  loss  may  prcwde  the 
paralyas  of  the  palate.  It  is  therefore  important  in  all  cases  of 
dlpJilheria  to  examine  the  condition  of  tlie  knee-jfrk  during  the 
Wige  of  convalescence.  In  sonte  cases  *evere  diplitheritic  paraly- 
sis follows  attacks  which  have  originally  been  so  light  that  (bar 
true  nature  has  Ijeeu  overlooked.  Under  thtwa  cireunislaiux'S  the 
arjy  ]ai»  of  the  knee-jerk  is  of  great  diagnostic  importance. 

In  the  early  stages  of  pseudo-hyptTlrophic  paralysis  the  knee- 
jerk  is  pn>»ent,   but  as  the  d<:^ueratiou  progresses  it  becomes 
'evand  less,  and  Hnally  disappears  entirely.     Occasionally  there 
"  some  difficulty  in  diagnosing  )>etwee[i  a  pseudivhypcrtrophio 
Pvalysis  and  a  verj  luild  spastic  palsy  of  childhtHMl.      In  the 
'stU-T  disease,  however,  the  tendon-reactions  arc  exaggerated. 
^^  is  commonly  stated  that  the  knee-jerk  is  lost  in  hysterical 
P^'^plpgia.     Dr.  W.  R.  Oowers  affirms  that  this  is  always  an 
error  of  observation,  due  to  the  inability  of  the  patients  to  relax 
^e  miiacle  of  the  thigh. 


or  oil  the  diseases  in  which  the  knee-jerk  may  lio  wantint;,  it 
U  e»):ef;iul[y  in  h)iu>niot<>r  iilaxia  that  il8  ab.'Knce  has  iIi.ign<Klic 
imponanee.  According  to  Alhrecht  Erlenmeyer  (AUatigt 
Nrttroloffuit,  vol.  V.  p.  455),  the  loss  of  the  |>atella-reflex  fiepei 
upon  the  sclenieis  being  localized  in  the  extreme  outer  portion 
exteriial  fibres  [bandeioiiea  aeiemes)  of  the  posterior  oolamns. 

Id  any  coec  of  chronic  nerve-fnilure  without  obvians  Armptoou 
or  obvious  caugatioD,  if  the  ktiee-jerk  be  ab^ut  (here  i»  a  probo- 
btlity  that  the  putient  is  t>uQcring  froni  posterior  spinal  sclerosig, 
aud  if  there  he  conjoined  any  other  symptom  nf  tbe  disease,  the 
diagnosis  may  be  considered  as  practically  certain.  Paio  k  next 
to  loss  of  knee-jerk  in  its  constanc)'  and  diagnostic  importance 
in  locomotor  atujcia.  When  unaccountable  neuralgic  pains  occor 
either  singly  or  in  i>arosysnis  in  (he  li^,  or  pain-cris<«  are  pn*- 
ent  (see  chapter  on  Pnin),  the  condition  of  the  knee-jerk  should 
always  be  carefully  examined.  It  is  remarkable  how  long  poste- 
rior Bolerosts  may  exist  without  producing  any  loss  of  ooH)rdii: 
tion.  A  patient  of  my  own,  who.  until  witliin  a  few  wwks 
bis  death  from  an  intercurrent  atfeclion,  was  ou  active  sporta- 
man,  had  siiflVreil  ft>r  fifteen  years  from  almmt  monthly  attackit 
uf  furious  neurulgic  pitin  in  the  legs,  which  hud  been  sup|)OQ(id 
to  be  of  :i  rliouiuatic  nature,  but  which  I  diagnosed  to  l>c  due  to 
locomotor  ataxia,  becaase  the  knee-jerk  was  lost,  and  becvuse 
there  was  no  pain  on  motion,  nor  sorcnww  of  the  legs  during  the 
paroxysms  of  iiufTcnng.  After  iloath  pronounced  |>o«terior  apinal 
sclerosis  was  found.  The  question  whether  the  presence  of  tb« 
knee-jerk  proves  that  the  patient  has  not  posterior  scleraeis  is  a 
very  important  one.  Of  all  the  symptoms  of  the  disease,  loss  of 
the  knee-jerk  is  the  earliest  and  most  c«>n.stant,  and  I  should 
loath  to  make  a  positive  dliignosts  iu  any  case  in  which  il  was' 
preserved.  A  cuexl^^ting  lateral  sclerosis  of  the  lateral  column 
might  in  some  measure  overcome  the  depressing  efTcct  of  a  poste- 
rior sclerosis.  Usually,  however,  the  loss  maslts  entirely  the  ooi 
dition  of  exaggerated  excitability ;  but  in  soiuh  cases  the  diagn 
may  becouie  a  mutter  of  diEBuuUy  when  poitterior  sclerosis 
lateral  sclerosis  coexist.  There  must  be  a  stage  in  commencing 
posterior  Anlenisiit  in  which  the  knee-jerk  is  only  slightly  diroin- 
ished,  and  it  is  possible  that  under  Mucb  circunistauces  other 
symptoms  of  ataxia  may  be  present  in  suQicient  force  to  create  at 


te- 


of    . 

-1 

Kite-    , 

SOtk^A 

lOsilV 
and^ 


d 


REPLEXEB. 


191 


A  flaafudoD  of  tbe  true  nature  of  the  affection.     Dr.  Covers 

ites  tliBt  he  has  in  the  early  Hlage  of  ti'uu  tulws  seen  the  knee- 
prtsent  on  one  side,  and  has  watohed  ita  gratlual  toss,  and  in 
case  its  gradual  return.  He  further  caills  atteutiun  to  the 
fact  that  in  some  rare  ea:ie>>  when,  as  he  believes,  tbe  true  knee- 
jerk  wan  lost,  tapping  on  the  |mle!lar  tendon  caused  a  contrao- 
lion  in  tlie  extensors  of  the  knee  very  like  that  of  the  true  kiioc- 

'k,  but  which  he  Itelieves  wan  a  true  reflex,  and  not  a  myotAtic 
«on  tract  ion,  l)ecaua« — 

I^rtt,  On  many  attempts  to  obtain  tbe  jerk,  attempts  made 

ier  the  nioet  satisfactory  couditionB,  no  movement  uonLd  be 
obtained. 

Secondli/.  The  contraction  ex<rite»l  was  oftener  in  tbe  flexors 
of  the  knee  tbau  iu  tbe  exleu»ors,  and  fretiuently  it  was  in  tlie 
musi-lps  of  tbe  opposite  leg. 

ThirfUy.  Exactly  similar  aintnictions  could  tje  produced  by  a 
Midden  prick  of  the  «kin  over  the  tendon  of  the  head  of  the  tibia. 

It  ts  not  very  uncommon  for  a  cutaneous  reflex  aetiou  to  persist 

early  tabes  wlieu  the  inyotaliu  irritability  is  entirely  lo»t.     U  va 

lly  iu  such  cjutes  that  diftic-uliy  of  diagnfuiH  arises:   thus, 

distinction  between  the  local  and  the  reflex  coutractiond  is  uot 

matter  of  mere  the«.iretical  interest.    In  a<lvance<.l  stipes  of  poste- 

xior  Sclerosis,  not  only  arc  the  su|)crtic!iul  or  skin  rctlexcK  alxil  t,^hei), 

t,  if  tbe  lesions  spread  sufBcIentty  bigb  up  on  the  cord,  the  deep 
true  reflexes  may  l>o  affected :  thus,  ibe  pnwor  of  gargling  may  be 
lost.  In  studying  any  such  wise,  however,  it  must  be  remembered 
that  there  are  some  people  who  never  can  gargle. 

X>wffiA^  which  incri-tuur  Kittre-Jerk. — The  knee-jerk  U  increased 
by  brain-lesions  which  cut  off  the  influence  of  the  cerebral  hemi- 
spheres from  the  spinal  cord:  ransMpienlly  in  most  cases  of 
faeaiplegia  it  is  inereai^.  In  some  cases  tliis  increase  does 
not  appear  until  eight  or  ten  days  after  the  accident;  but 
usually,  if  tbe  liemiplegia  l>e  at  all  cotuplete,  there  'a*  a.  notable 
ex!^^geration  io  the  course  of  two  or  three  days.  Sometimes 
directly  after  the  apoplexy  the  knee-jerk  is  diminished  or  aliol- 
inbed  on  tJie  |)aralyzed  side.  This  iw  probably  ilue  to  tlie  propa- 
gation of  tbe  irritation  of  the  ftbrca  of  tbe  brain  below  the  lesion 
downward  to  the  cerebral  inhibitory  centres.  The  increase  of  the 
knee-jerk  is  often  pronounced  iu  cases  of  beraii>legia  io  which 


0: 


192 


DiAGNoerric  neuhoixjot. 


there  h  nu  distinct  rigiditv;  but  when  either  an  early  or  a  late 
rigidity  niaiiirtvtit   i(«elf,  the  activity  of  tlie   myolatJo  contrao- 
tioD  in  ezce!«sive.     Section  or  lesion  of  the  pyramidal  tract  in  the 
Spinal  cord  is  even  more  decided  in  its  effect  upOD  the  koee- 
jerk  than  is  a  similar  ui-gaiiic  change  situated  higher  uj>:  lieuee  all 
aflbctions  which  interrupt  or  break  the  integrity  of  the  Bpinai  cord 
are  acrompaniMi  with  eiaggeration  of  the  tendon-reaction.     The 
most  important  of  these  affections  arc  traumatism  of  the  cord, 
trao-sverse  myelitis,  and  spinal  tumors.     Again,  any  lesion  which 
exciles,  without  destroying,  the  motor  ganglionic  cells  of  the  cord,      ' 
increases  the  knee-jerk :    hence  its  excessive  activity  in  various      ' 
forms  of  subacute  myelitis.      In  acute  myelitis  the  lesion   pro- 
gresses 80  rapidly  that  the  reflexes,  at  first  exa^erated,  may  be      , 
diminished  or  lost  in  the  course  of  a  few  hours  or  days.     ^^H 
chronic  myelitis  the  knee-jerk  is  diminished  or  increased  acoord-^^ 
iug  to  the  seat  and  character  of  the  lesion, —  i.e.,  as  the  organic 
alteration  excites  or  paralyzes  the  intra-spinal  mechanism  connected 
with  the  f>ate]lar  reaction. 

Of  all  climoic  aflcctioos  the  one  which  is  especially  associated^ 
with  exaggemtion  of  the  various  myotatic  reactions  is  sclerosia  ot^M 
the  lateral  coliinin>>.     In  marked  ca»es  of  this  atfection  not  only 
will  the  slightest  tap  upon  the  patellar  tendon  produce  violent 
contractions  of  the  quadricciw  feintiris,  but  even  a  blow  upon  the 
tibia,  or  upon  the  patella  itself,  will  suffice.     Not  rarely  a  single 
blow  will  produce  three  or  four  or  even  more  snccessive  contrat>-^g 
tions,  and  in  some  cases  it  is  possible  to  induce  a  knee<-lonua.        ^m 

Hysterical  contractures  may  beoonfouiitled  with  lateral  sclerosis  j 
but  the  myotatic  contractions  are  unually  not  so  pronounced  in 
hysteria  as  in  the  organic  disease:  novertlieloss,  they  may  Iw  just 
as  decided.  In  a  case  now  uuder  my  care,  which  I  believe  to  be 
chronic  multiple  ueuritts,  the  knee-jerk  is  as  active  as  iu  n  case  of 
lateral  sclerosis.  ^_ 

Effed  nf  J}tsea»e  on  AnkltrClontut. — Ankle-clonus  occurs  only^H 
when  the  myotatic  reactions  are  exceeilingly  exaggerated.     Its 
must  common  cause  is  lateral  sclenisis;  but  it  may  be  due  to  hys-^H 
teria  or  to  subacute  myelitis.  ^ 

Efect  of  EpUfjMi;. — Ac«>rding  to  the  observations  of  Westplial 
and  of  Gowers,  none  of  the  myotatic  contractions  can  beobtaiited 
immediately  after  a  very  severe  epileptic  fit,  but  at  the  end  of 


REFLEXES. 


103 


aboat  half  a  minute  the  knee-jerk  can  again  be  indueed,  and  fre- 

qnently  it  become*  excewive,  and  during  the  fii-st  few  minutes 

after  the  fit  ankle-clouuij  amy  be  present.     lu  those  cases  iu  wliiuh 

I  the  epilcptjc  fit  is  unilateral  and  due  to  an  organic  brain-disease, 

|the  mvotatic  contmrtions  are,  immediately  after  the  convulsion, 

[mnally  exaggerated  upon  the  side  of  the  convulsion.   Ocoiaionally 

the  tnyotatic  contraction  which  has  been  produced  in  the  affected 

mtujcle  artilidally  becomes  the  starting- (mint  of  a  general  seizure. 

After  slight  attacks  of  epilepsy  the  myotatic  contractions  oAen 

remain  as  normal,  and  after  moderately  severe  fits  there  may  be 

immediately  increased  knee-jerk  and  ankle-clonus.    The  true  re- 

flexes  are  ugually  abolished   for  a  few  moments  aller  a  severe 

,  epileptic  liL 

J-^eet  of  flifsteria  on  Myotatie  Contrartiong. — In  hysterical  oon- 
vnUions  the  myotatic  contractions  are  sometimes  normal,  but  are 
usually  in  severe  cases  increased.  According  to  Dr.  Paul  Biclier, 
in  hysterical  catalejjsy  they  are  abolished. 

The  increase  of  the  myotatic  contractions  in  the  major  hysteria 
Js  shown  by  the  excessive  effect  of  a  elight  irritation  upon  the 
muscle  directly  implicated,  and  by  the  tendency  to  propagation  of 
the  inyotaiie  contratitionn.  Further,  the  character  of  the  myotatic 
contractions  is  not  rarely  altered :  they  are  prolonged,  almost 
lie,  and  after  a  severe  blow  may  nmoimt  to  a  more  or  less  pcr- 
lent  contracture.  According  to  Richer,  the  propagation  of  the 
myotatic  contractions  frequently  occurs  from  the  leg  to  the  arm,  but 
never  in  an  inverse  method,  m  that  a  siiiglc  blow  upon  the  patellar 
tendon  may  give  rise  to  muscular  contractions  involving  the  whole 
of  one  side  of  the  body,  whereas  a  blow  upon  an  arm-tendon  affects 
only  the  musclts  of  tlie  neigtiborhood.  When  iiiis  abnormal 
11  euro- muscular  excitability  is  very  pi-onounced,  a  slight  blow,  or 
even  a  mere  pressure  upon  the  muscle  itself,  will  produce  eontrac- 
tions.     The  effect  of  striking  a  bone  may  be  very  marked. 


It 


CHAPTER    IV. 

DISTURBANCES  OP  EQUILIBRATION. 

tT2n}£R  tho  head  of  di<itnrhaiir«A  of  equilibration  I  propose  to 
consiHer  three  more  or  Ic*8  allied,  but  at  tlie  wimo  time  quite 
dialioct,  symptoms:  first,  disturbance  of  co-ordination;  secoud, 
cerebellar  tItuliatioQ  j  third,  vertigo. 


DieXURBANCE  OF  CJO-OEDINATIOK. 

It  does  oot  seem  to  me  Deoestiary  to  dif<<cuss  here  in  detail  tlie 
physioli^  of  co-ordination.  For  tiie  pur})0Kea  of  the  fliuiciau  it 
suffioes  to  define  it  as  that  fan(?tion  by  which  the  muscles  arc  so 
controlled  in  tlioir  movements  and  relaxations  »»  to  execute  com- 
plicated acts  under  the  iuipuUe  of  the  will.  Without  the  power 
of  oo-ordiuRtion  equilibration  cannot  exist,  but  co-ordination  may 
be  perfect  nnd  yet  equilibratiim  be  deranged.  When  the  power 
of  co-ordination  is  lost  for  the  legs,  equilibration  is  affected,  be- 
cause it  is  impossible  for  the  individual  to  control  the  move- 
mentB  of  those  niur^cles  upon  which  lie  ile|K;nda  for  his  upright 
position  and  for  the  power  of  walkiuj;;.  If,  however,  the  function 
of  co-ordination  be  lost  in  the  amis  alone,  the  gait  remains  [lerfect, 
altboogh  it  is  no  longer  possible  for  the  individual  to  execute 
deliinte  movements  with  the  hands. 

Ivoss  of  co-ordination  k  uminlly  first  manifested  in  the  legs, 
becaaoe  in  the  majority  of  cases  centric  disease  begins  in  the 
lower  portion  of  the  spinal  cord,  and  naturally  affecta  the  lower 
extremities;  but  when  a  sclerosis  commences  iu  the  upper  por- 
tjona  of  t!ic  cord  the  nrma  may  be  the  first  to  suffer.  Under 
these  circumstances  the  patient  notices  that  he  is  losing  the  power 
of  doing  6ner  actions  with  the  hands,  although  the  grip  and  the 
general  strength  of  thv  «rm  may  be  uuvve.ikeneJ.  Difficulty  is 
|>erceivcd  in  buttoning  and  nnbuttoning  clothes,  in  picking  up 
pins,  threading  needles,  etc.  When  the  fingers  are  from  any 
oauije  anffiathetic,  it  is  difiicult  for  the  patient  to  do  many  of 


» 


^eee  smaller  acts,  and  care  is  soraetim^s  neoessaty  not  to  mutake 
the  character  of  such  disablement.  A  rough  test  of  tlie  power  of 
co-ordination  in  the  general  movements  of  the  arm  is  made  hy 
causing  the  patient  to  extend  the  arm  nt  full  length,  with  the  liand 
cloeed,  except  the  forefinger,  and  tlien  to  bring  thia  rapidly  to  the 
point  of  the  oo«e. 

When  tlie  power  of  co-ordiualTOii  ia  entirely  toet  ia  the  1^  the 
patient  is  unable  to  stand  or  walk,  even  with  the  aid  of  cratches. 
When  Iving  in  bed,  iiowever,  he  can  kick  in  every  direction,  and 
can  execute  all  movemenla  of  the  leg  witli  great  force.  Before 
this  tnndition  of  complete  diKablemcnt  is  reached  there  is  usually 
a  stage  in  which  the  patient  is  able  to  walk  by  means  of  crutches. 
Uodier  these  circnmstanoeft  the  pceuliar  erratic  method  in  which 
the  legs  are  thrown  iu  stepping,  the  way  In  which  they  aeeiu  to 
thrust  themselves  about,  iudeiKudcntly  of  tlie  will  of  the  pti- 
tient,  is  charaeterisiic  of  diacjniered  co-ordinatiou.  Preoodinf;  the 
cratch  period  there  is  generally  a  pntloiigeil  st«ge  during  which 
the  ataxia  raanifeaiit  itself  in  a  peculiar  gait.  At  this  time,  hold- 
ing the  hand  of  a  second  |>erson,  or  using  a  cane,  is  uf  great 
Bssistanue  in  walking.  Tlie  feet  are  kept  widely  apart  and  strad- 
dling, and  it  is  impoasiblc  for  the  patient  to  walk,  or  even  to 
Btand,  with  his  eyes  shot.  Very  frequently  the  subject  will  him- 
self notice  that  hi«  difltcully  of  walking  is  greatly  increased  at 
night. 

When  the  loss  of  oo-ordinatiuu  is  very  slight,  some  little  oare 
and  examination  arc  necessary  to  detect  it.  Under  these  circum- 
stances it  will  be  found  that  the  patient,  when  \m  eyes  are  shut, 
Bways  more  than  he  ought  to  during  standing,  and  also  walks 
with  some  difficulty.  In  the  vcrj'  slightest  jicpceptiblc  kiss  of  co- 
ordinating power  the  only  dtiKvjverable  demngement  may  be  an  in- 
ability to  stand  upon  one  foot  with  the  eyes  closed.  In  its  incip- 
iency  tlie  sclerosis  of  locomotor  ataxia  is  often  more  pronounced 
in  one  side  of  the  spinal  cord  than  in  the  other:  henoe  a  patient 
may  be  able  to  co-ordinate  ^iiflRciently  to  sijind  lirnily  u[)on  the  one 
foot,  even  with  the  eyes  closed,  and  yet  be  unable  to  maintain  his 
position  upon  the  other  foot.  In  a  doubtful  case  the  patient 
should  li4!  required  to  walk  backward  and  to  attempt  to  turn  isud- 
denly.  Any  marked  awkwardness  in  these  actious  should  give 
riae  to  suspicion.     It  is  necessary,  howe\'cr,  not  to  confaimd  lUft 


196 


DIAGN06TI0  NEDROIjOGY. 


awltwardu€s8  arising  from  (uu»ctiilar  tt-eakoes*,  or  especially  from 
musrular  BlifTiiess  du<.-  to  inoipiuiit  spasmodic  tabes,  with  tliat  pro- 
duced by  a  8lij:;lit  Uiss  of  oo-ordiuaiin^  |)owcr.  Again,  in  certain 
cases  of  cerebral  di:-ease  with  vertigo  tlip  patient  vpill  execute  these 
movemeiitji  with  dilficully  aud  awkwimlne!^,  althougli  the  true 
co-ordiiiatiuj;  jwwer  is  nut  atfcctcKl.  In  sonic  of  ray  patieots  the 
6rst  petveptioD  of  disahlenient  lias  lieeu  in  walkijig  tbmugit 
woods  or  over  rough,  uneven  ground. 

Causes  of  Loss  of  Cb-orrfina/ioji. 

Jjom  of  oo-ordi nation  without  loss  of  aelual  raotx)r  power  is 
in  the  great  majority  of  cases  due  to  sclerosis  of  the  posterior 
root-zones  of  tlie  spinal  cord, — i.e.,  locomotor  ataxia.  It  may, 
however,  be  a  very  early  or  evea  a  prodromic  symptom  of  general 
^Hiralviiis  of  the  iiiijanv,  und  may  fHx.-ur  in  multiple  neuritis. 

Locomotor  Ataxia. — Ixpsp  nf  eo-ordinalinn  in  the  legs  without 
loas  of  power  is  so  characteristic  of  locomotor  ataxia  that  the  gait 
it  causes  is  commonly  known  a.^  the  tUaxic  gait  When  a  posterior 
Boierosts  is  snfGciently  ndvanceil  to  aOeut  jinigression,  but  hiu>  not 
yet  reached  thestnge  in  which  a  stick  or  other  support  is  necessary, 
the  ]Mitient  walks  witli  his  head  a  little  hent  forward  and  the  eyes 
directed  to  tlie  ground.  Tiie  trunk  inclines  u[k>u  the  thighs, 
whilst  the  feet  are  held  in  advance  of  the  buttocks,  with  the  legs 
widely  separated  from  eauli  otlier.  At  the  same  time,  owing  to 
the  excessive  contractions  of  all  the  muscles  of  the  lower  extrem- 
ities, the  leg  proper  is  extended  somewhat  rigidly  npoo  the  thigh, 
and  thens  is  very  little  movement  at  the  kuee-Joiat,  The  ad- 
vancing leg  is  therefore  raised  from  the  ground  In  some  d^rcc  by 
an  elevation  of  the  jielvis,  althisugh  at  the  same  time  some  flexion 
does  occur  at  the  knee-joint.  By  these  conjoint  movements  the 
foot  is  free<l  frum  the  ground,  and,  having  been  flung  forward  and 
OQtwanl  by  a  rapid  muscular  jerk,  comes  down  with  a  thump  like 
a  BoVid  niaas.  In  some  cases  the  heel  is  the  last  to  leave  tlic  ground 
and  the  first  to  touch  it.  Npt  rarely  the  pelvis  is  so  mnch  in- 
clined during  walking  as  to  carry  the  centre  of  gravity  too  far  to- 
wants  the  side  of  the  stationary  leg.  To  oountcract  this  aud  niain- 
tain  the  balanoe  of  the  body,  the  up|>er  portion  of  Uie  trunk  is 
curved  to^vards  the  advancing  1^  by  a  contraction  of  the  erector- 


DCSTCRBAKCES  OF  EQUtLtB RATION. 


197 


I  «ptn«  muscles,  or  the  arm  corrcAponding  to  the  advancing  1^  is 
thrust  out  laterally.  Tlic  Rllenmtion  of  tliese  iiiovL*mi'ut«  ut  eadi 
step  roaj'  give  a  pendulum-like  swing  to  the  body.  In  a  more 
advanced  stage  of  locomotor  ataxia  the  patient  is  able  to  walk 
only  by  the  help  of  two  sticks  or  crulclie*.  The  body  is  thro-vvn 
forward,  hx  order  to  counteract  the  teadency  to  fall  backward 
produced  by  tlie  iHxmliar  [K^Kitiou  assumed  by  the  legii,  whidi  are 
hehl  in  advanf.'e  of  the  buttock  on  account  of  the  lendencv  to 
undue  contraction  of  tJieir  extensor  muscles;  the  foot  is  tisually 
at  an  obtuse  angle  to  the  leg,  and  the  thigh  at  an  obtuse  angle  to 
(he  truck.  If  under  these  circumstances  tlie  trunk  be  exect,  tlie 
line  of  the  centre  of  gravity  would  fall  through  the  butttK-lis  [loa- 
terior  to  the  point  of  support, — i.f.,  tlie  foot,— and  consequently 
llie  patient  would  fall  b;u'kward.  To  overcome  thU,  the  trunk  is 
often  bent  so  far  forwttnl  that  the  tine  of  the  centre  of  gravity  is 
in  front  of  the  feet,  and  the  (ffiticnt  would  fall  forward  if  he  were 
not  8Uit[)oried  by  a  stick  orcnitehetn.  All  the  niovenients  executed 
with  the  legs  are  performed  with  great  stiffness  and  by  sudden  Jerks. 
The  straddle  is  usually  very  marked,  and  the  leg  is  raised  from 
the  grounti  by  an  elevation  of  the  ]>elviH  in  the  method  already 
described.  Still  later  in  the  disorder  the  legs  are  entircily  beyond 
tlie  control  of  the  patteni.  They  are  thrown  abont  irj  wild,  irreg- 
ular, choreiform  movements,  whicli  render  ihem  of  no  use  what- 
ever in  walking.  Under  these  circumstances  progression  is  impos- 
sible. When  the  le^jion  travels  up  the  fi'pinal  cord  all  power  of 
co-ordinating  the  mn^^cles  of  the  trunk  may  be  lost,  so  that  the 
ptitienc  is  no  longer  able  to  sit  in  a  chair. 

General  Pai-alysia. — In  general  paralysis  of  the  insane,  tlie 
early  lo&s  of  co-ordination  is  felt  almost  exclusively  iu  the 
hands,  and  is  shown  chiefly  in  delirate  skil]-r(>quiring  acts,  such 
as  writing,  engraving,  eic,  whilst  in  locomotor  ataxia  it  is  ex- 
tremely rare  fur  the  arnts  to  Ije  first  atlacketl.  The  other  symp- 
toms of  the  two  disesses  are  lu  no  way  similar:  luoomotur  ataxia 
is,  however,  a  very  common  complication  of  general  paralysis. 
(See  General  Paralysis.) 

Multiple  Neuritis. — Multiple  neuritis  affecting  the  sensory 
uervcs  is  ahvays  accompanied  not  only  with  pain,  but  also  with 
profKmnceil  tendeniesi  over  the  nerve-lrunks,  which  at  onwe  dis- 
tinguishes it  from  locomotor  ataxia.     There  is,  however,  evidenoe 


WAONOWIC  XFUHOI/WY. 


that  a  multiple  neuritis  is  often  incited  by,  or  at  least  follows 
Dpon,  ehronif  posterior  s<?lcrwis. 

Lose  of  Co-ordination  as  a  Complicating  Symptom.— Id 
multiple  Bclerosis,  and  in  certain  forms  of  chronic  myelitis,  tlie 
poBterior  onlumii  sliares  the  lesion  along  with  other  portions  of 
the  cord.  Under  these  circumstances  the  loas  of  co-ordination  is 
associated  with  various  symptoms,  such  as  palsy,  spasm,  etc.,  due 
to  other  portions  of  the  cord  being  aSTected,  ami,  indeed,  may  be 
8o  entirely  masked  by  these  symptoms  that  its  presence  cannot  be 
letectod. 

TITUBATION. 

Cerebellar  Afiiactiona. — If  a  lesion  be  confined  to  one  hemi- 
sphere of  the  cerebellum  it  may  produce  no  symptoms  whatever, 
and  in  any  case  cannot  be  diagnosiNl  with  certainty.  V«)miting, 
with  occipital  hf^ndaehe  and  jj^cneral  failure  of  health,  might  in 
•ome  of  tliese  cases  lead  to  a  suspicion  of  the  seat  of  tJie  dis- 
order, but  these  symptoms  may  be  entirely  wanting,  as  is  shown 
by  a  case  reported  by  Dr.  Loorais  {Amer.  Mfi.  7Vmc8,  1862,  iv. 
124),  in  which  the  symptoms  simply  resembled  those  of  a  low 
fever,  although  a  cerebellar  tumor  tlic  size  of  a  small  orange 
was  fouud  after  death.  When,  however,  a  growth  or  other  lesion 
of  one  hemisphere  of  the  cerebellum  causes  such  enlargement  as 
to  exert,  pressure  upon  neighboring  parts,  various  pnmlyses  result. 
The  encroachment  upon  the  medulla  may  lead  to  an  imperfect 
hemiplegia  or  even  to  general  motor  failure,  or  hypoglossal,  facial, 
or  other  Iwal  [tandyses  may  result  from  the  prcesurc  exerted  by 
the  enlargetl  hemisphere  upon  nerve-trunks.  If  the  trigeminus 
nerve  be  involved,  a  tjue  anfesthesia  dolorosa  may  be  produced: 
loss  of  the  power  of  swallowiug  may  also  be  a  prominent  symp- 
tom. On  account  of  the  proximity  of  the  corpora  quadrigemina, 
blindness  from  prcasurc  is  a  not  infrtH]uent  result  of  cerebellar 
tumors.  When  the  cerebellar  lesion  occupies  the  middle  lobe  it 
causes  peculiar  di»iturbances  of  motion,  which  arc  pathognomonic, 
and  to  which  the  name  of  ccrebdtar  titubalion  has  been  given. 
Very  frequently  cerebellar  titubalion  is  aaaociated  with  giddiness, 
but,  as  in  some  instances  giddiness  is  absent,  the  disorderly 
movements  are  plainly  not  caused  by  the  vertigo. 

Gail  in  OerdteUar  Pistase. — The  position  which  is  assumed 


* 

I 


mmnTBBANOES   op   BQinLIBItATION. 


IN 


tbe  victim  of  cerebellar  tilubation  duriDg  standiog  nsembles  thai 
of  locomotor  ataxia.  The  f<„-et  are  held  well  forward  ami  widely 
separated  from  each  other.  If  the  attempt  is  made  to  bring 
tbem  cloM  together,  peculiar  movementii  of  exteDsioD  and  flexion 
ooLnir  iu  the  feet,  and  at  the  sutue  time  the  trunk  begins  to  rock 
and  stagger  more  and  more  violently,  until,  in  extreme  oases,  the 
sabject  falls  nnlens  he  can  seize  some  .support.  In  unnsual  in- 
stances the  movements  are  definite  and  in  one  direction  ;  but 
^oommoDly  they  ore  irregular,  and  vary  both  in  direction  and 
^Bip  force.  The  staggering  may  be  so  great  that  the  patient  is 
unable  to  move  a  step.  V^ery  commonly  it  is  impossible  for  him 
to  turn  (fiiildenly  witfmut  falling.  Bometime^  the  <tymptoin<i  are 
intensified  by  durkne!ii§  or  by  closing  the  eyes,  whilst  in  other 
oases  they  are  not  thus  aflected.  The  walk  resembtee  that  of  an 
intoxiratal  man.  There  is  a  f^imtlar  staggering,  with  to-nnd-fro 
movements  of  the  whole  bo<ly,  resulting  in  a  zigzag  instea/l  of 
a  atraightforward  progr»ision.  Tn  moc^t  cuacs  the  feet  are  raised 
only  R  short  distance  from  the  ground,  and  are  moved  with  a 
peculiar  irregularity  of  step.  In  some  instances  the  jHttient  has 
Ba  tendency  to  fall  or  run  Imekward,  or  thi^  may  be  reversed  and 
the  patient  continually  falls  or  runs  forward.     This  is,  however, 

»by  no  means  a  constant  phenomenon,  nor  h  it  when  present  abso- 
latcty  characteristic  of  cerebellar  tumor.     At  least  I  have  seen 
oases  in  which  a  similar  symptom  existeil  when  tiiei'e  was  no  other 
reason  to  suppose  a  cerelK'lIar  tumor :  in  no  instance,  however, 
have  I  been  able  to  confirm  the  diagnosis  by  an  autopsy.     The 
movements  in  tilubatiuD   are  sufBciently  distinct  from   those  of 
ataxia  to  make  their  recognition  in  most  cases  easy.     A  further 
difference  is  to  he  found  in  the  fact  that  whilst  in  (%rehellar  dis- 
ease the  patient  lying  in  bed  is  able  to  move  his  legs  with  normal 
promptness  and  accuracy',  iu  spinal  disease  the  movements  in  bed 
are  almost   as  disorderly  as   during  walking.     Further,  wliihit 
ataxia  ot^  afTects  the  arms,  titultation  is  confined  to  the  lower 
extremities.     It  is,  indeed,  due  to  disorder  of  equilihralioa,  and 
^^ot  to  any  loss  of  muscular  control,  and  appears  only  when  the 
^bttempt  is  made  to  exercise  the  function  of  equilibration. 
H    Diagnoriia    Valun  of  THubaHon. — Titubation  is  probably  pa- 
^Thognomonic  of  disca-oe  of  the  cerebellum,  and,  as   Nothnngel 
has  shown,  of  the  middle  lobe  of  the  cerebellum.     There  have, 


aoo 


UIAOyOeriC  KBtTBOLOOT. 


however,  Wn  iwfwx  in  wliit>li  t.lie  middle  lobe  of  tlie  oerebcllam 
has  been  involved  without  tlie  production  of  titubatJon.  The 
explanation  of  Nothnagel,  that  thin  has  been  becaiue  sufficient 
of  thu  middle  lobe  to  perform  its  funcliou  has  mca|>ed  in- 
jury, may  be  accepted,  at  present,  aa  at  least  tlie  best  that  can 
be  given. 

Jiotatory  Movcm^nU. — Titubation  must  not  be  confonnded  with 
the  rotatory  oiovements  which  occur  when  the  cerebellar  pedun- 
*<il09  arc  implicated,  either  as  they  eater  the  pons  or  higher  up. 
These  rotatory  movements,  the  "  movements  of  manage/'  are 
around  the  long  axis  oF  the  body.  Prof.  Rosenthal  suni^  the 
diagnostic  points  of  tumori  of  the  cerebellar  peduncles  as  headadie, 
vertigo,  disorders  of  the  special  seuses,  hemiplegia,  unsteady  gait,  ■ 
u-ith  a  tcndeiiey  to  fall  u{ton  tlit>  m\e,  and  jtartial  rotation  around 
the  vertical  axis,  with  lateral  rotation  of  the  head.  There  have, 
huwever,  been  recorded  a  nnmber  of  casc^  of  leAiona  of  the  cere- 
bellar peduncles  without  rotatory  movements,  aud  it  is  probable 
that  6U<;h  movements,  when  present,  are  produced  in  some  iudirect 
manner. 


VERTIGO. 


I 


Vertigo  may  be  defined  to  be  a  sensation  of  moving,  or  an  ap- 
pearance of  motion  iti  .surrounding  objects  wliich  are  really  at  rest. 
It  ia  a  sense  of  defective  etjuiUbrium  without  actual  disturbance 
of  position,  and  varies  iu  loteDsity  from  the  slightest  giddin^-sa  to 
that  oonditiou  in  which  everything  aWuL  the  victim  seems  to  Iwfl 
involved  in  a  whirling  chaos  of  motion.  In  the  slighter  forms 
of  the  symptoms,  those  to  which  the  term  giddiness  is  well  ap- 
plied, there  is  a  feeling  as  though  tlie  head  itself  or  lis  ooiitenta 
were  in  motion:  hcnoe  the  popular  term  "swimming  in  the  head." 
Closely  allied  to  this  raitd  vertigt>  is  the  sensation  of  rising  through 
the  air,  which  almost  every  one  has  oxperienoed  after  fatigue  whea 
lying  in  bed.  An  abnormal  sensation  somewhat  similar  to  this, 
but  more  distre.ssing  and  terrifyiug,  is  that  of  falling  through  the 
air,  whi>{'h  in  extreme  oases  ia  aocompanied  by  a  feeling  as  though 
the  earth  were  opening  and  rising  up  to  swallow  it8  victim.  In 
vertigo  proper  the  movement  i»  in  the  surrounding  objects:  the 
furniture  and  other  contents  of  an  apartment  appear  to  revolve 
more  or  less  rapidly,  to  dance  backward  or  forward,  or  to  reel' 


I 


SranrRBAHCBS  of  EQUrtrBRATION. 


with  an  irregular,  sUiggering  gait.  The  ground  rises,  or  sinka,  or 
rises  and  ainki  like  the  waves  of  tlie  ocean.  Houses  move,  hills, 
tnea,  and  rocks  slant  hither  and  thither,  and  in  some  instances 
the  whole  lauftnuape  inverts  itjielf  and  hangs  above  tlio  bead, 
threatening  ruin. 

In  vertigo  relief  is  generally  afforded  by  assuming  a  horiiiontal 
position,  or  even  by  the  closure  of  the  eyes,  but  iu  severe  cases  theae 
measures  fail,  and  the  patient  lies  in  bed  cbitching  at  any  available 
support,  in  oont^tuut  fear  of  falling.  In  many  c^sas  along  with 
the  vertigo  there  arc  distinct  perversions  of  special  senses.  Mist- 
iness of  vision,  enlargement  or  lessening  in  the  stie  of  objects, 
tinnitus  aunuiu,  the  rush  of  water,  iutermitteat  pulsations,  the 
clanking  of  pumps,  the  hissing  of  teakettles, — these  and  many 
other  extraordinary  alteratioiw  of  perception,  or  even  absolutely 
i«uhjcotivc  sights  and  sounds,  may  form  a  part  of  the  vertiginous 
paroiysni.  In  the  majority  of  such  cases,  however,  disturlmnce 
tof  the  special  senses  is  the  origin  of  the  vertigo,  or  the  subjective 
sensations  and  the  vertigo  depend  upon  a  common  cause. 

Vertjgo  may  be  present  almost  all  the  time,  or  at  least  be  pro- 
duced by  every  change  of  position,  or  even  by  the  erect  posture,  or  it 
ojay  come  on  at  irr^ular  intervals  and  be  of  a  purely  paroxysmal 
ty |)e.  To  the  condition  in  which  paroxyfiins  of  vertigo  succeed  one 
another  in  rapid  successioa  the  name  of"  the  verfif/inous  gf-aius  has 
I  been  given  by  Br.  S.  Weir  Mitchell, — a  name  which  was  evidently 
suggested  by  the  parallel  between  tliis  condition  and  the  epileptic 
status.  When  the  type  of  the  diaonler  is  strictly  paroxysmal  the 
attacks  are  often  very  severe,  and  are  aocompiinled  by  nausea  and 
vomiting,  and  even  by  relaxation  of  the  bowels  and  the  rapid 
secretion  of  a  limpid  urine,  like  that  of  t]ie  hysterical  fit.  The 
gastro-totestinul  disturlxtuue  iu  a  Uirge  propoi-tiou  of  these  cases 
is  secondary  to  the  vertigo,  but,  ns  will  be  discussed  iu  detail  hiter, 
(he  vertigo  may  be  de|>endeiit  upon  the  giLt^tro-intestiual  Irritation. 
'  In  severe  vertigo  there  is  frequently  some  mental  confusion,  which 
may  end  iu  complete  hjss  of  oonaclousness.  When  this  happens, 
the  vertigo  is  probably  due  to  hysteria,  epilepsy,  organic  brain- 
disease,  or  uncmia.  As  insisted  ui>on  by  Dr.  Mitchell,  a  distinct 
jaiira  sometimes  precedes  the  vertiginous  paroxism,  or  in  some 
cases  tliere  is  an  abrupt  ouiiet  with  the  sensation  of  a  snap  in  the 
more  rarely  the  vertigo  is  ushered  in  by  a  seusory  dis- 


DrAGjmenc  neitbotjOoy. 


char^,  such  as  the  perception  of  light  or  Bound,  In  sach  caeeA 
there  is  reason  to  fear  that  the  vertiginous  attack  is  allied  to  epi- 
Iqjsy. 

Nature  of  Vertigo. — The  tlieory  that  vertigo  is  produced  by 
dii^tiirtiHni^  of  Ihe  ciroiilation  of  tht>  brain  h:t>i'  met  with  wide- 
sprend  acpe])t«noe,  but  1  do  not  think  it  can  be  received  as  a  gen- 
eral theory  applicable  to  all  cases.  I  am  not  preiwred  to  enter 
into  a  dtscnasion  of  the  theory  of  vertigo,  but  it  soems  to  roc 
probable  that  at  least  two,  and  perhaps  more,  distinct  conditions 
arc  habitually  united  under  the  one  name,  I>ecaiise  tlie  seu&ationa 
which  acoompiuiy  them  are  simitur.  The  vertigo  of  epilepey.  the 
vertigo  of  organic  brain-disease,  and  the  so-called  laryngeal  vertigo 
are  probably  oauBod  by  uer\-ous  discharges  allied  to  those  which 
provoke  epileptiform  oonvulsions,  whilst  the  gastric  vertigo  aod 
many  toxftmic  vertigms  are  of  different  character.  The  epilepti- 
form vertiginous  utta*:k  is  often  precedtd  by  an  aura,  and  naturally 
ends  in  uncousciousness,  whilst  the  typical  gastric  vertiginous 
paroxy&m  has  no  nura,  and  terminates  in  vomiting. 

CVmwm  of  Vei'tigo. — The  di&easea  u|>oa  which  vertigo  may  de- 
pend, or  of  which  it  is  a  symptom,  can  best  be  studied  under 
flight  headings : 

1.  Oipinio  Vertigo,  in  which  the  symptom  is  dependent  upon 
some  demonstrable  t^trurtural  alteratiuns  of  the  brain  or  spinal 
oord. 

2.  Cardiac  Vertigo,  in  which  the  vertigi>  depends  upon 
evident  alteration  of  the  circulation. 

3.  Epileptic  Vertigo,  in  which  the  attack  replaces  a  paroxy 
of  idiojKithic  epilepsy. 

4.  Hysterical  Vertigo,  in  which  the  symptoms  are  hysteriml: 
in  this  division  I  shall  include  tho«e  cases  in  which  the  vertigo  is 
the  result  of  nervous  exhaustion, 

5.  Peripheral  Vertigo,  in  which  the  paroxysm  depends  upon 
irritation  of  some  peripheral  nerve-Rl amenta. 

6.  Vertigo  of  the  Special  Senses,  which  ia  caused  by  some 
rangement  of  the  special  sen^^. 

7.  ToXiemic  Vertigo,  in  which  the  symptoms  are  toxaamic,  due 
to  a  mineral  or  a  vegetable  principle,  or  to  a  dieease- poison  in  the 
blood. 

8.  Casee  in  which  at  present  no  explanation  of  tlie  vertigo 


4 


I>iamJBBA>'OES  OF   BQUIUBRATIOHT. 


903 


is  forthcoming,  and  for  which  the  name  of  Egeential  Vertigo  has 
been  proposed  by  J.  Spence  Ramslcill. 

Organic  Vertigo. — Clironic  meningitis,  brain-absoesses,  spe- 
dfie,  caiicerooB,  or  simple  tumora,  atheroma  of  the  basal  arteries, 
adH  almost  any  chronic  brain-disease  producing  or  aocompanied 
by  coarse  structnral  alterations,  may  he  the  raiise  of  vert.iginon3 
attacks.  Vertigo  is  apt  to  be  especially  severe  when  the  focal  dis- 
MBB  is  sitaatod  in  the  cerebelluiu,  but  cerebellar  atrophy,  and  even 
oerebellar  tumors,  may  exit^t  without  ])roiioiinec'iI  giddii)i»i>8,  aud  a 
tnmor  may  be  located  in  any  [wrtion  of  (he  brain,  even  in  the  ex- 
treme frontal  lobes,  and  yet  cause  giddiness.  Organic  vertigo  is 
ID  the  majority  of  cases  not  severe,  allliough  it  has  a  distinct  ten- 
denf^  to  end  in  unconiwiou^ncss.  I  cannot  rcmciubcr  a  case  in 
which  the  cerebral  hemit-pheres  were  alone  impliaited  in  which 
the  sense  of  movement  cither  of  the  person  himself  or  of  sur- 
rounding objects  was  very  violent.  The  i-ecogoitiou  of  the  cause 
of  the  vertigo  in  cases  of  struc-tural  brain -disease  is  to  be  based 
upon  the  other  symptoms  of  the  cflse. 

In  general  ]>araly8is  of  the  intsanc  vertiginous  nttaolcs  are  not 
rare.  They  must  be  looked  upon  iis  an  abortive  form  of  the  epi- 
leptic convulsions  which  are  eopimon  to  these  dijsordcra. 

According  to  Charcot,  vertigo  marks  the  invasion  of  multiple 

cerebral  sclerosis  lO  alrout  three-fourths  of  the   cases.     I   have 

seen   a   Urge   number  of  cases  of  this  disease,  and  vertiginons 

attarks  have  certainly  been  the  exception.     Charcot  says  that  the 

11     vertigo  is  usually  gyratory;  all  objects  are  apparently  whirling 

^Hound  with  great  ra])i<Iity,  and  the  individual  himself  feels  as 

^Rhougb  revolving  on  his  axis.     Charcot  further  states  {Diaeasfs  of 

mihe  Nrrtouis  Sy^Um,  Pbik.,  1879,  p.  160)  that  "  the  vertigo  in 

question  is  all  the  mure  interesting  because  it  belongs  neither  to 

locomotor  ataxia  nor  lo  paralysis  agitana,  and  may  eonse<|Ucntly 

(help  in  forming  a  diagnonii^."  Notwithstanding  tins  stJitement, 
vertigo  IB  a  not  very  rare  symptom  in  locomotor  ataxia.  This 
Beema  to  be  true  not  only  of  cases  like  those  reported  by  Fournier 
{De  f  Ataxic  locomotricc,  p.  251),  In  which  the  ilisease  is  really 
not  locomotor  ataxia  but  ccrcbro-spiual  syphilid,  but  al^o  of  genuine 
poetenor  spinal  sclerosis.  In  the  last-named  afTeotion  the  giddi- 
ness occunt  especially  in  those  cases  which  have  marke<.l  ocular  or 
aural  disturbance  or  severe  gastric  crises.     It  is  very  probable 


204 


DIAGNOSTIC  NEUROLCXtY. 


that  in  suvh  !iiJjta[ioe6  tlie  vertigu  is  a  Kccoii'dury  and  not  a  primsry 
gymptoni  of  the  disorder, — i.e.,  is  caused  by  the  peripheral  irri- 
tattnii  or  the  sensory  disturbanoe.  Dr.  S.  Weir  Mitchell,  however, 
affirms  that  vertigo  may  occur  in  locomotor  ataxia  independeDtlj 
of  ocular  disturbance,  and  T.  Grainger  Stewart  (On  GtddintUf 
Edinburgh,  1884)  insi^ta  that  the  vertigu  may  be  due  to. 
centric  lesions. 

Epileptic  Vsrti^. — Attacks  of  giddiness  of  the  mildest  p09- 
sible  tyjje  to  be  noticeable  may  be  a  symptom,  or  rather  a  parox- 
ysm, of  a  hopeless  idio[}atbic  epilepsy.  FrcqaeDtly  the  nature 
of  iHii'h  a  jwinixyHui  is  mistaken.  The  epileptic  vertigo  may  be 
scarcely  perceptible,  or  it  may  bo  severe  and  end  in  disturbance 
of  consciousness.  There  is  nothing  in  the  vertigo  itself  ui>on 
which  the  diagnosis  of  its  nature  can  be  made.  Tbc  judg- 
ment must  be  based  upon  coocomitant  circumstances,  such  as 
known  tiert^liiary  tendency  to  epile|)Ky,  alienee  of  tlic  ordinary 
known  causes  of  vertigo,  age  of  the  patient  at  which  the  vertigo 
apjiearetl,  etc.  A  previous  history  of  a)nvtiIsions  during  child- 
hood, will)  persistence  of  the  vertiginous  paro-vysms,  would  be 
decisive.  If  in  any  case  recurrent  vertigo  be  ashered  tn  by  anfl 
aura,  and  be  followed  bv  mental  disorder,  a  sense  of  transportJi- 
tion  through  space,  a  marked  subjective  sensation,  such  as  that 
of  a  bright  light,  or  of  a  loud  sound,  suspicion  should  be 
strongly  roused  unless  the  subject  l)e  hysterical.  M''hci]  any  dis- 
turbtince  of  consciousness,  muscular  rigidity,  or  clonic  convulsive 
movcmcntA  accompany  the  vertigo,  the  prognosis  becomes  grave. 
Such  vertigo,  if  not  hysterical,  is  almost  lavariably  organic  or 
epileptic  The  occurrence  sooner  or  later  of  a  pronounced  epileptic 
jiaroxyum  will  generally  settle  the  diagnosis.  Dr.  George  Parker 
{Brain,  vii.  625)  affirms  that  in  epileptic  vertigo  there  is  "alwaj^^J 
falling  towflrds  one  side,  never,  as  in  brain-disea-e,  a  wnse  o^^ 
spinning  round,  nor,  as  in  eooeutrie  vertigo,  of  the  room  moviug." 
The  ooiTectnesa  of  this  statement  seems  to  me  extremely  doubtful. 

Cardiac  Vertigfo. — Vertigo  is  a  not  rare  syinptom  of  chronic 
cardiac  disease,  especially  of  fatty  degeneration,  or  other  diseases  of 
the  heart,  aocompauied  by  fiiiliug  power,  in  some  of  these  cases 
abrupt  alterations  of  {Ktsition,  eii[)eciully  sudden  rising  from  the 
bed,  or  prolonged  stooping,  may  produce  a  vertiginous  paroxysm. 
Even  in  the  normal  individual  it  is  not  rare  for  rapid  foroed 


DI&TCBBANCES   OF  EQUILIBEATION. 


SOB 


I 


breathing,  prolonged  standing  with  the  head  downward,  violent 
BtrainiDg  at  stool,  excessive  vomiting,  or  other  acts  which  cause 
marked  dititurbaoce  of  tiie  circulation,  to  provoke  giddiness.  In 
cues  of  doubtful  organic  brain-diseoitc  1  have  Romctime^  been 
aided  in  making  the  diagnosis  bj  the  ease  with  which  excessive 
giddineas  was  produced  by  act«  like  those  just  !<poken  of.  The 
giddiness  which  forms  a  jfromincnt  t^ymptoiu  of  tlic  mat  de  nion- 
tat/ngf  an  aSection  caused  in  some  [>erson,s  by  tlie  rarefled  air  of 
high  mountains,  nnd  manifestml  by  headache,  vertigo,  nnd  dysp- 
uattiy  with  sometimes  nausea  and  vomiting,  is  probably  due  to 
disttirbonce  of  the  circulation.  The  giddiness  of  aoiemia  and  that 
of  plethora  wiili  excessive  cardiac  action  probably  have  similar 
explanation.  Sudden  losa  of  the  oerebro-apinal  Hnid, — abrupt 
clianges  of  atniwtphcric  ]»re«aure,  such  as  Is  experienced  in  going 
from  a  chamber  containing  coiupressetl  air  into  tlie  ordinary 
atoioephere, — these  anil  other  conditiouHoractH  not  nece»!>iiry  here 
to  detail  may  cause  giildinci^s  by  disturbing  the  hmin-circuliition. 

Giddiness  Is  very  common  in  antemla.  Indeed,  it  may  be  said 
to  be  a  constant  symptom,  if  only  the  amemia  be  sufficiently 
pranoimced.  Severe  vertigo  is,  however,  rarely,  if  indeed  ever, 
caused  by  anemia,  since  In  extreme  cases  the  giddiness  soon 
merges  into  syncofie.  Anscmic  giddiness  is  prone  to  be  especially 
developed  by  changes  of  |)osture  which  suddenly  affect  the  blood- 
Bupply,  such,  for  instance,  as  abruptly  rising  from  the  horizontal 
to  the  erect  jio^ture.  After  protracted  illness,  dunng  the  feeble- 
ness of  conviilescenoe  t\m  first  attempla  at  getting  up  are  apt  to 
cause  swimming  in  the  head. 

The  vertigo  which  occasionally  develops  in  persons  of  advanced 
age  may  be  considered  as  an  organic  vertigo,  or  as  one  due  to  dis- 
turbance of  the  cirtnilalion,  for  it  probably  depends  njMin  a  lack 
of  blood-supply  to  the  brain-celts,  the  result  of  the  atheromatous 
degeneration  of  the  vessels.  When  onoe  develoi>ed  it  is  apt  to 
be  a  {>ersistent,  obstinate  symptom.  A  vertigo  of  similar  char- 
acter may  be  caused  by  syphilitic  or  gouty  changes  in  the  cere- 
bral veasels,  and  occasionally  prccales  brain-softening. 

HyBtericftl  and  Neurasthenic  Vertigo. — Vertiginous  sensa- 
tiona  arc  not  a  prominent  symptom  of  hysteria,  and  when  present 
are  apt  to  take  some  unusual  form.  Almost  any  variety  of  ver- 
tigo may,  however,  be  ao  closely  counterfeited  by  the  hysterical 


206 


DIAONOSTIC  MEtTROLOOY. 


disorder  tlmt  ^rcat  care  will  be  nooeasar}^  to  avoid  error  in  diag- 
nosis. This  is  e^fpeeially  true  when  tinnitu^^  aurium  or  otiier 
sensory  disturbance  coexists  with  the  vertigo  and  affordH  a  picture 
of  organic  brain-dlseasc.  A  diagaosis  of  such  organic  disease 
sliaiild  l>e  made  witii  great  niliiolance  whenever  Uiere  la  a  pro- 
nounced hyslcricail  temperament. 

In  nenrasthenia  giddiness  or  swimming  in  the  head  is  mod- 
erately oominon,  though  rarely,  if  ever,  severe.  It  ^eems  tmoie- 
timcs  to  be  connected  with  lack  of  proper  blood-supply  to  the 
brain,  and  so  far  to  be  related  to  an^niio  vertigo ;  it  is  also  based 
to  a  greater  or  lass  extent  upon  a  morbid  sensitivcooBS  of  the 
nerve-centres,  and  is  provoked  by  [jeriplieral  irritations  which  in 
UeaUli  make  im  impreKaion.  Hence  bright  tighUi,  aa  the  flashing 
of  a  mii-ror,  loud  sounds,  bad  smells,  etc.,  may  in  a  neurasthenic 
produce  11  giddinesfs  which  is  in  a  sense  ofitilar,  aural,  or  nasal. 

Ncnra*thenic  vertigo  is  often  the  result  of  long-continnDd 
overwork,  of  sexual  excesses,  or  of  prolonged  lactation.  Indeed, 
almot^t  any  |>«rsi!4tent  dtipresuing  cau^  way  bring  about  the  bodily 
condition  which  produots  vcrtipi.  It  la  evidenr  that  this  form  of. 
vertigo  is  in  many  cases  nllied  to  anemic  vertigo,  since  nerve 
exliftustioii  and  poverty  of  b]<wd  not  rarely  coexist. 

Poriphoral  Vertigroee. — Vcrligoea  which  are  due  to  irritation*^ 
of  some  peripheral    nerve-filaments  constitute  a  numerous  and 
important  class,  in  which  are  included  laryngcalj  gastric,  and  in- 
testinal vertigo. 

In  1876  (Oaz.  MM.  de  Paris,  :87(>,  p.  688),  Prof  Charoot  de-j 
Bcribed,  under  the  name  of  laryng&jj.  vcrtigQ,  several  cases  o€^ 
an  affection  tliat  ha^  ^iuL'e  been  re|>eat«4)Iy  observed.  The  attack 
begins  with  a  burning  or  itching  in  the  larynx,  that  causes  in  a 
moment  a  violent  access  of  spasmodic  cough,  which  is  soon  fol- 
lowed by  a  brief  vertigi>,  ending  in  complete  loss  of  oouiiciousneGs, 
lasting  for  a  very  few  minutes,  during  which,  in  some  of  the  caaesi.^ 
there  have  been  oonvalaive  movementa  of  the  face  and  even 
the  extremities.  The  paroxysm  is  not  followed  by  nausea  and 
vomiting,  as  is  ordinary  severe  vertigo,  nor  yet  by  sleep,  as  ia 
typical  epileiwy.* 


USi 


*  S«8  I>r.  Gawjuot,  PraatUtoner,  Auguai,  1878;  I>r.  gpianiwbrudL,  SeriiH. 
Klin.  WoefMn4ehr\ft,  SopUinb«r,  1876;  Dr.  firbliaber,  Aimatea  At  l'Or»U* 


»r«tU«^J 


DIBTURBANOES  OF   EQUIUBBATION. 


207 


in 

Pth 


'Withiu  oertaiu  Hmite  tbe  e^-iujitoms  lutve  varied  considerably 
in  the  recorded  coses.  Usually  the  cough  is  severe,  but  in  some 
"»"tn««w  it  has  been  slight.  The  vertigo  inny  be  prorvoun'Of^, 
hot  S6«nB  to  have  been  in  most  cases  very  mild,  and  in  some 
altogether  wantiDg.  Consciouaoess,  often  completely  lost,  may  be 
imperfectly  preserve*),  or  may  be  oveni  unaffected.  The  occurrcnoo 
in  tbe  eame  awe  (that  of  Dr.  Loffbrts)  of  attacka  varjing  from  the 
slightest  vertigo  to  complete  unconciousness  Kho^vl4  that  a  unity  of 
diaracter  runs  through  the  varying  paroxysms.  There  has  been 
conaidersble  discussion  as  to  whether  these  attacka  should  be  called 
vertiginous  or  epileptic.  Bui  the  question  in  probably  one  of  words 
merely.  There  is  probably  no  diffct^nce,  except  in  intensity,  be- 
tween some  forms  of  vertigo  and  an  epileptic  attack.  One  con- 
stantly replaces  the  oilier  iu  an  idiopathic  epilepsy.  The  probable 
explanation  of  laryngeal  vertigo  is  that  a  reflex  nervous  discharge 
IH  f-auHwl  by  the  lar\'ngeal  irritalion.  Tii  wmio  of  the  rases  gross 
larj-ngeal  lesions  (polypus,  Dr.  Soraraerbrodt)  have  been  noted, 

others  redness  of  the  laryngeal  mucous  membrane,  in  other» 
no  lesion.  Aifthmu  liu8  in  one  cnse  appureulty  ciuim^  tlie  attack, 
the  onset  of  which  was  felt  in  the  tracbca.  (i«  Proi/res  Mfd., 
1879,  p.  317.)  When  laryngeal  <lisease  has  been  fontid,  ite  cure 
has  been  followed  by  relief;  and  even  when  no  lesion  has  been 
apparent,  cauterization  of  the  larynx  has  done  goo<l. 

I  think  it  18  certain  that  vertiginous  and  epilcptoid  attacks  may 
be  produced  by  a  periplieral  laryngeal  irritation;  but  some  care 
may  be  necesfmry  not  to  mistake  a  true  epilepsy  commencing  with 
a  laryngeal  aura.  Laryngeal  crises  of  locomot<:ir  ataxia  also  may 
simulate  n  laryngeal  vertigo.  It  is  probable  that  in  some  cases  an 
attack  of  iinciinKdiousnpss  may,  a^  insif^teil  u[>on  by  Dr.  EUherg, 
be  precipiiau-d  by  a  spasm  of  all  the  laryngeal  abductor  muscles, 
arresting  respiration. 

Qaafrii:  vertiffo  occurs  in  an  acute  form  as  tbe  result  of  an  auute 
indigestion  or  gastric  irritation.  In  some  individuals  the  indul^ 
^oe  in  strawberries,  lobfltera,  ahell-fiwli,  or  other  article  of  diut 
(o  most  persons  harmless,  invariably  produces  a  severe  vertigo, 
undoubtedly  by  irritating  the  gastric  nerves.    Irritation  of  the 


et  Ai  Lforynx,  riit. ;  Dr.  0«org6  31.  Leffsrls,  Trant.  Amer.  Laryngot.  Soc., 
1888  i  Dr.  CIuiTVDt,  U  Pnffrit  UMicat,  April,  1879. 


208 


DIAeNO«TIC  SEtTROI>OGT. 


m 


mucous  membrane  of  tlit:  slomnch  not  intense  enough  to  cause  t 
vcrtiginoiift  |mrnxy»m  may  prfMlure  great  fliisliingofthe  face  or  an 
intense  pain  just  Iwlow  the  cars.  Acute  indigestion  with  cxeewive 
acidity  may  provoke  aa  intense  reflex  headache  or  a  violent  attack 
of  vertigo,  the  imroxytim  in  either  case  of^n  being  accompanied  bjr 
partial  blindness  or  double  vision,  and  finally  by  naiL«oa  and  vom- 
iting, followed  by  relief.  Not  rarely  the  headache  and  the  vertigo 
are  botli  pre^^nt. 

Chronic  gastric  vertigo,  due  to  persistent  dyspepsia,  is  a  much 
rarer  aflectioii  than  wa»  tiiipposed  by  Ti-outeeau  and  hU  followers. 
In  those  cases  of  chronic  dyspepsia  in  which  the  more  or  les 
constant  vertigo  Is  at  its  worst  two  to  four  hoors  before  eating, 
it  aeemd  to  mu  aa  ruLiooat  to  ascrilw  die  vertigo  to  the  presence  in 
the  blood  of  productB  nf  imperfect  digestion  as  to  attribute  it  to 
gaacric  irritation.  In  some  dys|>eptics,  however,  there  are  more 
or  leas  frequent  paroxysms  of  vertigo,  with  ocular  disturbanoi 
and  sick  stomach,  cloaely  simulating  those  of  an  acute  gastno 
vertigo. 

It  is  possible  that  the  vertigo  which  occurs  long  aAer  eating  ia 
chronic  dyspepsia  may  sometimes  be  due  loan  intestinal  irritation, 
aa  is  undoubtedly  the  giddiness  witli  a  sense  of  weight  over  the 
brows,  or  even  of  burning  in  the  eyes,  which  may  be  the  only 
manifest  symptom  of  tapeworm. 

Vertigo  from  tJie  Special  Senses. — It  Is  well  known  thatoet^ 
tain  rapid  changes  of  {XK^ition  produce  giddiness,  notably  rapid 
whirling,  as  in  the  waltz,  tfwinging,  as  in  the  play  of  childreu, 
and  tlic  rocking  motion  of  the  ocean.  Tlie  peculiar  sinking  feel- 
ing which  is  ezperieuoed  in  the  abdomen  during  the  descent  of  the 
swing  and  during  the  going  down  of  the  ship  into  tlic  trough  of 
the  sea  indicates  very  strongly  that  the  vertigo  and  the  giddi- 
ness which  atxTompatiy  these  movements  are,  at  least  in  part,  the 
result  of  afferent  impulses  which  arc  produced  in  the  abdominal 
viscera  by  the  rapid  assumption  of  positions  to  which  they  are 
unacLnLCitomed.  On  the  other  hand,  the  relief  which  to  some 
extent  is  secured  in  all  these  ca**H  by  closure  of  the  eyes  indi- 
cates that  tlie  rapid  passage  of  objects  in  abiionnal  ]>ueitiotis  or 
abnormal  succession  lieforc  the  eyes  Is  at  least  one  factor  in  the 
production  of  the  vertig^'noue  seusations. 

Ocular  ^  'crtigo. — Various  ooular  defects  or  diseases  cause  ver- 


DISTURBA^'CES  OF    EQCILIBEtATION. 


209 


tigOw     The  moet  frequent  nf  tlicsc  is  paralysis  of  the  external 
XQctos;  but  any  muMiuIar  palsy  wliicK  causes  a  disoonl  in  the  optio 
axia  nmy  {irodiiw  vertigo.    Under  llie^e  rinninistanioes  eloeiiig  the 
•ffeoted  eye  usually  puts  a  stop  to  the  gidrlniess.     In  most  cases 
BbuttiDg  the  soaod  eye  does  Dot  pitxluce  relief.  The  vertigo  which 
in  iheee  cases  \h  pi-e^nt  wlicii  liotli  eyes  are  o(>cu  is  pmlmbly  the 
result  of  the  oonfuiiiiDn  of  the  nerve-ceatres  produced  by  the  noD- 
■greement  of  the  eyea  in  their  reprcKpntaiion  of  olyects.     The 
giddiaeai^  whieli  exi^t^  after  closure  of  the  t^iund  eye  ik  probably 
doe  to  the  discord  which  still  remains  between  the  visual  pcrcep- 
tioOB  oo  the  one  hnml  and  the  wnisutionfi  arising  from  the  nititicuEar 
Moae  and  general  sensibility  on  the  other.     The  object  is  seen 
^^o  one  direction  but  felt  in  another,  or  a<<  directed  by  the  eye  the 
^Bsiueolee  assume  a  certain  [wsitioa  in  order  to  niaiulaia  the  erect 
^RHMture,  but  the  common  sensibility  and  the  muscular  sense  en- 
^'ferce  the  necessity  of  anotlicr  jiofitiirc.    In  tliiri  way  a  (Ktnfiision  of 
the  lower  brain-centres  is  pnKluced,  which  results  in  vertigo.    Dr. 
^■Q'.  Grainger  Ste^-ort  has  re[>orted  (On  Gitldines*,  TAiiihnrgh,  1884) 
^■Hcaseof  Dyi^tagniiiis  in  whicti  the  vertigo  was  very  strongly  niarketl, 
^Rmtwas  at  once  overcome  by  holding  the  eyeballs  forcibly  quiet, — 
a  very  strong  indication  that  the  giddine:«i  which  is  sometimes 
present  in  nysti^rnins  i*  the  result  of  the  rapid  changes  in  the 
position  of  sensury  impressions  on  the  retina.    The  reason  that  so 
many  persons  with  ocular  |HLUieH  or  with  eyes  which  are  not  opti- 
cally in  acf»r<l  do  uut  suffer  from  giddiness  is  that  the  habit 
^_ is  soon  acquired  of  neglecting  the  images  formed  in  one  retina, 
^K>r,  ia  other  words,  of  uaing  only  one  eye  in  conscious  visiou. 
H^    Attmi  VeHigo.—ln  18GI  {Oazetig  Mid,  de  Paris),  1*.  MGnJftre 
^^flescribed  a  case  in  which  a  young  man  was  suddenly  weized  with 
J      a  violent  vertigo,  accompani«l  by  deafness,  pallor  of  the  face,  ex- 
^fcessive  sweating,  and  apjuirent  symptoms  o^  an  imminent  eyucopo. 
^^Se  fell  to  the  curtli  without  being  able  Co  raise  liitnself  up,  and, 
^^Jyiog  upon  his  back,  could  not  o{>en  bis  eyes  without  all  the  aur- 
Hjrounding  objects  seeming  to  whirl  In  spa<«.    The  slightest  movfr- 
^Fment  even  of  the  head  increased  the  vertigo  and  producetl  violent 
"vomiting.      Id  a  second  case,  a  young  woman,  after  exposure 
during  her  catamenial  periixl,  suddenly  became  deaf,  with  violoot 
vertiginous  attacks  similar  to  tlioee  just  describwl.     Five  days 
later  she  died,  and  at  the  autopsy  the  brain  and  spinal  cord  were 

14 


2]0 


DIACNOSTIC  XEtmOLOOV. 


found  Qormal,  but  in  the  semicircular  cauuU  there  wns  a  bloody 
exudntion  of  wliicti  scarcely  a  trace  could  be  perceived  in  tlie  ves- 
tibulutii.  These  and  other  similar  vatvs  ]«!  Dr.  Mfnifrre  to  reoog- 
nise  a  form  of  violent  vcHlgo  produced  by  intense  congestion  or 
apoplexy  in  the  semicircular  cnnals.  Since  the  publication  of  the 
palters  of  Dr.  M6Ili^^t^  numeroiLS  articles  havt  a[>[)Gan.Hl  describii^ 
vertigiiiouii  attnciks  in  ccnnection  with  diseases  of  the  middle  ear. 
ProlMibly  all  the  diseases  of  the  Bemicirrular  ranal  are  liable  to  be 
a»>ociat«l  with  vertigo,  but  the  name  Mfni^re's  di^MW  should, 
1  think,  be  restricted  to  ihouc  ca^en  In  which  the  vertiginous  at- 
tacks are  due  to  an  apo]>lexy  or  a  sudden  c.<onge8tion.  1  have 
seen  violent  persistent  vertigo  reacmbllojif  that  of  Meniere's  dis- 
ease causeil  by  a  stnall  pistol-liullet  Lnlged  somewhere  in  the 
vicinity  of  the  semiciixjular  canals.  The  relation  between  the 
aural  apparatus  and  the  function  of  e^juilibration  in  undoubtedly 
a  close  one.  A»  lia?^  bt-eii  ithown  by  Dr.  S.  Weir  MiiWiell,  the  in- 
jection of  cold  water  or  of  rhigolene  into  the  external  meiitiu  gives 
rise  1o  convulsive  movements  in  the  rabbit  aiul  guinea-pig,  with, 
on  rejK'titioii,  the  production  of  a  peruianeutly  vertigiuous  state. 
Ill  man,  cold  water  suddenly  thrown  iuto  the  ear  will  sometimes 
cause  excessive  vertigo,  as  in  the  ca.se  of  Dr.  Mitchell  bimwlf, 
in  whom  a  jet  of  water  at  a  temperature  of  52°  F.  into  the  loft  ear 
was  immediately  followed  by  disturbance  of  vision,  with  move- 
ments of  surrounding  objects  to  the  left  and  a  fall  to  the  LefL 
After  getting  nj),  there  was  swimming  of  the  heail  and  a  scnao  of 
laclc  of  power  tn  tiie  whole  left  side,  with  staggering  to  the  left. 
The  relation  of  such  an  attack  as  this  to  various  reflex  vertigoes 
and  epilepsies  is  a  very  evident  one.  The  closeness  of  the  rela- 
tion is  still  further  enforced  by  the  fata  that  in  birds  many  parts 
of  the  skin  arc  competent  under  irritations  to  give  rise  to  vertigi- 
nous phenomena.  It  does  not  appear  to  me  that  the  eaae  with 
which  vertigo  is  caused  by  irritations  of  the  external  ear  proves 
that  the  external  ear  is  in  direct  oonnectiou  with  the  function  of 
equilibration  t  the  phenomena  are  readily  exjilainetl  as  reflex. 
The  cause  of  the  vertiginous  attack  in  labyrinthine  disease  is  as 
yet  uncertain,  lly  most  physiologists  it  is  believetl  at  present  tliat 
the  canals  have  a  very  diretrt  relation  with  equilibration,  or  are, 
in  other  words,  guiiliiig  organs.  It  is,  however,  possible  that  the 
vertiginous  sensations  which   their  injuries  produce  are  purely 


DISTC«BANCE8   OF    EQUILIBRATION. 


211 


of  the  nature  of  a  reflex  disturbance,  having  no  more  immediate 
vonuectioQ  with  equilibratlou  tluii  have  similar  vertiginuns  nttackB 
produced  by  permanent  laryngeal  and  Kaftro-intestinal  irrilnlioUB.* 

Toxcemio  Vertigo. — Cannabis  iiidica,  alcohol,  bcIIaJomia,  and 
various  other  |>ot»onH  are  capable  of  producing  a  more  or  less  pro- 
noonood  vertigo.  In  aiich  coses  the  cause  of  tlic  vcrti^i  is  to  be 
reoogniiKHl  by  the  prebenee  of  other  syiiiptoiiis  of  jioisouing,  and 
by  the  history. 

As  long  ago  as  the  dnys  of  Boerhaavc,  the  possible  dependence 
of  vertiginous  eyinptoms  upon  irregular  gout  was  recoguized. 
This  vertigo  of  lithoomia  may  be  very  mild  or  very  severe.  The 
attacks  may  occur  at  long  intervals  or  may  be  repcatal  several  times 
in  tlie  twenty-four  hours.  In  the  severer  atbichs  the  whirling  of 
olgects  is  very  pronounced,  and  the  confusiou  of  mind  may  be 
marked.  In  some  of  these  cases  there  is  along  with  the  severe 
vertigo  an  apparent  Iops  of  niemoiT,  which  is  liable  to  lead  to  a 
mistaken  diagnusis  of  or^nic  bniin-disea:5e.  Almost  always  irreg- 
ular or  shooting  pains,  depression  of  spirits,  irritability,  malaise, 
or  other  evidences  of  suppresswl  gout  can  be  noted,  aud  uhould 
lead  to  an  exatuiualiun  of  the  urine,  which  will  reveal  the  presence 
in  it  of  uric  acid  or  the  uraCcB,  and  coufinn  the  diagnosis.  Id 
some  cases  gouty  vertigo  is  associatoi:!  ^.vith  marked  irregularity  of 


*  VoUaluti't  DistMxe.—A  ilUcBM  which  ia  rclftted  Ut  aura)  vertigo,  but  pr^ 
•entA  ■ymptanu  mgre  closely  D^emliling  thc^e  of  t>Ritt1  meningitis,  witi  orlgl- 
nall;  <Io*cribod  by  Dr.  VulloUni.  IL  is  almost  ai>ii^liLiftly  t'onHnod  lo  child- 
bood.  The  utuick  U  sudden,  fomutimos  preceded,  liuwuver,  for  soniB  houn 
hy  r«*U«Mac«i,  with  ihootlns;  paina  in  both  enni.  Uni^onicifliuncsi  now  ds- 
wvkup*,  oflen  with  Rroat  sudden iic»#,  nnd  is  lusodntod  with  high  fever,  gr«ttt 
reetleatnee*,  conlntct«d  pupili,  and  ilrabitmus;  delirium  S*  occuionally 
proieal,  and  coQvulidve  moTenionU  or  cvidcnoea  of  lou  of  power  in  llio  cx- 
tromitiee  may  bo  temporarily  developed.  Ucilci»  tlio  cais  ond  fauUy,  con- 
acioutnea*  ia  rtf^lned  in  taar  or  fiv'<  daya.  During  conTaleacence  the  gait  1* 
Btafgeriof;  and  often  irregular,  and  dA&fnoaa  is  compteto.  The  «t&$g«riiig  » 
naually  r«c<>vered  from,  but  (be  Icm  of  hearini;  is  {jermaneDt.  Voltollni  and 
Betchel  believe  that  th"  »ympti>[ji*  are  thu  reimlL  of  primary  jinruteni  tefty- 
rintMe  oHHa,  but  other  observers,  ooUibly  Kiiapp,  affirm  that  tbe  diKiate  li 
klwayii  aewindikry  to  meningiti*  or  tome  septic  fi^vcr.  It  is  ccrt&tn  that  !n 
epidemic  c«rc>broiipitiul  mentn^lia  the  ioflatnmatiun  oci^iuiunatly  oxtendx  to 
the  Isbyrltitb,  and  it  is  probable  that  tho  same  thing  *otnutinin«  occurs  in 
olher  forms  of  lueniiigitis.  It  seem*  ia  me,  howeTer,  Ukelj  that  there  tra 
caaoc  in  which  IndainmatiDn  of  tbe  labyriatti  U  primary. 


212 


DIA0S06TIC  NEUBOLOOY. 


the  hrart's  action,  whicli  might  rcadJI}'  lead  to  the  suppoa'tion  of 
oerdiac  diseaso-s  atid  cnrdiac  vertigo. 

Chronic  kidncy-dlscasc  does  not  very  frequenlly  give  rise  to 
vertigo,  but  I  have  socii  pronounced  vertigioiHU  attacks  tltc  only 
decidal  riyinptoms  of  a  mild  urEemia.  Iti  one  case,  a  woman,  who 
eventually  died  in  urjcmic  convulsions,  tlic  paroxysms  of  vertigo 
came  on  only  when  no  fcKxl  had  been  taken  for  three  or  more 
hours,  and  were  for  a  long  time  tiupposed  to  be  gastric.  Th«  at- 
tacks comracnccd  with  exti'cme  jmllor  of  the  face,  and  the  appear- 
ance of  dark  rings  under  the  eyes;  then  the  woman  would  epeak 
very  hesitatingly  and  slowly,  and  a  moment  later  cease  with  a 
dazed  expi'eti^iou  of  couutonauoe.  The  mental  confusion  was  so 
marked  that  she  ilid  not  know  where  she  was  or  what  she  was 
doing.  A  fltcr  the  attack  she  did  not  remember  what  had  oociirred 
during  the  paroxy^^m ;  but  she  never  fell  in  an  attack,  and  she 
would  alway8  give  itomc  rcsiK>n*ie  when  spoken  to.  For  a  long 
time  the  attacks  were  at  once  relieved  by  giving  a  few  mouthfula 
of  i^ome  hot  drink. 

Eaeoiitial  Vertigo. — There  is  a  claas  of  rather  Infretjuent  caaes 
in  whicJi  none  of  the  known  causes  of  vertigo  can  be  discovered, 
and  to  which  the  name  of  essential  vertigo,  given  by  Dr.  Bama- 
kill,  may  be  well  applied.  It  is  entii'ely  po»«ible  that  in  some 
ioBtauota  a  hidden  peripheral  irritation  or  structural  brain-chaoge 
may  be  the  cauBC  of  the  symptoms ;  on  the  other  hand,  it  is  poa- 
sibJe  that  in  thehruto  there  are  centtx-s  connected  with  eijuiiibralion 
which  are  liable  to  suffer  from  functional  or  structural  disease  and 
tlius  give  rise  to  vertigo.  The  recognition  of  a  oaee  of  essential 
vertigo  implies  simply  that  every  known  cause  has  been  looked 
for  and  not  found. 


CHAPTER   V. 

TROPHIC   LESIONS. 

TJkder  tlie  liead  of  trophic  lesions  I  shaii  consuler  lliose  alter- 
ations of  structure  wliicb  arc  apparently  depeudent  upon  disease 
of  tlie  nerves  or  of  the  iierve-oeiitreB,  or  wliit^li  are,  at  leafil,  cUiseiy 
connected  with,  uud  Bubscriucnt  to,  such  nervous  affections.  The 
discussion  of  the  methods  in  which  these  trophic  le->*ions  are  pro- 
duced seems  to  me  beyond  the  province  of  the  preiscnt  work,  but 
it  may  be  allowable  to  state  my  belief  that  the  nervous  system 
does  exert  a  dirof;t  and  immediate  inSuencG  upon  nutrition, — that 
fa,  upon  the  structure  of  the  hotly.  A  functional  act,  whether  of  & 
gland  or  of  a  muscle,  is  nothing  more  or  1***  than  a  nutritive  act. 
It  has  been  long  proved  that  a  nerve  may  directly  so  alTeot  the 
nutrition  of  the  muscle-fibre  or  of  the  glandular  cell  as  to  cause 
the  one  to  contract  and  the  other  to  secrete ;  i.e.,  it  has  been  long 
proved  that  the  nutrition  of  the  muscle  and  of  the  glandular  cell 
may  be  directly  influeuced  by  the  discharge  of  nerve-foree,  aud 
tlinl  tliprcjfore  there  are  (ropliic  nerves. 

For  the  purposes  of  clinical  study  trophic  lesions  are  divisible 
those  which  ni|iidiv  destroy  nil  the  tissues  in  their  immediate 

irse,  and  Ihoeo  which  arc  not  tlms  destructive.  I^esions  of  the 
Kcond  class  ar«  for  the  greater  part  essentially  slow  and  progres- 
sive, although  included  in  the  clam  aro  some  acute  lejiions  which 
are  more  or  less  strictly  confined  to  a  single  ti^ue,  which,  how- 
ever, Uiey  do  not  rapidly  destroy, 


ACUTE  DESTRUCTIVE  TROPHIC  LESIONS. 

The  destnictive  tniphic  lesions  are  the  Decubitus  Acntus  of 
Continental  writer?,  or  the  rapid  Spontaneous  E^har;  the  mal 
perforaiu,or  the  l*erft>ratiug  Uloer;  and  Raynaud's  Disease,  or 
Acute  Symmetritsil  Gangrt'ue. 

Decubitus. — The  term  Dccubitns  is  an  unfortunate  one,  which 
really  refers  to  the  position  o^Aumed  by  the  patient  in  bed,  but  has 


214 


DIAONORTIC  NEIJROLOOV. 


been  irnnsferro!  to  the  sore,  formerly  supposed  to  result  solely  from 
pressure  due  to  t!ie  poi^ition  of  the  bedridden  patient.  It  usually 
attacks  the  sacru-gluteal  regions,  but  it  may  ajipeor  iu  any  portiou 
of  tlie  iKKly  which  is  subject  to  a  slight  coutinuous  pressure,  and  Is 
not  infrequently  seen  in  tlie  heels.  The  first  wnming  consists  of 
one  or  several  erythematous  patches,  variable  in  extent  and  irreg- 
ular in  sliape.  The  oolor  may  be  rosy,  but  more  frequently  is  dark 
red  or  evon  violet.  It  disapiicnrs  momentarily  upon  pressure 
with  the  finger.  In  rire  ca^s,  and,  according  to  Charcot,  only 
when  tliR  spinal  con!  U  involved,  there  is  about  the  erythematous 
patch  an  apparently  phlegmonous  swellmg,  with  sometimes  acute 
pain.  Within  twenty-four  or  forty-eight  hours  vesidcs,  or  ballse, 
form  in  the  central  )M>rtion8  of  the  erythema.  They  are  red- 
dish or  brown-oolorcd,  and  contain  q  liquid  sometimes  colorlcs, 
but  generally  o])aque  and  bloody.  In  rare  cases,  umler  careful 
management,  tliL>  vesicles  and  blubs  wither  and  disajipear  without 
further  fiviiiptiHus:  usually,  however,  the  elevated  epidermis  is  torn 
or  drops  off*,  Iciaving  a  hriglit  retl  surface  with  bluish  or  violet 
points  or  ]«tches.  There  is  now  some  swelling  and  sangninolent 
inlillrutiouof  the  tissue  for  some  distance  bcueuth  the  bared  surface. 
In  the  course  of  a  few  lioiirij  tlie  reddish  surface  becomes  black- 
ish, and  a  slough  of  variable  extent  forms.  The  whole  bultofik 
may  tlius  melt  down  in  the  course  of  a  few  hours.  Sometimes 
the  process  is  arrested  and  the  sluugb  separates,  but  oftener  the 
process  continues,  »nd,  unless  the  patient  die  too  quickly,  the 
dec|>rr  muscles,  with  the  uerve-truuks  and  arterial  branches,  are 
laid  bare,  and  finally  the  bones  themselves  appear.  Gcnernlljr 
death  occurs  from  exliau&tiou,  but,  according  to  Charcot,  a  secoud- 
ary  purulent  aficction  with  metastatic  abscesses  may  follow  upon 
the  acute  bed-sores,  and  in  rare  cases  gangrt^nona  emboli  our^ur  in 
the  lungs  or  in  other  portions  of  the  body. 

Acute  decubitus  onnirs  in  di<*a.se  of  the  brain  and  of  the  spinal 
cord.    In  cerebral  hemiplegia  it  is  uhvays  upon  the  paralyzed  side. 

In  1876,  A.  Joffroy  (Ardi.  de  MM.,  January,  1876)  attempted 
to  show  that  in  cernbral  cases  the  rsclmr  wsw  fllmiv-i  tho  result 
of  lesions  of  the  occipital  lobe  or  of  the  optic  thalanuis.  This» 
however,  is  not  correct,  as  the  sloughing  bed-sore  bus  developed 
afler  hemorrhage  in  the  externat  (!ti}>snIo  and  corpus  strltiluni 
(Broodbeut,  fjancet,  1876);  after  focal  lesions  in  the  convolutions 


J 


TROPHIC  LESIONS. 


216 


(De  Bearmnnn,  Soc.  Anat.,  March,  1876);  after  hemorrlmge  into 
ih*  oxtra-ventri<Milar  niicletis  of  the  striate  b(xly  ( Dusausfifly,  Ut., 
January  21,  1876);  uAlt  softeiiiug  of  the  Bplictioidal  lobe  (L«loir, 
Proffi-^n  JW(W.,  1879);  and  after  various  other  lesions.  Moreover, 
Charcot  has  reported  four  cases  in  wlilch  tho  ocnpital  lobes  or  the 
optic  tlialami  were  the  seat  of  the  lesion  wichout  the  production 
of  the  eschar.  It  would  seem,  therefore,  tliat  acute  decubitus 
may  follow  letiion^;  nf  ainioet  any  {xirlion  of  the  brain. 

Brown-86qanrd  has  domnnsiratal  that  if  the  spiuiil  cord  be 
divided  half-way  through  in  an  animal,  acnte  sloughing  iilcera 
will  develop  iti  the  sacral  r^ ion,  although  the  part  is  neither  i^ub- 
jectetj  to  compression  nor  irrifafed  by  the  urine.  The  most  inter- 
esting fact  in  connection  with  this  triiiimatic  spinal  decubitus  la 
that  the  eschars  arc  limited  to  the  side  opposite  to  the  section.  In 
man  acute  decubitus  has  l>een  noted  after  luemato-myelitis,  acute 
myelitis,  trauiuattc  uiyelitiH.  fracture  of  the  spine,  etc.  It  aj>- 
pears  to  be  e^jKMiially  connectetl  with  dtstrnction  of  tiie  central 
:  gray  matter  of  ilie  conl.  .^^■•iriHijg  to  the  statistiiw  eiillected  by 
Prof.  John  Aslihurst,  after  fracture  of  the  spine  decubitus  is  prone 
to  occur  in  direct  proportion  as  the  injury  is  low  down.  Sir  Ben- 
jamin BriHiie,  on  the  other  hand  {Mfxl.-Oiir.  TVrtmi.,  18;i7,  vol. 
XX.  p.  148),  affirnie*!  that  the  sloughing  bed-sore  develops  raoet 
rapidly  when  the  lesion  is  high  up. 

Perforating  Ulcer. — Under  the  name  of  [terfornliug  ulcer 
{mal pajorana)  is  ilescribed  a  peculiar  ulceration  which  usually, 
but  not  alwayti,  apfiears  upon  the  foot,  and  especially  affw^tA  the 
imme^liatc  vicinity  of  the  metufarso-pholangeal  articulations  of 
the  big  and  the  Itttle  toe.  Often  there  ig  but  a  single  ulcer  on  one 
loot,  but  there  uiny  be  im  many  as  three  ulcers,  and  iu  uot  rare 
cases  both  feci  are  symmetrically  attacliod.  The  [»erforating  ulcer 
may  api>ear  upon  the  hand,  and  there  Ih  rcjisttn  for  believing  that 
it  may  even  affect  the  internal  or^an^.  Thus,  M.  h.  Terrillon,  in 
the  BulL  fir  hi  &V.  ff'i  t'hir.,  I  s8o,  p.  403,  reports  a  case  of  poste- 
rior spinal  sclerosis,  with  fulguruut  pains  iu  tlie  hands  and  arms, 
in  which  there  were  symmetrical  ulcers  on  the  thumb  anil  the 
index  and  me<iian  fingers  of  each  hand.  Some  years  ago,  in  ;i  case 
of  gouty  dementia  (Trail*.  OoUtgt  of  Phymians,  Phila.,  1884-85), 
I  saw  a  circular  ulceration  three-fourths  of  an  inch  in  diameter, 
h  aniooth,  sharp  edges,  in  t»o  or  three  days  eat  through  the 


216 


DIAONOfiTIC   NEITROI/XJY. 


septiiui  K'fwe«n  the  vagina  aad  the  rectum.  It  is  well  kooKn 
that  not  rarely  after  extensive  liurns  rap  idly -pcrforaliiig  ulcere 
piert%  the  ounts  of  the  stuinacli,  or  mure  iLsually  of  the  duodenum, 
witti  fatfti  results. 

The  first  symptom  of  the  perforating  ulcer  of  the  foot  »  gen- 
erally a  severe  paiti.  Tliie  prodruniiK  pain  niay,  however,  be 
entirely  wauting.  A  snaall  hemorrhage  or  oochymotio  spot  dow 
appears  undor  the  opidernu»  ;  in  the  course  of  a  few  hours  the  skin 
detache»  Itself,  or  more  fre([uently  Ijecomea  excessively  thickeaed 
into  a  large,  dnt*,  corn-like  mam ;  a  siuall  slough  sooo  a^MUfttCBf 
leaving  the  ulceration  round,  with  sharp,  acute  edge?,  piercing,  it 
may  he,  only  tlirnugh  (he  skin,  but  uiiually  to  (he  de«|>er  tiiwuefi, 
and  in  many  cases  reaching  the  artieutatiou  or  the  boue.  Around 
the  uluenitioti  there  is  a])t  to  l>e  tierous  infiitratiun  and  Bwellii^. 
Ill  rare  in^itauccet,  especially  if  tlic  patient  be  put  to  Ik^I  and 
carefully  nursed,  tlie  perfonititig  iiloer  is  recovered  from  without 
loHof  bone:  aomewliat  more  frequently  the  )>aticnt  eM»peft  with 
(lie  llirovviug  off  of  small  necros*^!  flakes  of  boue.  In  meet 
case^,  however,  the  bune  becometi  iseriuusly  diseased  and  a  sinus 
fwms.  In  this  condition  the  lo^tion  appears  as  a  small  uftcrtare 
leading  by  a  narrow  sinus  to  diseased  Wne  and  sun'ounded 
by  thickened  superinipo»e<l  layers  of  epiderniU.  The  !«urfaoe 
of  the  s|)ot  is  usually  cold  aud  ona^tfaeticj  the  characteristic 
feature  of  the  ulcer  being  it»  inseutiibility  to  irritants  and  its 
freedom  from  pain  during  rcrtl  Walking  may  cause  sufTering; 
and  the  fulgurant  pains  of  locomotor  ataiia  are  very  frequcDtlj 
present,  but  do  not  have  their  origin  or  focus  iu  tlie  uloer. 
£ry»;ipelatoiui  inflummallon  or  erythematous  exudations  arc  apt 
to  occur.  Under  these  circumstances  tlie  limb  bejcoraes  greatly 
swollen  and  ooilematom,  and  the  attack  may  terminate  in  ery' 
eipelalous  Buppuratiuu  and  dcalli.  Except  iu  the  rare  caacH  in 
which  the  ulcer  heals  early,  all  the  boueti  of  the  foot,  aud  indeed 
all  tJie  tiesucB  of  tlie  fixtt,  beenme  diseased.  Not  only  la  the 
joint  that  is  in  immediate  relation  with  the  ulcer  apt  to 
affeciwl,  but  all  the  small  joints  of  the  fiwt  frequently  take  on 
ail  inilammattiry  notion  which  ends  in  an  anchyloeis,  or  undergo  , 
ulceration  aud  destruction,  rcsuUing  in  luxations  and  deform itieSi^H 

become   brownish,  dry,  greatly^^ 


d 

he     J 


The  nails  of  the  foot   iisnally 
Ihickeuetl,   curvetl,   aud   furrowed. 


In  some  cases  there 


TROPHIC  LESIONS. 


217 


raarke<l  increase  in  the  growth  of  the  hair  and  in  the  pignienta- 
tiuii  of  the  1^,  and  the  whole  foot  may  be  bathed  lu  a  jwcullarly 
feCid  fiweat. 

It  lias  been  denied  ihnt  the  connection  of  perforflting  nicer  with 
diaeaM  of  the  nervous  system  is  other  than  aocideutal ;  but  since 
tfae  paper  of  MM.  DupJay  and  Moral  (Arch,  de  M4<l.,  1873)  it 
seems  to  have  l>een  almost  universally  acknowledged  that  the  ulcer 
IB  the  direct  or  indirect  result  of  various  nervous  affcotions^  The 
similarity  between  the  pcrfomting  ulcer  ati<l  the  nlcemtions  of 
leproey  was,  in  1871,  strongly  commented  upon  by  B^llander,  and 
io  1872  M.  PoDc«t,  in  tracing  the  relations  between  leprosy  and 
perforating  ulocr,  found  that  the  nerves  in  |»erfnraliiig  nicer  have 
their  conoMrtive  tissue  increased  and  their  fibrils  atrophied.  0u- 
play  and  Morat  sobjecteil  the  affected  parts  in  six  cases  of  perfo- 
nitiug  ulcer  to  micruscopieal  ejianiiuatious,  and  in  e:ich  oa^  found 
an  advanced  degeneration  of  the  nerves.  Morat  {hyan  MM..^ 
'  March,  1876}  reported  a  ctwe  in  which  the  |M<rforating  nicker  fol- 
lowed traumatic  section  of  the  sciatic  nerve.  These  observations 
have  been  confirmed  by  a  number  of  observers  (see  Ross,  2d  ed,, 
vtil.  i.  |).  269),  and  it  would  Hp]H>ar  that  {lerforating  ulcer  may  be 
doe  to  a  disease  of  the  nerve-trunks. 

The  great  frequenoy  of  the  affection  in  locomotor  ataxia  in- 
dicates, however,  that  it  is  not  caused  solely  by  le«ioQ8  of  ibe 
ncrve<trunks.  It  is,  of  course,  possible  that  the  nerve-truuka  ara 
diseased  iu  thoee  cases  of  locomoloi'  ataxia  in  which  perforating 
n!cpr  oocurB ;  but  until  this  is  prtived  we  must  consider  that  the 
|»erfnrating  ulcer  may  be  prodtice«l  by  various  nervous  diseases,  of 
which  the  mwt  inipurtaut  are  posterior  t)clen)$i»  and  diseaiie  of  the 
nerve-tranks.  In  locomotor  ataxia  this  ulceration  may  be  a  very 
early  symptom ;  and  if  in  a  case  of  mal  ]>erforanB  the  knee-jerk 
he  absent,  the  diagnosis  of  locomotor  ataxia  may  be  considered 
eatablisbed,  unless  positive  }«ym[ilon>s  of  di»«ase  of  the  nerve- 
trunka  (bucIi  as  teudemesis)  or  of  myditis  \k  present. 

Raynaud's  Disease. — Under  the  names  of  Bead  Finger,  Aqee^- 
luic  Sph!icelns<  Myrtle.  Lniufi,  i.,  1S63),  Local  Synco]>e,  Erythro- 
<  myalgia  (Mitchell},  and  Symmetrical  Gangrene,  there  have  been. 
described  by  various  writera  groujie  of  cases  which  are  at  present 
generally  tlionglit  to  represent  a  single  distaise,  (umnionly  known 
0:1    Kaynauil's  disease,  because  the  first  clear   recognition   and 


218 


PIAOK06TIO  jnEUROLOOY. 


elaborate  deacripliou  of  it  were  giveo  by  Dr.  Muurtoe  Raynaud 
{L' Aephyxiv.  looafc,  Paris,  1862).  The  unity  of  these  groups  U 
not,  however,  entirely  csLiblishwI. 

In  the  raoet  acute  form  of  the  disease  as  described  by  Raynaud 
the  beginning  of  tbe  attack  is  painless  and  sudden ;  the  skin  of 
the  afiectcd  pxvt  becomes  of  a  dead-white  color,  BouiettmeA  even 
a  little  yelluwii^h,  and  appears  entirely  devoid  of  blood.  Cuta- 
neous sensibilit}'  '\s  lessened  or  nlCogclher  destroyed,  so  tliat  tbe 
fingers,  which  are  the  parts  usually  affected,  may  be  pinched  with- 
out pain :  even  when  tbe  Ketiijatlon  of  contact  is  entirely  lust  the 
power  of  diBtiiiguishing  heat  and  cold  may  bo  rctaiuod.  The 
temperature  of  the  parts  is  very  notably  diminiahed ;  the  power 
of  niovcQicnt  is  lost.  After  a  time  re:iction  seU  in;  the  white 
color  gives  way  to  a  cyanotic  tint,  which  deepens  to  violet,  and  in 
some  oasisi  (o  a  black  compared  by  Riiynand  to  that  of  a  spot  of 
ink.  Presanro  on  tlii>  [larts  now  prtMlucea  whiteness,  followed  by 
instant  return  of  color  on  removal  of  the  ppessnre,  showing  that 
the  discolorattou  la  owing  to  blood  ntill  Inside  of  the  capillaries. 
The  parts  arc  at  this  time  swollt-n.  During  the  tttnge  of  reaction 
there  is  excessive  burning  pain,  which  may  bi^n  even  before  the 
congestion,  atid  in  the  height  of  the  paroxyjim  rises  to  n  pros- 
trating agony.  In  cases  of  the  severest  type  the  local  oongcstioo 
soon  deepens  into  gangrene. 

Of  the  acute  form  of  tho  affection  described  by  him  Raynaud 
makes  three  stages.  The  first  is  the  |>eriixl  of  invasion:  It  may 
last  only  for  some  hours,  and  U  never  prr>tructe<l  beyond  a  month. 
The  second  |>eriod  is  characterized  by  intense  congestion  of  the 
[Kirt;  by  the  perpetual  recurrence  of  pain-cj'i.ses,  which  ui^ually 
pa^  oil'  with  an  al>uniluut  eiuiiiaion  of  urine;  and  by  the  termi- 
nation in  gangrene,  which  is  so  rapidly  develu|}eil  that  tlte  local 
destnicdon  is  complete  and  limitai  in  from  eight  to  twelve  days. 
Tbe  third  stage  is  tliat  of  thruwiug  off  the  gangrenous  tissue,  and 
is  of  variable  length. 

In  the  clironic  type  of  the  di^eaae,  ac(,-nrding  to  Raynaud,  there 
are  frequent  remissions,  with  violent  attacks,  which  may  be  pro- 
voked by  exposure  to  cold,  by  a  suppression  of  menstruation,  by 
fright,  by  a  sudden  emotion,  or  even  by  a  more  momentary  excite- 
ment. This  Btatc  may  last  for  several  years,  and  finally  end  either 
in  gaogreue  or  in  reoovetj  without  loss  of  structure. 


J 


TROPHTC   LK8ION8. 


S19 


The  term  looal  syncope  is  applied  to  that  condition  in  which  the 
parts  are  excessively  pale ;  the  term  loctU  atphyxia,  to  the  state  of 
ooogestion. 

Siboe  the  publication  of  Rarnand's  article  a  number  of  cases 
have  l)een  reported  upon  the  continent  of  Europe,  in  England, 
and  in  America.  It  is  (|U(!Klionab1e  whether  the  local  asphyxia 
16  nut  always  preceded  by  the  local  5ynco[)e,  and  whether  LhoHe 
enes  in  which  there  U  no  ocoount  of  a  local  syncope  ought 
not  to  be  oonsiderod  as  a  distinct  group.  It  is  cprtain  that  in 
many  of  tlie  caws  the  local  8yucoi«e  had  dLHap[>««ire<i,  if  it  had 
existed,  at  the  time  when  the  sufferers  first  came  under  medical 
observation :  moreover,  no  history  of  its  exiHtent*  could  lie  oli- 
tained.  Some  of  Dr.  S.  Weir  Mitchell's  jwticnta  were  so  intelli- 
gent and  80  clear  in  denying  a  primary  gynoope  that  its  eiiBtence 
is  not  probable.  It  wiis  to  ca-ses  of  tliis  character  that  Dr. 
Mitchell,  believing  thorn  to  be  a  distinct  group,  gave  the  uame 
of  erythroniyalgia.  On  the  other  hand,  in  HOme  recorded  cascH 
frequent  attacks  of  syncope  occurred  in  the  earlier  months  of  the 
disease,  and  finally  gave  way  to  a  perpetual  local  asphyxia  whilst 
the  OBse  was  being  watched  by  the  pliyt^iclan.  Thus,  Dr.  Caloott 
Fox  {Om.  Soa.  TVmu.,  vol.  xviii.  p.  30fi)  details  the  case  of  a 
woman  whose  fingers  for  ten  years  suffered  from  frequent  parox- 
yHQis  of  local  syncope,  but  at  last  passed  into  a  condition  of  con- 
tiiiaoas  local  asphyxia.  In  these  chronic  asphyxia  cases  the  pain 
is  inereasei]  by  allowing  the  part  to  hang  down,  by  warmth,  by 
exertion,  or  by  any  act  or  posilion  which  naturally  tends  to  incretwe 
the  niDount  of  bloo<l  in  the  affected  member.  During  the  ood- 
dition  of  congestion  or  local  o.'iphyxia  there  is  tendenuss,  which 
may  be  accomjmnied  by  excessive  hyperaisthesia  or  may  be  re- 
vealed only  by  firm  pressure.  Gangrene  may  at  any  time  come  on, 
even  in  cases  which  have  lasted  for  many  years,  but  in  the  moat 
chronic  form  of  the  affection  other  nutritive  alterations  are  not 
rare:  thui<,  in  a  case  reported  by  Dr.  Fox,  uccafiional  blood-blis- 
ters  formed  ou  tho  affected  fingers,  leaving  raw  surfaces  which 
were  slow  to  heal,  and  especially  affected  the  eilges  of  the  nails. 
In  euch  cases  some  of  the  tingera  Tuay  have  their  phalanges  com- 
pletely atrophied  and  their  nails  shrivelled  up,  whilst  in  other 
fingers  the  ends  become  markedly  conical,  with  their  nails  curved 
[Over  them. 


220 


DIAOKOSTIC  NEUROLOOY. 


During  tiie  &ti^  of  t^'OODpe  the  hx^l  temperature  is  markedly 
abated:  thus,  M.  Lnnnoia  {Paralyse  vago-motrux,  Paris,  !880) 
has  noted  it  4.7°  C.  below  that  of  the  opposite  aide.  During  the 
pM'iod  of  congestion  the  temperature  rises,  and  it  has  been  noted  us 
high  as  19'^  P.  above  that  of  the  opptsite  side  (M.  Allen  Stnrge). 
In  one  of  Mitchell's  eases,  whenever  the  foot  was  Hu=tiiended  In- 
tense congestion  osmo  on,  accompanied  by  cxcscssive  paiu  and  by 
great  rise  in  the  temperatnre. 

Erytbromyalgia  ap|)eara  to  aflect  children  more  frequently  than 
older  people.  In  many  of  the  reported  cases  the  patient*  had 
been  previously  of  robuiiit  health ;  in  mme  instances  ilie  neurotic 
temperament  has  been  strongly  expressed  ;  and  in  a  few  cases  the 
affeelion  has  developed  during  the  progress  of  diabetes*.  In  sev- 
eral more  or  lets  })ronuuuee<l  ease?)  h hemoglobinuria  lias  been  pres- 
ent, sometimes  accom}Hinying  the  attacks  of  local  synoojMJ,  in  other 
instan(*H  occurring  iiidiirerently  to  them.  In  two  or  three  cases 
ocular  troubles  have  been  noted,  and  once  or  twice  disorders  of 
audition.  The  reflexes  have  occflsioimlly  Iteen  increased,  but  geu- 
erally  have  been  normal. 

Although  the  fingers  are  the  parts  most  commonly  affeRted, 
other  extreme  portions  of  the  body  are  often  attacked.  The  toes 
are  frequently  the  scat  of  the  disease,  and  in  several  of  Mitchell's 
cases  the  gangrene  a^ected  a  great  portion  of  the  sole  of  the  foot. 
All  the  phenomeDfl,  of  the  disea^  liave  frequently  beeti  observed 
in  the  ears,  and  in  a  few  instances  the  end  of  the  nose  has  suf- 
fered destruction. 

The  exact  nature  of  Raynaud's  disense  is  still  obscurt-.  The 
condition  known  as  local  syncope  is  probably  due  to  an  inteJise 
vaso-niotor  spasm,  but  the  caui«e  of  such  spasm  ban  thus  far  eluded 
observation.  That  it  is  a  general  wide-reaching  influence  is 
shown  by  the  implication  of  the  ears,  nose,  fingers,  and  toes,  and 
by  the  occasional  hematuria.  The  occurrence  of  ischiemic  aphasia 
(Weiss,  ZeUachr.fiir  Jleilk.,  1882)  strongly  indicates  that  inlcrnal 
vas(iidar  areas,  as  well  as  Ihose  of  the  exireinities,  may  suB'er.  No 
such  condition  as  local  asphyxia  follows  even  the  complete  vaso- 
motor paralysis  of  nerve-section,  and  if  it  be  really  paralytic  it 
can  be  explained  only  by  supposing  that  the  muscles  of  the  walls 
of  the  vessels  are  so  absolutely  exhausted  by  over-effort  that  when 
relaxation  follows  their  local  tone  is  eutirety  lust. 


TEOPmc  LE6IOSS. 


221 


Professor  PitrtB  {Art^iveA  de  Ph^tioloffie,  1885,  p.  106)  found 
in  one  case  of  Raynaud's  disease  exteusive  periplieral  ueuritis,  and 
Dr.  A.  Bidder*  Jias  repurteJ  {Arch,  fur  KHn.  Chir.,  xxx.  810)  a 
one  in  which  j^iigrene  of  the  finders  followed  fracture  of  the 
ann  wilh  injuries  to  the  nerve ;  but  it  does  not  seem  probable^ 
and  vertaitily  is  iu  do  way  proved,  tliat  peripheral  uerve-lesion  is 
mtetautly  prcscot  iu  the  disorder. 

Various  facts  iiidicute  an  obt^cure  but  close  relulionship  between 
'the  dead  finj^ere,  Belerodcrma,  and  morpho^a.  In  some  cases 
of  dead  fingers  a  peculiar,  raised,  wheal-like  ernptlon  has  been 
jffwent.  Further,  the  rejteatetl  coexistence  of  two  sudi  rare 
■flotioos  as  scleroderma  and  Raynaud's  disease  (for  cases,  see 
Dr.  C.  Fox's  article,  Oin.  .S(»r.  Trurin.,  vol.  xviii.  p.  30fi;  also 
Dr.  Fiolayson,  Miedieal  Oironiele,  1884-85,  p.  315)  ainnot  be 


iTBOPHIC  LESION'S  NOT  ACCOMPANIED  BY  WIDE-SPREAD 
DESTRUCl^ION  OF  TISSUE. 

Trophic  cliangew  wbieh  are  not  acconipiinied  by  wide-spread 
dtttructiou  of  tieiisue  and  are  niore  or  less  cotifiiied  to  &  single  tissue 
are  best  claseiGed  for  study  according  to  the  tissues  afiecbed.  I 
Hki]  therefore  discusR — Brst,  trophic  changes  in  the  skin  and  its 
appendages;  secondly,  trophic  changes  in  the  muscles;  thirdly, 
trophic  change;)  in  the  bones ;  and,  fourthly,  vnso-niotor  disturb- 
ances aud  disorders  of  secretion. 


TROPHIC  BKIN-CliANGES. 

Skm-DiseafiOB. — It  is  probable  that  many  of  the  diseases  of 
the  skin  are  dependent  u|>on,  or  at  least  connected  witli,  affections 
of  the  uervoua  system.  Thus,  Jainiog  de  St.-JuBt  {article  "Scar- 
latine/'  Did.  KncycL,  3e  sfiric,  vJi.  307)  relates  the  case  of  a 
Jtemiplegic  iu  whom  for  two  ilays  the  eniptinu  of  sfarlatina  was^ 
imited  to  the  normal  side,  and  Chevalier  {Thlae,  Paris,  1878) 
ribes  a  case  in  which  variola  was  confluent  and  hetnorrhagio 
upon  the  paralyzed  8ide  but  di^icrcte  upon  the  other ;  and  in  a  case 
M.  Bouilly  (cited  by  Arnozan),  during  au  attack  of  smallpox 


^^mi 


^ 


*  Coai1d«r)og  the  pouible  1«aion  to  htontl-vcai'cU,  and  tlio  freo  um  of  ths 
I  buidagv,  QOl  nucb  w«[gbt  can  be  altuclied  to  thHOua, 


222 


DfAQSOSmC  NECBOIjOOV, 


* 


no  pustules  apiicarcil  upon  the  leg  the  sciatic  nerve  of  which  had 
previously  l)een  diviileil.  Our  present  knowledge  of  this  subject 
is,  however,  go  scanty  that  a  mrvtt  important  field  of  rcAearcfa 
rematusaltnust  uncultivated.  That  desquamation  may  be  effected 
by  nervous  influents  is  Hhown  by  a  case  rv|>arted  by  N.  Boatlly 
(AriioMQ,  Den  IjfsioTui  irophujtu!*,  Paris,  1S80,  p.  151) :  a  man  had 
a  neuroma  of  the  sciatic  nerve,  aud  below  the  tumor  the  epidermis 
was  oovered  with  Rmall,  dry,  bluckish  or  brownish  scales,  cuiljr 
detached,  and  haviii;,;  an  appearance  like  that  of  iditliyoeis;  after 
removal  of  the  neuroma  tlieHkin  resumed  its  normal  appearance. 
Ballet  and  Dutil  (FrogrH  Med,,  U\y,  1883)  reported  three  cflsen 
of  skin-nlteraliou  resembling  ichtliyosis  in  disease  of  the  6pinal 
oord,  and  M.  Gaulier  one  in  a  person  sufTeriug  from  lead  palsy. 
Tisehor  has  seen  exfoliation  of  the  ^kin  follow  the  ronrse  of  an 
inflamed  nerve,  and  Schiefferdecker  the  skin  thickened,  soalj, 
bro^^Tt,  perpetually  ooverofl  with  malodorous  sweat,  and  adorned 
by  hypertrophic  nails  and  hair.  (See  Roes,  loc  oit.,  p.  248.)  The 
pigmentation  of  the  BktJi  which  somotimett  occurs  in  llayiiaud'a 
disease  has  already  been  pointed  out,  and  it  is  prolxible  that 
the  bronzing  which  is  characteristic  of  Addison's  disease  is  due  to 
nervous  influence.  According  to  Moreelli,  there  is  a  peculiar  form 
of  vitiligo  seen  in  the  insane  in  which  wliitl^h  ti\miB  surrounded 
by  pigmented  Ijorderu  are  more  or  less  symmetrioaltv  armnged 
about  thip  head  and  neck.  BourneviUeand  Poirier (/"ro^At  Mfd., 
1879,  No.  24)  have  rejKirted  somewhat  similar  discoloration  of 
the  skin  in  a  |wr<un  suffering  from  cerebral  tumor,  whilst  Du- 
tneuil  has  noted  pigmentary  alterations  following  chronic  neuritis. 
G.  Roasolymmo  {Arch,  fur  Psych.,  1884,  vol.  xv.  p.  723)  has  re^ 
corded  a  case  of  a  |)craon  suffbriug  from  locomotor  ataxia,  the 
right  half  of  whose  forehead,  cheek,  and  nose,  etc,  became  cov- 
ered with  irregular  .sharply -bounded  B|H)t8  in  which  the  hair  turned 
white. 

In  1831,  Dr.  R.  Bright  called  attention  to  the  possible  etiologi- 
cal dependence  of  herpes  zoster  "u[w>n  distention  of  the  sentient 
nerves."  In  1863,  Rotnbertr  [^yd.  Soc.  T^fiairfd/joii*,  vol.  i.  p.  84) 
also  note<l  the  seeming  eunnivtiun  between  her{)e3  zoster  and  inter- 
coBtal  neuralgia.  In  186.0,  M.  Delioux  suggestwl  that  herpes 
zo»ter  might  be  due  to  neuritis;  and  in  1859,  M.  Charcot  pub- 
lished cat>es  of  herpes  fullowiug  upon  a  wound  of  the  nerve. 


TROPHIO  I.SBI03IB, 


323 


Tltese  obscrvatiou^  have  b€«n  aluindantly  conf)rme<1  (see  Roes,  vol. 

i.  p.  243),  mil)  it  Itas  been  sliowii  that  iieuritisi  may  give  lise  to 
er|ieUc  and  lulier  forms  of  eruption.    The  first  stage  of  acute  de- 
ibitus  is  a  bulla,  and  pemphigus  has  l>ecn  noted  in  various  ner* 
diseases.    (See  Boan,  toe.  eU.,  p.  247.)    Papular  and  pufitular 

^croptionn  afier  neuritis  have  been  noted  hy  Charcot  and  by  Vul- 
|nan;  whiUt  the  quicknese^  wttli  which  erythemat^iUHeruiitiom  atid 
urticaria  are  developed  by  certain  forms  of  gastric  irritation 
demonstrates  that  they  are  often  nothing  more  than  reflex  nervous 
phenomena.  I  have  seen  a  furious  urticaria  replace  (lie  chill- 
i,tag«  of  n  malarial  paroxysm ;  Charoot  reports  a  case  of  locomotor 
ataxia  in  which  eiiorinoii.s  wheats  covered  the  parts  through  whicrh 
(he  pains  were  dartinj^ ;  and  ecchymotic  spots  not  very  infrequently 
appear  during  the  pain-crises  of  posterior  flclerosts. 

I     In  the  elaborate  studies  itiode  by   Miteliell,  Morehouse,  and 

'Keen  of  the  results  of  gun-shot  injuries  of  the  nerves  (see 
Mitchell,  Iiijurieg  of  N^rt'es),  h  wiis  shown  thiit  in  many  cases 
the  eruption  following  the  nerve-injury  is  composed  of  small 
•cutely-pointed  vesicles,  which  may  well  be  described  as  eczeraa- 
toos:  eruptiuni^  of  similar  character  have  been  also  nuLetl  after 
injuries  to  the  uluur  ner\'e  (see  Mitchell,  p.  154), 

Tlie  so-called  "gloMtf  akin"  (caiuialgia  of  Mitchell)  is  a  very 
curious  alteration  of  the  «kin,  which  was  first  distinctly  described 
by  Mr.  Paget,  although  noted  as  early  as  18P3  by  Mr.  A.  Den- 
nmrk.  It  iKcurs  as  th'C  result  of  injuries  to  nerves  and  tin;  c<i.tn- 
scqueut  neuritis.  The  affected  skin  has  the  nppearaiico  of  thinness, 
is  very  smooth,  glossy,  and  shining,  as  though  varnished,  is 
tisually  deep  red  or  mottled,  or  red  aud  pale  in  pat^dies,  free 
from  hair,  and  often  looks  as  if  it  were  tightly  drawn  over  tho 
tissues  l»e!ow.  This  condition  of  the  skin  is  alwnys  associaled 
with  a  horrible  burning  pain,  which  frequently  rises  to  agony, 
and  often  pi-e*:«les  ihe  nutritive  cliangei.  Over  the  altered 
Hurface  uome  and  go  groups  of  vesicles,  whose  eruption  is  attended 
with  a  terai»rary  amelioration  of  pain.  Dr.  Mitchell  Iwlievoa 
that  this  caU'yilgia  may  result  from  central  nervous  disease ;  but  the 
case  Upon  which  he  appears  to  have  based  this  opinion  resembles 
so  cloecly  spinal  meningitis  with  a  descending  neuritis  that  in 
ihe  aljeence  of  an  auto|)fey  the  diagnosis  is  exceedingly  uncertain. 
Hair  and  Noils. — Trophic  changes  frequently  take  place  in  the 


inAONosrrc  yETFOijOGy. 


hair  and  in  the  nails.     The  whitening  of  tho  hair  which  oocural 
during  an  attack  of  migraine  will  he  dlKciiiv^  under  t^ 
IVIigntiue.    Tho  chuuge  which  occurs  !u  the  culor  of  tlic  hair  from 
Bervous  influence  is  very  remarltuble,  nnd  at  present  inexplicable. 
There  Is  a  prtinjlnent  fiurgcoii  in  this  chy  the  hair  nf  whose  head 
19  said  to  undergo  a  distinct  tem[»orary  alteration  whenever  be 
ha:»  a  severe,  trying  surgical  operation  on   tiaod.     It  is  well  es- 
tablishfxl  that  tlic  hair  may^  under  eiiiotiomLt  excitement,  diange 
its  oolor  entirely  and  permauently  during  tlie  course  of  a  few 
hours  or  a  few  days.     One  of  the  best  authenticated  of  motlem 
iDstanoes  of  such  a  phenomenon  i»  report«<1  by  D.  P.  Barry,  staflf- 
Burgeon  in  the  Britii^h  anay  {Medical  Times  and  (ihzttte,  AprU, 
1S59,  vol,  i,  p.  367).     Near  the  close  of  the  Sepoy  Rclwlllun  a 
Bengalee  was  bronglit  in  and  questioned  previous  to  execution. 
While  actually  under  observation,  within  the  space  of  half  an 
hour  liis  liuir  bet^me   gray  ou   every   portion  of  his   bead,   it  j 
having  been  glossy  jet-black  at  llie  beginning  of  the  examination*^! 
The  attention  of  the  by-stauderH  was  first  attracted  by  ilie  aer-      ' 
gcflut,  whose  prisoner  he  was,  exclaiming,  "  He  is  turuiog  gray !" 
Gradually  but  decidedly  the   change  went  ou  until  a  uniform 
grayish  color  was  reached.     The  older  rccorda  oontiu'n  various 
reports  of  this  abrupt  canUies.     Thus,  Ludovioo  Sforzo,  having 
been  taken  prisoner  by  Ijcmis  XII.,  his  mortal  enemy,  wa.-)  seized 
with  such  terror  that  the  night  before  he  suffered  punishment  hi 
hair,  which  had  been  before  verj'  black,  became  very  white,  ao 
that  liifi  guardi*  tlio  next  d:iy  iltouglit  him  to  be  anotJier  |>erson 
Montaigne  commetita  upon  a  gentleman  one-half  of  whose  lieard 
and  one  eyebrow  suddenly  became  white  in  oonsequeni"©  of  a  vio- 
lent emotion.   Guariui  da  Verona  suddenly  Uirueil  gray  when  the  j 
loss  at  sea  of  the  Greek  nmuuscriptfi  which  he  hod  with  infinita^l 
toil  collected  at  ConRtariiinopIe  wuh  announcetl  (o  htm,     Richat  ^ 
{Anatomic  Oinh-ak,  iv.  815)  and  M.  llayer  {TraiU  des  Maladies 
de  la  Ptau,  iii.  733)  each  reconl  a  case  in  which  the  hair  turned 
white  during  a  single  uiglit;  and  a  number  of  cases  have  been 
collected  by  J.  Moleschott  [Vhyaiohg,  Skizzenbitch,  Gieiseu,  1361) 
showing  that  a  similar  alteration  may  tjike  place  more  gradually 
in  the  course  of  a  few  days. 

Peripheral  nervc-lcsiong  undoubtedly  also  aflfect  the  nutrition 
of  the  hair.     In  cauKilgia  the  hatr  usually  falls  out, — a  result 


I 


I 

result      1 


TBOPHIC  LG3IOK8. 


which  iu  atilmala  Imhltually  follon-s  evoLion  of  the  nerve.  On  the 
other  hami,  ImpIK  I'outeau  and  Larua  saw  the  hair  become  eoarse, 
hard,  and  sillily  erect  in  traumatic  neuralgias.  Hellingcri  aho 
noticed  the  hair  becoming  ihifker  and  harder  and  growing  faster, 
whilst  iD  a  cose  reconled  by  Uaniilton,  dunn^r  neuritic  gyaiptonis 
following  a  lancel'Wound,  the  arii)  became  thickly  covered  with 
hair.  (See  Mitchell,  Injuries  of  Ntrvat,  Phila.,  1872,  p.  164.)  In 
a  case  of  arsenical  poisoning,  with  wide-sprend  neuritis  and  com- 
plete degeneration  of  the  muscular  structure,  which  I  watched  for 
many  n)ODtl]s,  the  It^  became  covered  with  a  lhii.-k  growtii  of  hair 
several  inches  long, 

Aa  was,  I  believe,  first  observed  by  Dr.  Mitohell,  the  growth  of 
the  nails  i«  habitnully  arrested  upou  the  pat-alyzetl  sides  in  cases 
of  eerebrai  hanotrhage.  This  is  i-nsily  demonstrated  by  Btaiaiiig 
tl)0  nails  of  the  twn  hand^  with  nitric  acid:  frdjuently  a  lunate 
appearaooG  of  growth  nt  the  bottom  of  the  nail  is  the  first  evi- 
dence of  returning  functional  power.  After  total  section  of  a 
nerve  the  uails  are  apt  to  become  clubbeil,  and  iu  rare  cases  pain- 
less whitlows  are  developed.  Id  traumatic  neuritis,  especially  in 
connection  with  can.'talgia,  nails  to  wliich  the  nffected  nerves  are 
dislributed  umlcrgo  remarkable  changes.  The  alteration  cuusisls 
in  a  curve  iu  the  long  axis  and  extreme  lateral  arching,  and  some- 
timefi  a  thickening  of  the  cutiR  ttencath  the  end  of  the  nail, 
whilst  the  skin  is  retracted  from  ihe  base  of  the  nail  so  as  to 
leave  a  partially-exfvosed  sensitive  matrix.  Tn  certain  cases  of 
nerve- lejfi one  the  nails  become  dry,  scaly,  and  cracked,  and  in 
others  they  undergo  atrophy;  sometitues,  as  in  the  case  reported 
by  Hayem,  tiiey  fall  out  entirely. 

iAs  will  be  explained  in  discussing  the  trophic  lesions  of  bones, 
it  is  not  rare  for  the  teeth  to  fall  out  in  locomotor  ataxia,  on  ao- 
cwunt  of  the  destructiou  of  the  alveolar  jirocesses. 
>W1 


1 

1 


THOParC   BONE-CHANGES. 


Peripheral  Nervous  Dieeases. — Trophic  alterations  of  tlie 
bonee  may  be  produced  by  diseflse  of  the  nerve-truuks.  M. 
Avezou  {Th^e,  1879)  has  collected  a  number  of  cases  showing 
tliat  nerve-lesions  can  product;  atrophy  of  the  bones,  and  Lobstein 
details  a  case  of  a  man  who  had  an  injury  of  tlic  sciatic  and  crural 
nerves,  in  whom,  after  death,  Jhe  femur  on  the  i^jviKd  fevitviBa 

15 


226 


DIAOKOSriC  NECHOLOOY. 


foand  to  weigh  only  one-thinl  lliat  nf  the  norioal  side.  Ogle 
recorda  a  caac  (J^.  Qeorge's  Hospital  Heporl»,  1871)  in  which  sec- 
tion of  the  luedian  nen-e  was  followed  by  wasting  of  the  bones 
tlirough  (he  whole  dii^tnbutiou  of  the  uerve.  It  \&  well  knowo 
that  ill  polioniyelitiB  of  the  young  arrest  of  development  follows 
the  alteration  of  thp  Kpinnl  cells.  The  foetal  trophoneuront 
of  Romberg  w  possibly  of  this  nature, — an  arrest  of  develop- 
nieiu  of  the  hone  following  poHoniyelitIc  atrophy  of  the  facial 
miiiHrlfH.*  M.  Bouchiit  ((riii.  lUs*  H6pUaux,  1H78,  p.  629)  has  re- 
ported the  cose  of  a  child,  seven  years  old,  in  whotn  an  ascending 
neuritis,  the  resmlt  of  an  injur}*,  had  been  followed  by  marked 
lessening  in  the  bones  of  the  arm,  as  well  as  by  arthropathies,  of 
which  it  is  uncertain  whether  they  were  trophic  or  rheumatisraal. 
Central  Nervous  Diseaee. — Many  years  ago  it  was  noteil  that 
the  bones  of  insane  patient*  are  frequently  broken,  and  that  mul- 
tiple fractures  are  quite  common.  These  constantly -recurring 
fractures  have  been  bi-ougUt  forward  by  the  opponents  of  toatuie 
asyluniH  as  evidence  of  cruel  and  rougli  handling  on  the  port  of 
attendants,  but  it  is  now  provetl  that  the  caunes  of  llu:  accidents 
lie  chiefly  in  the  bones  themselves.  Under  certain  circuuistauces 
the  boniM  of  jMirBons  Buffering  from  general  paralysis,  and  probably 
the  bones  of  those  sulTiTing  from  other  forms  of  intanily,  become 
enlarged  and  brittle.  When  broken,  these  bones  unite  easily 
and  very  ra}Mdly,  with  the  formation  of  an  excess  of  callus,  so 
that  there  may  be  a  large  tumor  at  the  iseat  of  fracture.  Ailer 
deatli  ill  Kuch  catics,  it  will  be  foumi  that  the  lx>aes  are  notably  en- 
larged ;  that  they  are  so  &ofl  as  to  be  readily  cut  with  a  knife; 
and  that  there  exiidfit  from  the  cut  Rurfaee  a  ]iink  or  reddish  san* 
guinoleut  juice,  which,  when  placed  under  the  ni  teroscu{»e,  in  found 
to  contain  large  quantities  of  nuclei  and  iin[)erfectly-devcIo]N3d 
cells.  On  HeiTtioii,  .sneli  Ixuic  will  be  found  to  be  more  porous  than 
normal,  and  the  microscope  will  reveal  great  dilatation  of  the  Ha- 
vereiau  canals,  which  are  filled  with  a  fluid  containing  embryonic 
cells.  A  very  curious  feature  iu  this  form  of  boiie-dieease  is  that 
it  attacks  almost  ejiclusively  tlie  skeleton  of  the  trunk.  It  Is  the 
ribs,  the  bones  of  the  pelvis,  or  the  vertebne  that  are  affected. 

*  For  fta  aooount  cf  tbis  iifl«ction,  se«  Frimy,  iHude  erxtiqine  mr  la  Tnpho- 
ntrronf/afialt,  TJtitt,  1R7S  ;  kito  Liindfl,  ApUuU  taminmue  jtrvffrenm,  Tkiae, 
1870. 


J 


TROPniC   1.R8ION8. 


227 


Dr.  Moore  is  stated  to  have  made  a  cliumical  anal^HiH  of  these 
bones,  and  to  have  found  a  remarknhle  Ipsscning  of  their  inor- 
ganic mattor.  I  have  seen  one  case  in  wliich  an  osti.'oporosis  h'ke 
that  of  geueral  paralysis  existetl  in  a  patient  who  was  supposed,  to 
be  suffering  only  from  clironiti  alooholism.  As,  however,  I  saw  the 
man  but  onoe  during  life,  and  a«  the  history  was  very  imperfect, 
the  diagnosis  may  have  been  erroneous. 

TROPHIC   CHANOes    IS   iOINTO. 

The  meet  )in|Kirtant  of  the  (■haiiges  which  are  pnxluced  in 
bony  tissues  by  diseases  of  the  nervous  system  are  those  which 
are  connected  with  alterations  of  the  joint*. 

Heuiplegic  Arthropathies. — As  was  espt-ciuliy  polutwl  cut 
by  Prof.  Charcot,  tiiere  la  a  peculiar  form  of  arthritis  eonuected 
wttli  hemiplegia  which  is  especially  apt  to  oct^ur  whi>n  the  paral- 
yiia  i«  dependent  u|)on  minute  foci  of  softening.  Very  otVn  this 
form  of  arthritiii  is  supposed  to  be  due  to  rheumatism,  nod  the 
patient  is  believed  tr)  be  sufTeriag  from  another  disease — auuteor 
subacute  rlicumatisra^-supervcninf;  on  the  attack  of  hemiplegia. 
The  diaguosis  between  trophic  and  rheumatic  arthritis  is  to  he 
made  by  attention  to  the  following  parttculant :  Brat,  the  hemi- 
pl^O  arthritis  dcvelopt^  about  the  time  at  which  late  muscular 
oontmctures  usually  c^me  on  ;  secondly,  the  trophic  tnflnnimation 
of  the  joints,  at  least  in  the  early  stage,  is  limited  to  the  affected 
side;  thirdly,  the  pain  may  be  moderate,  but  the  lendernc<)s  is 
exoesuve;  fourthly,  the  swelling,  which  is  pronount.'ed,  develops 
rapidly^  and  is  aocoraijanied  by  di:^lin;.'t  ccdema,  with  pitting  on 
pressure. 

The  hiMory  of  hemiplegia  arthritis  differs  entirely  from  that  of 
chronic  rheumatism.  In  rheumatic  arthritis  there  is  uo  tendeni.7' 
to  the  development  of  pu!>,  and  little  or  no  tendency  to  the  break- 
ing down  of  bony  tissue,  the  cITusiim  within  the  j{)int  being  Herous 
and  remaining  so  for  months.  The  cartilages  may  he  removed, 
but  the  bone  beneath  the  cartilage  Itecomea  hard,  thickened,  and 
of  irregukr  growth,  and  has  very  little  tendency  to  ulceration 
and  destruction.  Frequently  osteopliytca  ore  found  in  the  effu- 
sion. In  the  joint  afTetrted  with  hemiplegic  arthritis,  although 
the  proce^  is  \'ery  slow  and  the  arthritic  changes  may  a^ullnue 
for  months  and  even  yeare,  ther«  is  a  tendency  to  the  formation 


228 


DlAONOenO  NBCROLOQV. 


of  imnilfiit  li<]iiiil»,  iind  tn  tliG  detl ruction  not  only  of  the  cartilagesj 
bnt  alsn  uf  the  bone. 

Tn  A  patient  of  my  own  there  wiui  complete  hemiplegia  on  the 
right  side,  with  aphafiia.  She  onraphtincd  greatly  of  pain  in  the 
leg  anil  arm.  The  moment  she  thouglit  the  limb  was  to  be  ex- 
amined she  TTonld  MTcim  with  the  mere  fear  of  contact:  when 
the  joint  was  touched,  the  emotioual  dislnrbaoce  became  uocon- 
troUable.  The  joints  were  swollen,  very  glossy,  and  hard  t"  the 
totich.  When  she  fii'sC  name  cimler  olk^o-rvalion  the  aflectitin  was 
ponfiiied  to  ibe  hemiplegic  side,  and  was  evidently  not  rheumatic. 
There  was  no  history  of  rhenmatism,  and  the  joints  did  not  pre- 
sent the  pecnHarilies  of  rheumatic  joints.  For  a  year  or  more  the 
joints  remained  in  the  .-^me  condition,  but  finally  tho.se  of  the 
other  side  licfame  slightly  affiirle*!.  After  death  the  ori^'nnl  lesiotT' 
of  the  brnin  was  found  to  have  been  a  large  hemorrhage  in  the 
neigIiborlio(Kl  of  the  clanstnim,  entirely  destroying  the  external  cap- 
sule: liuitie  the  complete  hemiplegia  and  aphasia,  and  the  trophic 
IrstonR,  On  opening  one  of  the  joints,  I  found  that  it  eonininwl 
n  moderate  amount  of  purulent  scrum,  that  the  cartilages  were 
almost  entirely  destroyed,  and  that  tlie  surface  of  the  articulatiooa 
was  largely  affected  and  eroded.  After  ihc  bones  were  boiled,  the 
articulating  surfaces  were  found  to  be  exceedingly  porous,  and  in 
Kome  places  part  of  the  bone  had  l»eon  eaten  away.  The  bones  of 
the  arm  were  very  light,  owing  to  the  thinness  of  their  shafts 
There  had  been  not  only  a  destruction  of  the  joint,  but  atao  an 
atrojihy  of  the  shaft  of  the  bone. 

Spinal  Arthropathies. — Changes  in   the  joints  wbicb  must 
be  looked  upon  a^  trophif  are  not  rare  phenomena  in  lowjmotor 
ataxia.     They  belong  among  the  pri>dromic  symptoms,  uaually 
being  developed  al^er  the  fulgurant  pains,  but  before  marked  die-      I 
onler  of  cn-ordinatiim.     In  rare  inHtanoes  tlioy  are  of  diagnostio 
importance.      In  any  case  their  presence,  aasociutcfl  with  loss  of-^J 
knee-jerk  or  witli  fulgurant  p»ins,  wonki  be  sufficient  for  tbe^H 
diagnosis  of  indpienl  locomotor  ataxia,   Souiettmcs,  though  rarely, 
Ihoy  are  developed  in  advanced  stages  of  the  disorder,  but  nlmoet      ' 
invariably  under  these  cirnnnstances  they  affect  an   np|>er  ex- 
tremity, and  therefore  really  represent  the  early  changes  in  th« 
spinal  cord,  up  which  (he  disease  is  ascending. 

Dr.  M.  Ball  {Des  ArOmtpaUm*  ntmshnUives,  Faris,  1869)  al 


1 


TROPHIC  LS8I0N8. 


239 


» 


* 


I 
I 


I  its  typical  develnptnem  there  are  three  stages  of  eclerotio 
pothy.  Id  the  6rst  stage  the  joint  suffers  from  hydrar- 
throsis. The  eifusion  is  serous,  aixl  never  amtains  blood,  pus,  or 
altHiniiiiouB  flocctili.  It  in  not  limited  to  the  articular  lavity,  but 
distends  the  bursa  or  the  fibrous  tissues  around  the  joint,  and 
may,  indeed,  involve  for  a  ronsiderable  distance  the  whole  leg. 
The  joiut  at  this  time  is  enormously  swollen,  hani,  usually  pale, 
■od  so  resistant  as  not  to  pit  on  pressure.  The  amount  of  iiuid 
which  it  contains  is  very  large.  Thus,  in  a  <auw  reported  by  Dr. 
Boll,  three  hundn-'*!  gramiiica  of  liquid  were  taken  out  of  the  joint 
by  three  successive  punctures.  There  is  uo  ini^animation  of  the 
joint.  At  a  post-mortem  examination  made  by  Dr.  Ball,  the  syno- 
vial membrane  did  not  show  any  abnormal  vasculariiy,  and  there 
were  no  vegetations  in  the  articular  cavity.  In  rare  cases  the  effu- 
sion is  abmrbod,  hut  unually  the  second  stage  in  socm  developed. 
Ac  this  time  the  joint  is  much  swollen,  hard,  and  bouy,  with  on 
evident  increat>e  in  the  size  of  the  bony  Kurfat^t;^.  In  the  third 
stage  there  is  destruction  of  the  articulating  surfaeea,  and  in  come 
cases  so  mueh  absorption  of  the  Imne  and  changes  in  the  ligamen- 
tous tttructure  as  to  produce  great  alterations  in  the  power  uf  move- 
ment. The  epiphyses  e£|MxriaIly  undergo  atrophy  and  change ;  the 
ligaments  are  ehtngateil.  urobably  as  a  L-on-iequence  of  prolonged 
Btretrbing  by  the  ex(t:»t  of  Bnid,nnd  at  lastaoonditinn  of  suhluxii- 
tlon  or  perhaps  of  complete  luxation  of  the  joint  occurs,  so  that 
the  ataxic  may  be  able  voluntarily  to  put  out  of  joint  a  shouldei^ 
a  knee,  or  other  joint  without  }>ain,  though  marked  grating  cau 
be  felt  during  movement.  la  a  case  reportal  by  M.  Oulmont,  the 
patient  was  al>le  to  l>cnd  \n^  leg  in  KU<^b  a  mftnner  that  the  sole 
of  ihv  foot  could  be  placetl  ufHtu  the  internal  surface  of  the  thigh. 
Tabetic  joints  usually  develop  with  great  rapidity,  and  in  most 
caaes  witlioiit  ap)Kirent  cause.  The  patient  will  go  to  lied  in  the 
evening  with  the  joint  seemingly  in  lU  normal  condition  and 
wake  up  with  it  swollen  in  the  morning.  There  are  recorded 
cases,  however,  lu  which  these  artliru[>achieH  followed  exposure 
to  damp  or  slight  traumatisms.  In  seveml  of  my  own  cases 
the  patients  insisted  that  they  had  broken  the  fool  or  ankle  during 
some  moderate  exertion.  It  is  probable  that  iu  these  lnstanoe«t 
a  slight  sprain  was  fotloweii  in  the  course  of  a  few  hours  by 
immense  exudation. 


230 


DIAOKOBTIC   XEUBOLOOY. 


TTaually  in  the  beginning  of,  aa  well  as  later  in,  the  attack, 
the  joint  is  not  red,  and  there  is  little  or  no  dts<:oloration;  but 
M.  Michel  spoaks  of  having  iseeu  gt-eat  eulargement  of  Uie  veins, 
Bod  even  rapture  of  the  large  saphenoua  vein,  which  cnaf<od  the 
whole  leg  to  turn  l>Iaok.  In  one  of  my  cases  a  similar  blacken- 
ing of  the  limb  waa  asserted  to  have  aurompanied  the  first  de- 
velopment. It  is  doubtful  whether  there  is  ever  any  fever  or 
local  h»it,  although  M.  Bull  reports  one  or  two  caees  in  which 
fever  was  said  to  have  existed  in  tlie  beginning;  but,  as  no  thcr- 
mometric  studies  seem  to  have  been  made,  there  is  considerable 
doubt  as  to  whether  the  general  tetii[>emture  wan  really  elevated. 

MM.  Charcot  and  Bouchard  have  noted  in  two  instaiiocs  a 
peculiar  artiailar  creaking  or  crepitus,  precaJing  by  some  days 
the  serouR  exudation. 

Spinal  arthropathies  are  most  oomraonly  observed  during  the 
second  stage  of  M.  Ball :  »uch  joints  are  lai^  very  bard,  evi~ 
dcntly  containing  much  water,  and  at  the  sanio  time  having  lui 
increase  of  their  coin]N>8ite  bono.-?,  are  perfectly  indolent^  and  free 
from  redness  or  heat,  although  attempted  movements  imuallyoaase 
pain.  In  one  of  my  own  eases,  in  which  it  vas  doubtful  whether 
the  alteration  of  the  joint  should  be  considered  hyetericai  or 
ataxic,  there  ^vas  marked  hyperasathcsia.  It  is  possiI>!e  that  such 
hypencsthesia  may  be  looked  upon  as  a  diagnostic  means  of  dis- 
tioguishing  between  the  hysterical  and  (he  ataxic  joint.  From 
the  rliiL-urnatic  joint  the  ataxic  \t>  at  once  tie^Kirated  by  the  alisence 
of  heal,  excessive  tenderness,  and  pain.  Care  is  sometimes  neces- 
sary not  to  mistake  the  fulgnmnt  pains  of  the  locomotor  ataxia, 
which  may  dart  aud  play  about  a  joint,  for  the  true  joiut-patns  of 
a  rheumaLiBtn. 

The  ataxic  arthropathy  is  somelimefl  unilateral,  but  in  very  fre- 
quently more  or  less  symmetrical.  It  attacks  especially  the  knees, 
and  next  in  order  of  frequency  the  other  joints  of  the  lower  ex- 
tremities, but  it  may  occur  iu  any  Joint  of  the  body,  lu  eighteen 
e&Bes  collected  by  M.  Ball,  the  knees  were  affected  in  eleven 
cases,  the  hhoulder  in  three,  the  coxo-femoral  articulation  in  one, 
the  melacariw-phalangeal  jointa  twice,  and  the  elbow  once.  The 
small  joints  of  the  foot  arc  frequently  attacked,  giving  rise  to  a 
peculiar  deformation  to  which  the  name  of  the  tabetJu  foot  {pied 
iabHique)  has  been  given  by  Prof.  Charcot.      The  outer  border  of 


4 


TKOPHIC  LESIOSa. 


tst 


the  foot  is  oflen  enormonslr  thickeDetl,  so  that  the  uumt  border 
does  not  touch  tlie  irroiind.  A  pecolitr  impnaeioa  oi  tbe  foot  ia 
thas  produced,  like  lliat  of  the  aooompuiTiiig  dnwing,  reprodoeeJ 
from  a  paper  in  JSuff.  Soe.  da  H6p.^  Paris,  Xorembv  4j  18S5. 


c 


////^ 


Flo- 6. 


ii^^//' 


V^'tti.Vv 


V^> 


Id  a  txm  of  this  character  of  my  own  the  arch  of  the  foot 
'was  entirely  lost,  so  a«  to  bring  the  plantar  wiirfare  rontinuou!i]y 
to  the  groDnd  from  the  heel  to  the  toes.  The  change  had  been 
acoompunied  by  ao  increww  in  thickDess  over  the  tarso-meta- 
tafsal  articulation,  so  tliat,  although  the  foot  rested  flat  u|>on  the 
gronnd,  thia  region  was  very  prominent.  The  prominence  was 
moet  marked  on  the  inner  edge.  The  deiormi^  was  greatest  id 
[the  left  foot. 

Flo.  7. 


At  the  autopsy  in  my  case,  besides  advanced  posterior  spinal 
sclerosis,  the  following  condition  waa  found : 
K      The  ankle-joint,  which  was  the  first  examined,  exliibil«<l  no 
Hmlargenieut,  nur  did  the  ariic:ulating  surfaces  of  the  tibia  and 


232 


DIAGNOeriO  NEUROLOOY. 


filjuln  yield  any  evidences  of  disease.  The  nrtirulating  pnrfaces 
of  the  astragalus,  however,  were  here  and  there  denuded  of  carti- 
lage and  muc-ii  rougheiiet).  Similnr  changes,  though  slight,  were 
Dutiued  in  the  oalcaneum,  but  it  wa6  in  and  about  the  joint  formed 
by  the  internal  euneiform  aud  firat  metatarsal  bones  that  the  great- 
est amount  of  change  had  occurred.  The  cartilage  had  entirely 
<li8api)eared  from  at8  upper  iwrtioii.  Here  the  two  boues  had  be- 
come firmly  united.  The  microscope  revealed  a  continuous  osse- 
ous structure  from  one  to  the  other.  The  lower  portion  of  the 
joint,  which  was  equivalent  to  about  three-fourths  of  its  entire 
area,  was  filled  by  continuous  or  adherent  surfaces  of  cartilage, 
while  here  and  there  a  narrow  chink,  representing  the  original 
cavity  of  tlie  joint,  was  leH:.  Tlie  bones  appeared  cnlai^cd  aud 
distorted,  and  an  examination  of  their  iniernnl  .fracture  showed 
that  the  cancellated  tissue  had  been  replaced  here  and  there  by 
flmall  u)U>>»v8  of  deuiic  06Kilic  depoeiit. 

The  middle  caneiTorm  and  second  metatarsal  bones  were  portly 
crowdiCil  over  the  internal  cuneiform  and  ilrst  metatarsal  lumes, 
and  presented  lesions  similar  to  those  just  described.  The  heads 
of  the  two  metataisal  bones  had  iu  one  place  become  continuotis, 
and  one  si-ctlon  reveuletl  an  isthmus  of  hone  inttting  an  angle  oi 
the  internal  cuneiform  with  the  bead  of  the  second  metatarsal. 

The  general  impression  given  by  the  study  of  these  lesions  was. 
that  of  a  Diass  of  boues  which,  b«ing  at  r>ue  time  softener!,  bad 
been  m(^>hauicaUy  distorted  aud  displaced.  The  absorptioD  or 
deput^ition  of  bony  tiei&ue  ap{K»reil  to  follow  no  rule,  nor  did  tlie 
destruction  of  the  cartilage  distinguish  itself  by  any  peculiarity 
other  than  that  it  seemed  to  precede  the  changes  in  the  bones. 

Mucli  more  rare  than  the  tabetic  foot  is  the  tabetic  hand,  of' 
which  I  have  never  seen  an  example.    The  cut  on  the  opjinsite 
page,  after  Ball,  indicates  that  it  is  scarcely  less  characteristic  and 
peculiar  than  is  ihe  pied  tabHique. 

The  portionsj  of  the  boue  most  prone  to  be  attacked  iu  locomo* 
tor  ataxia  are  the  epiph>'ses:  although  Grst  much  enlarged,  they 
finally  undergo  airophy,  wliioli  may  readi  such  an  extreme  that 
only  the  traces  of  the  head  of  the  bone  can  be  found,  surrounded 
vary  frequently  by  long  stalactitie  poiuta.  Although  Arnoxan 
i<cems  to  deny  it,  and  there  are  very  few,  if  any,  autopsies  to 
prove  it,  the  clinical  evidences  show  very  clearly  that  the  stage 


of  atrophy  is  preceded  in  most  if  not  in  all  cases  by  one  of  liyi>er- 
trophy.  M.  Liouvillo  ((|unte(I  by  Aniozan)  found  in  one  case  of 
scapular  arthropathy  dilatation  of  the  Haversian  canaU,  which 
w«Te  &iled  with  enibryouiu  oelU  and  fatty  matter.  M.  Regnard,  in 
making  an  analysis,  found  tlie  iiiweinc  in  normal  quantity,  but  the 


Pio.  8. 


phosphates  very  remarkably  diminished  and  the  fatty  matter 
enormously  ini^rcascd.  These  histological  and  chemical  results 
show  a  strongly-marked  rewmblance  between  the  bonea  of  looo- 
motor  ataxia,  of  oeteoiualacia,  and  of  geueral  paralye^ls. 

Not  rarely  in  locomotor  ataxia  the  shaft  of  tlie  Iwne  i.i  also 
attacked,  and  fractures  from  mn^cutar  exertion  during  life  are  in 
Auch  casc5  very  common.  Although  in  various  post-mortems  the 
HliaftH  of  Hucli  b<)iic-»^  have  l>ccn  found  much  ati-ophiei)  nnd  very 
hard,  yet  there  is  reason  for  believing  tliat  the  pathological  process 
is  not  esjsentially  different  from  that  which  occurs  in  general  paral- 
ysis, la  casm  of  fracture  ttierc  is  an  ciiormou««  and  exceitsively 
rapid  formation  of  callus,  whilst  in  some  instances  portions  of 
the  bone  have  been  found  liaril  and  atrophied  mid  other  parta 
incrcaacd  in  size  and  spongy.  Again,  one  femur  has  been  fomid 
atrophied  aud  ita  fellow  enlarged  and  in  a  condition  similar  to 
that  which  occurs  iu  general  paraly&ie.  It  would,  indeed,  a[)- 
pcar  as  though  various  diseases  of  the  nervous  system  produce 
changes  in  bone  whicli  may  end  iu  atrophy  and  hartlnesy  or 
may  result  in  a  permanent  ]>roduction  of  a  condition  allied  to 
osteomalaaa ;  since  not  only  have  the  alterations  which  have  just 
been  described  been  met  with  in  genenil  paralysis  iiml  in  loco- 
motor ataxia,  hut  Lagmugc  [IVtise,  1874)  has  reported  a  case  of 
scleroderma  with  neuritis  in  which  the  phalanges  were  extremely 
atrophied  and  their  articular  surfaces  lost,  while  the  microscope 


334 


DiAONoernc  hetrotogt. 


revealed  structural  lesions  very  Himilar  to  thoee  which  oocar  in 
genera)  pnmlysi)?  itml  lonnmotnr  utaxiii, — namely,  engorgement  of 
dilated  Haversinn  canals  mtli  fal-grannles  and  embryonic  cells. 
There  is  also  reason  for  suspecting  that  similar  changes  in  the 
T>one8  ocoiir  in  lejiroey,  although  close  studies  are  at  present  a 
dGsidcratnm. 

Loss  of  TftfJi, — A  curious  result  of  trophic  bone-changes  which 
)6  not  very  rare  in  locomotor  ataxia  h  a  rapid  loss  of  the  teeth. 
This  occurs  entirely  independently  of  the  condition  of  the  teeth 
and  gurns,  which  may  !«  |)erfectly  sound  and  free  from  all  Kore- 
neas.  The  attention  of  the  patient  is  suddenly  awakened  by  the 
teeth  lieconiing  toose  and  dropping  out  one  by  one  at  intervals, 
sometimes  so  rapidly  that  all  the  teeth  of  one  jaw  are  lost  In  the 
course  of  a  few  hours  or  days.  It  is  rare  for  the  two  jaws  to 
be  simnltaneonsiy  nrtackwl.  Tn  some  instances  a  shedding  of  the 
tW'th  en  inoMM  has  occurred  during  sleep  and  threatened  stran- 
gulation. The  edentulous  jaw-bone  continues  to  waste  until  it 
is  reduced  to  a  inure  shell.  Attliuugh  there  is  no  soreness  in  the 
gums  or  teeth,  it  almost  invariably  happens  that  for  many  months 
or  even  years  preceding  the  lesion  the  patient  suffers  from  violent 
pains  about  the  face.  TlieiMj  pains  are  shooting,  and,  even  though 
tliey  occur  in  regular  crises  and  are  associated  with  loss  of  sensi- 
bility, they  are  usually  supiwsed  lu  represent  simple  trigeminal 
neuralgia.  They  are,  however,  the  fulgurant  [wiins  of  locomotor 
ataxia,  and  are  caused  by  the  involvement  of  the  nucleus  or 
roots  of  the  trigeminal  nerve  in  an  asccndiug  posterior  sclerosis. 
The  falling  of  the  teeth  is  due  to  the  destruction  of  the  alve- 
olar proceasM  by  progressive  tropliio  changes,  which  in  the  jaw- 
bone proceed  in  a  manner  entirely  j''^™^'^'  ^*'th  those  of  the  loog^^j 
bonea.  ^H 

If  posterior  sclerosis  begins  in  the  upper  portion  of  the  spina!  ^* 
cord,  the  loss  of  the  teeth  ooiuiw  early  in  (he  alTection,  liecauae  it 
represents  the  stage  preceding  loss  of  co-ordi nation.  When,  how- 
ever, as  is  usually  the  case,  the  degeneration  of  the  spinal  cord  is 
an  ascending  one,  it  may  not  reach  Uie  trigeminal  nucleus  until 
late  in  the  general  disorder. 

Artificial  Spinal  Arthropathies. — The  only  attempts  to  pi 
duoe  by  operations  upon  the  nervous  centres  bone-Iesious  similar 
to  those  of  locomotor  ataxia  which  liave  been  crowned  with  anj 


I 


TBOPHTC  LESIONS.  235 

SDCoeas  hive  boen  llia.se  of  Dr.  Giacoino  {Soe.  de  Biologic,  March, 
1885,  p.  156).  This  investigator  out  in  a  ver}*  large  dug  the 
posterior  roots  of  three  lumtwr  nerves  between  tlie  ganglia  and 
tbu  cord.  After  ttume  months  the  joints  of  tlie  left  foot  became 
enormously  swollen  and  <mleraatous,  williout  incrense  of  sensibility 
orof  tcin|ienitare.  At  theantopny  it  wa»i  found  that  degeneration 
had  occurred  in  the  spinal  cord,  and  that  tlie  leaJon  of  the  joint 
corresponded  in  posttioa  with  the  secondary  spina]  alterations. 


TEOPHIO  LESIONS  OF  MUSCLES. 


I 


Of  all  the  trophic  dislnrbances,  the  most  important  to  the 
practical  neurologist  are  thuee  which  occur  in  the  uiusctee.  The 
{{anglionic  cells  immediately  connected  with  tlie  nutrition  of  the 
muscles  are  grou[ied  together  in  the  anterior  cornua  of  the  spinal 
cord.  In  any  nervous  diseaj*,  bo  long  as  the  spinal  cells  and 
their  tsannection  with  the  paralyzefl  muscle  are  intact^  no  rapid 
change  occurs  in  tlie  structure  of  Uie  muscle.  Whenever  there 
is  a  destruction  of  the  spinal  cells  or  an  interruption  of  their 
pathway  along  the  nerve,  the  muscle  at  once  begins  to  undergo 
degeneration,  and  in  from  five  to  ten  days  such  change  is  readily 
demonstrate!^!.  The  early  appearance  of  trophic  lesions  in  a  para- 
lyzeil  iiiuM^lo,  ttierefore,  [iroves  that  the  lenion  is  situated  either  in 
the  ganglionic  spinal  cells  or  in  the  motor  nerve-trunk. 

The  detailed  discussion  of  the  anatomical  changes  in  the  mus- 
cles is  foreign  to  the  intent  of  the  present  volume.  Suffice  it 
to  state  tliat  atrophy  with  granulation  of  the  muscle-fibre  is  first 
apparent,  then  distinct  fatty  degeneration  of  ilie  muscular  filinw, 
with  marked  proliferation  of  nuclei,  and  finally  a  replacement  of 
the  muflcle-fibre  by  cellular  tissue,  until  at  last  the  muscle  is  re- 

.Dced  to  a  fibrous  baud. 
When  a  mu^ile  is  de^nerating  for  want  of  spinal  in6iience,  it 

irsl  loficft  its  tK>wer  of  responding  to  rapidly-interrupted  faradio 
or  chemical  currents,  then  to  slowly-interrupted  farad ic  currents, 
then  to  aIowly-interrupte<l  chemical  currents,  and  lastly  to  slowly- 
rc\"ersed  cliemical  currents.  At  this  time  ix'tnirswitli  llie  galvanic 
ciurent  the  so-called  reunion  of  (^generation,  firet  discovered  by 
Brenner,  and  since  elaborated  by  Ziemssen  and  by  Erb.    To  com- 

reheud  this  reaction  it  must  be  remembered  that  it  Is  obtainable 


DIAQNOemC   MKtTBOtjOOr. 


only  by  applying  the  electrode  to  the  ma'^de.  This  is  evidently 
cx>tinei^t<ed  with  the  fmt  tJinl  a  niiiscle  ai'tificifLlly  ftep«mt«il  t'roai 
its  nerve  does  not  readily  respond  to  the  faradic  carrent,  although 
it^  answer  to  the  slow  galvanic  current  is  the  same  as  is  that  of 
the  nerve.*  Aouording  to  some  authorities,  the  sepanited  muscle, 
before  it  gives  the  reaction  of  degeneration,  responds  more  slowly 
than  normal  to  the  cnrrent:  this  is  the  so-called  modnf.  chan^. 
£ven  ut  tliis  time  llie  miuicle  may  respond  to  milder  currentd 
than  it  normally  notices.  The  divided  nerve  rapidly  losea  its 
power  of  ans\f'ering  the  fui-adic  current;  bo  die  galvanic  current 
it  is  ohca  at  6rst  abnormally  sensitive,  but  Boon  its  jHiwer  of 
responge  declines  to  extinction.  These  quantitative  changes  are 
not  attended  with  uity  qualitative  alteratiuus:  the  formula  remaiofi 
unchanged  throughout.  ^H 

In  accordance  with  what  has  jnat  been  said,  if  the  electrode  ber^^ 
applied  to  a  ncrvc-irnuk  of  a  degenerating  mnsolc,  it  will  be  found 
that  reaction  is  diminished  in  quantity  but  not  altered  in  qtiality. 
Wlieu  a  galvanic  curreut  of  very  moderate  strength  is  oacd^ 


a«^ 


*  I  bave  ncv«r  ciporiTnQnit«d  with  tlio  acKion  ot  gttlvnnic  nnd  fBradic 
ronU  upon  ikolnttxl  muffles,  and  authuriLJes  ftre  flomewhikt  al  vcmnce 
regard  to  lucli  action,  tliighwt  Rpnnntt  nflirtn*  {RUrlrifDiagnons,  ji.  8fl) 
thnt  tDUtclot  have  no  Irus  farsdio  exoitabillty.  Krb,  on  th«  oUier  banil 
{^Electro^TheraptMliea,  p.  76),  st»tw  Ui>t  thg  miuclu  ba>  \\»  own  Irritiibltliy. 
Tho  ncrVD-endlt]g«  in  the  muiclce  are  io  clnely  astociatod  with  th<i  mtucl*- 
lllirc  tlml  it  is  uot  pouLbl.e  b;  any  mecbanical  procedure  to  ■epara.tc  one  ^m 
the  Dther,  Hnd  tlmj  gnlvonic  or  faradic  current  which  is  thrown  into  the  miu- 
cl«  must  HCL  upoQ  lh«  periphpral  nvrvit-fllsmetitx.  Br  th«  action  ot  curare 
we  aru,  llu^pvuvv^,  uiiablvd  U>  paralyze  the  motor  n^rvo-vrtdini;,  and  phyaio^H 
lof^iciiiiy  to  isolute  the  muacle-Sbre  without  injury  la  it.  Uader  tboM  vip^H 
cumttanccn,  uccnrdtitg  tn  T>ftndol»  and  Sterling,  faradic.  con iractilit j  of  l)ie 
ruu»a]»'tii<iue  is  much  diminiihcd,  but  not  lost.  It  would  app«ar  that  the 
muscto-Hbre  in  cnpabltt  of  rexpouding  to  any  form  of  el«ctricity,  but  i>  much 
more  ilugglsb  than  is  th«  norve-Uisue.  Ili^nco  it  mpond«  more  hIowIj,  and 
U  !■  neouMarjr  for  ttio  current  to  ooutinuo  for  a  c«rtaiD  leagth  of  lime  in  order 
for  any  recponae  to  occur.  ^H 

There  In  no  Msenlial  dilfcrcnco  botwccn  iho  faradic  and  the  galranic  current^| 
All  l]i«  cbutuica)  «trHctA  uf  the  galvanic  or  chemical  current  are  product  by 
the  iadu<:<ed  current  obtiiinod  fniin  tha  mug ntttu-eliy: trie  dj'namoe.  The 
muulo  b«lng  le«  sensitive  than  the  nerve  simply  requires  more  tiuio  for  the 
i-eceptton  of  the  imprcmion.  On  account  of  the  exceeding  brevity  of  faradic 
(-arrvnbt,  it  nupondit  leas  readily  to  them  than  doM  the  nerve.  It  respond*  Just 
(M  badly  to  tha  galvanic  or  cbetnical  current,  provided  lucti  current  b«  ve 
mpidly  iulvrniptvd. 


TROPniC   LESIONS. 


237 


the  negative  pole  (cathode)  placed  over  the  normal  muscle,  but 

not  over  its  motor  point,  a  strong  contraction  occurs  at  the  cincture 

of  the  circuit;  when,  however,  the  positive  pole  (anode)  is  plaped 

over  the  nortual  niii»^le,  the  L-uatmciiun  i.s  much  ]em-  in  neither 

vaae  k  there  any  contraction  whim  the  circuit  in  hroken :  in  other 

words,  with  the  normal  muscle  and  a  feeble  curront  we  obtain 

good  cathodal  closiug  coDtmctioa,  slight  anodal  closing  oontrao- 

ttoD,  and  no  motion  whatever  at  either  cathudal  or  anwlal  opening, 

Vben  a  current  of  sufficient  |>owcr  is  used,  opening  contractions 

are  produced,  and  the  anodal  contraction  is  greater  than  the  ca- 

tho<lal.     The  "reaction  of  degeneration"  consists  merely  in  a  more 

or  IcEB  perfect  reversal  of  the  above  formula.     The  anodal  (positive 

pole)  cluMire  then  auises  a  stronger  contraction  tliaii  the  cathodal 

(negative  pole)  closure.     When  there  is  only  n  slight  degree  of 

degeneration   present,  there  is  a  correspondingly  slight  increase 

of  aD'xlal  closing  uver  utthodal  chiaiug  cuulracLiou.     A  luiuimuni 

degeneration  would  be  indicated  by  ac  equality  of  the  two  ckising 

contractions. 

These  alterations  in  the  electrical  reaetions  of  a  degenerating 
muscle  ore  readily  formulated,  iuhI  iu  this  way  perhaps  will  be 
more  readily  gnui|ied  by  tlie  etudent.  The  symbobt  are  as  follows : 
An  CI  C  repnsents  anodal  closing  contraction ;  An  O  C  repre- 
sents nnodal  opening  contraction ;  Ca  CI  C  represents  cathodal 
dosing  ooDtraction ;  Ca  O  C  represents  cathodal  openiug  con- 
traction :  <  represents  is  less  than ;  >  represents  is  more  thaa 
I  (the  point  of  the  <  being  towanis  the  lesser  quantity). 
Then  the  formulas  are: 
An  CI  C  <  Ca  CI  C 
Ac  O  C  >  Ca  O  C 
An  CI  C  =  Ca  CI  C  \  ,    .    „ 

.     Op cor  j"'*'^*'''^  ^"  ^^^  stage  of  degeneration. 
An  CI  C  >  Ca  CI  C  1  muscle  in  raore  advanced  st^e  of  de- 
An  O  C  <  Ca  O   C  J      generation. 
After  the  reaction  of  degeneration  (D  R  of  some  authorti)  has 
been  efttnbliAhe^I,  if  the  muiwle  continue  to  undergo  chanf^,  the 
galvanic  irritability  slowly  diminishes,  etronger  and  stronger  cur- 
rents beiug  required  to  produce  au  eBect.     When  a  certain  stage 
I  is  reached,  all  reactions  oease,  save  a  feeble  An  CI  C,  and  at  last 
this  is  lost,  and  tlie  muscle  does  not  respond  at  all.    When  recovery 


.  muscle  nurui&L 


238 


DI&GKOeriC  SKOBOVOQY. 


occurs,  the  electrical  reactions  of  the  muscle  pan  upmrd  along 
the  pothwny  they  have  ilescetitletl. 

The  priu^ical  itn|>ortauoe  of  the  rmctifHi  of  degeDeratioo  is 
greatly  lessened  by  the  circumstance  that  its  demonstnition  asu- 
ally  requires  much  skill  and  patience,  and  that  it  probably  ia  never 
present  when  a  muscle  retains  its  integrity  as  regards  the  faradic 
onrreat.  For  the  purposes  of  diagnosis  the  failure  of  respond  to 
the  rapidly-interrupted  faradtc  current  is  usually  a  8nffici«it  teet 
of  the  condition  of  a  muscle.  When  a  rausclo  loses  its  power 
of  responding  to  the  rapidly-interrupted  famdic  current  in  a  week 
or  ten  days  afler  tlio  opcurrejic-e  of  |iaraiyhis,  whether  the  reaction 
of  degeuemtjon  can  or  cannot  be  satisfactorily  demonstrated,  tlie 
inference  la  positive  that  trophic  changes  are  talcing  place  in  the 
muscle.  If  a  few  daya  later  such  muscle  ia  unable  to  respoud  to 
any  faradic  current,  this  inference  becomes  a  certain^.  For  the 
purpoae  of  progunois  the  »tu<ly  of  the*  reat^tion  of  degeoemtion 
may  he  ncccsgary,  but  it  mil,  according  to  my  experience,  often  be 
found  <li8api>ointing. 

DiaeaiBes  which  oauB«  Muscular  Deeeneration. — A  sudden 
loss  of  power  in  the  muscle  followed  by  rapid  trophic  changes 
miutt  de[)end  upon  an  interruption  of  the  [>athn'ay  between  the 
spinal  cells  and  the  muncle,  or  ujwn  disease  of  the  cells  theni- 
eelvQB.  The  pathway  may  be  interrupted  by  traumatism,  or  by 
neuritis  of  an  acute  and  violent  ty|)e,  whilst  the  c^lls  may  lie 
acntely  di.<Ka<>erl  as  the  result  of  a  violent  and  general  inBammation 
of  the  cord,  or  as  the  result  of  the  affection  knon'n  as  poliomyelitis 
(idiopathic  or  toxio),  in  which  the  ganglionic  cells  alone  are  in- 
volve]. The  diagnn^is  of  the  traumatism  must  lie  made  out  by 
the  history:  an  acute  myelitis  is  readily  recognisable  by  the  nu- 
merous symptoms  which  attend  it  (nee  page  65),  and  which  dwarf 
the  mere  wasting  of  the  muetcle  and  loss  of  power.  A  general 
neuritis  producing  palsy  and  trophic  changes  is  almost  Invariably 
attended  with  violent  {uiin  and  tenderness;  and  even  in  the  rare 
cases  in  which  no  severe  pain  is  felt,  the  nerve-trunks  are  from 
the  6ret  exce!*»ively  tender.  In  poliomyelitis  the  nei've-tninks 
are  never  tetider.  For  the  furtlier  consiileration  of  the  symp- 
toms of  multiple  neurltU,  sec  page  56. 

The  difficnUiea  which  offer  themselves  in  the  diagnoais  of 
idiopaihk  polimnytlUu  are  usually  confined  to  the  early  stages 


TBOPHTO  LESIONS. 


239 


'of  the  aciite  form,  when  it  is  liable  to  be  miataken  for  an  acuto 
constitutional  disorder.  Poliomyelitis  of  an  acute  or  sulmcute 
type  occiira  especially  during  chilclliood,  although  it  may  happen 
at  any  age.  Its  tcudeiicy  to  attack  early  in  life  is  probably  due 
to  the  fact  that  at  this  time  the  trophic  cells  are  iu  an  habitual 
romlition  of  intense  functional  activity  and  excitement,  bocanso 
they  have  not  only  to  maintain  nutrition,  but  also  to  direct  de- 
velopment.* 

For  the  purposes  of  deaeription  it  is  necessary  to  recognize  two 
types  of  poliomyelitis, — namely,  the  acute  and  the  sabacute,- — 
although  in  nature  these  two  types  pass  into  each  other  by  insen- 
sible gradations.  Iu  the  most  severe  acute  cases  constitutioual 
eytnptoms  are  often  very  violent  and  are  apt  to  mask  the  char- 
acteriRtie  hx^l  syraptntn^. 

Labordc  considers  acute  poliomyelitis  as  conrtisting  of  four 
stagesa :  in  this  he  i$  followed  by  Grass^t;  and  if  it  be  nnder- 
fttood  lliat  these  stages  grade  into  one  another  and  are  arbitrarily 
<»ettted  or  separated  for  the  purposes  of  description,  the  division 
is  a  good  one.  The  lirst  stage  '\^  that  of  nitai^k;  th>rt  seoond, 
that  of  more  or  less  complete  and  generalized  paralysis;  tlie 
third,  that  of  remission  and  localization  of  the  paralytic  phe- 
nomena  ;  the  fourth,  the  |H>riod  of  muscnlar  atrophy  and  de- 
lb  ruiiiy. 

During  the  first  stage  and  in  very  severe  oases  the  constitu- 
tional symptoms  are  most  prominent.  They  consist  of  fever, 
disluriicd  cerebration,  and  convulsions.  The  fever  is  usually  of 
short  duration,  lasting,  it  miiy  be,  only  a  few  hours,  sometimes 
a  HHgle  day,  but  more  rarely  as  long  as  one  or  even  two  weeks. 
It  may  be  of  a  continuous  type,  but  is  very  prone  to  be  remittent, 
eepecially  when  it  endures  for  any  leugUi  of  time.  £veu  before 
the  attack  great  nervous  irritability,  emotional  excitement,  and 
paroxysms  of  terror  and  other  evidences  of  disturljwl  cerebration 


*  Acut«  poliomjelUid  u  it  occurs  in  adult*  'bts  been  considerad  hy  many 
wrilfln  M  a  dUttnct  iiOcctioii ;  and  vvvn  to  clou*  aud  oyitvinatic  an  author  as 
nraM«C  alill  do\'oU»  a  acparate  chapter  to  it^  flonai deration.  The  acute  iplno] 
|)araty«t8  of  adaltc  is,  hnwover,  without  doubt  tho  samo  dta«Me  aa  tbo  cesoo- 
linl  paUj  or  childhood,  or  infanlile  paralysis.  Thn  old  naniM  abould  l>o 
abandoned,  and  wbother  it  occur*  laie  or  «u-]y  in  life  tfa«  diteate  should 
b«  known  MS  poJhmy\iiilli. 


240 


DIAOXOSnC  NEUROLOGY. 


are  often  present;  and  when  the  fever  deveJope,  confasion  of 
ideas  passes  into  delirium,  and  slight  soiuuoleucy  into  jirofouod 
coma.  At  the  same  time  convulsive  manifcsUilionB  ap|)ear. 
These  nmy  be  lucal,  but  are  more  nsaally  wide^spread :  when 
generalijwd,  they  may  amaiat  of  twltcbings  or  of  freqoenilr- 
repcated  spasmodic  oontractions,  or  may  rise  to  the  severity  oi' 
the  moet  furious  general  oonvidi^iione,  which  are  ofVen  accom- 
panied by  vomiting,  but  arc  vc-ry  rarely,  if  ever,  fatal.  It  ts 
possible,  however,  that  some  fatjil  obscure  convulsive  attacks  in 
children  really  repreBent  incipient  poliomyelitis,  the  recognition 
of  which  may  be  impossible  owing  to  the  early  death. 

So  soon  a^  the  paralytic  phenomena  become  prominent  the 
patient  may  be  considered  to  have  entered  u[K>n  the  second  stage: 
at  lliLS  time  the  fever  usually,  but  not  always,  abates.  The 
paralysis  may  be  general,  aUaclctng  the  trunk  and  neck  and  all 
the  extremities,  and  if  at  the  same  time  the  Icvss  of  |M)wer  be 
complete,  the  child  is  unable  to  move  any  portion  of  the  body 
below  the  face.  (Jonorally,  however,  it  will  Ije  found  that  a  le^ 
or  au  arm  or  some  portion  of  the  body  is  only  partially  aftected. 
Even  ID  cases  of  most  oomplete  paral}'sis  the  sphincters  are  not 
implicated,  alihongh  urinary  inoontinenoe  is  not  rare;  and  in  the 
Bevereat  cases  there  is  no  tendency  (o  the  formation  of  acute  bed- 
sores. It  ia  the  exceptional  cose  in  which  the  whole  body  is 
paralyzed.  As  has  ju.sl  l»een  described,  paraplegia  is  more  fre- 
quent than  general  paralysis;  hemiplegia  and  simple  monoplegia 
are  at  this  stnge  alike  very  rare. 

Trophic  changes  in  the  muscles  can  usually  be  detected  by  the 
sixth  or  seventh  day,  sometimes  as  early  as  the  fitlb,  rarely  not 
until  the  eighth  or  ninth. 

The  first  decisive  evidence  of  such  changes  ia  loss  of  faradic 
contractility  and  the  appearance  of  the  reactiou  of  degeneration. 
In  those  iuusclc8  which  are  tu  recover  their  power,  trophic  changes 
oociir  very  slowly  and  only  to  a  slight  extent.  It  is  n  sufficiently 
accurate  rule  for  the  pur[)f,»seH  of  ordinary  prognosis  to  say  that  those 
niuscleff  in  whit^h  the  reaction  of  degeneration  is  pmnounced  at 
the  end  of  the  eighth  <Iay  will  in  all  probabiitty  never  ix'cover 
their  inlegrity,  but  that  those  which,  although  more  or  less  com- 
pletely paralyzed,  respond  to  the  famdic  current  at  such  time  will 
probably  regain  their  functional  power. 


lOPHlC  1.^10X8. 


The  ihii-J  stage  of  the  disorder  is  that  of  remission  and  im- 
provement.    The  juinilysiei  begins  in  certaiu  partd  of  the  body  to 
improve  slowly:  if  the  iniiirovement  involves  equally,  or  nearly 
equally,  all  the  muscles,  the  prognosis  beootnts  very  favonvhie,  as 
the  case  usually  goes  on  to  complete  recovery.     In  the  mnjorityof 
instanceB,  however,  certain  grou{>8  of  muscles  Ho  not  regain  power 
■long  with  the  general  system.     Indeed,  the  reawtloii  of  degener- 
ation in  thrift  miu«'Ie.H  may  hccf>me  more  and  more  prononnce<I, 
and  steadily  advance,  whilst  electro-contractility  in  tho  other  mus- 
cles Is  becoming  normal.     The  paralysis  ue^ually  amellor»t4»«  firtt 
in  the  neck  and  trunk,  then  in  the  nrmn,  Unnlly  in  the  lower 
extremities.      In    rare  cases   the  legs  improve  before  the  arms, 
nder  such  ciroumstflnoes  almo'^t  invariably  many  of  the  muscles 
of  the  aruLt  fcettli.-  into  a  permanuut  paraly:«ie<.     In  the  majority 
of  instauces  liie  final  loss  of  power  is  confined  to  the  lower  ex- 
tremities, and  in  them  only  certain  grou]^  of  musclea  remain 
pttralyzed.      The  groups  which  arc  least  apt  to  escape  are  the 
aolerior  and   eslernal   muscles  of  the   leg,  and   even    more  frc- 
queutly  liie  abductor  muscles  of  the  foot,  especially  the  peroneal 
tnUBclee.     The  rauecles  of  ihe  foot  itself  are  rarely  permanently 
I      paralysed  ;   the  gasmHmemins  fMxiision silly.      Of  tlie  muscles  of 
I      the  upper  extremity  the  deltoid  is  the  most  likely  to  suffer.     It 
^■iB  very  exceptional  for  the  muscles  of  the  neck  or  of  the  trunk 
^B^  to  recover,  although  the  erector  spi nee  mut^cles  do  sometimes 
■Rphy. 

^M  The  fourth  stage  of  acute  poliomyelitis  which  is  recognized  by 
^^  Laborde  and  Gra.-set  is  really  not  a  part  of  the  disease  at  all.  It 
is  the  stale  of  paralysis  that  follows  the  dis<>,aBe:  it  is  the  per- 
manent condition  into  which  the  patient  ib  thrown  hy  the  disease. 
The  masclcs  are  atrophied;  in  rare  instances  their  wasting  is 
masked  by  fatty  deposit-^.  If  the  patient  has  been  attacketl  early 
in  life,  llic  bones  are  arrested  in  development,  so  that  the  limb 
remains  not  only  much  smaller  but  also  much  shorter  than  its 
fellows.  That  the  ligaments  also  Huffer  trophic  changes  is  indi- 
cated by  the  complete  relaxation  of  the  joints. 

The  picture  which  has  just  been  given  applies  to  the  acutest 
form  of  jioiiomyelitis.  In  tlie  gi-eater  proportion  of  cases  which 
are  met  with,  the  onset  is  far  more  insidious.  The  febrile  symp- 
toms may  be  overlookedj  on  account  of  their  brevity  and  their 

IB 


242 


oiAOKOsnc  MzaaoLoov. 


mildnees;  bat  it  is  probable  that  in  Ta&ny  cases  tliey  are  eneirelf' 
wmatuig.  Certainly  in  tljti  majoritj.'  of  the  luauy  casus  that  I 
have  seen,  no  history  of  the  fever  cnulil  be  obtniucd.  Under 
these  oinTunwtaiioes  tlif  iwiralysis  is  usually  not  griieral  or  wide- 
spread; moreover,  its  development  seerus  to  be  eomparolively 
slow,  so  that  not  rarely  at  first  only  the  gait  of  the  child  is 
affected,  but  allcr  some  dayti  the  [ranilysis  deepens  into  a  com- 
plete lorv  of  power.  It  U  probable  that  in  these  cases  tlie  orifflnal ^ 
attack  is  limited  to  a  certain  number  of  spinal  tx\U,  and  is  no^| 
sufficient  to  produce  constitutional  dittturbaoce,  such  as  fever, 
deliriiiiu,  etc.,  and  also  that  in  the  aEfecLod  cells  some  days  ara^ 
required  fur  the  full  <lcvulopmetit  of  the  degenerative  process. 

Arsenical  Poisoningr. — A  r^et  of  symptoms  closely  rewemblinf 
thube  of  acute  or  subacute  poliomyelitis  are  soirietimes  prodi 
by  metallic  poisoning.  It  h  probable  that  various  metals  ai 
(npable  of  causing  thise  effects,  but  I  have  never  seen  them  ezce[ 
fls  the  result  of  arsenical  or  of  lead  poisoninfj;.  In  arsenical  jm)!- 
eouing  they  are  usually  preceiletl  by  such  acute  and  characteristic ^ 
luauifustations  as  to  make  the  recognition  of  iheir  nature  vecjfl 
easy;  but  in  one  or  two  cases  of  saturnine  disease  tliat  have 
come  miller  my  notice  the  poliomyelilic  sympl^ims  were  not  pre- 
ceded by  any  of  the  ordinary  characteristic  evidences  of  lead- 
poisoning.  There  must  be  a  lesion  either  iu  the  trophic  centres 
or  iu  the  nerve-trunks,  or  more  proliably  in  eacli  of  lliese  tissues. 
For  an  elahonitc  diacuAdioti  of  this  question  tlie  reader  is  referred 
to  my  treatise  on  ThcrapeutiiW. 

Iu  llie  cases  of  arsenit-al  poi.-Toniiig  with  poliouiyelitic  syni[rtoi 
which  have  eome  under  my  caiv  tlie  muscular  atrftpliy  has  lieea"^ 
associated,  at  least  in  it»  earlier  stages,  with  violent  darting  pains, 
much  tenderness,  and  loss  of  sonsibility, — symptoms  all  pointing 
to  the  presence  of  neuritis;  the  falliug  away  of  the  muscles  ia  ^ 
rapid,  reijuiring,  however,  some  weeks  fur  its  full  developmeutyH 
and  ia  associated  witli  the  presence  of  true  reaction  of  degencm- 
tinn.  Although  all  portions  of  the  Istdy  may  suffer,  the  distal 
ends  of  tlic  extremities  arc  mo!it  prone  to  be  attacked,  aiui  the 
legs  prcienibly  to  the  arms.  In  an  elaborate  monograph  (Paris, 
1881)  Imbert^Gourbeyre  has  shown  that  H(n>phic  arsenical  imlgy 
may  take  on  a  [laraplegic  or  even  a  hcmtplegio  fiirm,  and  may 
also  simulate  a  multiple  {mralysis,  to  which  last  variety  of 


•rod 
>ouM 

•CCtlV 


TROPHTO  LBSIONB. 


243 


it  may  indeed  be  considered  to  belong.  According  to  Imbert- 
Gourbeyre,  iiinety-»even  [tcr  oeiit.  of  the  CRses  recnver. 

Lead-PoisoniBjT- — in  niy  experience,  when  aympionis  resem- 
bliDg  tbose  of  acute  poliomyelitis  have  resulted  from  lead-poison- 

l,  the  upiier  extremities  have  been  usually  primarily  attaekwl, 
the  flexors  and  extensors  both  being  attainted,  and  the  alterations 
of  Ihe  deltoid  muscles  following  very  rapidly  upon  ihnsp  in  the 
IbreAnns.  In  several  cases  from  the  arms  the  paralysia  has  s]}read 
throughout  the  whole  body,  uutil,  in  the  course  of  a  few  da^'s, 
almoBt  all  (he  vobiiiiary  miiecles  Imve  been  involved,  ami  in  ex- 
iretne  cases  the  patient  has  at  last  become  unable  lo  do  more  than 
lum  tlie  head  ou  the  pillow.  The  affected  muscles  waste  rapidly, 
oSeriug  the  reaction  of  d^eneratlun  ;  paiu  and  disturbanuc  of 
sensibility  have  been  abseot,  so  that  the  picture  has  very  cloaely 
resembled  that  of  ordinary  infantile  pandysis.  The  euooessive 
implication  of  all  the  muscles  occurring  \a  an  adult  is,  however, 
bufiicieut  to  raise  a  suspicion  of  toxic  ortgiu,  and  in  all  my  caaes 
tlie  blue  line  upon  the  gums  revealetl  at  uncu  the  nature  of  the 
affbction.  Undoubtedly,  however,  this  Rattirniue  atrophic  ]ialsy 
may  exist  without  the  blue  line.  Under  these  circumsWnces  tlie 
diagnosis  can  be  po!«itivety  determined  only  by  finding  lead  iu  the 
urine.  A  symptom  which  in  severe  caacs  separates  Uic  toxic  from 
the  idiopathic  disorder  is  the  iuvulvement  of  the  ephiricters,  which 
are  never  altackwl  in  idiopathic  poliomyoHtJH,  but  arc  very  apt  to 
be  paralywd  in  acute  satuniine  atrophy  of  the  rau-'»eles.  The  di- 
agDOBW  is  a  matter  of  great  importance,  becauM;  all  my  tiutuniiae 
cuee  have  yielded  to  trciitiucnt.^ 

ProgroBsive  Muscular  Atrophy. — Chronic  wasting,  with  lose 
of  power,  of  mnsi-lo3  occu[)ying  a  more  or  less  extensive  tcrritttry 
of  the  body,  is  usually  due  to  the  disease  known  as  progressive 
muscular  atn)phy,  an  affection  which  might  be  considered  to  repre- 
Mnt  the  slow  form  of  ainiie  iK>liomyc]itis,  and  therefore  be  named 
chronic  poliomyeHtis.  We  have,  however,  no  poeitive  knowledge 
SA  to  whether  the  lesion  i&  esAentially  the  same  in  the  acute  and 


*  Althoog^h  thenpeuticfl  »tc  not  ftt  pr«t«nt  uhAct  consid«r«.tion ,  It  ts  per- 
haps  ftlldWKblo  to  cnll  Mtlenliun  to  the  exlrHurdinnry  |>ow«r  nver  satlirniTUt 
psItT  poMMUd  by  enormoiiH  Ame«  tit  «trycbi)iDe.     ()f  anuno  tbe  iiidtde 
p(»tanium  ibould  bo  adrntiiUtervd  u<  ul<l  In  tb«  ollmioKtion  of  th«  Imd,  bu 
never  In  tbojarae/vstoriptfun  wilb  the  strychnine. 


244 


DIAOXOftTIO  NETROLOOY. 


the  chronic  disorder.  We  know  only  that  the  lesion  in  each 
tioii  owtipios  the  sume  site, — namely,  the  gjiinal  ganglionic 
The  cliffercncc  is  timt  in  acute  poliualyelitt^  or  itifiinlilc  paratysis 
lai^  maswfl  of  cells  are  attacked  simultaneously,  while  in  the 
chronic  progreMivo  muscular  atrophy  individnal  oells  are  afTecteil, 
one  after  the  other. 

The  onset  of  progressive  muficular  atrophy  ia  always  very  slow 
ami  iiii^iilious.  In  most  ca»eSj  before  any  marked  change  lan  he 
noted  in  the  mnsclo,  the  Biifferer  perceives  a  loss  of  cndnrancc,  ao 
that  the  part  tires  easily,  or  there  may  even  be  ahsoltite  loas  of 
power  for  short  exertion.  Careful  examination  will  now  i^how, 
even  if  there  Ix-  no  Keri»;ihle  wanting,  that  the  ninsete  is  softer  and 
more  flaccid  than  normal.     Sensihility  is  not  imiwired. 

A  symptom  whieh  often  precedes  any  marked  change  in  the 
volume  of  tlie  niuselw  is  fibrillary  contractions.  The  variation  in 
the  amount  of  the  librillary  coiitrantion  is  imleed  ao  excessive  m 
to  lead  to  the  »uitpieion  that  possibly  the  iiiscs^  process  whicli 
attacks  the  gangltonie  cells  is  not  always  the  .-ame,  so  (hat  two  or 
more  diseniw^A  are  comprised  in  pnigre^ivc  rauiwular  atrophy  as  ai 
present  recognized. 

In  their  niilduft  form  the  fibrillary  oontraetiotis  conatKt  of  nligK 
irregular  twitrliings,  occupying  now  this,  now  that  portion  of  the 
belly  of  the  roiiscle,  and  producing  no  effect  except  a  corresponding 
movement  o{  the  skin  over  the  contractions.  The  fibrillary  con- 
traclioris  in  their  severest  munifcstations  may  amount  to  stormy 
peristaltic  movements,  hurrying  tlirungh  the  miu>ele  one  ufller  (he 
Other  in  immediate  rejwtition.  When  the  fibrillary  oontractioos 
are  very  severe,  the  disease-process,  at  least  in  my  esperieuce,  is 
rapid,  the  wonting  of  the  muscle  notably  increa»ing  from  day  to 
day  under  observation.  In  the  slowest  forma  of  tlie  disease,  in 
which  many  months  or  even  years  are  required  for  much  destruo- 
Uon,  the  fibrillary  contractions  are  usually  sluggish. 

The  loss  of  power  takes  the  form  of  a  multiple  paralysis, — that 
is,  groupii  of  muscles  moru  or  less  isolated  arc  attacked  in  diOer* 
ent  parts  of  the  brjdy.  In  tlie  majority  of  cases  the  changes  are 
somewhat  symmetrical.  Thus,  if  one  region  of  the  hand  be  at- 
tacked, the  same  regiou  upon  the  other  hand  will  be  alTected. 
This  rule  is  not  invariable,  and  even  when  the  symmetry  is  de- 
ddcd  it  may  often  he  noted  that  uut  precisely  the  same  musoles 


ai 1 

14 


TBOPniO   LESIONS. 


245 


are  affected  upon  the  oppoiiite  side  of  the  body.     Although  loss 
of  endurance  or  even  partial  paralysis  may  apparently  iireoetlc  the 
of  muscular  sulwlaiice,  the  loss  of  power  is  due  to  the  loss  of 

oacular  aubetance,  and  not  the  loss  of  ttubstauce  to  the  loss  of 
power;  or,  perhaps  more  correctly,  it  may  be  considered  that  both 
eymptuiuH  have  a  oiniinmn  ba»i« :  i.e.,  v,-hcu  a  spiunl  gtingliouic  cell 
w  attacked,  the  fibres  of  the  muscles  individually  supplied  by  it 
laiffljr  simultaneously  in  their  nntrilion  and  in  their  motor  func- 
tions. Usually  the  hands  are  the  first  portions  of  the  bixly  to  be 
aStx-ted,  the  symptoms  frequently  being  much  more  severe  lu  the 
right  hand. 

According  to  Kulenberg,  the  interosseous  muscles  are  almort  in- 
variably the  tirst  to  be  attacked,  whilst  Roberts,  Wacbsnmtii,  and 

riedrelch  state  tliat  the  the  ball  of  the  thumb  is  usually  impH- 

ted  before  the  interosieous  muschw.  TIk;  first  external  inter- 
csseouti  is  said  to  be  the  first  to  feel  the  influence  of  the  di.-^case, 

liilH  the  op]>onens  and  the  adductor  pollici.s  are  more  apt  to 
Igtiffer  than  the  exteusori^,  the  abductors,  aud  the  flexurs  of  the 
tljumb.  lu  the  few  uase^  in  which  I  have  had  an  opportunity  to 
pec  the  disease  in  its  earliest  stage  the  internsscoufl  muscles  were  the 

rst  affected.  The  wasting  of  the  muscles  of  the  hand  is  usually 
ttadily  jieroeived  by  the  flattening  of  the  tlieuur  etuiueuce  and  by 
the  falling-iri  of  the  interoHHeon.^  i^jmiciw.  The  diminisheil  power 
of  the  interosseous  muaclea  can  usually  be  detected  by  noticing 
that  when  the  [Miticnt  attempts  to  abtlnct  the  index  finger  he  sep- 
arates it  with  less  vigor  from  the  middle  finger  than  normally, 
beo  only  one  hand  is  attacked,  the  contrast  of  movement  is 
ofion  decided.  Instead  of  iittJiL-king  the  linnd,  progi-etssive  mus- 
cular atrophy  may  first  make  itself  felt  in  other  portions  of  the 
body,  and  especially  is  this  true  of  tlie  deltoid  mancle;  but  It  ia 

aied  that  the  .pectoralis  major  and  the  sermlus  mugnus,  or  even 
the  lumbar  ninscles,  may  have  to  hear  the  onset.  The  upper 
exlrt-niiticB,  the  nock,  and  the  trinik  are  i^rtainly  much  more 
frequently  affectetl  than  are  the  legs;  ncverthclcas,  the  latter  do 
not  always  e«cape. 

Owing  to  the  loss  of  |>ower  in  certain  muscles  and  to  (lie  tea- 

lency  to  contractures  in  their  atilagoulsta^  the  sufferers  from  pro- 
iive  uiuscular  atrophy  arc  prone  to  ansurae  peculiar  jwsitions 
hare  extraordinary  deformities.    lu  &  yalwul  vuid^c  m^  <jwu, 


^. 


i 


246 


DIA0N06TIC  KBOBOLOQT. 


:4 

red  ^j 


oaie,  tbe  loee  of  power  in  tb«  muscles  of  tlie  neck  vn 

that  the  haul  pcrpetuiilly  fell  forn'anl,  the  ohin  almost  restiag 

upon  the  breast.     In  thta  case  the  u})[>Gr  armx  were  much  more 

pnmiinently  affbcterl  than  were  the  forearms,  so  that  whilst  tbe 

mail  tftill  preserved  a  gmxl  grip  the  amia  were  perfectly  flaccid  and 

helpless,  owing  to  the  complete  puralyi;!^  of  tlie  deltoid,  bicK))e,  ami 

triceps. 

The   most  characteristic  of  the  dernrmitics  is  that  whirh  is 
known  as  ihe c^au-ai  h^nd  (main  m  grtfe,  Klatunhanrl),  and  which 
18  pro«)uc«d  by  tlie  |)«nuaoent  flexion  of  the  lafit  two  phalanges 
the  Sngent  which  arc  cxtemlod  at  the  iii(^hu-Hr|ial  joint.     As  waa 
shown  by  Ducheniie,  this  dcforniity  is  the  result  of  atrophy  of  the 
internal  and  external  interosseous  muscles  with  tbe  preservatioa 
of  jHJWt'r  by  the  exteuisora  and  flexoi-ij  of  the  flngcra.     It  most  bs^H 
remembered  that  this  deformity  ia  really  patliogooraonic  of  paraly-^^ 
sis  of  the  intera««eoiiH  nmsclen,  and  is  characteristic  of  progreaa- 
ivc  muscular  atrophy  only  for  the  reason  that  tos<;  of  power  of  ch«^H 
interoHsenus  muscle  is  rare  from  other  causes.     If,  however,  from^^ 
local  diijcatte  of  the  nerves  tlie  iuleruiirieoua  muaoles  are  {KirBlyzed, 
the  clawetl  hand  ib  developed.     If  only  one  hand  ia  clawed,  the 
suspicion  of  local  disease  should  l»e  at  once  aroused.     When  th« 
musi'les  about  the  alioulder-joiiit  are  paralyzetl,  either  by  sharing 
in  the  trophic  changes  or  by  the  loss  of  tlic  support  of  tlie  muacleit, 
the  ligHmeut<^  !?iifrer  elotigailon  and  the  joints  become  very  looee, 
BO  tliat  a  imbluxation  readily  occurs. 

A  very  imponant  symptom  in  the  diagnosis  of  progressive 
muwular  atrophy  is  tbe  preservatioo  of  tbe  electro- muscular  con* 
tnietilily.  This  at  iin^t  sight  may  ap|>ear  to  l>n  nt  variance  with 
the  theon,*  that  the  lesion  in  tiie  muscle  ia  the  result  of  destruc- 
tion of  the  trophic  wlU  in  tbe  anterior  cornua  of  the  spinal  cord. 
The  explanation  of  the  paradox,  however,  is  simple.  Tlie  de- 
struction of  the  ganglionic  t^ells  progressively  involves  individual 
cells  one  aAer  ihn  other,  and,  ooiiHequontly,  the  trophic  destrui 
tiou  of  the  muscles  conipromi.'<eH  individual  bundles  of  fibres  ODi 
after  the  other.  The  mu«;le,  i-Ufref"re,  Iwes  power,  not  en  ntow^ 
but  fibre  by  fibre,  and  that  portion  of  the  muscle  whicli  retains  its 
functional  activity  preserves  its  normal  electriml  reactions. 

1  liave  never  seen  the  reaction  of  degeneration  demonstrated 
progrewive  muscular  atrophy,  allliough  it  is  affirmed  by 


nted  in^M 


TROPHIC   LESIOSS, 


347 


berg  that  iu  the  later  perioJ  of  the  diaeaae  there  may  be 
qunlitativc  aUemtions  in  tbe  mitscular  raKtioo,— uu,  ut  in- 
cr«as«l  reaction  under  anodio  closure  aud  loB  mmmoaij  oadar 
caichodic  opening.  Eulenberg  .«taift»  thai  be  has  never  teem  ia 
progreiJBive  lutucular  atrophy  extreme  degrees  of  qoalitBtive  devi- 
ation frum  tlie  tioniial  reaction.  The  Hx^alled  (iiplcgic  eoBtnfr* 
tioiis  which  Remak  ha^^  aiHrmed  to  bu  of  freqn 
in  progree8>ive  muiwalar  atrophr  are  nueljr  lo  be  dc 
The  following  paragraph  from  Ealeob<^  explains  the  method  of 
developing  thise  oontraetions : 

"  Kcniuk  fontid  Uiut  (he  oontractiooB  ooald  be  pradoeed  in  tb« 
atrophied  munclca  of  the  arm  when  the  poBitiTe  elnsrode  warn 
plare<l  in  an  '  irritable  zone/  which  extendi  from  tlie  first  to  tW 
_lit'th  uervical  vertebra,  or,  still  better,  io  the  caniud  fosa.  or  tbe 
riaiigle  betweeo  the  lower  jaw  sod  tbe  extcnial  tar,  while  ilw 
itive  was  put  below  the  fifth  cerrkal  vertebra.  Tlte  eootza^ 
were  always  on  the  ^ide  o|tpaate  to  tbe  aaode,  bat  wbto 
lie  electrodes  were  applied  ia  the  mcdtao  line  tlwv  oecmwd  on 
bfith  sides.  If  the  cnrn^nt  was  verr  weak  thej  were  limited  to 
the  muRcIcs  most  severely  afieded.  Remak  rcgartied  these  aa 
reflex  contractions  originating  frora  tbe  Mpencr  arrica]  ^b- 
glion  of  the  sympstbettc,  and  eq>eetaUjr  as  the  patient  petueived  a 

(nsation  behind  the  hell  of  tbe  eye  when  tbe  namnt  naa  doaed." 
In  some  cases  of  pragresive  muacular  atrof^r  the  neyiMee  to 
e  faradic  current  appears  more  active  than  normal.     This  n^ 
10  some  iostanoes  be  due  (o  waetji^  of  the  anado,  enabling  iba 
^carrent  more  rapidly  and  thomoghlr  to  reaeb  tbe  portion  of  ibe 
insclc  left ;  bat  it  would  seem  that  there  i*  Mcnetimo  a  basrtt- 
oed  irritability  of  the  ma«-ular  fibras  which  bare  not  wftml 
meratiou,  ajad  1  have  thought  thia  was  e^Beially  prmnt  wbsa 
lie  fibrillary  contractions  were  very  aerere;  A^n,  in  tlK«e  eMce 
wliich  the  mtiscle  an  it  wastes  is  reptaoed  by  &tty  tMnev  tbe 
^eleotro-muscolar  contractility  may  appear  (o  be  bdow  miwr^}  on 
acuouot  of  the  renstaooe  which   the  &l^  aatser  rrftii  to  lb* 
laradic  carreot. 

The  coarse  of  a  tme  idiopathic  [ain^Hnrini  ■nwnlii  atmobr  h 
utiuslty  steadily  pn^ressive  antil  tba  final  dertmdioa  of  all  the 
aSected  mosclea. 

aiomo-Lmbial  fWay.— Id  I«n,  DocbcMC  AttKri\nA,  vOm 


248 


DLAONOBTIC   KEUBOT-OOY. 


the  name  of  GtosBo-Iifiliial  Paraly^iiit,  a  slowly  prograarive  loss 

of  power  in  the  tongue,  \i[)s,  palutc,  and  muscles  of  the  throat, 
which  h  only  a  form  of  progi-essive  muscular  atrophy.  The 
medulla  o!)tongnla  iti  simply  the  upper  [jortinu  of  Ihc  spinal  eord, 
and  when  tlic  nuclei  within  it  undergo  degeneration  the  muscle 
iribmary  to  it  suffer  fhangCB  precisely  like  thnw  prodDced  by 
similar  degenerations  of  the  nuclei  of  the  lower  spinal  cord.  The 
degeneration  of  the  nuclei  of  the  medulln  may  accompany  that 
of  other  s|iinal  ganglia,  when  the  patient  suffers  from  progroesive 
muscular  niropliy  and  glos?o-lal)ial  pnruIysB  so  called,  or  the 
bulbar  nuclei  may  alone  suffer  when  a  pure  glo8»o-Ubial  palsy 
results.  The  symptoms  lu  gloaso-Iabial  i)ara!y8i8  varj'  in  accord- 
ance with  the  varying  of  the  degenerations  in  the  medulla.  Fre- 
qtieatly  the  paral}'ai8  of  the  tongue  Is  the  first  to  ap|ieflr,  bnt  the 
tremulousnc-'is  and  loss  of  the  labial  articulation  may  precede 
lingual  affection. 

The  vtHirse  of  glosisu-labial  paralysis  is  entirely  parallel  wi 
that  of  oth<ir  forms  of  pi-ogressive  muscular  atrophy.  Its  aym; 
toms  are  j>eculiar,  on  account  of  the  eouneetion  nf  the  a 
muscles  with  pronunciation ;,  and  its  ending  comparatively  rapid, 
because  deglutition  Is  interfered  with.  There  are,  however,  the  i 
Bumc  progresi^ive  weakness,  the  same  slow  wasting,  and  the  same 
fibrillarj'  coiitractioTis  in  the  affectetj  muscles,  with  persistent  W-^j 
teutlon  of  eleotro-cOBilractilily,  as  in  other  forms  of  pr<^;;reMtv^H 
atrophy.  The  tongue  is  protruded  more  and  more  slowly  and^' 
im|jerft3etly,  and  becouies  more  and  more  Ireinulous.  Owing 
loss  of  control  over  it,  the  pronunciation  of  the  lingual  vowels  ani 
of  the  dental  consonants  is  im|wrfect.  The  weaknesB  of  the  \\ 
shows  itself  by  failure  in  urtlculatiuu  of  tlie  labial  consonants, 
the  inability  to  whistle,  by  tremnlouaness,  and,  finally,  by  llie  1 
of  the  power  to  contain  the  saliva  in  the  mouth,  which  dribbles 
constantly.  As  the  disease  is  almost  always  symmetrical,  the 
mouth  is  not  dmwn  to  one  side,  but  the  wasting  of  the  parts  about 
it  may  be  suflkient  to  make  the  orifice  appear  much  larger  than 
normal  and  to  i-oufuse  the  noso-labinl  folds.  Sometimes  the  lips 
during  laughter  separate  themselves  but  arc  incapable  of  sponta- 
neously returning  to  their  natural  |>osition,  so  that  the  patient  is 
forced  to  replace  lliem  with  his  fingere.  If  the  palate  is  markedly 
afre<--ted,  tlie  voire  becomes  iiassil.     De^lwUdou  toa.-^  tie  la.® 


Port  «^         I 


I 

I 
I 


early  or  late  in  the  dUorder,  aod,  as  the  Ioob  of  ptnrer  of  flnllcNr> 
ii^  is  peralytlcT,  liquids  are  swallowed  with  nmcb  difficultr,  ud 
are  apt  to  be  Kcuroed  throng  the  noee.  In  boom  ens  the  hrymx 
is  attacked,  and  the  voice  beoomtt  almoal  inaadihle,  wilhoat,  how- 
ever, being  completely  loet.  In  tboK  cmm  hi  vhkh  the  mxid 
of  the  r^iiiratory  uervee  are  implicated  the 
andcrgo  wasting  and  the  respumtiaa  heeowM 
Adt  attempc  at  violent  movement,  or,  later  m  the 
ordinary  walking,  may  cause  a  tenn  attack  of  drapiKea.  At ! 
these  cyanotic  criiies  oome  oo  spaatamtaaaXy  ia  farioai 
whiufa  may  occur  eitlier  hy  day  or  fagp-aight.  A 
torn  wbich  especially  cbancterins  thb  dyvpooa  ■■  a 
of  excessive  falness  of  the  chetC,  vhiiA  ii  pnifaably  piwIiJBJ  bgr 
the  fecbteueaa  of  the  moadea  pwwoliag  them  firoa  thonw^y 
emptying  the  lungs.  In  aoae  cm  the  ondei  of  the 
nervMt  8pj>ear  to  be  attacked,  and  carffiae  oin  beeo«a 
and  alarming.  Then  axe  cfpeaaUy  apt  k>  be  faiauM  fai 
cases  iu  which  (be  resptratioo  ia  afcttid,  km  maj 
the  respiratorv  mtuelea  aaSenam,  The  pafae  ia  the  < 
is  vtry  feeble,  irregnlar,  InleriaittMt,  and  at  haL  maf  he 
oepttble.  The  face  is  exceeding  pale  aad  aaiioM^  amd  thm  i* 
habitually  an  intense  terror,  with  a  aewe  at 
The  ocular  mosclea  may  be  aflecttd  n 
altfaoogh  tliey  u.'^ually  E^ape. 

The  *'  ophtbal  moptegia  extena^  of  H— >*!*■»■  ■»  tm  i 
the  expression  of  a  progrcanre  ■aHolar  amphy,    ^Baa 
on  Special  Senses.) 

Although  gloKCHlabia]  panlyEit  ooean  with  i 
tn  be  recognized  as  a  olioieal  grampf  it  bhC  he 
nil  sorts  of  irn^;iilanties  exiii  in  the  aedi 
muKles  about  tite  face  any  be  aBuettd  mmaitaaaamata  «S4| , 


I 


muaclw  in  tlie  body,  and  that  the 
forms  of  progrwiiTe  oitBealar  atrophy. 

Progreestre  ?acinl 
the  face  reqaires  ■entiou  here, 
tro[^ic  lesion  doe  to  soae  eeaCal 
although  at  pcseU  this  maaat  he 
disease  usually  appears  fical  a>  a  t 
KMNi  heoMMa  btvwmiA. 


ha^maafOmmaaf 

•^tntbf  vftmaitia^i 

k  nay  y^iOAf  U  ■ 

»«M<l»|>nftwyatttfi, 

~    M^mui,    The 

4^  in  the  sUn,  whW* 

m  m^  Mwvnfc  i4  \W«a 


360 


D:A0N<MTIC   H£OROIX)OV. 


8]wtA,  which  finally  coalesce.  In  a  little  while  Uie  Kkiti  becoraea 
tluDtier,  BO  that  a  (iepretwioa  iii  firoduceH.  As  the  change  widens, 
ti)c  folds  of  the  skin  fade,  and  tlic  siirflioe  gruw-i  smooth  nnd 
parchment-like.  Then  the  giibcuUneous  cellular  tissue  atrophia)). 
The  muscular  tinsue  yiehlt  sluwly.  The  bones,  and  even  the  car- 
tilages, cspMially  of  the  noae,  finally  waste.  Thr  Uwtli  may  fall 
out ;  and  the  tongue  and  palate  have,  in  some  caaes,  partjeipated 
in  the  ehanjjes.     The  hair  IwiHimcs  white  or  is  shed. 

Fn   scleroderma  and    leprosy  allemtioiis  of  the   nerve-trunks 
have  been  found,  and  the  lesions  of  both  ufiections  are  by  somei 
writers  considered  to  be  trophic:  at  preeent  this,  howBver,  fieems 
Boaroely  probable. 

TROPHIC  CHANGES  IN  THK  NERVOUS  8VSTEM. 

The  conducting  nerve-fibresj  both  in  tlie  brain  and  in  the  spinal 
cord,  and  in  the  nerves  ihemselvea,  upfH-nr  to  have  their  nutritioa 
regulated  by  certain  ganglionic  cells  with  ffhiob  they  are 
nected,  so  that  when  iHoIatwl  from  i^iinh  cells  they  nndergo  d^eo 
eratton.  Tiit^e  trophic  changes  in  the  nervoua  system  arc  usually 
so  hidden  from  any  poaeible  external  examination  that  tliev  can 
Ik'  known  during  life  only  by  their  socondnry  efTects,  of  which 
muscular  contracture  is  the  ooly  one  definitely  established.  Those 
contractures  have  already  been  sufficiently  discussed  (see  page  167), 
and  any  further  remarks  upon  the  matter  of  tmpliic  altemtions  ofi 
the  nervous  system  may  seem  out  of  plime  tri  a  work  upon  symp- 
tomatology. Ncverthelesw,  I  shall  point  out,  in  a  few  words,  the 
]avra  which  govern  the  trophic  changes  of  nerve-fibres,  and  thd 
directions  in  wbicli  such  changes  travel. 

The  trophic  celU  which  dominate  the  fibres  of  the  pyrarnidil 
fasciculi  are  situated  in  the  cerebral  cortex,  so  that  when  the 
pyramidal  f(uicioulu3  is  broken  anywhere,  either  in  (he  brain,  in 
the  peduncles,  in  the  medulla  oblongata,  or  lu  tlie  spinal  conl, 
degeneration  always  begins  upon  the  lower  or  distal  side  of 
the  injury,  and  iraveiR  d(iwn\\'nrd  until  it  rearhes  tlie  gangliooio 
cells  in  the  spinal  cord.  These  eelU  are  new  trophic  centres 
governing  the  motor  nerves.  We  have  no  knowledge  that  the 
deeeeuding  degeneration  ever  jiaBiies  over  fi-om  the  fibres  of  the 
pyramidal  tract  to  the  trophic  centres  in  the  cord.  Hence  it  is 
that  ill  cerebral  palsies  the  muscles  preser\'e  their  integrity  for 


I 

I 

i 


^ 


TROPHIC  T.ESIOSS.  261 

such  a  length  of  time.  Whenever  the  motor  fibres  paatinig  from 
the  gaDgliooic  8i>inal  cells  outward  are  injured,  whether  such 
injiirj"  be  uUuuted  in  the  (.-ord,  ici  the  uerve-root,  or  in  the  trunk, 
d«g«Derntion  always  begins  in  the  lower  or  ptTiplieral  negnient 
of  the  nerve,  And  travels  Hownnmrd  until  the  periplieral  filaments 
of  the  ner\'e  are  Involved.     In  other  words,  in  the  motor  system 

e  trophic  influence  rises  from  higher  nerve-centres,  and  degen- 

tiun  therefore  travcl»<  downward  and  outward. 

In  the  senaory  system  the  trophic  infJuenc^  uriginatefl  in  the 
peripheral  or  lower  {e^nglionic  masses,  so  tliat  the  course  of  eec- 
oodary  d^ueration  is  from  below  upward.  Thus,  as  was  origi- 
nallv  discovered  bv  Waller,  if  the  nerve-roots  are  dividi^d  above 
tiie  ganglia  of  the  piwterior  roots,  whilst  the  motor  root  degener- 
ates below  the  section,  the  sensory  root  degeaerat^e  abtive  the 
•fiction.  Again,  if  the  spinal  cord  be  divided,  in  the  animal 
by  (he  knife,  or  in  man  by  a  diiiMniiw  (such  aa  the  transverse 
myelitic  which  often  accompanies  I'ott's  distatse],  below  tlie 
point  of  »ertion  tlie  antennlateral  columns  which  contain  the 
deacending  motor  fibres  of  the  pyramidal  tract  undergo  degen- 
eratioa,  which  progresses  downward.  The  descending  degen- 
eration travels  more  rapidly  along  the  lateral  columns,  so  that 
at  m  oertain  height  In  the  cord  it  am  be  noted  that  they  have 
andergone  change,  whilst  the  anterior  fibres  are  .is  yet  inta^u 
Above  the  point  of  section  the  antero-Iateral  columus  remain 
normal,  but  the  posterior  columns  are  altered  through  their 
whole  extent  The  lesion  travels  more  rapidly  along  that  Iwnd 
of  the  fibres  which  lies  next  to  the  [josterior  fissure  and  is  known 
as  the  columns  of  Goll,  so  that  at  a  oertain  heiglit  these  fibree 
are  dl-ieatiwl,  whilst  the  posterior  nwt-zoue  is  uuafiected.  When 
the  original  li^ion  in  situated  in  tlie  dorsal  region,  the  ascending 
degeneration  is  not  confined  to  the  posterior  columuH,  but  alw 
pajHeti  np  along  a  fine  hand  situated  in  the  poaterior  external 
portion  of  the  lateral  columns,  or  the  tract  to  which  has  been 
given  tlie  luime  of  direct  cerebellar  fasciculus. 
I  In  catses  of  infiamrantions  of  nerves  the  neuritis  frequently 
travels  upward  along  the  trunk.  There  is,  however,  no  reason 
for  supposing  that  trophic  inlluence  has  anything  to  do  with  this 
progrcEsioD.  It  is  simply  a  propagation  of  the  inBammation  by 
oontinuity,  in  accordance  with  a  well-known  g;eneral  tuw. 


i 


CHAPTER  VI. 


SENSORY   PARALYSIS. 

Tk  t1i«  present  volume  (tic  t«rm  antnthMia  is  need  as  equivalent 
to  paralysis  of  sensation.  Like  motor  paky,  it  may  be  complete 
or  inooniplete;  but^  siore  ecnsation  is,  unlike  motion,  a  complex 
function,  sensory  palsies  vary  not  only  in  degree  but  also  in  kind 
and  in  position.  An  nnfcsthcsia  may  affeoi.  the  surface  of  the 
body,  wbeu  it  Is  8]iokcn  of  as  cutaneous,  or  it  may  be  located  in 
mucous  membranes  or  in  muscles  or  in  internal  viscera,  or,  finally, 
it  may  t>e  tuitimted  in  tlm  rt'gion  of  .°|)ecial  8en.se.  Special  aense 
aniEstbcsiaa  will  be  discussed  in  tbe  chapter  on  the  Special  Senses, 
and  oonceroing  Uiem,  Iherafore,  nothing  further  will  be  luiid  in 
thU  place.  Tbe  function  of  seusation  in  not  highly  developed  in 
mucous  membranes,  and  wc  are  not  able  to  disttngntsh  the  viine- 
ties  of  anicsthesia  in  ihe^  iMKjitiuus  that  are  m.'pn  u]Km  (he  Hkin. 

Cutaneous  sensations  may  be  divided  for  clinical  purposes  into 
two  gi'oups;  Jird,  tlioee  which  are  known  as  general  or  ix>ramon 
semititions,  as  pain,  itching,  titillatiou,  sensual  pleasure,  and  the 
feelings  arising  frori]  elei^tritatl  excitation ;  second,  special  sensa- 
tions of  pressure,  of  temperature,  and  of  bxstlity.* 

In  practical  medicine  cases  arise  in  which  special  sensations  are 
piu-alyzcd,  although  cummon  sensibility  is  preserved.  It  is  there- 
fore necessary  to  employ  various  testrf  for  the  recognition  of  the 
eacact  condition  of  tlie  part  to  Iw  studied.  It  must  be  remembered 
that  the  i-esponses  whic-b  wc  receive  from  these  tests  are  made  by 
tbe  patients,  and  may  be  misleading,  especially  in  hysteria  and 
malingering.  In  the  exauiiualion  «)f  such  catucK  subjective  symp* 
toms  cannot  be  relied  u[ion,  and  tlic  judgmcut  must  be  funned 
from  tbe  objective  symptoms  which  are  iieyoud  the  control  of 
tlie  paticut  and  are  aeeu  by  tlie  physician  himself. 


*  Xd  upfintting  tbe  go-c&llFd  at^n^o  of  lncfttity  from  common  nfrnsBtloii  I  bATt 

folloured  ciutom,  but  hnvo  iii-'ver  liueii  tilile  l»  cunvince  myself  ttml  tlic  Kpttn- 

tion  is  correet.     It  baa  nlwaya  i^emwl  Co  titp  tliiit  \h«  pover  nf  Ei;piirnling  tb* 

puiuU  of  tlwt  luatliMioauitiir  dwpwtb  iipoa  tbe  cuuditLon  of  geocrnl  seiuibitit?. 

2&3 


BKTfWRT  PARALYSra. 


ifoda  of  Tenting  SenMfioTi. — Common  sensibility  may  be  tested 
Vfitli  any  small  ^^harp  iniitniment,  as  a  nip^dlc  f*r  a  knife-point,  or 
by  piucliiug,  or  by  oieaus  of  the  electric  brush.  The  latler  lustru- 
lent  is  especially  valuabte,  l)ocaii9e  the  ptTipheral  nerve- filaments 
"may  be  intensely  irritated  by  it  withtmt  musing  any  Htnirtnral  r>r 
periuaofnt  change.  In  gome  va&es  of  disease,  although  acusntiou 
is  Dot  completely  abolished,  its  pathway  is  so  blocked  up  that  a 
much  longer  time  U  reijuircd  than  imrnial  for  tlic  fH'i-eeption  of 
the  peripheral  sensory  impulse  by  the  brain.  In  extretnc  cases 
this  rctanlfltion  of  ftonaation  is  perceptible  by  the  watch.  The 
detection  of  minor  degrees  of  it  requires  very  delicate  appara- 
tus^ and  much  physical  training,  and  is  of  no  avHiI  in  practical 
R medicine. 
I  Tho  instrument  used  ibr  testing  the  seiiw  of  locality  is  known 
W  the  truth faiomfter.  It  conftist'?  in  ilfl  simplest  farm  of  a  pair 
tit  ordinary  compastses  with  blunted  points.  In  lU  niorti  refitied 
forms  it  is  compoM^d  of  a  pair  of  potnt-'>,  one  of  which  filidca  upon 
a  liar,  so  that  Uie  difitnnft'  iMilwa^n  the  [minis  when  separated  is 
known  ;  or  the  compasses  themselves  may  be  furnished  with  a 
graduated  scale.  WLen  the  points  of  the  testhesioructer  are 
brought  into  contact  with  the  surface  of  the  biHiy  they  are  felt  as 
two  points  or  as  a  single  [Hiint,  accurding  us  they  are  more  or  Icsa 
widely  «cpnratod  and  as  the  akin  is  mure  or  less  sensitive.  The 
sensibility  varies  greatly  in  different  parts  of  the  skin,  hut,  ac- 
cording to  1-he  rwtults  obtained  by  Wel>er  and  Valentin,  the  dis- 
tance at  which  the  |>otnts  of  the  compass  must  be  separated  in 
order  to  be  felt  as  two  points  is  to  some  extent  constant  in  the 
•atne  region  of  the  bo<Iy  in  different  individuals.  The  following 
may  bo  taken  as  the  normal  scale  from  which  any  marked  devia- 
tiona  mtiEt  be  reganled  as  pathulogioal :  the  top  of  the  tooguo, 
1,18  mm. ;  the  end  of  the  fingers,  2.2.')  mm. ;  the  side  of  the  first 
phalanx,  16  mm.;  the  back  of  the  band,  31  mm.;  the  upper  arm 
and  thigh,  37  mm,  Tho  RraRllcst  reqnireil  di.4tarice  is  oflener  Ie68 
in  the  tramsverse  thau  in  the  longltudloal  dii'cctioii  of  tlie  limbs. 

Although  u  certain  degree  of  constancy  docs  c.\i.st  in  different 
individuals  in  regard  to  cutaneous  st-n.'^iiiveness,  yet  the  differences 
ar»  so  wide  that,  when  it  can  be  done,  it  is  preferable  to  comjwre 
the  affecte<l  part  with  the  opposite  siile  of  the  body  rather  tlian 
with  any  theoretic  formnlu.     Care  mu^t  be  taken  In  applying  the 


2M 


DIAONuenC  NEUROIXJGY. 


t<ompas%s  to  see  that  their  two  points  are  brought  simultAnBOiuIj' 
in  contact  with  the  skin,  otluTwise  the  sense  of  double  contact  may 
be  produced  by  the  alterations  of  time.  Also  the  oompass-poiots 
mast  be  kupt  quiet  ami  a  tinifurniity  of  pi^-ssure  be  iimintaine<l. 
When  tlie  hands  are  the  sent  of  the  supposed  loss  of  sensation,^ 
the  use  of  the  sestheaiometer  may  well  be  supplemented  b>*  de 
termining  whether  the  patient  with  the  eyes  shut  can  tell  the 
difference  Ixitwecn  a  rough  and  a  smooth  object.  ^^ 

The  seuise  of  pressure  is  tested  by  laying  the  hand,  foot,  eicj^M 
upon  a  Arm,  hard  tnirfat^e,  like  that  of  a  table,  and  placing  grad- 
uated weights  upon  it.     Scvend  forms  of  apparatus  have  been  in- 
vented for  the  pur[)<]se  of  testing  the  pressnre-eense,  but  none  of 
tlu^m  have  any  material  advantage  over  the  simpler  plan.     I 


hp~ 


4 

.1^ 


a 

I 


order  to  avoid  bringing  into  play  the  mu»eular  ^nse,  it  is  esaeulial 
that  the  part  on  which  the  weights  are  laid  be  thorongldy  sup- 
ported. A  very  couveaient  mulliud  is  to  fill  a  aeries  of  ordiuan* 
shot-gun  cartridge-shells  with  shot  and  wadding  so  as  to  form  a 
regular  series  of  weights  wliicli  reAemblc  one  another  exactly  tdj 
the  eye. 

The  power  of  recognizing  tlie  (I'tfercnca  of  temperaiare  may  Wl 
tested  by  thealteriiuie  applif^tion  of  hot  and  cooler  liudieb.     Mon 
or  leas  «impli«Mtcd  instruments  have  been  constructed,  under  the 
name  of  thermo-frtithfjiiomdetv ;    bnt  vials  of  water  of  different 
tem]>erature8  are  »uflj<:ient  for  pnictical   imiHwes,      The  teniper- 
aturc-rangc  of  most  accurate  seusalion  lies  between  27^  and  30'^      i 
C,  then  between  33°  and  39°  C,  and  lastly  between  14°  and  27"fl 
C   The  variations  almvc  orlx'Inw  those  limits  produce  simply  sen-  ^* 
ealioud  of  pain.     According  to  tlie  cxjieriments  of  Nothnagel,  the 
smallest  perceptible  diHerv^noes  of  temperature  are  tlie  following: 
on  the  breast,  0.4"  C. ;  on  tlio  hack,  0.9"  C. ;  on  the  hat^k  of  Uio 
hand,  0.3°  C.  j  palm  of  the  hand,  0.4"  C. ;  arm,  0.2^  C. ;  b«ck_, 
of  the  foot,  0.4°  C. ;  lower  t!Xtrcmitic8,  from  0.5°  C.  to  0.6°  C; 
the  cheek,  0.4°  C.  to  0.2"  C. ;  the  temples,  0.4°  C.  to  0.3°  C. 
practice  few  normal  individuals  will  reoognizc,  I  believe,  diffe 
euL'eB  of  t«ui[K^ratiire  so  sn]all  us  ihoeie  mentioned. 


For  the  purposes  of  clinical  study,  antestbesia  of  the  surface 
of  tlie  boiiy  is  Ijest  separated  f'nim  nniestlicaia  of  the  muooiis 
membranes  and  of  otber  internal  tissues.    For  these  respective 


J 


SRNSORY   PARALYSIS. 


S6fi 


thesias  tlie  names  VUoeral  aiiil  Cutaneous  may  be  iiaed  as 
oooTciiient,  alUiougli  not  absolutely  correct. 


* 


I 


VISCERAL  AN-S^STHESIAS. 

Tlie  important  vlsoernl  antesthoiuas  met  with  in  practice  are 
those  of  the  throat,  rectum,  bladder,  and  vagina.  It  is  prnl>ahle 
that  certain  obscure  aRVctioiis  of  the  internal  viwera  may  be  con- 
nected wiili  paralysis  of  their  sensory  apparatus,  but  of  such  dis- 
eases or  such  affections  we  hnve  at  present  tiu  ikriiiite  knowledge. 
like  cutaneous  anaRsthcsia,  these  dee]>er-aeated  losrws  of  sonaatiou 
may  be  either  of  hysterical  or  of  organic  origin.  The  distinctions 
between  hyttterioal  anil  organic  amesthesia  will  he  fully  develofied 
in  the  section  on  Cutaneous  Anaathcaia.  For  the  present,  I  shall 
merely  point  out  the  aymptonis  wlncli  are  proilnce<l  by  anffstluwia 
at  deep-seatod  parts,  and  ibeir  usual  etiological  i-elations. 

Axueetheeia  of  Throat. — Anfeslhesia  limited  to  the  throat  19 
a  rare  condition,  which  may  iwcur  after  diphtheria,  or  in  con- 
seqaenec  of  disease  of  the  ucrve-trunkR,  or  may  he  seen  in  other 
limited  organic  afTections  of  the  nervous  system.  In  combinn- 
tion  with  otlier  symptoms,  biicx'al  and  pharyngeal  anffisthesia  Is 
frequently  prc^nt  in  general  ana«th<jaia  or  hcmiauassthcsia  of  the 
ks-blerical  or  organic  ty|)e.  It  i»  especially  apt  to  be  pronounoed 
in  hysterical  cases.  M.  Clmirou  (fyudai  eiinifpteH  mir  ta  Paralynie, 
1870)  has,  indeed,  insisted  upon  the  insensibility  of  the  pharynx 
and  of  the  epiglottis  as  almost  patliognomonic  of  hysteria.  In 
many  coses  auastbesia  of  the  throat  produocs  no  distinct  symp- 
toms, and  is  discovered  only  when  the  parts  are  touched.  The 
Iftck  of  symptoms  is  evidently  due  to  the  fact  that  the  loss  of 
sensitiveness  is  usually  either  eonlined  to  one  side  of  the  throat 
or  is  not  couiplete.  A  complete  aiifBiithesia  of  tlie  pharynx  and 
upper  ccsophagus  would  suspend  the  reflex  nioveHionls  of  swallow- 
ing: It  pn)liably  enters  largely  into  the  difficulty  of  deglutition 
which  sometimes  follows  diplithcrla. 

Bectal  Ansestheaia. — Rectal  aufesthesia  may  be  due  to  hys- 
teria, to  wide-spreail  degenerations  of  the  brain-cortex,  to  myelitis, 
or  to  locomotor  ataxia :  when  it  i.s  comfilete  the  desire  for  defecation 
does  not  exist,  and  the  fseccs  may  be  retained  in  the  rectum  until 
there  is,  as  in  (he  iuoontineuce  of  utiuary  retention,  an  overflow, 

Mr.'-"'"", 


256 


DIAONOBTIC  NEUBOI/IOT. 


vhicli  19  niantfeatod  by  a  perpetual  disfliarge  of  small  maeamtit 
fiBoes.  If  ttie  fiecfs  art-  liiirxl  from  lack  of  accretion,  the  rectnm 
becomes  distended  with  an  cnormoiiB  stony  maw.  If  the  dw- 
cltarges  are  moderately  soft,  the  pli>'aician  is  usually  informed  tliat 
the  patient  (^nirerK  from  diHrrhiBii.  In  some  of  these  cases  not 
only  the  rectum  but  also  th(^  anus  nud  its  -surroundings  are  diii> 
tinctly  anspsthetic.  Sensibility  may,  however,  be  [>erfectly  pre- 
served iri  the  skin  and  mucot)><  nietubranes  upon  the  vei^  of  the 
aQUs,  although  no  amount  of  strettihinj;  of  the  sphincter  ur  intee- 
tine  hurts  the  [>atieiit  (Mitchell).  An  anffisthesia  of  one  side  of 
the  rectum  prolmhly  often  oe-curs  in  rauiPB  of  nrgiinic,  and  perhaps 
also  of  hysterical,  heraianjesthesia,  but  is  not  discovered  becaiw 
the  sensitive  side  of  the  rectum  is  sufficiently  alive  to  perform  all 
the  necessary  functions. 

Vaginal  AneeBtheaiA. — Vaginal  nnEesthe^ia  is  a  not  rare  hys- 
terical disorder.  It  is  usually  aflsooiawd  with  a  loss  of  sensihih*^ 
ID  all  the  organs  of  generation,  and  complete  lo^  of  sexual  desire, 
eomettmes  even  absolute  repugnance  to  sexual  iuteroourae.  £x- 
cept  in  married  women,  it  generally  eAca|K»  notice. 

Bladder  Aneeetheeia. — Anesthesia  of  the  bladder  gives  rise 
to  retention  of  urine  as  it?*  chief  symptom.  It  is  es|)ecially  in  thti 
fortn  i)f  urinary  retention  that  a  perpetual  overflow — i.e.,  incoati' 
nence — is  liable  to  mislead  the  unwary  into  believing  that  the 
bladder  is  suffictcntly  emptied.  Thts  danger  is  much  inereased 
by  the  lack  of  desire  for  urination,  a  symjitora  whicli  in  almort 
diagnostic  of  the  condition.  Sensory*  pomlysit;  of  the  bladder 
oocurt;  in  hys^teria,  and  is  an  ncca.sional  symptom  of  locomotor 
fltn.'cia.  When  it  is  due  to  posterior  sclerosis  of  the  oord  it  it 
as!*ociate<l  with  genito-urinary  pain-cri-'ies,  winch  often  serve 
ditstinguifili  it  from  the  hysterical  disorder. 

CUTANEOUS  ANESTHESIA. 

Cutaneous  anse^thesia*  is  in  itw  locatiini  parallel  with  motor 
palsy.  It  may  affect  the  whole  or  the  greater  j>orCion  of  the  sur- 
face of  the  body,  coustituting  a  general  auassthesia.     It  may  be 


^HereaHer  In  ihl*  book  tlie  term  Bnwthculn  will  be  OKd  u  tiga\tjUtg 


aBNSOHY  PARALYSIS. 


257 


tted  to  one  lateral  half  of  the  body,  constituting  the  so-culled 
iansesthcsia.  It  may  be  ooiiSned  t«  one  fxircmiiy,  whon  it 
known  as  monoanaesihesia ;  and  precisely  as  two  monoplegias 
Biay  coexist,  so  wc  uiav  have  a  double  moooanKetb<»ia,  which 
y  simulate  hemianiesthesia,  or,  existiug  Ujwn  the  opjKiKile  sides 
'  the  body,  may  produce  a  crossed  seueory  paralysi:*.  AntEs- 
lesia  may  affect  the  lower  half  of  the  person,  constituting  a  par- 
Bittftbttia.  It  may  affect  only  the  terrltury  uu<1er  tlie  domination 
'  one  nerve,  or  of  one  group  of  nerves,  constituting  a  local  uuccs- 
lesia. 

For  the  purposes  of  study,  cases  of  anicstheiia  are  best  arranged 
certain  etiolt^ical  group:*, — namely,  hysterical  anaesthesia,  jwy- 
liu  anteHtliesia,  urguuio  amestllieiiia,  and  tuxtcmiu  auu»tliesia.    The 
§t  two  grou|i6  mit^ht  without  violence  to  nature  be  considered 
igecher,  but  the  chaiigeH  in  the  Hcn^ir)-  nervva  whioh  occur  in  tox- 
mic  anffisthcMa  may  not  be  sufficiently  gross  to  be  recognized  by 
le  microscope;  moreover,  the  distinction  between  functional  and 
ri^tiic  dibeases  is  uu  arbitrary  one,  and  it  is  clinically  more  con- 
enient  to  study  toxicniic  anict^thesiati  an  a  single  group. 
Psychic  ans^tho-sia — i.r.,  »ntBsthe»iia  connected  with  jjsychosifj — 
DO  doubt  dependent  upon  changes  in  the  brain-cortex,  which 
'may  or  may  not  be  sufficiently  gross  to  be  recognized,  but,  for 
reasons  similar  to  tliusc  jml  adduceii,  i  prefer  to  consider  it  as 
separate  from  organic  anesthesia.     There  is  no  positive  relation 
between  the  etiology  of  an  ans^sthesia  and  its  location.     An  hys- 
Lierical  aiipwthcsia  or  an  orj^anic  ante^tliesia  may  take  ujxiu  itself 
pny  one  of  the  forms  based  upon  the  distribution  of  the  palsy 
pcd  ouiistitute  a  monounEcsthe^ia  or  hemianseaithtsia,  etc.,  as  tEie 
'CB-w  may  be.     A  crossed  antesthesia  is,  however,  very  rarely  or- 
ganic, while  a  toxieiitic  aiia^thesia  usually  is  wide-spread  in  its 
distribution,  although  it  may  afiect  local  areas  which  are  more  or 
numerous  and  more  or  less  widely  sei»irated. 


HYSTERICAL  AN-^TIIESIA. 

Hysterical  amcsthcsia  may  be  couSued  to  a  limited  area,  but 
usually  wide-spread:  frerjucntly  it  is  strictly  rouijucd  fur  the 
le  being  to  one-half  of  the  body,  either  as  e  heiuiauiestbcsia  or 
..ft  paraniesthesia;  not  rarely  it  is  irregular  in  its  distribution, 
ad  it  may  exitit  upon  opposite  sides  of  the  body.     It  especially 


258 


DtAOKOBTIO  NEUBOUlOy. 


afTectd  the  skiu,  but  may  make  itself  maDifest  in  tlie  def>pe«< 
6tructun%>.  It  may  Ik  cuniplete  or  iiioumplute.  Tu  a  case  rei>ort«d 
by  Briquet,  a  young  girl  had  tmraplete  sensory  paralysis  of  tJie 
skin  anil  the  inus^-le:* ;  the  hearing  and  vision  of  the  left  side  were 
gone,  and  tlie  senses  of  taste  and  smell  entirely  lost.  Her  insensi- 
bility waa  BO  eoniplcic  that,  after  the  eyes  were  bandaged,  she  Itad 
no  |ier<?eption  of  Ijeing  lifted  from  the  carriage  to  the  bed.  In 
many  caw*  of  hyjrtcrlcal  anccsthpsia  the  loss  of  sciiBibility  is  limited 
to  snmll  poitioDS  of  the  trunk,  and  in  a  case  reported  by  Leroy  it 
waa  eon6ned  to  the  conjuncliva  and  cornea  of  one  eye.  M.  Four- 
nicr  hofi  reported  as  occurring  in  nervous  i^yphitis  a  localized 
annestliesia  of  the  nkin,  of  the  hands,  and  of  llie  mantmary  region, 
wbioh  was  almost  (*r(iiiidy  of  hviiterimil  origin.  Not  rarely  the 
hysterical  anwathesia  occupies  the  lower  halt*,  or  the  lower  two* 
thirdii,  or  a  greater  or  le»<s  fractional  part,  of  t}ie  body.  It  is  rare 
In  the  face,  hut  oerlainty  doos  ocmir  there:  it  is  exceedingly  ud- 
ooramon  for  it  to  impttcate  the  whole  face. 

Hyjiterioal  amestliesia  may  l»c-  w>mplete  or  incomplete.  In  it 
especially  o^Kui-s  tfiermo-anirMhesia, — (,e.,  that  conditioii  tu  which 
the  power  of  distinguishing  between  heat  and  cold  is  lost,  al- 
though general  sensibility  is  preserved.  AnnffffMa,  or  loss  of  the 
]>aiu-t»oiise,  existitig  by  it^^elf  in  aim*  almost  invariably  b^ttterical. 
Thermo-anfcstbesia  and  Hualgesia  may  coexist  in  hysterical  subjects^ 
but  in  the  iimjurity  of  casee  tlie  paralysis  afTecls  all  the  seoaury 
fun  nt  tons. 

A  phenomenon  which  is  usnaliy  present  in  marked  hysterical 
antesthesia  is  tlie  au-called  i»cJurmia.  In  this  condition  the 
surfntie  is  pale,  oud  the  pri<ik  of  a  noe{lle  or  even  an  extirOi^ivc 
Bnperfit'ial  inci.'itti  wound  tloM  not  pmduw  bleeding.  Aniesthetic 
i»chnmia  appears  to  he  specially  pronounced  in  the  violent  epi- 
demic forms  of  hysteria,  such  ns  occurrei-l  in  the  conrui«ionnaire$ 
of  the  Middle  Ages:  heuue  the  miracle  that  Auperfietai  wuu 
were  not  followed  by  loss  of  blood. 

When,  under  tlie  iitfluenoe  of  locsil  appltrations  of  metal 
mustard  plasters,  or  other  active  or  indiffeivnt  aubstanoes  (see  page 
260),  sensatiou  i^eturxis  temporarily  in  a  coso  of  liyslcrical  hciui- 
antcethesia,  the  ischienila  disappears  and  the  neeille-prick  bleeds. 
Ischscmia  has  been  hehl  to  be  characteristic  of  hysterical  hemi- 
ansesthesia,  but  it  has  been  observed  by  Dr.  S.  Weir  Mitchell  in 


api-     I 


A 


tar 


SEN-SORT   PARAI.T8B3.  25fl 

cerebral  hemianrcsthcsta,  and  also  in  the  complete  loas  of  sensation 
which  follows  nerve-«ection.  Tlitut,  iu  a  ca«e  in  which  the  snatic 
and  crunti  nen-e^  had  been  dividetl,  repeated  punctures  with  a 
very  large  needle  wore  not  followed  by  any  blood :  as  the  needle 
was  withdrawn,  a  small  snow-white  ring,  filightly  rawed,  formed 
arouud  tlie  orifice  and  iieemed  (o  close  it. 

Hysterical  HemiansestheBia. — Of  the  varieties  of  hysterical 
anK»«tiK¥ita,  lieiniunttj^iht^ia  \»  llie  mo6t  iiii|K>rtatit,  l>evaiiKe  of  its 
frequency  and  of  its  close  simnlalion  of  the  organic  affection. 
In  its  full  extent  it  ocenpies  one  side  of  the  IwxJy,  and  affects 
the  special  senses,  causing;  deafness,  loss  of  smell  and  of  taifte, 
and  disturboncea  of  vision.  The  latter  may  take  (lie  form  of 
more  or  less  complete  amblyopia,  but  nBimlly  there  !»■•  a  ennwutric 
larrowing  of  the  field  of  vision  and  a  peculiar  loss  of  color-ftcnac, 
which  the  name  of  (tchromatopsia  has  been  given  by  Galezow- 
ski.  In  some  csises  the  power  of  seeing  the  colore  is  entirely  lost, 
so  that  all  objects  appear  of  a  tinirnrm  sepia-tint.  When  the 
achromatopsia  is  not  complete,  the  colors  disappear  in  a  constant 
order.  The  first  color  that  an  hysterical  person  ceases  to  see  is 
violet;  usually,  but  not  always,  blue  is  lost  before  red,  the  inter- 
mediate tints  fa<ling  out  in  regular  succession.  The  loss  of  sensi- 
bility in  hysterinil  hemtanccsthesin  is  dt.'^tinctly  limited  by  a  line 
I      drawn  through  tlie  centre  of  tlio  body. 

^^  MdafioOierapg. — In  1849,  Dr.  Burk  discovered  that  in  hysteri- 
^■cal  ansesthesia  it  was  possible,  by  the  application  of  metals  to  the 
^^sarfooe  of  the  body,  to  recall  sensibility,  and  in  1S6T  he  presented 
an  inaugural  thesis  nj>on  the  snliject  to  tlie  Faculty  of  Paris,  It 
waa  not,  however,  until  1876  that  he  succeeded  iu  attracting  the 
general  professional  attention  of  France  to  tlie  matter.  In  that 
I  year,  in  answer  to  his  ira]>ortunttic8,  the  SociCt^  de  Biologie  of 
[  Paris  appointwl  a  commission  to  examine  into  the  nocnrac}'  of 
^^}it»  alleged  facts.  The  report  of  this  commis-sicn  (Paris,  1879) 
^^  cvntirmed  the  ptatements  of  Dr.  Burk,  and  also  extended  our 
knowledge  of  the  subject.  It  was  found  that  difl'ercnt  individuals 
have  different  relations  with  metallic  iiubstanccs,  some  cases  being 

L affected  by  zinc,  others  by  iron,  others  by  gold,  cojiper,  etc. 
In  exceptional  instances  the  hysterical  person  has  relations  with 
two  or  eveo  more  metals.  When  a  small  disk  of  the  appro- 
priate metal  w  bound  over  the  anieathetic  surface  of  an  \\^&teiUa.l 


260 


DIAONOenO  HEOBOLOOY. 


subject,  after  from  l^iu  to  Lweuty  minutes  a  sea^tioD  of  wanulb 
is  developed  beneath  the  dit>k,  and  a  distinet  nxldi^h  color  a]>pean(. 
At  thiK  time  the  jirit^k  of  a  im>d]c  is  distinctly  felt,  even  pain- 
fully so,  not  only  at  the  spot  over  which  the  plate  has  been  ap- 
plied, but  aUo  in  a  more  or  less  extender]  zone  around  it.  lu 
aoQie  casCG  the  gvnmbility  returns  only  in  the  immediate  vicinity 
of  the  application;  in  others  the  whole  arm,  or  more  rarely  the 
whole  side  of  the  body,  becoincs  sensitive.  With  the  return  of 
aensitiveuesa  there  is  a  disappearance  of  the  ischiemia,  and  if 
motor  palsy  has  existed  there  is  alao  an  iacrease  of  the  motor 
power  siir  nieiiRvii'ed  by  the  dynamometer.  lu  most  cases  of  hys- 
terif^'ol  anaesthesia  there  is  ii  distinct  coldness  of  the  sur&oe,  or 
indeed  of  the  whole  arm,  and  with  the  disappearance  of  the 
palsy  of  seuaatiou  and  of  motiou  there  is  an  increase  in  the 
temperature.  Thus,  in  a  ciuse  of  right-sided  hysterical  amustheEia 
ami  aniyostlieuia,  the  thermometer  lield  in  the  right  liuiid  AttXKl  at 
ZB"  C,  in  the  left  at  34.5°  C.  (Dr.  Dumontpallier,  La  M^aOo- 
tcopU,  Paris,  1880),  but  nfter  the  application  of  the  metal  the  tem- 
perature of  the  lel\  baud  was  higher  than  timl  of  the  right.  In 
many  instances  not  only  is  the  sensibility  of  the  skin  restored, 
but  at  the  same  time  the  special  senses  gradually  i>ecome  nearly 
uorinal,  although  in  other  cases  it  is  neccsi^iry  in  order  to  affect 
the  special  senses  that  the  metallic  plates  should  be  in  the  neigh- 
borhiHHl  of  the  orbit  or  in  the  tciu])oral  i-cgion.  When  achro- 
matopsia is  relieved,  blue  is  usually  the  first  color  to  return,  or 
more  rarely  red.  Sorac  mtuutca  after  this,  yellow  is  perceived, 
then  green,  and  at  last  violet  (Dr.  Aigre,  La  JifftaUo»copie^  Paris, 
1879,  p.  23].  As  seenis  to  have  been  first  discovered  by  M. 
Gell6,  at  the  time  of  the  disapiicaninec  of  the  aiiicHtlieKtu  under 
the  induenoe  of  the  metal  the  loss  of  sensibility  appears  in  a 
corresponding  position  upon  tlic  unpnralvKed  $ide,  and  is  acoom* 
panied  by  a  fall  of  the  local  temperature.  In  a  few  costs  severe 
poius  have  developed  during  tliu  application  of  the  metals.  Ac- 
cording to  the  ex[K>ricnec  of  thr^  Fivntrh  (Hiininissioii,  which  seems 
to  be  identical  with  that  of  subsetiuent  observers,  the  effect  of  the 
application  is  usually  in  hysteria  at  lirst  temporary,  and  lasts  from 
a  few  minutes  to  some  bount. 

Dr.  Burk,  ill   his  coininiinicaiion  to  the  Soci6i£  de  Biologie, 
stated  that  if  the  melal  which  had   been  found   temporarily  to 


SENSORY    PARALYSIS. 


261 


I 


I 


tion  in  a  person  suffering  from  hysterical  aniesthesia 
ere  given  to  sudi  ptitiect  in  ooDtinuuuji  dusm,  all  symptoins  of 
h^-sleria  would  after  a  time  permanently  (liaapiiear.  THr  cora- 
tnt.^<;ion  (•onfirmwl,  in  a  mwisiire,  this  statement:  in  sundry  wises 
they  found  under  such  adminii^iration  that  menstruation  became 
regular,  dipcstion  improved,  and  the  muscular  force  and  sensi- 
l)ility  reUirn«l.  They  further,  however,  nia<Ie  the  extraordinary 
dbcoverv'  that  if  a  piece  of  the  metal  were  bound  down  on  the 
of  the  person  who  had  recovered,  a  return  both  of  ana^thesia 
of  motor  palsy  took  place  in  from  twenty  to  forty  minutes. 

It  having  been  suggested  that  the  metal  upon  the  skin  acts 
by  imluction  of  feeble  galvanic  currents,  the  French  tiommisaion 
found  that  the  application  of  most  metals  to  the  surface  of  the 
human  body  gives  rise  to  an  electric  current  sufficieutly  powerful 
to  be  measured,  that  the.*ie  currents  vary  in  power  with  difTerent 
metals,  and  that  electriail  currents  of  jKiwor  erpial  to  that  of  those 
produce*!  l)y  the  appropriate  metals  applied  to  the  aniesthetic  sur- 
fnee  brouRht  about  a  return  of  sensibility.  The  obsGrvationa  of 
M.  Luya  showed  that  the  application  of  the  appropriate  metals 
was  also  able  to  nxluce  hjiiterieal  hypene-ithcsia  to  the  norm. 

That  the  phenomena  of  the  fio-ca]lo<l  metallo- therapy  a<  I  have 
snmmarized  them  may  frequently  be  obtained,  iu  more  or  less 
C-impleteness,  is  shown  by  the  confirmation  of  the  report  of  the 
French  commission  not  only  by  a  number  of  French  observers, 
but  also  in  Kngtund  by  Dr.  A.  Hugha-i  Bennett  {Brain,  vol.  i. 
part  3  J  Brit.  Med.  Journ.,  Nov.  25,  1878),  in  Italy  by  Kneeola 
and  SepilH  {Lond.  Mai.  Record,  voJ.  ix.),  and  in  Germany  by 
Dr.  F.  Gratx  (iiid.)  and  various  other  obtserverw.  It  is,  however, 
certain  that,  nt  least  in  this  country,  they  arc  cxocptional.  In 
an  elalmrate  series  of  observations  made  in  the  wards  of  the 
Philadelphia  HoApita!  by  my  colleague.  Dr.  0.  K.  Mills,  ibe 
transfer  of  sensibility  wjis  obtained  in  only  a  very  few  cases, 
whilst  Dr.  9.  Weir  Mitchell  affirms  as  the  result  of  his  great  ex- 
perienoe  that  neither  he  nor  any  of  his  assistants  have  ever  been 
able  to  bring  about  amesthesJa  of  the  sound  side,  although  tliey 
have  very  frequently  obtained  temporary  returns  of  rensibility 
by  the  application  of  various  substJUHHis,  e.'^pocially  by  mustard 
plasters,  aud  even  more  pronouncedly  by  freezing  the  skin  with 
rhieoleue.     It  was  at  first  believed  tbat  the  production  of  sensi- 


262 


D1A0K06TIC  KEUROLOOY. 


bility  bv  rcsthcsiogonetic  agenta  is  proof  of  the  hjraterical  na 
of  an  auiestlieaia ;  but  ia  the  oonree  of  his  early  ob««rvatioo9  upon 
the  iiut^ect  M.  Cbarcut  fuund  thai  even  iu  orguDic  heruiaritt«th««ia 
the  application  of  the  plaits  of  metal  was  followed  iu  twentj'  ur 
thirty  minutes  by  a  return  of  the  normal  sen>^ihility  and  of  tlie 
special  Ben««».  Theae  observatiouei  have  been  confirmed  by  several 
French  observers.  JH 

It  ia  also  asserted  that  if  powerful  magnets  be  used  instead  oF^ 
metal  plateA  in  casen  of  hysterical  or  orf^anic  hcniiaoBBthena  with 
coDtractorcs  and  motor  palsy,  there  will  be  relief  not  only  of  the 
paralysis  of  fusibility  but  alM>  of  the  distarbances  of  motility. 
Tiiu^,  M.  T^boulbt>ne  n!|Hirtfi  a  i;asc  (Gaxlte  da  II&pHa\Lr)  of  a 
man,  sixty-seveo  years  of  age,  suffering  from  organic  left  hemi- 
plegia and  complete  hemiamosthe^,  in  whom  tlie  application  of 
a  str^>tig  magnet  wag  followed  by  tlie  reappvarauce,  Bret  iu  tlw 
arm  and  aflei-wartls  in  the  1^,  of  the  Dorrnal  sensibility,  and  by  a 
nitirked  increase  of  the  motor  power  in  the  liand  as  tested  by 
the  dynamometer.  It  is,  however,  to  be  noted  that,  so  far  as  my 
examinations  of  the  record;)  go,  there  has  not  as  yet  Iteeu  re- 
ported a  case  of  organic  hemiaineHthesia  in  whioli  any  transfer  of 
anoethesia  has  been  noted. 

The  explanation  of  the  faotN  of  melallo-thcrapy  is  a  matter  of 
difiGculty,  and  no  (h«ory  has  as  yet  been  offered  which  is  satisfac- 
tor}'.  That  the  phenomena  are  not  th(^  rettiitt  f>f  the  action  of  a 
feeble  electric  current  u|hhi  tiie  iwriphcnil  nerves  secm>;  to  be 
shown  hy  their  having  been  produced  by  metals,  such  as  platinum, 
which  are  practically  non-oxidizable,  and  by  absolutely  inert  siib- 
stflUOCR,  such  as  disks  uf  wuud,  and  even,  us  in  the  case  reported 
by  Bennett  {he.  cU.),  by  the  application  of  a  handkerchief.  The 
theor}*  adopted  by  most  Knglish  writers,  tlmt  they  are  tlie  result 
of  expectant  attention, — i.e.,  that  they  are  the  result  of  the  patient's 
believing  that  the  phenumeua  are  ubuut  to  hapj>eu,— is  asserted  to 
be  disproved  by  the  fuct  that  in  many  cases  the  patient  did  not 
know  wluit  w»s  to  happen.  Tlie  ^o-cnlled  molecular  llieory,  which 
teaches  that  there  issomemysterloiit^  molecular  inHuence  produced 
by  the  applied  plate  on  the  peripheral  nerve-filaments,  amounts  to 
uotliing  more  than  words. 

Jjiuf/nods  of  Hyderieal  AiKreOiema. — Only  in  rare  oaees  is  there 
any  difficulty  in  distinguishing  between  an  hysterical  and  an 


orjpiuic  aniBtfheaa.  HemtaiiRMtJiesia  ocr-urring  in  a  woman  is 
a.sually  hrstprioal ;  in  man  it  is  oomraonly  orfpinic.  Tlierc  ia 
n  peculiar  atmofipliere  siin'ounding  tlie  liystericAl  (lerHon  which 
to  Uit'  ex|ieriencc()  pliysiuiaii  revoalii  llie  nature  of  tlie  caeu,  even 
when  there  arc  no  distioci.  aympioins  of  hj-steria  other  tlmn  the 
ditturbaocet;  of  sensibility.  Almost  invariably,  however,  a  his- 
tory can  be  elicited  of  past  oonviilsivo  seizures  or  of  shifting 
panUysis,  of  globus  hystericus,  of  caprices  of  teai{)er  t>r  (lisposi- 
tioD,  or  of  other  hysterical  manifesialiniis.  Further,  in  ur^nio 
OBsee  the  form  of  the  palsy,  the  iii»turh(i]]{.'cs  of  Intcjiectiuu,  iind 
the  history  of  the  case  generally  strongly  inditaie  the  existenoe 
of  or^pinic  (.lieetiBe.  In  the  ^rettl  majority  of  caries  of  hysterical 
bemiaoicsthesia  tlic  patJcuc  dtMu  not  know  of  the  cxistent^e  of  the 
condition.  If  a  motor  and  a  sensory  paralysis  ooexint,  they  are 
as  likely  as  not  opon  opposite  aides  of  the  body  in  hysterical 
amesthesia,  whilst  in  cerebral  hen»ianffslhft»ia  they  are  of  neces- 
sity upou  tlic  same  «do,  uialeso,  indeed,  tliere  be  two  distinct 
leeious  in  opposite  hemispheres.  According  to  Briquet,  the  hcmi- 
am^thtwia  of  hy»tcria  'm  in  seventy  }ier  cent,  of  tlie  caned  u|iou 
the  leA  Mde. 

The  recognition  of  hysterical  hernia ntesthesia  is  further  faolH- 
tatc<l  by  attention  to  the  following  cuii'^ideraiiuns  : 

J-frat,  The  organic  anoathesia  i=  fixed,  and  does  not  vary  from 
day  to  day  in  its  limits,  whereas  tn  the  hysterical  disorder  very 
often  the  locality  of  the  sensory  palsy  varies  markedly  from  day 
Co  day;  and  even  when  this  does  not  occur,  the  exact  limitii  of 
sensatiou  can  be  noted  U>  shrink  and  increase  i>erpetually. 

Secondly.  In  hysterical  hemiannBtbesia  there  are  usually  spot* 
located  within  the  general  aniesthetic  region  in  which  there  h 
bypertBatiieRia  or  normal  seiusatiou.  The  school  of  Clioruit  bw 
eapeeially  directed  attention  to  the  almost  univeml  pn»enoe  of 
hy{)erieHtheffia  of  tlie  ovary  upon  tlie  affeotixl  side.  In  America 
this  ovarian  hyperesthesia  can  very  rarely  be  demonstraUil,  Imt, 
as  has  been  elaborately  detailed  by  Mitchell,  there  is  frtviuently  a 
r^uu  in  the  groin  in  which  hyiieneBtbeiia  exiita,  although  tha 
ovary  may  not  be  afr(--ctcd.  Thi^  tenitoiy  reachas  from  the  lina 
of  the  groin  upward,  somesimei  as  far  m  the  navel.  The  MMi- 
tiveues  may  be  limited  to  the  skin,  or  may  be  felt  only  upuu 
deep  pressure,  or  may  be  bolit  super6cial  and  deeftHieatod.     Xu 


264 


DIAONOeriC   NKUnULOQY. 


presence  has  been  noted  hy  Mitoliel]  in  caaea  in  which  the  ova 
bad  been  removed  by  the  surgeon. 

It  is  probable  that  8]>ot8  or  trsots  of  Bensitiveoess  frequentlv 
occur  in  the  raidst  of  the  annsthctic  region  and  arc  overlooked. 
M.  FCre  (Archives  de  Neurologie,  1882)  found  such  a  sensitive  spot, 
the  »iiize  of  the  hand,  lietween  the  dortail  and  lumliar  regions,  and 
Dr.  Mitrhcll  Iuls  called  eapecial  itttention  to  the  frequency  with 
■which  the  an»«ith<«ia  is  wanting  in  a  limited  vertiral  9{)ace,  from 
one  lo  two  inches  wide,  Btretching  froni  the  lower  oervicsl  n^oQ 
to  some  position  in  the  dorsal  rcj^ion. 

Payobic  Anseetheeia. — In  1SS3  (Nnimf.  CnUmlb.,  xxiii.),  Dr. 
B.  Thom-scn  announced  that  cutimeoiu  and  Kcnwiry  aniesihediaa 
often  exist  in  epileptics,  and  in  connection  with  H.  Oppenheim 
{Arch,  far  PmjvhiairiCf  xv.  858)  he  published,  in  1884,  an  elaborate 
paper  Li[)nn  the  mibjent.  An  examination  of  ninety-four  cases  of 
epitepsv  showed  that  no  sensory  distarbanoe  follows  the  ordinary 
motor  epileptic  nttack,  and  that  there  \a  no  permanent  alteration 
of  sensibility,  except  in  the  case  of  old  epileptics,  who  present 
other  mure  or  Icse  distinct  sympioniB  of  permanent  functional  or 
organic  degradation  of  the  cerebral  cortex.  Teniiwrary  antB»- 
lliesia  M-ax  found  to  occur  after  attacks  under  three  circumstarHKS : 

Kiret,  when  the  convulsiou  was  followed  by  p06t-epil^tio 
delirium  with  halbiriuaiions. 

Secondly,  when  the  attack  was  followed  by  violent  emotional  or 
psychical  disturbance  without  delirium. 

Thirdly,  when  the  motor  epileptic  convulsion  was  replaced  by 
an  abortive  attack  more  or  leas  violently  afiecting  the  mental  or 
emotional  uphere. 

It  would  appear  from  these  rescnrches  that  when  the  epileptic 
discharge  does  not  chiefly  or  solely  affect  tlie  motor  aphere,  bat 
Hpreud*^  itself  through  the  up|ier  brain-centres  and  aiu^es  intel- 
lectual or  emotional  disturbance,  it  \s  very  apt  at  the  same  time  to 
exert  ita  iu6nenee  uiwn  tlirjse  portions  of  the  oortex  wh  iidi  are 
connected  with  sensation. 

The  absence  of  sensibility  in  many  eases  of  inMnity  is  notorioiw, 
but,  for  obvious  reasons,  in  the  Insane  it  is  exceedingly  ditbcult  to 
determine  the  exact  timita  or  extent  of  the  lose  of  sensitiveness. 
Especially  is  this  true  of  acnte  dementia,  melancholy,  and  acute 
tnauia. 


^ 


^ 


SENSORY   PARALYSIS. 


265 


I 


OROAiaC  AUiESTHESIAS. 

Hon  of  the  Senaory  Palkteayt. — Before  dtsctweiog 
organic  origio  it  seems  proper  tf>  point  out  very  briefly 
the  pathvay  which  sensorr  impalfies  follow  in  going  from  t)ie 
Iieriphery  to  the  respectivo  centres  of  the  bnin-cortex.  From 
the  inirfaces  of  the  body  pase  the  sensory  nerve-fibrts,  vhich  enter 
the  spinal  cord  through  the  so-called  posterior  root-cones  and  go 
to  the  gray  matter. 

The  decussation  of  the  spinal  6bres  Iiaa  been  much  diiooawd. 
It  appears  to  be  the  general  belief  of  phynologHta  that  the  im- 
mediate sensory  decussation  is  not  complete,  althoi^h  the  mqor 
portion  of  the  fibres  do  cross  over  directly  after  coteting  tlw 
spinal  cord  :  in  accordanve  with  this  view,  a  seoBory  tnpalae  pil- 
ing upward  from  the  foot  croeses  in  large  part  to  the  lambar 
r^ion  nf  the  cord,  but  to  some  extent  ntntintMs  upward  withoot 
decussation  to  the  dortial  or  possibly  even  as  far  m  tlw  cerrioU 
spinal  cord.  The  exact  upward  pathway  of  sensDry  impolMi 
after  decitssation  cannot  be  ooasidend  m  finally  drtcmiined;  but 
^  the  ph>-siologica]  evidence  whiob  we  hare  indioatei  that,  whilst 
^P  motor  impulses  descend  along  the  antero-lateral  colummi  of  th« 
con],  sensory  impulM!<  pass  upward  through  the  po»t«rirM-  enlumofl 

•  and  the  gray  matter.  Many  phynolagi^  teach  that  the  t^ttm- 
tiims  of  general  ftensibility  and  the  sAreat  impalwa  which  giva 
rise  to  reflex  acts  are  transmitted  by  the  gr^  matter  in  all  di- 
rections, wbil$<t  tactile  f^en-^tiaoB  travel  cxdwively  \rf  tSi*i  jkj*- 
•  teriorcolui]in!>.  Thit<,  however, does  ooCMen  to  be  fully  pronwl  t 
the  facts  of  diseajie  simply  warrant  the  oondoHon  tliat  aflpTMit 
impulses  of  alt  character?  find  their  way  cslfaer  throogfa  tlu;  pfM- 
lerior  columns  or  throagh  the  central  gray  matter,  and  that  an 
ioterruptiog  lesion  of  theae  regioos  h  followiad  by  \nm  of  mnmJAnn 
of  all  characters  in  the  parts  below  the  lesion.  Tba  atiMory  p 
ways  through  the  medulla  oorre&ptmd  in  poiitios  wflh  i\vtm 

I  other  portions  of  the  apinal  oofd :  in  the  pOM  th*ty  f^viipy  t 
outer  nerve-bundles;  in  the  peduncle  th<y  lie  in  Uw  ■o-aUlad 
tegmentum, — i.e.,  upon  the  poMerior  or  Mperior  [Kirtion^,  iwpa* 
rate<t  more  or  leas  distinctly  from  tlie  eraita,  or  iiioU>r  paihway, 
by  the  gangli<H]ic  man  known  aa  the  taoM  o(|[er.  Aa  wiw  lint 
pointed  out  by  Meynert,  after  Ictrtng  tb«  |mlniiol<ii  tiw  MtMory 


PIAONOemC  XEUTIOLOGY. 


fibres  pass  upward  and  backward  and  form  the  posterior  Uiird 
of  the  »o-ca11ed  internal  ca[»iile,  in  immediate  relation  with  the 


Fia.  9. 


'M 


* 


<^v-^ 


.v^' 


poBterior  and  external  aspect  of  the  optic  thalamus  on  the  one 
hand  and  witb  tlie  posterior  ]>ait  of  the  lenticular  uucleiie  ou  the 
other  (!>ee  Figs.  9  and  10):  at  thii;  [tohiliuii  (lie  ascending  asnaory 
spinal  fibres  are  joined  by  other  fibres  coming  upward  thixingh  the 
corpora  geniculata  an<l  the  optic  thalami  from  the  optic  tract 
Owing  to  the  ouiijunction  of  all  the  eciuory  fibres,  a  lesion  at  this 
position  produces  a  complete  amesthesia  of  special  and  general 
sensation  upon  the  opjMisile  side  of  the  biidy.  From  ihe  in- 
ternal capsule  the  sensory  fibres  radiate  in  the  so-oalled  ooroua 
radiata.  Their  exact  termination  in  the  cortex  remains  at  present 
a  matter  of  duubt. 


OROAtaC  GF.NERAI,    AX.ESTHESIA. 

A  general  amesthcsia  of  organic  origin  is  usually  due  to  a  wide- 
spread degeneration  of  the  bniiu-cortex,  or  to  a  double  lesion  of 
the  uortex,  or  to  a  lesion  ocL-iipyiug  the  po&terior  tbiixt  of  the  in- 
ternal cajisides  of  the  two  hemispheres,  or  to  a  wide-spread  periph- 
eral neuritis.  The  diagnosis  of  tlie  site  of  the  lesion  lunst  be 
made  from  the  concomitant  symptonin.  If  tliere  be  dementia 
pointing  to  profound  degeneration  of  the  cerebral  cortex,  the  diag- 
nosis of  such  lesion  is  made  out;  if  there  be  p»in  and  marked 
tenderness  over  the  nerve-trunks,  peripheral  ncuriiis  U  indicated. 


SENSORY    PARALYRIH. 


267 


A  spina]  general  auieetbeHia  is  theoretiailly  possible,  but  la 
order  for  it  to  involve  the  faoe  the  lesion  would  have  to  be  situ- 
ated in  the  medulla  oblongata.  If  in  auy  uiae  of  general  iiures- 
tb««ia  tliere  were  a  history  of  slow  progressive  development,  with 
symptoms  of  spinal  iru]}li(ratioD  and  no  neural  tenderness,  the 
probable  diagnoeii^  wuuhl  be  an  astiending  ohrntiic  lu^iun  either  of 
the  posterior  columns  of  the  spinal  cord  or  of  the  central  gray 
matter. 

Qouty  Aneestlieeia. — Dr.  J.  A.  Ormerijd  liac)  (.-ailed  attention 
to  a  variety  of  general  aniesthesia  in  which  the  patient  on  awakea- 
ing  has  a  feeling  of  nunibuGeti,  deadnesH,  pins  and  needles  in  tlie 
hands  and  ann-t,  and  Rotnctimeii  also  iu  the  legs.  There  is  also 
loee  of  power,  and  uccasiouatly  the  hands  are  so  far  (wralyited  that 
the  patient  is  unable  to  hold  anything.  Soiuetioies  tlie  syiu])toma 
pasB  off  in  tlio  course  of  a  few  hours,  in  other  cases  they  leave 
more  or  less  permanent  disablement,  and  even  llie  tem|)orary  at- 
tacks are  prone  to  recur.  In  sonic  of  these  eases  the  victim  is 
gouty,  and  with  the  aueestbesia  arc  associated  severe  pain  and  stiflf- 
n«B6.  Such  caHs>  must  be  looked  u)k)11  iu;  probable  iu»tanc-(js  of 
gouty  multiple  neuritis.  In  otherK  of  the  cases  reported  by  Dr. 
Ormerod  the  a^ection  was  plainly  hysterical. 


OHGANIC   HESnANjfSTHESIA. 

Organic  liemianfesthesias  for  olinicat  purpoees  are  best  divided 
into — firalj  those  in  which  the  special  senses  arc  not  involved  at 
all ;  secondly,  tliOM  iu  which  the  senses  of  taste  and  smell  alone 
ar«  impliukted;  thirdly,  tho^e  Iu  which  all  the  special  seuses 
are  aficctcd. 

Oiyanic  Hemianwtlhaiia  ipUJiqiU  Involva/ietil  of  Special  Sinwew. 

Oi^^ic  hemiauu»thesia  without  iuvolvem«Qt  of  the  special 
■ernes  may,  theoretically,  be  due  to  a  spinal  lesion  situated  very 
high  up;  to  di»eH8e  of  the  medulla  oblongata;  to  lenion  uf  the 
pons ;  to  structural  chanji;c8  in  the  peduncle,  the  internal  capsalts, 
or  the  cortex  of  the  occipital  lobes. 

Spinal  Hemianteetheeia. — Tn  spinal  unilateral  toes  of  sensa- 
tion the  loss  uf  sensation  is  upon  the  aide  opposite  to  the  lesion, 
whilst  any  motor  paralysis  which  is  present  is  upon  the  side  of 
the   lesion.     If  the  le^^ion  lie  of  such  character  (a  gummatous 


368 


DIAONOSTrC  NEUROI>0GY. 


tamor  spriDging  from  the  membranes,  for  example)  &<?  to  invoh'd 
nerve-roota,  an  upper  zone  of  ansesttliesia  may  exist  npon  the  side 
of  the  lesiou  a!on|j^  the  upper  margiu  of  the  motor  paralysis. 
The  motor  and  scDsory  distnrboDoes  never  extend  abo\'e  the  npiual 
lesion,  and  a^  the  latter,  if  above  the  origin  of  the  respiratory 
nerves,  wotihl  of  iiw-eewity  produce  fatal  respiratorii'  paralysis, 
Hpinal  lieiuiaiiiesthesia  never  involves  tlie  face  or  the  ne^-k,  and 
very  rar»?]y  tin;  arms. 

A  gummatous  tumor  or  a  transverse  myelitis,  whilM  affecting 
chiefly  one  side  of  the  cord,  may  at  the  same  time  influence  to 
some  extent  the  other  side.  The  result  would  be  complete  motor 
palsy  on  the  side  of  the  lesion  and  amcfithcsia  on  tlie  side  oppo- 
site to  the  lesion,  with  partial  Iosjr  of  [Miwer  on  the  side  opposite 
to  the  lesion  and  partial  loss  of  seneibility  on  the  side  of  tItaH 
lesion, — all  these  symptoms  being  present  only  in  those  portiona^l 
of  the  body  wliicb  are  l)elow  liie  spimil  lemon.  To  make  this 
more  clear,  suppose  that  the  tumor  existed  upon  the  left  side 
of  the  wpper  dorsal  cord:  then  tliere  would  be  eompletc  loss  of 
sendibility  in  the  right  \e^,  and  partial  loss  in  the  left  leg,  whilst 
motion  would  be  entirely  lost  in  the  led  I^,  and  {mrtially  id  the 
right  leg. 

Bulbar  HemianEestheBia.— Acute  lesions  of  the  medulla  pro- 
duce such  stormy  symptoms  and  so  rapidly  fatal  a  paralysis  tliat 
sensory  disturbances  are  very  rarely  noted  :  when  they  exist, 
they  almofit  invariably  take  the  form  of  a  partial  general  a. 
thcsia. 

EemianffiBthesia  from  Disoaae  of  Pone. — A  hemianieHthesia 
without  involvement  of  the  special  senses  may  be  due  to  diseoM 
of  the  pons,  when  it  i;^  almost  always  asKfciated  with  hetulplegia. 
According  to  the  collection  of  cases  made  by  Couty  (Oozetts 
Hehdom.,  IS77,  vol.  xiv.)  and  by  Nothnagel,  small  lesions  situ- 
ated in  the  middle  portion  of  ihc  pons  produce  no  anicsthesia 
of  the  extremities,  but  only  motor  paralysis,  whilst  aniesthesia 
results  when  the  leston  is  sitaateil  more  to  one  side  or  near  the 
floor  of  the  fourth  ventricle.  Our  pathological  material  does  not 
seem  sufGcient  to  warrant  a  iwsitive  formulation  of  the  apparent 
laM',  but  indicates  that  destruction  of  the  outer  bundles  of  the 
(KJD8  is  necessary  for  the  prtKhnrtion  of  antcsthesia. 

Owing  to  the  high  origin  of  the  trigeminus  nerve,  a  crossed 


ins»>^ 


SEKSORY  PABALV&IS. 


269 


I 


senaoT>-  paralysis  may  be  produced  by  a  lesion  of  the  pons;  tliat 
is,  the  l«A  face  and  tlie  right  side  of  the  body  may  be  auicetbetic, 
or  vice  veraa.  Stricily  unilaleral  ano^ethesia  may,  however,  result 
from  a  diftease  of  the  pons.  The  following  scheme,  taken  from 
the  paper  of  Dr.  Sigeraou  {Ihibim  3fed.  Jotinl.,  vol.  Ixv.,  1878), 
reports  the  difieieat  forms  of  paralysis  which  may  be  produced  by 
disenH)  of  the  pons,  and  siiggeete  names  for  such  varieties : 

1.   SIUPIJ!   Al.TERNATK   PAIIAI.YSIS   (UCVTOB  OR  EJBKSORY). 

£end'<lexler. — Right  face  and  teft  exiremities. 
Satd'tini&ter. — Leii  face  and  right  extremities. 

2.  COrXCIDENT  ALTERNATE  PABALYSIB. 
Sensory  and  motor  paralysis  of  same  r^ions. 

3.    DOUaLE  AiTEKNATE    PARALYBIB. 

Compldc. 
X-diaped  Paralyfrxs. — 3oth  aides  of  fiwie  and  extremities  of 
both  »de3  of  body  alfected. 

Incomplde. 
V-akaped  Paralysis. — Both  aides  of  face  afiected. 

Y'^haped  Paralyse. — Both  sides  of  face  and  extremities  of 
(me  side  ".(f  body  affected. 

Lambda-shaped  Paralyaig. — One  side  of  face  and  extremities 
of  both  aides  of  body  more  or  lesH  alTected. 

HemianBCBth<?6ia  from  Lesion  of  Peduncle.  —  A  general 
hemianieiilhesia  without  involvement  of  the  special  senses  may 
resnlt  from  a  lesion  uf  the  |>eduncle.  I  know  uf  no  case  in  litera- 
ture in  which  sensory  without  motor  paralysis  has  been  proved  by 
so  autopsy  to  have  been  due  to  a  lesion  of  the  peilunele,  hut  in  a 
case  reported  by  M.  Mayor  {quoted  by  Nothnagel)  a  small  fotail 

■  disease  was  found  in  the  inner  half  of  the  peduncle,  and  during 

■  life  motor  pidsy  had  existed  without  (teiisory  disturhnnoe.  This 
I  would  indicate  that  the  sensory  ^bres  run  through  the  outer  or 
I  superior  portion  of  the  podiincle.  In  all  reported  cases  of  lesion 
I     of  the  peduncle  the  hemianKstliesia  and   humiplegia   have  both 


J 


270 


orAQNoeno  keurolooy. 


pftralyns,  when  it  haa  existed,  has  been  upon  the  same  side  as 
the  leeiou,  aod  therefore  is  crossed  with  the  hemianKSthesia  and 
the  hemiplegia.* 

Pio.  10. 


-jS^ 


n~ 


'">A 


te' 


Oerobral  Hemianeeetheeia. — A   unilateral   sensory  paral^ 
not  implitating  the  special  senses  may  he  due  to  a  lesJou  in  the 
brain,  provided  sucli  lesion  be  so  situated  as  to  avoid  llie  fibres 
special  senses.     According  to  Meynt;rt^  ii  very  limited  lesion  in 
the  optic  thalamus  near  ttie  geniculate  bodies  is  capable  of  par-^ 
alyzing  solely  the  fibres  connected  with  the  special  sensee. 
little  in  front  of  this  the  fibres  of  general  sensibility  are  fu 
with  those  of  the  special  senses.     More  in  front  tlie  Bbros  con- 
nected with  general  senstbility  exist  by  themselves,  and  conse- 
quently a  minute  k»ion  at  such  point  would  produce  a  hemian-j 
cesthetiia  without  atfection  of  the  special  senses.     A   lieniorrbagfrj 
or  minute  tumor  in  the  anterior  portion  of  the  optic  thalamus^  I 
or  in  the  lenticular  nucleus,  might  thcref«jre  by  pressure  parulyzej 
tlie  fibres  of  general  sensibility  without  affecting  those  of  special 

•  The  cii»o  repurwd  by  Dr.  G.  E.  Paget  (Attd.  Timet,  I8S6,  vol.  xxxi.)  hu 
bMO  mdol;  quoted  u  i^xDeptinDul.  In  it  u  tumor  wae  found  springing  tn>ia 
thfl  right  oruR,  ulthoiigh  during  life  Ihera  hnd  b«en  nculo-mot^r  pkraljiii  of 
t3i«  leit  *ide,  witti  r^nhX  hominnioxlhrviii  iind  ri<;ht  li<<m1p1i!i);iK.  It  h  plaiD, 
however,  that  llio  ]e»iun  Invxlvnd  tlit<  left  cru«  nivn.'  (bun  ildid  the  right,  tor 
wo  wc  told  thai  the  "  miiB^  rominencutl  »  Hitlo  pQEterior  to  the  Junctlita  of 
th«  crura,  and  oxCcndcd  obllqudy  furwnnl  trt>m  the  rlgbl  into  (he  ttfl 
Tba  CMO  onnot,  therefore,  be  efmiidorod  as  asceptional. 


8BRB0RY  PARALYSIS. 


271 


tioi),  and  llierehy  give  riac  to  a  hemianesthesia  withoat  dis- 
order of  tlie  aeusee. 
^m  The  di&lurbana!  of  sight  whidi  occurs  in  cerebral  heiuiaua>6- 
^Hke»ift  18  alvnye  an  homonymous  hemiflnop^ia, — that  is,  a  hemian- 
^hieia  which  affects  tlie  same  side  of  each  eye.  The  detjiils  and 
^^xi>liiimtion  of  this  will  be  given  in  the  chapter  on  Special  Senses. 

The   brief  forronlation  of  the  diagnoelic  iwlata  is,  that  when 
H^xvth  nasal  or  both  tempura)  fielils  are  affected  the  lesion  is  in  the 

optic  chiasm  and  not  within  the  <«n'l)ral  hcmisphens,  but  that 

when  a  temporal  and  a  nasal   field  are  conjointly  paralyred  the 

region  is  within  the  cerebrum. 

IHanwrur«t}t€»ia  involving  Spfcial  SmKS. 
BemianKsthet-ia  involving  tiome,  thongh  not  all,  of  the  special 
Dses,  although  very  rare,  does  occur.  As  is  shown  in  the  cul- 
,cCtion  of  eases  made  by  Couty,  in  hemianaatheaia  due  to  disease  of 
the  pong  the  senses  of  smell  and  lastc  may  Ik-  involved  without  any 
disturi^ance  of  vision  or  audition.  Loss  of  taste  is  to  be  expected 
iu  the  lesiou  of  the  pons,  because  the  gustatory  Bbres  of  the 
gloefio-pharj'ngeal  nerve.s  pans  through  the  pons;  but  it  is  difficult 
to  explain  the  loss  of  smell,  except  by  supposing  that  the  pons 
]e«ioD  is  situated  so  far  anteriorly  as  to  press  upon  the  olfactory 
bulb?,  or  eW  that  it  is  placed  so  far  posteriorly  as  to  eucraach 
upon  the  immediately  contiguous  uncinate  convolutions,  in  which 
some  physiologii^is  locate  the  seuHe  of  smell.  Heuiianiesthesia 
■with  loss  of  hearing  and  sight  without  implicntion  of  the  senses  of 
sai«ll  and  taste  probably  never  occurs  as  the  result  of  an  intra- 
cerebnil  lesion.  I  have,  however,  ueen  one  case  in  which  there 
WHS  partial  hcmiaiiEesthcsia  ^^'ith  epileptic  attacks,  Jacksonian  in 
type,  complete  hemianoi^ia,  and  jiartlal  loss  of  hearing  upon  une 
side,  with  demonstrable  alteration  of  taste  and  smell,  all  due  to  a 
Uuid-like  gumma  wliicli  stretched  obliquely  across  the  auterlor 
end  of  the  pons,  reachiog  ats  far  forward  as  the  cribriform  itpaee. 
The  corpora  qnadrigemlna  aud  the  optic  tract  were  involved  in 
the  exudation,  as  was  also  the  auditory  nerve  of  one  Kide:  hence 
the  alTeclion  of  sight  and  hearing.  One  end  of  the  tumor  was 
niiicii  thic1<er  and  heavier  than  the  other,  and  cnniiecjUi^Jitly  tliere 
was  a  slight  hemiano-stlieaia  and  liemiplegla.  In  a  case  of  lEiis 
,  character  the  basal  situation  of  the  lesion  in  plainly  reve-aled  during 


272 


D1AGX<>STIC  NEDROWWY. 


life  by  the  hemiaaoptitia  not  being;  homonymous:  thas,  in  the  c&se 
just  detailed,  both  the  temporal  fieldK  were  paralyzed. 

Complete  bennaiKestbesia  involving  both  coiuiaoD  den^bility 
and  the  sp^xnal  si-u&e:?  out  rarely  cuexi!>tti  with  iieuiiplegia.  UmJer 
theae  fircurustances,  if  the  symptoms  are  the  result  of  a  sinj^le 
l(3^ton  tlie  hemtanopoia  h  always  homonymous.  The  lesion  mo&C 
be  higher  up  than  the  ^niculate  bodies,  and  muhl  be  sufficiently 
large  to  destroy  or  to  paralyze  by  prenure  the  whole  of  tbc  inter- 
nal capsule,  except  tlie  anterior  segment,  which  cuutains  cerebellar 
fibres:  in  other  word»,  the  lesion  must  diroctly  or  indirectly  par- 
alyze the  posterior  s^^nient  and  the  knee  of  the  internal  capsule. 

I  have  aeeu  several  ca»e!t  in  whii.-h  htfiuiauopsia  coexisted  with 
hemiplegia  and  with  absolute  aphasia,  but  have  never  had  au  op- 
portunity to  make  the  autopsy  of  wich  cases.  As  Uie  tibns  of 
the  facial  and  hypoglossal  nerves  are  believed  to  run  through 
the  kuee  of  the  ca[)«ule  (see  Fig.  10),  a  lesion  at  such  place  might 
afftnit  artioulaiiuu  ;  hut  iu  tlje  cases  of  which  I  aui  uow  speaking  a 
true  amnesic  aphasia  existed.  So  far  as  present  knowledge  goes,  no 
[ideetruction  of  the  internal  cnpeule  is  able  to  produce  such  aphaata. 
The  knee  of  the  capsule  is,  however,  about  on  the  same  level  in 
the  braia  as  the  island  of  Ecii,  so  that  a  laige  clot  iu  the  lentic- 
ular nucleus,  which  liet>  between  the  ifiland  of  Reil  and  tlie  knee 
of  the  capsule,  might,  by  pressure,  [uralyze  on  one  side  Broca's 
convolution,  and  on  the  other  side  the  internal  capsule,  thereby 
producing  complete  hvmiausestlietiia,  hemiplegia,  and  aphaaia.  Aa 
embolus  of  the  middle  cerebral  artery  might  also  produce  these 
symptoms  by  destroying  a  large  area  of  the  bi-ain-i-ortex.  When, 
however,  symptoms  in  a  case  are  complicated  and,  as  ocicuHioually 
occurs,  in  a  measure  contradictory,  there  ia  alway«  a  possibility  of 
a  double  lesion. 

ORQANIC  PARASJSTnESrA. 

Paranspsthesia  is  in  the  vast  majority  of  coses  of  spinal  orij^m 
Theoretically,  it  might  be  pnxtuoed  by  two  coexiiitiug  braia- 
letiions,  aud  a  multiple  neuritis  vuuiiued  to  the  lower  extremities 
would  cause  it.  In  the  latter  case  the  pain  and  tendoruGSB  over 
tlie  nerve-trimks  would  reveal  the  nature  of  the  affection. 

For  diagnostic  purposea  cauea  of  parauasslhesla  are  bxbe  divided 
into  four  groups : 


I 


I 


SENSORY    PABALYSI8. 


273 


1.  Ctoe*  ID  which  the  development  is  ahrapt. 

2.  Ca«8  iu  which  a  few  hours  are  required  for  the  production 
[of  the  sjrmptoms. 

3.  Cssea  in  which  some  dayst  are  neoesBary  for  the  prodiictinn 
[of  the  Dvraptoms. 

4.  Cases  in  which  many  mouths  are  required  even  for  the 
partial  development  of  the  symptoms. 

Fird.  A  paraniEstbesia  abruptly  developed  without  much  pain 
is  oharacteristic  of  hemorrhage  into  the  spinal  cord.  Under  these 
circumstances  it  is  complete,  and  affects  the  rectum  and  geuito- 
ariuory  organs.  A  very  sudden  paranceijthesia  is  sometimes  pro- 
duced by  embolism  and  consiH]ueni  arro^tt  of  function  and  .soften- 
ing of  a  portion  of  the  cord.  It  may  be  produced  by  a  traamatisra, 
such  as  a  stab  or  other  injury,  which  suddenly  puts  an  end  to  the 
faoctious  of  the  spjual  cord. 

Sa^nd.  A  porante:^the:iia  which  has  come  on  in  the  course  of 
a  few  honrK  and  has  been  associated  with  grout  pain  is  almost 
certainly  due  to  rupture  of  a  blood-vessel  within  the  spinal  mem- 
branes. 

7%trt/.  A  paransBsthesia  which  becomes  nearly  complete  iu  the 
oooree  of  a  few  days  usually  is  caused  by  a  central  myelitis  or  by 
a  very  rapid  transverse  myelitis.  A  more  slowly  developed  par- 
aniesthesia  may  be  the  result  of  a  subacute  myelitis,  or  of  soften- 
ing of  the  cord,  or  of  a  rap  idly -developed  tumor. 

Fourth.  Chronic  sclerosis  aSccting  the  {Misterior  columns  uf  the 
oord,  whether  it  occurs  in  foci  or  in  tracts,  produces  below  the 
lesion  a  loss  of  .sensibility  which  is  characterized  by  extreme 
slowness  of  development ;  by  its  rarely,  even  in  its  later  stages, 
becoming  complete ;  and  by  its  connection  with  lass  of  kiicc-jcrk  or 
of  ciwirdination,  shooting  pains^  or  other  well-known  symptoms 
of  locomotor  ataxia. 


DKOANIC   MONOAN.£iTH£&IA. 

Monoame^tbesia  may  be  produced  by  a  cortical  lesion  affecting 
<3entres  in  the  occipital  lobe  which  arc  connected  with  s^^nsation. 
It  may  also  be  caused  by  a  wide-spread  traumatic  or  idiojwthic 
neuritis.  Thus,  I  have  seen  it  as  the  result  of  concus^iou  and 
subsequent  inflammation  of  tlic  brachial  plexus,  due  to  a  curling 
Btorm-wavc  giving  a  downward  stroke  from  above  the  clavicle. 

IS 


274 


DiAONoerrc  NEiniOLOOV. 


OROANIC  LOCAJ.  ANESTHESIA. 

Ijncai  anfRflthcjiiM  may  l)e  tlie  result  of  narrowly-defined  oorU- 
cal  braio-lesioiis,  or  may  be  produce*!  by  tntuiuatisms  or  diseases 
of  the  nerves  tliemselvos.  The  moet  ordinary  forms  of  local  aa- 
BBthesias  arc  those  whicli  aocompuiiy  motor  paralyns  dne  to 
^ifiesare  opoa  nerve- Iran  kg,  A  partial  local  anaestheBia  often 
accom[>anies  neuritis,  and  mar  even  be  a^uciated  witb  a  tme 
hypcnustliet^ia;  that  it^all  inflameil  nerve  may  lose  its  funr4Joasof 
sjtectBl  (wnaibility,  and  at  the  same  lime  be  cxoessively  susoeptible 
to  the  pain*reaction;  so  that^  although  the  slightest  touch  upon 
the  part  may  produce  severe  paiu,  tho  patieut  is  uuable  aocurately 
to  locate  the  points  of  the  compass  or  to  distiaguish  degrees  of 
temjierature. 

Anreathesia  produced  by  section  of  the  nerve  would  I»e  expected 
to  follow  the  di.stribtition  of^uch  nerve  a.s  given  in  standard  treat- 
ises upon  anatomy ;  but  tbe  results  of  clinical  observation  of  the 
effects  of  section  of  nerves  show  that  this  expectation  is  not  tbor- 
uughly  realizeil.  Thus,  a  princijuil  nerve  of  die  brachial  ptexw 
may  be  divided  without  giving  rise  to  complete  aniestliesia  iu  any 
way ;  oud  uhen  a  fx>mplete  aneesthesia  does  result,  the  portion  of 
the  surface  so  aOected  is  very  liniiiefl,  and  of^cn  tlie  area  of  par- 
tial anfficttheeiu  does  not  oorrcspotid  with  the  generally  recogiticed 
anatumical  distribution  of  the  nerve.  Moreover,  the  division  of 
the  same  nerve  in  different  people  produoes  different  results  in 
its  relation  to  amesibcsia.  Aoiesthesia  the  result  of  Derve-sectioa 
tends  to  become  progressively  less  in  degree  and  extent  with  tbe 
lapi^e  of  time. 

I  shall  not  enter  into  an  elaborate  discussion  of  this  subject, 
bat  shall  give  a  series  of  figures  representing  observations  made 
by  several  oliservers.  For  details  the  reader  is  rofcrretl  to  the 
paper  of  Dr.  James  Ross  (lfr«»n,  vol.  vii.  p.  fiO),  to  the  work  of 
E.  Lgtiferant  {Traiii  de»  Sexiiorut  nfrvetisen,  Paris,  1S73),  and  to  the 
articles  referred  to  by  the  writers  just  najued. 

Fig.  II  represents  the  distribution  of  the  cutaneous  nerves  as 
given  by  Flower ;  I  H,  W,  I  C  B,  respectively,  representing  the 
intercosto-humeral  nerve,  tbe  nerve  of  Wrisberg,  or  small  internal 
cutaneous  nerve,  and  the  internal  cutaneous  nerve,  all  derived 
from   tlie  routs  of  the  eighth  L-crvical  and  the  first  ami  seotmd 


ttiid  £  C  B,  the  internal  and  external  cutanmus  branches  of 
the  uiu9eu)o-spiral  nerve;  M  C  and  M  C  B,  the  cutaneous 
braDchea  of  the  mnBculo-ciitaueous 
nerve,  probably  derived  from  the  fift-h, 
sixth,  and  seventh  cervical  roote ;  R, 
the  radial  nerve,  and  U,  the  ulnar 
nerve.  The  distribution  of  the  nerves 
in  the  hand  given  by  Kraiwe  a|>i>ears 
to  be  more  in  aooord  wilh  clinieal 
resulte  than  that  wfaieh  15  usually  ad- 
hered to  by  the  English  anatomiHtn. 

Fig.  12  represents  this  distribution, 
the  ietteiK  standing  for  the  nerves 
whose  names  tliey  bejL;in. 

Fig.  13,  after  Lfiti^vant,  represents 
the  effects  of  an  ana^tiici;ia  which 
followed  section  of  the  »;iatic  nerve. 
The  dark  ahading^  signified  total  aoseetbetjia,  tU«  lighter,  ^xutial 


Fig.  14,  aHer  James  Ras3,  showH  the  interior  and  pa<)tfriflrl 
aapects  of  an  arm  after  a  rupture  of  the  brachial  plexus,  in  which 
tlie  motor  fibres  from  the  fourth  o.!rvi«iI  nerve  probabl}'  esoaped.jM 
The  loss  of  sensation  in  the  part  was  ooniplcte.  ^| 

A  section  of  the  brachial  plexus,  reported  by  Maary  and  Duh- 
ring  (Amer.  Jour.  Med.  Sci.,  ii.,  1874),  was  followed  by  a  loss  of 
sensation  in  (he  forearm  and  a  di&turbance  in  the  upper  arra, 
indicated  in  Fig.  16:  the  interrupted  line  marks  the  boundary  of!^| 
tlie  anasthesia  on  the  inner  surface  of  the  arm,  wliilst  Uie  noin-  ~ 
tcmipted  line  a  a  markH  the  Iwiindary  of  the  anasthesia  on  the 
outer  surface  of  the  arm.  This  case  would  seem  to  show  that 
the  intercosto- humeral  nervo  and  the  detcoriding  branuhes  of  the 
cervical  plexus  supply  tdosI  of  the  inner  surface  of  the  upper  arm 
and  a  little  of  the  outer  surface. 


8KHB0RY   PARALYtOS. 


Fig.  16,  after  L^ti^vant,  represeute  the  loes  of  sensation  two 
years  and  a  half  after  divisioD  of  a  maaeulo-spiral  nerve  by  a 
pooiard.  Tlte  depth  of  the  shading  indicate^)  the  degree  of 
sensory  {lalsy.    The  ana  of  ihe  aiieoetliesia  in  this  case  is  reinark- 


Fio.  14. 


ably  in  contrast  with  that  of  the  aneeHtliEsia  whioh  followed  in  a 
CAM  of  Dr.  S.  Weir  Mitchell's  division  of  the  rau8culo-;*piraI  uud 
median  nerve,  as  represented  in  Fig.  17:  in  this  figure  the 
light  shading  indicates  tlie  area  in  which  tactile  seosibility  was 
diniiniahed,  and   the  deep  shading,  that  in   which   it   vrtm  loet. 


278 


DiAaKoeno  neuboloot. 


The  marks  >  <  indicate  the  appreciataon  of  separate  potnts. 
A  single  mark  (V)  indicates  that  the  points  are  not  felt  as  sepa- 


FiQ.  16. 


Pro.  16. 


Fio.  17. 


rate.  The  absence  of  the  mark  indicates  complete  loss  of  tactile 
sensibility.  H  indicates  a  small  area  in  which  there  was  hyper- 
algesia of  the  skin. 


CHAPTER    VII. 


EXALTATIONS  OF   SBNSIBILrrY. 

HYPER  JESTHESIA. 

By  the  term  hypcrBcwtlictiia,  as  iiscd  in  this  book,  is  meant  a 
condition  of  the  seosory  ocrvous  system  which  canaes  it  to  re- 
spuod  more  actively  than  normally  lo  irritatioos.  This  condition 
is  closely  assoriaiKl  with  paiti,  hut  la  (1i>ttlnoi  from  it,  since  a  |)art 
may  be  hyperetsthetic  and  yet  not  {Miinful  so  long  aa  no  external 
irritation  is  present.  Often  a  part  is  both  jiainful  and  hyjienes- 
tbelic     Thus,  an  iuflatued  nerve  suflfer^  from  pain  origlualiug 

itbio  iteelf,  and  is  also  excet-sively  sensitive  to  esLcrnul  irrita- 
tions. Precisely  as  antt^^lht-sin  of  s|>fdal  Hensibilities  may  cx)exist 
with  or  may  exist  separately  from  anwsilicsia  of  genoral  sensi- 
bility, so  may  special  and  general  liyperieatlieaias  exist  alone  or  to- 
gether. Hypenesthesia  or  excessive  functional  aciivity  of  specnal 
BensibiliticB  is,  however,  rare,although  tliere  are  hysterical  cases  in 
which  there  is  a  positive  increase  of  Mnsibility  as  regards  the  dis- 
crimination of  locality  and  of  temperature.  Probably  nne  expla- 
nation of  the  extreme  iofrequeney  of  increase  of  s|>ecial  sensibili- 
ties is  tu  be  found  in  the  fuel  that  whenever  a  spetnalized  nerve 
becomes  hypcncsthetio  it  is  very  prone  to  respond,  even  to  its 
normal  stimuli,  by  pain  rather  tluin  by  extraordinary  acuteness  of 
functional  activity.  Thus,  a  hyperu^thelic  eye  commonly  does 
not  see  more  acutely  than  normal,  but  sutlers  intensely  nmlor  the 
stimulus  of  light.  There  is,  however,  in  hysteria  wcasionally 
bypcncstbesia  of  the  sjwicial  senses,  in  which,  with  or  without 
tiie  coexisLcnoe  of  the  pain -reaction,  there  is  an  excessive  func- 
tional power,  so  that  the  eye  will  see  clearly  in  a  darkeneii  room, 
or  the  ear  will  hear  sounds  which  are  inaudible  to  the  normal 
ear. 

For  the  purposes  of  study  and  discuissioi],  hyperteslhesias  may 
be  divided  into  Ilystcrical  Hypera^sthesJa,  Psychical  UyperH!!!- 
ithesia,  and  Organic  HyperGssthesia, 

281 


282 


DIAONOffrrC   SEOHOIjOOY. 


HYSTERICAL    HYPER^STHBSfA. 

Hysterical  liy[>E?rfBBthesia  nmy  follow  the  regional  fliatribulion  j 
which  is  cotumoD  Id  anieethesia  of  the  same  nature :  usually,  howt^f 
ever,  it  is  more  irregular  iu  its  distrihatioD,  occurriog  in  patches  ~ 
which  may  inlerrii|)t  aiui-sllietic  tnicts.     Coiioeriiing  these  inter- 
rupting tracts  sufficient  haa  already  been  said  under  the  head  of 
Anicsthesia.     It  seems  here  necessary  only  to  point  out  in  detail 
certain  forniH  of  local  liyoterical  hypene4tlie«ria  which  are  liable  to  h 
be  confounded  witli  discoac  of  other  character.  ^ 

Qenital  Hyperseetheaia. — Among  the  local  hysterical  hyper- 
aathcsias  to  be  here  mentioned  is  hypcncsthcsia  of  the  genital 
organs.  Tins,  seen  almost  exclusively  in  the  female,  is  rarely 
associated  with  an  excess  of  nexual  desire,  but  usually  gives  rise 
to  severe  pain  during  the  sexual  ad,  and  often  lies  at  the  foon-^l 
dation  of  the  vngitnil  spasm  known  as  vaginismus.  V 

HyBterioal  Breast. —An  im]M>rtant  and  common  form  of  local 
hypertesthesia  is  the  hysterical  or  neuralgic  breast,  which  haa  fre- 
quently been  mistalci-n  for  cancerous  or  other  organic  disease.  The 
breast  is  often  much  Awotlen,  and  the  [uiin  cxoc^sive,  sometimea 
shooting  down  the  arm  and  being  made  wot^c  by  using  the  arm. 
The  diagnosis  between  this  condition  and  organic  tumor  of  the 
bi'eat^t  can  usually  Ik^  made  without  difficulty  by  paying  attention 
to  the  following  puint.n.  In  the  first  place,  the  tenderness  is  exces- 
aive,  and  is  «u|wriinal,  so  that  as  much  pain  la  pradnced  by  merely 
brushing  or  handling  the  breast  as  by  hard  pressnre.  In  organic 
tumor  the  pain  is  proportionately  increased  by  pressure.  Again, 
the  swelling  is  ninrc  difluHc  in  the  hysterical  breast,  and  lacks  tlieM 
definite  limitation  usually  seen  in  organic  disease.  If  a  distinct^ 
tumor  be  simulated,  it  ts  commonly  le<»  iiersiatent  in  form  and 
more  tender  than  is  the  organic  altei-alion.  The  neurotic  breast 
varies  in  sixe  and  in  consistency  Mtntinually,  and  is  often  enlarged 
and  more  pninfut  at  the  menstrual  period ;  the  paiu  is  often  ex- 
cessive, and  is  increased  by  the  approach  of  stormy  weather  and 
by  general  fatigue.  In  almost  all  cases  marked  cvidenoes  of  the 
neurotic  or  hysterical  terapcrament  exist. 

A  form  of  the  neurotic  breast  which  nut  rarely  gives  rise  to 
alarm  on  the  |Mirt  of  [wronb!  occurs  nt  the  age  of  pulwrty.  When 
the  system  is  expanding  from  childhood  to  womaohood.the  breasts 


I 


J 


383 


■Hiallv  beoooM  ««onm  and  HiJu,  b«t  if  all  t^  geaital  orgsM 
unfold  ihtamAwtB  mmmUmKomiy  a*  tlwftU  is  takw  abe«l  tW 
matter.  Ib  Bcsntie  jvbb^  K'*'  ibbc  ib  oAm,  hovcrcr,  iRif£U- 
lariir  of  sexnal  — feMiag,  »  Aai  vhile  ooe  bnafli  rettuns  « 
bentofore  tli«  o(W  Bairlwlr  gn>v9  Iwt,  aod  so  pwafol  and  Itsxkr 
■B  mAterially  to  i^adc  tkm  ^  of  the  am.  I  ltt¥e  seen  ■  niui- 
ber  of  Bimikr  anmitiB  bmels  oennnii^  in  bars  at  tbe  ag?  of 
puber^,  a&d  mm  af^A**!  witb  tbe  lecretioti  of  a  few  drops  of 
sero-lacteal  fluid. 

Hrstehcai  Jotota. — Ujnicncml  patknts  are  venr  liable  bo 
•floctionB  of  the  buser  jaiola  aJaialatiag  a  ebrooie  toflainniatina, 
btit  doe  to  a  ncaralie  hyyewalhcgia.  Of  all  tbe  latter  joints  tbe 
knee  is  the  one  omhC  tHoallj*  attacked.  Tbe  hvstertoal  di«aaie  of 
this  jotDt  ift  tu  be  reoogmaed  b;-  atteotioo  to  tbe  follgw-ing  voasid<- 
oalioDs:  fird,  the  muscular  rtgiditr  or  conirartioD  cnn  be  over- 
eome  by  mtldljr  pervtstrat  HTun;;  wbile  iho  iiatieni'i;  luiud  is 
diverted, yields  readilr  daring  natural  sleep,  ami  diappears  during 
al^ht  anaectbesia,  or  even  under  a  full  do»  of  chloral  nr  opium : 
9eaondh/f  there  a  no  rise  of  tonperatute  io  tbe  joint,  alllKHigb 
^he  part  looks  red  and  inflaswd :  tkirdfy,  tbe  reH<iiiiD  of  the  otm- 
tncted  and  apparently  atrophied  muscles  to  (he  fnradic  current  U 
Dorrnal. 

To  oi|;aoic  diseaw  of  tbe  knee,  relaxatiou  never  takes  place 
except  iu  profound  aiii»«tbesta,  tlte  temperature  of  the  surface  ia 
above  normal,  and  tbe  fantdic  reaction  of  the  aflected  miiacl^  is 
lost. 

A  mimetic  diiteuse  of  t)ie  hii>-joiut  is  oHen  di^liiiguishcd  with 
some  diCBcalty  from  the  organic  affection.  It  is  to  be  recognized 
by  noticing  that  the  ap[»areiit  tenderoftw  of  tbe  limb  as  rev«il«l 
In'  the  limp  varies  jircatly  from  time  to  time,  and  especially  is  less 
when  the  attention  of  the  patient  is  diverted  :  it  is  ahto  made  worse 
by  fatigue  ur  nervous  excitement,  and  bencv  \s  u^^tiidly  mnch  more 
dii'tinct  in  the  evening  than  in  the  moruing.  Fain,  whicli  in  the 
organic  dtAeasc  commonly  follon-s  the  limp  iu  the  onlcr  of  ite  de- 
velopment, in  the  hysterical  disease  generally  precedes  the  limp. 
The  muscular  rigidity  in  the  hysterical  affection  varies  greatly, 
and  can  l>e  readily  overcome  by  cliloral  and  nnaifthetira,  and  di»* 
appears  <luring  sleep.  Cven  if  muscular  atrophy  exists,  llie  normal 
electrical  contractility  is  preserved.     The  evidences  of  the  liya- 


I 


DiAosoeric  neurology. 

tcHail  temperainent  abound  in  this  as  in  all  other  mimetic  joint- 
afi<H7tioitA,  imd  the  ayniptoms  arc  much  \csa  severe  when  a  great 
ilesire  arises  on  the  part  of  the  patient  to  perform  acts  requiring 
exertion. 

Spinal  Hypera&BtheaiB. — An  important  local  form  of  hyster- 
ical hyperiesthesia  is  that  which  is  present  in  theaxalled  spirud 
irritation,  or  wpinat  ana-mta.  Thia  condition,  which  by  msny 
writers  of  text-hooka  on  nervous  diaessea  is  raised  to  the  rank  of 
a  distinct  disease,  is  tiiHSMJingly  frequent  and  variable  iu  d<^ee. 
In  a  very  large  proportion  of  ncurotie  young  women  there  exists 
a  tract  somewhere  in  tlie  spinal  column  which  is  especially  tender 
to  touch.  Tlie  ordinary  iwsition  is  between  the  shoulders ;  the  ^ 
hyjwncsthetio  n^ion  may,  however,  be  as  low  as  the  lower  lumbar  f 
or  as  high  as  tlie  upper  cervical  vertebne.  Even  in  moderate 
oases  a  alight  touch  produces  a  acose  of  faintoess,  and  sickness  of 
the  stomach,  and  I  have  seen  cases  w  severe  that  painting  with 
ft  a  camelVhair  brush  would  cause  excessive  agony,  and,  if  per-  ^ 
BiHted  in,  even  general  convulsionSj^-coses  in  which  the  laying  of 
a  hanil  or  even  the  touch  of  a  pillow  oti  the  Imck  would  make 
the  patient  fall  in  the  bed  and  lie  for  days  ap|)arently  at  the 
point  of  death,  unable  to  turn  or  to  speak,  save  in  the  faintest 
of  whispers.  In  such  women  violent  hysterii-al  (Nuivnlsioiis  occur 
oocasionally.  The  symptoms  arc  commonly  inieosified  by  fatigae, 
and  not  rarely  much  pain  between  the  shoulders  is  complained 
of.  This  pain  U  iiici'eased  by  Jarring,  and  by  any  prolonged  use 
of  the  arms.  There  is  not,  to  my  mind,  the  slightest  evidence  of 
the  exisletice  of  anffiniia  or  congestion  or  of  any  other  po(H>gnizable 
alteration  of  the  spinal  cord  in  this  so-called  spinal  irritation. 
The  diagnosis  is  very  easy;  in  seriom  disease  of  the  vertebne, 
and  even  in  inllammatiou  of  the  jioaterior  nerve-roots,  the  een- 
sitiveueas  is  not  so  extreme,  und  usually  cannot  be  developed 
except  by  firm  pressure.  Further,  hy|>er»sthe>iti  of  the  spinal 
region,  unless  excessively  severe,  is  not  accompanied  by  spasm  of 
the  spinal  muscles  or  restriction  of  the  movements,  sucli  as  are 
seen  even  In  Jnoipieiil  disease  uf  the  vertebraj.  When  to  thene 
facts  are  superadded  the  existence  of  the  hysterical  constitution, 
the  absence  of  evidences  of  severe  coa'ititutional  disorder,  and  the 
shifting,  varying,  evidently  neurotic  tyjHi  of  the  tenderness  itself, 
the  character  of  Uic  case  becomes  evident. 


I 


I 


I 


• 

L 


EXALTATIONS  OF   BENBIBTI-ITY.  286 

OKGANIO  lIYPERjEBTHESlA. 

Oi^Dic  hypcrasthesias  replace  organic  antesthcsias  when  the 
leeioii  irritates  ratber  than  paralyzes:  Jhenue,  theoretically  at  least, 
it  ip  |M£hibIe  to  have  hcniihy]>cnesthesiafl,  itaraliy|)ere»4(lie}iiaK, 
moDohyperssthesiaa,  etc.,  each  corresponding  tu  an  organic  nnas- 
theRtB.  Clinically,  however,  hyp&ne!tth«ia.q  due  to  dieeaf^.  of  the 
nerve-centres  themselves  arc  so  exceedingly  rare  that  detailed 
consideration  of  them  doea  not  eecm  necessHiy.  It  is  otherwise 
with  diffuse  of  the  mciubnuies  which  cover  the  iicrveHxinlree. 
The  roots  of  the  sensitive  nerves  pass  through  the  spinal  mem- 
branes, and  have  for  their  shoaths  the  prolongations  of  sufrlt  mem- 
bnuee:  consequently  iu6amuiatiuii  of  llie^  nieitibraues  gives  rise, 
aimoet  of  neoessity,  to  an  inflamniatiou  of  the  posterior  or  sensory 
nerve-roots,  wilh  the  necessary  production  of  pain  and  hyper- 
esthesia. These  sensory  symptoms  are  always  accompanieil  by 
spasm  of  the  muscles,  on  account  of  the  coexistent  inflammation 
of  the  motor  roots.  The  groups  of  symptoms  which  are  thus  j)ro- 
duccd  have  been  sutljciently  detailed  under  the  head  of  Spasmodic 
Afiections  (sec  page  IfiS).  It  seems  only  necessary  here  to  point 
out  that  hypenesthesia  of  the  neclc  and  face  may  be  symptomatic 
of  iDflanimatiou  of  tlie  basal  braln-membraneu,  and  laiend  hypcr- 
ffiBtheuafi  ami  hypersathesias  in  the  limbs,  of  inflammation  of  the 
spinal  membranes. 

PAR-^ESTHESIAS. 

Uoder  the  name  of  paresthesias  may  be  grouped  the  almost 
itinumerahle  dii>agr(;euble  eeusatiuns  which  accompany  functional 
and  organic  nervous  diseases,  and  which  are  usually  refem-d  to 
the  surface  of  the  body,  or  more  rarely  to  nuit«us  tracts,  Such 
are  formications,  prickling,  a  feeling  aa  of  the  flowing  of  water  or 
of  the  crawling  of  ants  or  other  insects  over  tlie  sui'face,  ilclirng, 
6uahes  of  heut,  waveH  of  culd,  etc.  These  symptujns  may  be  due 
to  hysteria,  and  aro  veiy  common  in  women  at  the  cliniartcric 
perio<l,  even  when  no  distinctly  hysterical  symptoms  are  present. 
In  rare  cases  of  insanity  they  are  iwycbical, — i.e.,  of  the  nature  of 
a  delunion,  the  subject  simply  imagining  their  cxisteneo.  They 
may  be  prmluced  by  various  |H)isuns.  They  are  often  the  result 
of  disease  of  the  spinal  cord,  either  simple  congestion,  myelitis,  or 


I 


386 


DIAONOSrriC  NETBOLOGY. 


I 


tlie  curious  ooudition  wliich  occasionally  follows  spinal  concossion. 
"Wlien  localize!  in  one  arm  or  in  one  side  of  the  body,  they  may 
be-  ])roduced  by  local  braiu-allerations,  aud  ouoaiuouaDy  ibey  exi^t 
as  prodromes  of  hemiplegia. 

When  parresthcsla*"  are  not  hysterical  or  due  to  diseftae  of  the 
spinal  cori),  they  arc  usually  the  outoome  of  iwine  poison  in  the 
blood, — notably  either  the  gout-polsoa  or  lead.     Id  a  case  which       i 
had  l>eeu  under  the  care  of  inoet  of  the  leading  neurologists  ia^| 
the  United  Slates  without  pliinihism  having  been  suspected,  the  " 
chief  BymploiiiB  were  an  apparent  insomnia,  with  horrible  itching 
over  the  whole  snrfaoe,  and  Itching,  with  burning  pains,  in  tbe 
urethra.     A  chemical  examination  of  the  urine  and  of  the  water 
habitually  drunk  by  the  [latieot  demunstruted  the  existence  of 
lead  in  each.     The  insomnia  was  undoubtedly  due  to  the  panw- 
thesia. 


PAIN. 


Pain  is  a  symptom  so  variable  and  so  universal  Uiat  it  is  diffi- 
cult to  discuss  it  pro[>crly  in  connection  witii  one  clasH  of  diseases. 
Its  importance,  however,  necessitates  its  consideration.     In  esti- 
niatiog  the  intensity  and  the  (liagnostic  value  of  paio,  it  luust  be 
remcmL>cred   timt  what  may  be  called  the  imin-reaction   varies 
almost  inde6iiitely  in  individuals.    A  disease  which  iu  one  person 
produces  a  veritable  agony  will  in  nnother  cause  but  little  sufTeriog. 
Tt  is  stated  thnt  an  old  hardened  cart-horse  will  quietly  eat  bi»^fl 
oats  whilst  the  operator  is  cutting  down  upon  the  thoracic  duct,  ^1 
altlioiigh  a  thoroughbrct]  squeals,  plunges,  anil  l>eoomefi  entirely       . 
unmanageable  at  the  first  touch  of  the  scalpel.     In  man  the  dif-  fl 
fercni-es  in  sensitiveness  are  as  great  as  in  the  horse.     Moreover,       i 
the  statements  of  patients  vary  enormoubly  In  n^anl  to  pains  of 
equal  Intensity.     The  hysterical  person  habitually  overstates  bis 
euffbrin^:    indeed,  the  iKonliar  exaggeration  leads  the  experi- 
enced practitioner  almost  at  once  to  a  correct  diagnosis,     A  very 
important  assistance  in  the  recognition  of  an  hysterical  or  other 
exa^erated  pain  is  to  be  obtalneil  by  noticing  the  disagreement 
between  the  words  of  the  paticut  and  the  expression  of  the  fooe. 
A  well-timefl  eompltmcnt  to  a  woman  groaning  in  agony  will 
of^eu  bring  the  reward  of  a  momentary'  pleasant  smile  or  expres- 
Hon  of  gratification  and  tbe  consequent  diaoovery  of  the  meaning 


I 


EXAI-TATrO.VR  OP  SESHIBIUTY. 


S87 


I  of  the  alleged  pain.  Sometitnee  the  words  and  tlie  expressioa  of 
the  face  |>erpettiall^  give  llie  H&  to  (■a<:^))  other.  Again,  by  skiU 
full^-  dtstnictiug  tlie  alleotion  of  the  patient,  the  ]>ain  or  alleged 
tenderness  cnn  ofken  be  caused  to  diHap[)eQr :  thus,  engaging  tlie 
patient  in  acti%*e  conversation  may  cause  her  not  to  notice  firm 
pressure  tipou  the  8jK)t  which  is  alleged  to  be  intensely  sore. 

As  mo&t  local  iuflaoimatioDs,  ulcenttiont»,  or  other  orgauic 
olmigee  produce  more  or  lens  jiain,  it  is  essential  that  a  careful 
examination  he  made  to  discfjver  the  exiBtenceofany  local  diecase 
before  the  consideration  of  the  nervouii  origin  of  tlic  puin  m 
entered  upon.  In  the  discuasion  which  follows  in  this  chapter  it 
will  be  taken  for  grantetl  that  such  examination  has  been  made: 
aU  Oie  diagnontie.  jimcetiures  and  ndat  t/ieen  are  founded  upon 
the  Kippoaiiion  that  (he  existence  of  focal  disease  has  been  ex~ 
Oudftt. 

The  diaguoiitie  iu]]>ort  of  pain  in  nervous  diseases  ia  best 
Bttidied  by  dlvi<ling  the  body  into  three  regions,  ami  discussing 
each  of  thft*  Beparatcly.  Tiicae  r^iona  arc  the  extrcmitict!,  the 
trunk,  and  the  head. 

Neuxalgic  Temperament. — Before  taking  up  the  sy&tematio 
cotwideration  of  the  various  localized  ncrve-painti,  it  seems  nctxB- 
aar)'  to  say  a  few  words  in  regard  to  tlic  obscure  but  intolcmble 
pain.s  which  may  be  included  umler  the  term  Nettralgia.  For- 
merly almost  all  forms  of  nerve-[>ain3  were  spoken  of  as  neuralgic, 
80  that  whenever  there  was  a  lack  of  obvious  local  lesion,  such 
as  of  ubtKxHi,  etc.,  the  patient  wa;^  «iid  to  Ihi  sufTeriitg  from  neu- 
ralgia. Most  of  the  varieties  of  Icwalizod  puiiis  wliicli  wilt  be 
treated  of  in  sulisequent  sections  liave  been  split  off  from  neu- 
rnlgia,  but  then*  yet  remain  pains  fur  which  we  caunoL  account, 
and  to  which,  therefore,  the  term  neuralgia  is  still  afiplicd.  In 
many  cases  autopsies  will  show  that  the  supposed  neuralgic  pain 
was  cftoscd  by  a  definite  lesion:  thus,  a  clot  forming  near  the 
trigeminal  nerve-centre,  or  a  spicule  of  bone  liidden  from  exter- 
nal view  pressing  upon  b  nen'o  in  suofa  a  way  as  in  irritate  it 
occasionally  but  not  to  provoke  a  define<l  neuritis,  would  give  rise 
to  pain  that  during  life  might  have  to  be  termed  neuralgic. 
There  is,  however,  n  final  group  of  oases  in  which  neither  during 
Hfc  uor  after  death  arc  we  able  to  detect  any  taiusQ  for  the  pain. 
It  would  seem  that  there  may  be  a  molecular  change  either  in  the 


Benson*  nerve-centreftorin  tlienervesthemselv^ssofincasto  escape 
our  instruments,  which  predisposes  the  individua]  to  siiifer,  so 
tli&t  a  change  of  weather  or  other  untoward  influence  too  slight  to 
be  felt  by  the  normal  man  caused  a  pain-etonn.  In  a  lar^  pro- 
portion  of  cases  nearatgia  is  mulouhtedly  of  ^utir  or  lirhsmic 
origin ;  hut  it  has  iweroed  to  me  that  we  must  acknowledge  that 
there  is  also  a  general  condition  which  may  be  known  as  the  oca- 
ralgic  lemperanieat  or  diathesis.  This  is  alien  inherited,  but  may 
be  devitloiml  hy  prolong^]  bodily  exhaustion  or  other  cnascs. 
When  once  acquired,  it  may  persiee  although  the  original  cauM 
has  been  removed.  The  pains  which  come  to  some  persons  in 
tnalarial  ansemla  probably  are  often  neuralgic,  but  when  tlie 
anaemiii  has  been  rclicviHl,  if  the  nervous  syaleni  has  been  suffi- 
ciently long  in]pr«wecl,  the  pain-tendency  becomes  stamped  upon 
it,  precisely  ns  the  epileptic  tendency  liecoraes  eonstitutinnal  in  a 
case  of  reflex  epile|isy  and  per^istm  after  tlie  removal  of  the  origi- 
nai  irritation.  Thuse  neuralgic  [>uini^  are  (o  be  recognized  by  their 
pereiateocy,  by  the  absence  of  taufic,  and  by  the  excluding  of  alt 
other  sources  of  pain.  I  believe  that  the  acquired  or  tuherited 
neuralgic  tem|)eranienl  frequently  is  clowly  connected  with  or 
complicates  some  of  the  pains  hereafter  to  be  described.  Thas,  £^ 
have  seen  cases  of  migraine  in  which,  i^eeides  (lie  definite  aitaelcs,^ 
there  were  not  rarely  seizures  in  variou-s  parts  of  the  l>ody,  and 
still  more  freqnently  a  complete  departure  of  the  migraine  from 
its  typi'.'al  cfiaractenstics.  Under  tliese  circumstances  possibly  a 
iieural^'ic  temjteruineiit  is  superadded  to  au  iuiierited  migraine. 
The  neuralgic  temperament  is  iindoubteilly  closely  allied  to  iiilier- 
^^Kjted  gont ;  but  the  facts  that  the  neiintlgic  tem]>erameitt  f^  often 
^^Voorrefpouds  with  the  general  neurotic  tcuiperameut,  that  it  is  more  _ 
W  frequent  in  women  than  in  men,  and  that  it  is  so  often  prevalent  fl 
I  in  dry  neurotic  cHmnle^  and  in  ficrsons  free  front  gouty  symp- 
I  toms,  indicate  that  the  neuralgic  temperament  is  something  more  _ 
I        than  a  gouty  diathesis.  f 

I  Reflex  Pains. — Although  in  the  following  pages  much  will  be 

I        said  in  r^artl  to  the  occurrence  of  pains  at  a  distance  from  iJie 
I        point  of  irritation,  some  gencnil  rcmarlcs  upon  the  subject  seem 
I        necessary.     Precisely  as  there  may  be  reflex  disturbances  of  mo-  ■ 
I         tility,  so  may  we  have  reSex  sensory  disturbances.      Usually  the 
I        pain  is  fell  in  some  region  near  to,  ur  at  least  iu  relatloa  with,  tlie 


\ 


EXAl^TATJONS  OF  SEKSIBWJTY. 


289 


* 


of  irritation.  Thus,  Anstie  describes  several  cases  of  ueu« 
Tnlgia  ID  tbe  uretlirs  and  testicles  as  the  I'esutt  of  aelf-abuise.  A 
facial  pain  caused  by  a  diseased  tootb  may  be  due  to  a  projiagated 
neuritiB;  but  that  such  pain  may  be  reflex  U  Khown  by  its  not 
rarely  occurring  upon  the  side  of  the  bead  oppoait«  to  the  afiecteil 
tooth,  aud  also  by  the  cases  reported  by  Dr.  Ferrier  {Thise,  1884, 
p.  376),  iu  wliicli  fadal  tictiralgia  was  prudiiued  ininiply  by  the 
irritation  of  tartar  upon  the  teeth.  Other  not  uncommon  in- 
stances of  neuralgic  pains  oorurring  n«ir  the  seat  of  the  irritation 
are  the  intestinal  neuralgia  which  often  at-companies  impacted 
fjecee,  and  the  pain  in  the  bladder  which  sometimes  results  from 
Bfisure  of  the  anus.  Although  uRualEy  thus  clofie  at  hand,  the 
reflex  neuralgic  pain  may  be  at  a  long  distant^  from  the  irritated 
point  and  have  no  apparent  connection  with  it.  Xbu9, 1  have 
seen  a  mastoid  pain,  no  violent  as  to  lead  to  the  diaguo^is  of  disea&e 
of  the  bone  and  to  a  deep  iucisioii,  caused  by  tapeworm  in  the 
large  intestine;  and  in  the  thesis  of  Ferrier,  quoted  above,  there 
are  recorded  instances  of  cervioo- brachial  neuralgia  resulting  from 
a  disened  tooth,  Tlie  recognition  of  the  character  of  the  pain  in 
these  oasBB  depends  u|K>n  the  acutenens  of  the  physiciati  in  per- 
oeinng  the  absence  of  other  causes  and  the  presence  of  the  irri- 
tation. 

PAIM8  1»  TB£  £XTBEmT££tJ. 

A  persistent  pain  occurring  in  the  It^  or  in  the  arms,  aud  not 
dependent  u)>on  ubviou^  Unial  diseatie,  may  be  due — 

1 .  To  gout  or  rheumatism. 

2.  To  neuritis. 

3.  To  dirouic  metallic  poisoning. 

4.  To  disease  of  the  spinal  oord. 

6.  To  neuralgic  or  malarial  cachexia  or  other  obvious  or  ob- 
•cnre  cause. 

In  deciding  to  which  of  these  categories  any  individual  case 
belongs,  the  diagnosis  must,  to  iionie  extent,  be  reached  by  the 
procesB  of  cxcJusion,  and  aid  must  be  ohtain^rd  from  the  concomi- 
tant symptomg.  The  character  of  the  pain,  alihoogh  of  some 
importance,  is  not  decisive,  for  the  same  quality  and  severity  of 
pain  may  arise  from  various  causes,  and  in  dliferent  individuals 
the  same  cause  varies  almost  indefinitely  iu  its  pain-efi*ects. 

Pain  is  mobile,  shifting,  or  darting,  or  it  is  flxed  in  one  spot, 

19 


S90 


DlAGNOeriC  NEUROLOGY. 


FieedPaiM. 

I  msv  be  the  i 


bat 


permanent  iized  pain  may  be  the  result  of  a  neuritis, 
in  the  great  raajcrity  of  cases  the  expression  of  gout  or  of  rheu- 
matism.   This  18  especially  tlie  case  when  it  is  aaaociated  vith 
teu()criii.>^  upon  pressure  or  upon  motion.     A  fixed  pain  may  be 
the  rcsuh  of  .1  sprain  or  other  injury;  bnt  a  traiimati.tm  may 
cause  tlie  fixation  of  a  general  rheumatic  irritation  in  the  injured 
part,  so  that  care  is  sometimes  aecessiry  to  prevent  being  deceived 
in  the  diagnoKi'!.     If  a  rheumatic  Heiziire  Ik;  very  sudden,  and 
occur  at  the  time  of  maUing  an  exertion,  the  pain  may  be  sup- 
poeed  to  be  the  result  of  an  injury.     Thus,  I  saw,  not  long  biooe, 
a  grocer  who  had  been  under  jtrofesNional  care  for  nearly  a  year 
for  strain  of  the  hack,     I  fouud,  however,  that  at  the  time  of  the 
Budden  coming-on  of  the  pnin  he  waa  lining  only  a  few  pounds, 
whereoB  ho  had  been  nccustoraed  for  years  to  lift  ocea-siontlly  a 
barrel  of  flour  without  Injury.     There  «-as  also  a  distinct  hiatoty 
of  exposure  to  damp,  with  increase  of  the  pain  at  night  and  oa 
chancre  of  the  weather.     On  piittinji  the  patient  on  anti-rheumaiie 
treatment,  relief  was  soon  nftorded.     In  another  case  a  gcotletntn 
spriuging  from  a  wagon  was  perfectly  well  when  he  lef)  bis  car- 
riage, but  on  reaching  the  ground  had  a  disabling  pain  at  tba 
iiMertioii  of  the  tendon  of  the  right  patella,  and  supposed  that  be 
had  wrenched  his  knee.     It  turned  out,  however,  that  the  attack 
was  rheumatic. 

The  mere  jwrraaueiice  of  the  gouty  or  rheumatic  pain  some- 
times misleads  the  practitioner,  especially  when  it  affct^ts  the  ex- 
tremities symmetrically.  A  rheumatic  pain  may  continue  ia  1 
single  spot  for  months,  and  even  for  years,  and  may  be  located  ia 
exactly  oorresiionding  portions  of  opposite  limbs.  A  rheumatic 
pain  i»  to  be  diiitinguj sited  from  a  pain  of  nerve-origin  by  the 
tenderness  on  presanre  and  on  active  movement,  and  ali^o  by  the 
jiain  which  is  elicited  when  passive  movements  are  so  made  u 
forcibly  to  stretch  the  affected  muscle. 

Mobile  Pains. 

The  diagnosis  of  the  nature  of  mobile  pains  is  often  one  of  amoh 
difficulty.  In  deciding  the  nature  of  such  a  |>aiu  the  Si^t  ooncjd- 
eration  is  as  to  whether  it  is  unilateral  or  bilateral.     The  lesioni 


h 


EXALTATIONS  OP  SKSBIBir.ITy.  291 

of  the  spinal  cord  itself  which  produce  pains  ore  almost  iuvari- 
El>!y  bilateral.  In  tJie  b^inniiigof  a  nyphilitic  or  oliipr  tfwsilizeii 
diMaae  of  the  spinal  membraoos,  one  side  may  be  afTected,  and 
eoneequently  a  uuilateml  pain  b«  produced  by  involvement  of 
Uie  spinal  roots  of  titat  side.  It  is  rare  for  a  lixiialtKed  meningeal 
affection  to  be  situated  so  low  as  to  implicate  the  nerves  going  t^o 
the  legs:  consequently,  only  in  the  rarest  cfl-'res  is  a.  unilateral  pain 
ID  the  leg  due  to  disea^  of  tlie  cord  or  of  its  membrane?.  In 
like  manner,  a  pain  situated  iu  one  arm  and  not  in  the  otlier 
is  practicsilly  never  due  to  disea^ie  of  the  cnrd  itself,  and  only  in 
rare  instances  to  an  affection  of  the  membrane.  A  unilateral 
pain  in  an  extremity  is  therefore,  except  in  the  nirest  of  canes,  not 
dne  to  org:miudi&ea^  of  the  nerve-oeutrcs  or  of  their  membranes. 

Painii  which  arc  the  result  of  a  general  toxaemia  nre  apt  to  be 
bilateral,  beeautte  the  nervous  system  on  ea^h  side  of  the  body  is 

ually  under  the  influence  of  the  poison,  bat,  as  altvady  stated, 
'tlie  constitutional  disoitler  may  for  long  iierlods  of  time  expend 
it»lf  uiM>D  one  jwiut.  If  the  toxemic  uiiilatenil  pain  be  darting, 
ihooting,  or  shifting,  it  is  due  to  the  couslitutiooal  affection  iiifln- 
ncing  a  nerve-tnink,  so  that  it  may  he  laid  don-n  as  a  general 
diagnofilic  rule,  whose  excei>tion8  are  exceedingly  infrequent,  thai 
a  ■unilaierat  pain  ciiher  in  (he  ar^n  or  in  Uic  leg  J«  due  to  an  inflamma- 
tion of  the  nerves  t/tanadves,  whioti  neuritis  in  generally  tiie  result  of 
a  constitutional  disorder, — alcoholism,  gout,  rheumatism,  «yi)hili3, 
In  llie  examination  of  a  case  suffering  from  a  unilateral 
pain  in  the  I^,  pressure  upon  the  sciatic  nerve  at  \t»  emergence 
from  the  pelvis,  upon  the  popliteal  nerve,  or  upon  some  of  the 
analler  nerve-trunka,  will,  tia  a  rule,  detect  the  existence  of  dis- 
tiDc*  tenderness,  or  such  tenderness  of  (he  nervo-tranks  will  Iks 
made  manifest  on  stretching  the  nerve  by  forced  niovemenls  of 
the  limbs.  Iu  the  arm  the  brachial  plexus  or  itfi  branches  will  be 
founrl  sore.  Under  these  circumstaucea  the  diagnoeis  of  nenritiii 
becomes  plain,  and  in  the  miijoriiy  of  vasea  such  neuritis  is  rheu- 
matic or  gonty. 

Theoretically,  wq  should  expect  to  find  cases  of  unilateral 
oerve-pflinB  in  the  extremities  without  tendern&ss  of  the  nerve- 
tmaks  and  without  obvious  cause, — ]^a\ns  pandlcl  to  those  wi 
frequent  in  the  liead, — but,  for  some  reason  as  yet  unknown, 
tliese  obscure  nerve-storms  are  very  infrequent  in  the  extremities. 


DII 


292 


&IAGKOBTIC  NEUKOLOOV. 


One  of  the  most  character ii<tic  symptoms  of  posterior  sclerosis 
of  the  Bpiiial  cord  'a  the  palu.  Aa  tliia  paiu  may  precede  by 
m&uy  years  other  mnDifestations  of  the  disease,  its  sLady  is  of  , 
grrat  importnnoe  from  a  diagnostic  [wiiit  of  view.  In  a  majority^ 
of  case*  the  legn  are  the  first  p>rtions  of  the  body  to  suffer.  In™ 
the  rare  instaoces  in  which  the  scleroeiH  oommeQces  to  the  upper 
poriiciiis  of  tlie  coi'd  the  arine  are  primarily  implicated,  aud  even 
the  rej^ion  of  the  fuoe  may  be  the  first  to  be  invaded.  The  pain  is 
usually  very  severe  and  moraontnry.  It  h  Viiriously  descril>ed  by 
the  patients  an  shouting,  darting,  as  a  feeling  as  though  ligfatniug-H 
were  shootiug  through  the  part,  or  as  though  a  red-hot  wire  or  a 
sharp  dagger  were  thrust  tlirotigb  the  limb;  rarely  it  is  buniiDg. 
In  ^ome  c&iien  these  M-callcd  fulguraat  pains  occur  continually ; 
in  other  in»tauces  they  oome  ou  in  paroxysra^ii,  which  may  in  tbeir 
severity  amount  to  a.  veritable  crisis.  Even  if  Uiey  have  been 
habitimlly  present  for  a  length  of  time,  tlicy  may  cease  for  a 
time.  Sometimes  they  distinctly  follow  the  distribution  of  the 
ner\"CK.  They  are  commonly  felt  Rcvcrely  in  the  ncigbborho(jd  of 
joints:  thus,  the  inside  or  the  out<>ide  of  tlie  kitee,  or  the  inside 
of  the  ankle,  is  oHeii  the  seat  of  violent  darts.  Usually  they  are 
not  as-sociatt-d  with  i-otlncss  or  any  soreness,  and  oRen  the  jMitient 
seiiMA  the  nfiected  i>art  forcibly  and  obtains  by  the  pressure  some 
relief.  In  some  iastauces,  however,  a  certain  amount  of  redoes 
and  tendcrnci^  is  present  during  tlie  paroxysms  of  the  pain,  and 
ill  exceedingly  rare  ca.4es  trophic  eruptions  occur.  The  peculi- 
arity of  the  paini4  of  locomotor  ataxia  is  sufficient  to  enable  us  to 
recognize  their  chamctcr,  even  when  other  symptoms  of  the  *f"fl 
fectioii  are  not  perceptible,  although  the  diagnosis  cannot  be  can- 
sideri'd  iLs  ]>08itively  et^taUliRhed  until  the  ItKs  of  tlie  knee-jerk, 
or  some  other  symptom  of  the  disonier,  is  developed.  The  pains  fl 
are  always  bilateral,  are  not  increased  by  motion,  and  are  not 
acouinpanicd  by  a  persistent  soreness  of  the  part.  If  there  be 
any  teuderoess,  it  is  only  during  or  immediately  after  the  pains. 
Wandering  gonty  \k\\\\a  HOiiietinies  Rimidnte  ibe  pains  of  loco- 
motor ataxia,  but  are  never  so  Bovere  or  so  (xursisteni,  unless  there 
be  a  gtmty  neuritis,  which  will  be  at  once  revealed  by  the  per- 
sistent tendernesK.  Moreover,  the  Hhootiug  gouty  ptiin  is  nlwaya  fl 
assoriatetl  with  other  marked  evidences  of  the  diathesis. 

Although  bilateral,  a  moving  pain,  accompanied  with  tender- 


I 


d 


EXALTATIONfi  OF  SEXSIBILITY. 


293 


ness  of  the  n«rv«-lriiDkB,  with  pain  on  motion,  passive  or  active, 
is  never  the  direct  outcome  of  a  disease  of  the  Bpinal  cord.  It 
may  be  a  Bvraptoni  of  a  descending  nenritie  due  to  an  involvft- 
nient  of  the  ner\'c-root8  in  diaeoaes  of  the  apinai  membraoea. 
Moreover,  there  is  much  evidence  to  show  that  descending  nenriiis 
oo»tra  io  certain  diseaaeK  of  the  epinal  cord  itself.  Under  such 
circumstances  icndeme»!  of  the  nerve-trunks  is  naturally  to  be 
expected ;  but  it  must  be  remembered  that  sucli  tcndernetis  does 
DOC  develop  until  late  in  the  dutordcr,  and  then  only  in  mre  cases. 
In  various  disea^e^i  of  ilie  nerve-centres,  oontractures,  especially 
in  lateral  sclenmis,  may  exist,  and  the  attempt  at  forcible  extcii- 
aion  of  tlie  limb  may  give  rise  to  pain.  Thia  pain,  however, 
must  not  be  looked  upon  as  the  result  of  hypersen.sibility  of  the 
affecteil  muscles,  but  as  similar  to  that  which  would  be  cau&cd  by 
attempting  to  stretch  1>eyond  its  normal  length  a  muscle  which 
has  not  undergone  contnicturets. 

TBUNKAL  PAINS. 

Refl«x  Pftins. — MaDV  dueasM  of  the  muscles,  membranes,  or 
viscera  of  the  trunk  are  acxiompanied  by  |>ain.  A  dibcuseion  of 
audi  paiiiB  liett  without  the  province  of  the  present  work,  but  it 
mar  not  be  improper  to  say  a  few  words  in  regard  to  certain  of 
tbem  which  are  reflex  In  origin,  and  which,  althongh  due  to  local 
dinsBe  of  viscera,  are  situated  at  such  a  distance  from  the  point 
of  o^anic  alteration  that  they  arc  liable  to  be  mbtakra  for  pure 
nervona  or  npnr»Igi<-  painn.  The  mrMi  ini|Ktrtaiit  of  ih&e  reflex 
puDsare  those  producetl  in  the  »hou1den>  or  in  the  back  by  di»*- 
•MOB  of  the  liver  or  of  the  stomach.  A  pcculi.ir  5xed  pain  in  the 
apper  portion  of  the  right  filionlder  i^  a  not  very  uncommon  symp- 
tom in  congestions  and  other  diseases  of  the  liver.  The  puin  of 
pstHo  uloerotion  is  usually  referred  to  the  l)ack,  between  the 
Mapulie.  I  have  known  it  to  b«  in  the  lumbar  region,  and  occa- 
nonally  it  is  high  up  in  the  shouldere.  I  have  seen  the  abdominal 
pojo  which  ia  pnMluce<l  by  tlio  est»[»e  of  a  meal  into  the  alxluininal 
avity  through  a  sudden  perforation  of  the  gastrio  wall  entirely 
masked  by  a  horrible  mortal  ngony,  referred  by  the  |Mitient  lo  the 
top  of  the  left  shuuldcr,  and,  what  st^-ms  meet  extraordinary, 
markedly  increased  by  movements  of  the  body.  At  the  height 
«if  the  agony  any  alteration  uf  {losture  pnKluced  a  violent,  exoru- 


3>IAGN08TrC  NKCTIOLOOT. 


ciating  spnsm  of  the  scapulaiy  and  dorso-oervical  nmsclcs.     In 
this  case  the  nicer  was  not  inspected  during  life. 

Sheumaiic  Pahis. — It  secitiB  liardly  uecvtsatry  to  say  mucli 
oonoerning  rhcutuattc  pains  tn  the  musclea  of  the  trunk,  but  it 
is  pcrtmpA  proper  to  call  attention  to  tho  fact  that  M>tnctime!i 
they  are  excessively  severe,  and  ap]>ear  with  such  abruptuess  that 
they  may  he  supposed  to  be  the  result  of  traumatism.  They 
are  always  aotwmpaiued  by  exees»<ive  pain  on  mution^  and  vnu 
scarcely  be  mistaken  for  other  idiopathic  uflcetions. 

Pains  of  Chronic  FUiroju  Tnfinmmation. — A  form  of  bork-pain 
which  is  not  infrequent  ae  the  result  of  injury  is  a  perwslent 
acliing,  with  a  marked  and  pronounced  sense  of  weakness  of  the 
parr,  and  sometimes  KtifTiieas  and  ]>ain  on  movement.  This  con- 
dition, which  may  last  for  years,  is,  I  believe,  not  a  nerve-pain, 
but  is  due  to  a  very  slow  chronic  inflammation  of  the  fibrous 
tissues  which  bind  tugellier  the  vertebrEe.  It  is  o^McdalJy  apt  tiL 
be  present  in  the  lower  portion  of  the  back.  ^H 

TbcBonm/*  PnijiM. — Toxremic  pains,  due  either  to  gout  or  t^^ 
Tnalariii,  are  liable  to  attack  any  portion  of  the  body.  They  may 
locate  them&elves  in  the  neighborhood  of  tbe  kidneys,  and  under 
these  circuni8taiK!es  closely  Kininlute  the  pains  of  renal  coUc  They 
(«n  usually  be  distinguished  by  their  not  being  so  severe  or  so  per- 
sistent, and  by  their  not  shooting  into  the  genital  organs.  Not 
much  aid  in  the  diagnosis  can  be  obtained  from  an  exaininatioo 
of  the  urine,  since  crystals  are  often  not  present  in  the  urine  in 
liases  of  renal  calculi,  and  the  elimination  of  uric  acid  often  ac- 
oomitnoieB  the  gonly  poin -paroxysm.  In  a  malarial  case,  a  more  or 
less  regular  periodicity  will  usually  l>etray  the  nature  of  the  disease. 

Utrpdic  Pain. — A  violent  stinging  jNiin  shooting  along  the 
course  of  the  intercostal  nerves,  or  located  in  irregular  sjiote  in  the 
front  of  the  Iwdy,  not  rarely  preoedes,  but  |H!rhH|B  more  generariy 
aocompaniefl,  the  eruption  of  her|ie«  zoster.  Both  tlie  emption 
and  the  pain  are  due  to  iuUammation  of  the  intercostal  nervea,  in 
most  cases  of  a  gouty  nature. 

Pain  of  Vertdrral  (iiriea. — A  fixed,  unaccountable  pain  in  the 
shoulders,  or  very  rarely  in  the  lumbar  region,  may  be  the  first 
obvious  aymptom  of  a  commencing  spinal  caries.  I  have  so  fre* 
quently  hvcu  this  pain  of  sympathetic  iuflnmniation  of  the  nerve- 
roots  precede  the  more  manifest  symptoms  of  spinal  caries  tliat 


EXAI.TATIONB   OF  SEN8IBri-ITY.  295 

I  look  upon  it  aa  a  forertinoer  of  very  serious  disease.  If  an 
individiul  be  of  such  :ige  and  phytiical  diaractcr  an  to  bring  an 
attack  either  of  syphilitic  or  of  tubercular  disease  of  the  ver- 
Utbne  within  the  range  of  pmhahility,  u  fixed,  apparently  cauae- 
lesw,  Kcvere  neuralgic  pain  cither  in  the  shoulder  or  in  the  front 
lumlrar  region  sboiiM  be  viewed  w!(b  tbe  gr^itcat  suapiciouj  and 
ationld  lead  to  the  most  careful  study  of  the  case. 

Oirdie  Pain. — The  girdle  sensition,  so  mlled,  is  a  feeling  m 
tbongh  a  band  were  tightly  drawn  aroinid  the  body.  If  really 
present,  and  not  imagined  by  the  patient  after  the  suggestion  by 
the  physician,  it,  I  believe,  aKvaya  indicates  organic  disease  of 
the  spinal  cord  or  of  the  nerve-root^.  When  not  amounting 
to  ab>4tlu1e  pain,  it  is  usually  due  to  chronic  myelitit*  or  to  spinal 
sclerosis.  When  very  severe,  it  may  be  caused  by  iaflamraa- 
tion  of  the  nerve-roots,  due  to  c-ancerous,  syphilitic,  or  tubercular 
degenerations  of  the  spinal  niciubruue.  lu  souie  cases  this  girdle 
pain  instead  of  Ix-ing  around  the  body  eneiniles  aome  portions 
of  the  legs.  Under  these  circumstanoes  it  is  biluicrnl  and  sym- 
metrical. I  cannot  remember  lo  have  seen  it  lower  than  the 
garter  line. 

Pain-Crisee. — The  most  important,  as  well  as  the  most  severe, 
of  all  the  nerve-pains  connected  with  the  human  trnnlc  arc  the 
s(>-calle<l  {Hiin-ci'ises  which  occur  in  locomotor  ataxia.  When 
ODce  established,  these  cris«  usually  persist  through  the  whole 
ODurse  of  the  alTectton,  but  they  ai-c  l'r<e<|uently  among  the  earliest 
of  prodromes,  an<l  may  by  inapy  years  precede  the  more  common 
symptoms  of  the  disease. 

In  a  remarkable  case  now  under  my  care  in  the  University 
Hospital,  in  which  the  symptoms  Ibllowed  an  injury  to  the  foot, 
and  are  apimrently  (lie  result  of  an  astvnding  neuritis,  moder- 
ately wverc  gastric  pain-criaca  occur  simulating  those  of  locomo- 
tor ataxiii.  The  symptoms  in  the  case  are  and  have  been  violent 
pain,  gradually  exteuding  up  the  leg,  and  tbence  to  the  half  of 
the  body  of  the  same  side,  at  present  very  severe  ia  the  arm  aud 
face;  marked  tenderness  over  all  the  nerve-trunks  wtiicli  are  the 
Mat  of  pain;  ei^genition  of  the  patella-reflex  upon  both  sides, 
but  more  markedly  upon  the  side  most  affected;  cootraotlon  of 
the  Geld  of  vision,  with  atrophy  of  the  nerve  much  more  pro- 
nounced ID  the  eye  up(m  the  affected  side ;  failure  of  strength  of 


( 


tho  »ff«:ted  leg,  with  some  contractions  of  (he  timsrJes  ami  paaa 
on  stretching  the  foot ;  distinct  atrophy  of  the  muscles  of  the 
ftfiected  leg,  with  morlal  chaiigis  in  their  electric  con  tract  ility ; 
upon  the  diseased  t^ide  great  coldness  of  the  foot  and  luiver  leg, 
with  a  somewhat  similar  condition  in  the  forearm. 

A  pain-cmia  consists  in  its  essential  ports  of  a  paroxysm  of 
pain  as  violent  as  bumaD  uatar«  can  endure,  accoDi|>anied  by- 
excessive  functional  disorder  of  the  part  attacked,  developing 
luiuolly  with  ^^rent  rai>idity,  hut  disup|>oaring  at;  rapidly  as  it  ap- 
peared, and  associated  with  a  condition  of  undisturbed  functional 
activity  of  the  affected  viscus  between  the  paroij-sms.  The  crisis 
may  at  first  returu  only  at  long  intervals^  but  as  the  disease  pro- 
gresseiii  it  comes  on  more  frequently,  and  often  more  eeverelj, 
until  at  last  in  some  pHmxynnis  syncope  alone  brings  relief. 
During  the  paroxysm  thci-c  is  no  fever;  but  the  patient  is  often 
left  in  a  condition  of  profoiuid  ex]iaU!<tion. 

The  most  important  of  the  paiu-orises  are  the  muscular,  the 
gastric,  the  viiicenil,  the  rectal,  the  urinary,  tlie  genital,  the  car- 
diac, and  the  laryngeal. 

The  mujtcular  pain-crises  are  extremely  rare,  but  have  be«n 
de.scril)cd  in  two  cases  by  Dr.  Titrts  {I^Off.  Mid,,  July  12, 1884). 
They  ciKiBittl  of  a  feeling  of  ta.-«itiide,  deepening  into  an  cxceaMive 
muscular  weariness  and  soreness  like  that  which  follows  violent 
exercise  in  one  unaocustomed  to  it,  and  at  last  entirely  paralyzing 
for  the  time  being  the  affected  muscles.  They  appear  to  attack 
more  usually  the  lumbar  group,  and  to  make  it  impossible  for  tlie 
|iatient  to  awnme  an  erect  jtoeition.  They  are  said  to  last  from  a 
few  hour«  to  many  days. 

The  ffagtric  crises  appear  to  be  the  most  frequent  of  any  of 
the  paiii-[Hiroxysms  of  locomotor  ataxia.  They  are  diarBc^terized 
by  violent  pains  having  their  focus  in  tlie  epigastric, region  and 
radiating  in  all  directions,  laterally,  iipwnni,  and  downward, 
until  at  times  t}icy  seem  to  fill  with  agony  tlie  whole  abdomen 
and  chest.  The  pains  are  sometimes  spoken  of  as  constrictive, 
more  usually  shooting  like  a  dagger'thrust;  not  rarely  they  are 
burning.  They  arc  generally  incj'eascd  by  the  ingestion  uf  food, 
ami  arc  always  accompanied  by  nausea  and  excessive  vomiting 
and  the  rejection  of  everything  that  is  put  into  the  Stooaach. 
The  vomiting  is  repeated  many  times  aa  hour,  and  is  aocom- 


EXALTATHK\8  OF  SENSIBILITY. 


297 


paoied  by  horribly  distressttig  mtobing.  Aftf-r  tbo  stomach  has 
been  emptied,  glairy  or  ropy  mucus  is  ejected:  this  soon  be- 
comes groeniab  from  the  presence  of  bile;  and  in  severe  fioses 
Etrcaki^  of  blood  appear  in  the  muctu:  more  rarely  there  is  ftbun- 
dant  coflec-grouud  vomiting  or  even  prououoced  h»mateniesis. 
(See  case,  Vulpian,  Mairvliea  dit  Si/^^e  rurvetur,  vol.  i.  p.  267.) 
In  •nme  casa-i  the  focus  of  the  psun  is  in  the  neighborhood  of 
the  umbilicus,  when  the  crisis  might  properly  be  spoken  of  as 
rtUatinai.  Occasiooally  lai^  ((uantilies  of  gas  form  in  (he  gastro- 
iote^inal  tract,  and  produce  a  vciy  obstinate  meteorism,  which  is 
itself  more  or  less  painful,  and  is  t'canxly  diminished  by  the  in* 
oeisant  discharge  of  gaa  by  the  mouth  or  rectum.  This  paroxysm 
of  atrocious  suffering  may  last  from  one  (o  a  few  hours,  or  even 
for  days,  interrupted,  it  may  be,  by  KVQco}>e,  uud  Anally  leuviog 
the  patient  in  a  condition  of  profound  collapse,  it  is  sometiraea 
aocompanied  by  a  hyperesthesia  of  tho  epigiistric  region  »>  cxoes- 
sire  that  the  mere  contact  of  the  hand  will  provoke  violent  paius. 
During  the  attack  it  is  absolutely  impossible  for  the  patient  to 
take  food,  but  usually  the  panjxysm  ends  abruptly,  aud  food  is 
immediately  denin^l  and  i»  digeste<I  without  difficulty.  Wbeu 
the  force  of  the  paroxysm  expends  itself  upon  the  stomach  there 
tc  DO  disturbance  of  the  bowels,  but  if  cnteralgia  be  severe  there 
is  nsoally  with  it  au  ubun<laiit  disclmt^'  of  bilious  or  mucous  or 
Hram  stools.  In  such  cuse^  the  patient  may  assume  the  faeJts  of 
choIeiB,  the  Itkenem  being  made  complete  by  the  loea  of  the  voice, 
the  suppression  of  urine,  the  extreme  coldness  and  cyanosis  of 
the  body,  and  even  the  presenoe  of  cram|}!<.  Vulpian  re]>orts  a 
osae  of  death  during  mvh  a  puroxysni. 

Tlie  gastric  or  gustro-inttstinal  cri^tis  is  distinguished  from 
umilar  attacks  due  to  disease  of  the  stomach  or  the  bowels,  by 
(b«  suddennuts  of  its  development ;  by  Uie  excessive  severity  of 
the  symptoms ;  by  the  absence  of  the  ordinary  signa  of  organic 
disease  of  the  stomach  or  intestines ;  by  the  abruptn^^  of  the 
tvmiiMtion  of  the  parox)'sm ;  and  by  tlic  complete  performance 
of  the  normal  functions  1>etweea  the  attjick^.  It  might  be  stm- 
nlated  by  hysterical  gastralgia  with  vomtling,  but  in  the  latter 
diwase  the  ^rmptoiui«  ore  not  so  severe  as  in  the  crisis,  oud  are 
attended  l>y  globus  hystericus,  great  emotional  disiurbuocei  con- 
vulrive  inovemeiits,  anesthesias,  or  other  wo)Urec(qi;niKcd  syup- 


298 


DJAONOHTIC  KBUEtOLOOY. 


nis  of  hysteria.  The  occurreuce  of  liEBioaterueBis  in  gastric  crlsU 
muiit  always  suggest  the  presence  of  j^tric  uloer,  but  between 
tlie  |mrox}'8iriK  the  syntptoms  of  sucli  uloer  ought  to  be  flpfjardit 
if  the  lesion  realty  exist. 

Much  more  rarely  than  the  stomach  arc  other  abdomiual  via- 
cero  the  i>i>at  of  |Hiiii-critiCH  in  lo<x>mutor  utaxlu.  In  somo  caises 
true  rrxial  cmes  occur,  with  violent  pains  of  a  cattit^,  ahoottu^, 
burning  diaract^r  radiating  from  the  rectnm  in  every  direction. 
Not  rarely  the  patient  <,»niplaiiia  bitterly  uf  m  !«ea<sation  as  tltough 
the  rectum  were  Blled  up  by  an  enormous  body  heated  to  red- 

ineiSe,  burning  ami  scorching  every  part  near  it.     (See  Trousseau.) 
Among  ihe   most   painful  of  these  aklomiiml  crises  arc  th< 
cunneoted  with   the   urhxani  orgaus.      The  aymptonis    may  re- 
semble so  cloisely  thotie  of  reuat  colic  us  to  make  the  immediala 

'diagtiosiB  almost  im|iosaiblc.     Thus  (M.   Raynaud,  Arch.  (ten. 

'(fa  MM.,  OcttAier,  1876),  a  man  attacked  in  the  streets  of  Paris 
was  brought  to  the  hospital  bent  double,  suffering  from  n  furioiu 
pain  ill  the  belly  mclialiiig  inn>  the  lumbar  region  along  the  tract 
of  the  ureters,  and  accompanied  by  retraction  of  the  testicle     A 
incorrect  diagnosis  of  renal  colic  vrm  at  flrst  made.     More  fre- 

i.quenlly  the  pains  are  in  the  urethm,  where  they  manifest  theni- 
Belves  as  intense  burning,  or  as  lancinating  darts  of  agony  sh<x»t- 
ing  through  the  whole  length  of  the  urclhra  and  simulating  the 
pain  uf  caiciilus.  Usually  at  the  same  time  there  is  great,  distre?^ 
in  the  bladder,  and  an  iaccssant  desire  to  pass  urine,  with  tlie 
emission  of  oidy  small  quantities  with  great  straining  and  with- 
out relief.  These  ymns  in  some  cases  occur  in  paroxysms  similar 
to  Uiosc  of  the  gastric  crisis;  in  others  they  are  more  persistent, 
so  that  the  patient  .-juffers  irom  almost  constant  distress.  Umier 
these  eirciirastanccs  there  may  be  ansssthesia  of  the  ureter  and  4>f< 
the  hladik-r,  with  consequent  retention  of  urine  and  ammoniattil 
fermentation.  In  some  of  these  cases  the  urine  becomes  loaded 
with  phosphate,  and  the  mistaken  diagnosis  of  phosphatic  calculuA 
might  be  readily  made. 

QenUal  Crmst. — Genital  disturbance  Is  almost  universally 
present  in  looomotor  ataxia.  Usually  it  takes  the  form  of  loss  of 
fntictioaal  power.  It  is  in  ray  exfienencti  very  infrequent  for  tlii» 
depression  to  be  preceded  by  sexual  excitement,  but  Trousseau  re- 
lates the  case  of  a  mau  in  whom  the  first  symptoms  of  the  disorder 


I 


I 


EXALTATIONS  OP  SENBIBILITY. 


2fl9 


were  exoctssive  liwt,  aod  a  straugt  |iower  of  repealing  coitus  a 
great  namber  of  times  in  rapid  sQocession.  Associated  with  such 
aeztial  excitement  is  [dually  exoe-ssive  qiiickiicsH  of  cmi#iiun 
during  the  act, — a  quickooss  wltich  augments  until  it  amounte  to 
a  veritable  spermatorrhcea,  tbe  eeueo  being  discharged  upoa  the 
slightt^t  provocation,  and  a  true  impotence  resulting. 

Id  rare  oases  veritable  genital  crises  occur.  These  are  of  two 
characters.  In  one,  violent  paroxysms  of  pain  centre  in  the  tcsti- 
clea  and  shoot  along  tlie  penis  to  its  heati,  or,  iu  the  female,  burn 
and  bore  in  the  ovaries,  the  labia  minora,  and  the  clitoris.  la 
these  ]>an>sytiin>;  the  agony  is  only  a  little  less  than  that  of  the 
gastric  crisis.  In  other  ca-^es  spontntieous  venereal  orgasms  re- 
place the  pain-|ttiroxyi>m,  eitl)*-r  in  llii'  mnle  or  the  female.  T}imi, 
in  a  case  reported  by  Prof.  A.  Filr^,  a  woman  sufiTere^l  with  fre- 
quent pamxysms,  commencing  with  a  sense  of  vibration  in  the 
vagina,  followed  at  once  by  erection  of  the  clitoriK,  voluptuous 
senaation,  ond  rapid  o:^;asm.  The  venereal  crises  often  occurred 
four  or  five  times  in  the  twenty-four  hours.  After  the  la|»e  of 
four  years  tbey  became  assfK-tatal  with  fulgurant  paine.  Four 
years  later  a  gastric  crisis  occurred,  uud  the  other  symptoms  of 
locomotor  ataxia  slowly  develo(K<i.  The  close  connection  betwwtn 
tl>e  venerenl  and  pain  paroxysms  was  shown  by  the  fact  that  in 
the  later  years  a  violent  attack  of  fulgurant  or  gastric  pHins  was 
always  ushere<l  in  by  au  crutio  crisis.  In  another  case  reported 
by  PitrJts  the  vencreol  paroxysms  preceded  the  fulgarunt  pains 
by  ten  years. 

Laryngeal  0*j*e«. — The  larj-ngcal  crisis  is  a  very  rare  pho- 
aomenon  in  locomotor  ataxia.  Briefly  spoken  of  in  18R2  by  M. 
Bourdon,  it  lias  been  fully  described  by  M.  F6r£o]  {Cfaz.  HdHivm., 
February  12,  1869)  and  by  M.  Jean  (ihid.,  July  7,  1876).  It 
consists  of  violent  paroxysms  of  coughing,  with  great  larynjita! 
disturbances  of  respiratiou,  atrocious*  fulgurant  pains  to  the  shoul- 
ders and  along  the  spinal  column,  and  prououin.'ed  symptonir^  of 
asphyxia,  The  face  is  red,  intensely  congesteil,  ami  finally  cya- 
nosed.  The  cough,  fnrinus,  hoarse,  grating,  is  rapidly  repeale<l  in 
paroxysms,  ending  in  a  raucous  inspiration  like  that  of  whoopitig- 
oougb.  The  oxfiecto ration  is  of  a  scanty  ealiva-like  secretion,  or 
rarely  of  little  pellets  of  mucuj*  stained  with  bhmd.  The  [niriial 
expirations,  abrupt  and  jerky,  follow  one  another  with  convulsive 


PTAONORTIC   SrEUKOI-OOT. 


hjiste,  to  be  sncccodcd  bya  prolangol  blovring  ingpiration.  When 
the  paroxysm  is  severe  ti\c  Hyspnflwi  is  extreme,  and  the  orine  ami 
fw(.'«>  may  be  jmsswl  invoIuDlarily.  The  paroxysms  occur  sjwuta- 
neoiisly  by  day  or  by  uigbt,  but  arc  abo  produced  by  draughts  of 
air,  or  by  the  Hwallowing  of  hot  dnnkn  or  f(»od,  etc  There  is  no 
a>)thmatir  dyspnoui  lx'lvv(t:n  the  paroxysmB,  although  a  permanent 
emphysema  may  be  producod  by  the  strain  of  the  violent  cff^'>rt.s  at 
breathing.  The  attack  usually  begins  ami  ends  abruptly.  Id  the 
vaHG  re|K)rte(l  hy  M.  Jean,  Kpn^m  of  iJie  niiiM.>Ia>  of  the  pharynx 
finally  prevcnleil  Hwnltowing  altogi'ther;  asphyxia  ahemat(»l  with 
flviicope,  until  trut^  roma  appenrrd,  to  t-nd  in  death.  At  the  au- 
tojwy  puetcrior  i^piual  ?«lero^ii«  was  found;  but,  as  there  was  aIt«o  a 
pronouneed  [e.sioti  in  the  medulla,  it  remains  doubtful  how  far  the 
laryngeal  sympt^mis  were  the  n«uIlof  the  8])ina]  degenerntion. 

Otrtiiac  CHsfv. — In  1879,  Vtilpiaii  called  attention  to  the  fre- 
quency of  valvular  disea-te  of  the  heart  in  locomotor  ataxia,  and 
hift  obiiervatioos  have  siuoe  been  confirmed  by  both  German  atid 
French  writers.  Insufficieney  of  the  aortic  valve  appears  to  t>e 
the  most  freqticiU  luBion;  hut  Gnu^i^t  ^Iiowh  by  a  report  u[Km 
twenty-four  cases  tliat  the  heart^losiona  are  various.  This  is  con- 
firmed by  A.  Jauberl  {Tli^se,  Paris,  No.  137,  1881),  who  further 
makes  it  plain  that  not  only  the  valves  but  also  the  heart-walls 
may  be  atTccted. 

It  is  at  present  uncertain  whether  the  cardiac  lesions  are  due 
directly  to  the  disease  of  the  nerve-oentrefl,  or  whether  both  the 
uervuuK  and  the  eunliae  uQeotious  are  the  result  of  a  common  cause. 
That  the  changes  in  the  heart  are  not  trophic  or  paratiel  to  thoee 
which  occur  in  the  joints  of  the  ataxic  is  strongly  indicated  by 
tlic  fact  that  in  a  number  of  Graseet's  cases  the  cervical  spinal 
cord  was  not  implicated.  The  clot<e  connection  between  syphilis 
and  locomotor  ataxia  on  the  one  hand,  and  between  syphilis 
and  arterial  degenerations  on  the  other,  sn^^esti^  that  the  two 
diseancR  arc  frequently  the  result  of  a  common  cau.se.  In  many 
cases  the  cardiac  affection  ooraes  on  verj'  iusidiously,  and  symp- 
toms may  not  appear  until  long  after  serious  lesions  have  been 
developed:  therefore  the  practitioner  should  habitually  auscult  the 
heart  in  cases  of  posterior  spinal  sclerosis.  In  some  cases  violent 
cardiac  crHcs  occur.  It  is  unrert-iin  whether  they  are  always  asso- 
ciated with  lesion  either  of  the  heart-valves  or  of  tlie  heart-walls. 


. 


4 


EXALTATIONS   OF  SEXSlBLLITy. 


301 


They  liave  beeu  preMot  wfaeo  there  were  no  sufficient  physical 
signs  to  justify  tbe  diagnosis  of  canliac  lesioD,  and  it  is  therefore 
probable  that  a  canliae  crLsin  may  rvpix-se lit  a  nerve-storm  similar 
to  that  of  a  jpiatric  criais,  Charcot  has  noticed  that  there  is  ufien, 
if  not  alwap,  a  permanent  aoceleratjon  of  the  pnlse  in  th»e 
cases.  The  symptoms  of  the  cardiac  crisis  are  similar  to  those  of 
■ogina  pectoris, — namely,  violent  pain  in  the  regioa  of  the  heart, 
sreuctated  with  great  dyspmea,  inteusti  dislresa^and  irregularity  of 
the  pulse,  with  or  without  intermission  of  the  heart-beats. 

UKAI>-rAlNS. 

The  caoses  of  headache  arc  almost  innumemble,  and  to  discuss 
them  fully  would  require  a  volume.  I  sliall  therefore  confine  my 
attention  to  a  consitleratiiiii  of  the  chief  varieties  of  headache 
oot  connected  with  acute  disea^^e,  such  as  fevers,  pneumonias,  etc 
Id  treating  any  individual  case  of  chronic  headache,  the  firet 
vital  decision  is  as  to  the  cause  of  the  head-pain.  For  this  reason 
it  seems  proper  in  this  work  to  view  headache  chiefly  from  an 
flUoIogical  »tand-poiiit.  The  character  of  hcadnrhc  varies  cxces- 
Mvely.  It  is  sometimua  deup-seated  ;  sometimes  superlicial ;  some- 
times a  distress;  somctimtK  a  violent  pain;  sometimes  a  heavy 
acsbe  ;  sometimes  an  acute  throbbing;  now  it  lilts  the  whole  cra- 
nium, again  it  radiates  over  the  surface,  or  settles  in  some  one 
point.  It  is  jwroxysmal  or  constant,  shifting  or  fixed.  Unfortu- 
nately, the  cliaracter  of  tbe  headache  variea  in  different  individ- 
uals with  the  same  cause:  thu^,  even  the  headache  which  is  the 
result  of  an  organic  brain-lesion  is  (HfTerent  in  diflbrcnt  imtient^. 
It  is  impoHible  to  make  the  diagnosis  as  to  the  nature  of  the  head- 
•die  from  a  «twly  of  tJic  headache  itself:  only  by  a  considcratioa 
of  tbe  cxincomitunt  symplonis  and  in  many  eases  by  the  proocs  of 
exclusion  are  wc  able  to  arrive  at  an  approximately  correct  view. 
Ones  not  a  few  offer  themselves  in  which  the  nature  of  the  boad- 
•dic  is  finally  made  out  only  by  studying  its  raiponse  to  thera- 
peutic agents,  Nevertheless,  something  oau  often  Ik;  inferred 
from  the  seat  of  tlie  pain  nod  from  its  character,  and  thcrcrore 
I  thftll  point  oni,  aa  far  a<t  may  be,  peculiarities  in  individoal 
beadacbes.  The  best  Hrrangumcnt  of  headaches  for  clinical  study 
that  I  have  been  able  to  formulate  is  comprisei^  in  the  following 
Kbeme: 


292 


DUONoenc  nbdkoloot. 


One  of  the  most  cliaracteri-ttic  Rymptoms  of  posterior  sclerottig 
of  tlie  spinal  coitl  is  tbu  pain.  As  this  pain  may  precede  bj 
many  years  other  imuiifeBtations  of  the  disease,  its  study  is  of 
great  importuned  from  n  diagnostic  point  of  view.  In  n  majority 
of  cases  t}ie  legs  are  the  first  portions  of  tlw  body  to  suffer.  lu 
the  rare  instances  in  which  the  scleroi^iM  commeuocs  id  the  upper 
portions  of  the  eord  the  arma  arc  primarily  Implicated,  and  oven 
the  rej^iou  of  tlie  fuoe  nmy  be  the  first  to  be  invaded.  The  pain  is 
U8U.illy  very  severe  and  momentary.  It  is  variously  described  by 
(he  [mtients  as  shooting,  darting,  as  a  feeling  as  though  lightning 
were  Hhooting  through  the  part,  or  as  though  a  red-bot  wire  or  a 
sharp  dagger  were  tbru»t  llirongh  the  limb;  rarely  it  ia  burning. 
In  Aomc  cases  these  so-called  fiilgurant  pnins  occur  oootioually; 
in  other  instances  they  oonie  on  in  paroxysms,  which  may  in  their 
8evt;rity  amount  to  a  veritable  crisis.  Eveu  if  tliey  have  been 
habiiunlly  present  for  a  lengtti  of  time,  they  may  cease  for  a 
time.  Sometimes  they  distinctly  follow  the  distribution  of  the 
ner\'CB,  They  are  commonly  felt  severely  in  the  neighborhood  of 
joints:  thu!<,  tlie  ini^ide  or  the  otitsltle  of  tlie  kuee,  or  the  inside 
of  the  ankle,  is  oflen  the  Heat  uf  violent  dartH.  Usually  they  ore 
not  asaociat«1  with  redness  or  any  soreness,  and  often  the  {Mticnt 
seijtes  the  aft'ecte*!  part  forcibly  and  obtains  by  the  pressnre  some 
relief.  lu  some  iustaitces,  however,  a  certain  amount  of  redness 
and  tenderness  is  present  during  the  paroxysms  of  the  pain,  and 
in  exceediugly  rare  eoHes  tropliie  eruptions  oocnr.  The  peculi- 
arity of  the  pains  of  locomotor  ataxia  is  sufficient  to  enable  us  to 
recogniiM  their  character,  even  when  other  symptoms  of  the  af- 
fection are  not  perceptible,  although  the  diaguotits  cannot  be  oon- 
sidercil  as  jMisitively  established  until  the  loss  of  the  knee-jerk, 
or  some  other  symptom  of  (he  disonler,  is  developed.  The  pains 
are  always  bilaternl,  are  not  iuereawd  by  motion,  and  are  not 
accompanied  by  a  persistent  soreness  of  the  part.  If  there  be 
any  tenderness,  it  is  only  dunng  or  immediately  after  the  pains. 
Wandcriu);  ^<>*ity  pains  sometimes  simulate  the  pains  of  loco* 
motor  BUUEio^  but  are  never  so  severe  or  so  persistent,  unless  tlicre 
be  a  gouty  neuritis,  which  will  be  at  once  revealed  by  the  |>cr- 
sisleiit  teiuicrnaw.  Moreover,  the  shootiuj;  g*Hiiy  |Kiin  is  always 
assoelatcit  with  other  murketl  evidences  of  the  diathesis. 

Althongl)  bilateral,  a  moving  pain,  accompanied  with  tender- 


EXALTATIONS   OF   SKNHIBIl.ITY. 


303 


Thxtrmif.  {Teatfach^ 

The  moBt  important  varieties  of  toxsmio  hendachp  arc  malarial, 
rb«iimatic,  gouty,  Dneniic,  diabetic,  alcotiolic,  au<)  cafreinic. 

Malarial  Headache. — A  headache  may  occur  in  a  malarial 
sabjeet  as  a  secondary  result,  pnxluccd  by  the  aiiieiiiia  or  by  the 
disorder  of  the  gajjtro-iutetitiiial  tntcl,  etc.  Such  liciiduches  are 
insemic,  gaMric^  etc.,  rather  than  truly  malarial.  The  specific 
malarial  headache  occurs  in  paroxysms  at  more  or  less  regular 
iotervals.  It  aintwt  invariably  takes  the  tbroi  of  the  so-called 
''brow  ague,"  iu  which  an  iatcuec  paiii  rapidly  develops  at  fixed 
hoan  in  the  immediate  neighborhood  of  one  supra-orbital  forametu 
This  jiain  lasts  from  five  to  ten  hours,  is  often  of  frightful  in- 
tensity, and  may  or  may  not  be  a>tsociated  with  fever  aud  BWcat 
or  other  indications  of  a  malarial  paroxyatu.  It  is  a  malarial 
paroxysm  which  is  to  l>c  recognlxcd  hy  iiA  form,  and  especially  by 
the  re(;ulnri(y  of  ite  recurrence  and  by  ila  rapidly  yielding  to 
quinine  when  given  in  sufficient  doses.  It  must  bo  remembered 
that  it  is  often  necessary  lo  administer  as  luueh  as  thirty  grains  of 
quinine  ju.n  previons  to  the  expected  paroxysDi  in  order  to  obtain 
difltioct  relief. 

Rheumatic  Headache. — Rheumatic  headache  is  not  infre- 
qovat.  It  usually  takes  tlie  form  of  heavy  aching  pain,  worse  at 
uight  and  on  the  approach  of  storms,  and  accompanied  by  more 
or  less  soreness  of  the  rmlp :  under  these  circiimstanc«s  the  rheu- 
matic irritation  undoubtedly  expends  itself  u;)on  the  fibrous  tifi- 
8oe  of  the  scalp.  In  other  ca^es  the  jwio  is  severe,  sluirp,  and 
sliooting,  puBHing  into  tlie  jaws  or  oouning  over  the  forehead: 
such  pain  is  the  expression  of  a  rheumatic  neuriti.4  iiflTectii)^  the 
bnacfaes  of  the  trigeminal  nerve.  The  rheumatic  hcaduchc  may 
be  without  any  characters  indicating  ita  nature.  In  a  sculptor 
wbo  was  about  to  abandon  his  profession  on  account  of  excessive 
iotnKtable  headacheK,  I  fiiund  that  the  headaches  had  occnrred 
ooly  during  the  time  when  the  artist  was  working  upon  the  mod- 
elling in  wet  clay  of  a  vfry  large  compmite  life-size  group,  and, 
not  being  able  to  make  out  any  other  explanation  uf  the  bead- 
•ehes,  I  put  the  patient  on  an ti -rheumatic  treatment,  with  the 
noBt  satisfactory  nsiitts. 

LlUuemio  Headache. — Lithsmic  or  gouty  headatjie  id  iti 


301 


DIAONOSnO  NEDBOLOOY. 


usiinl  form  is  dull  and  lieavy,  and  often  worse  on  rising  Jn  the 
mornings.  It  may,  however,  be  acute,  and  I  have  Been  it  exoes- 
sively  violent:  in  oat  case,  for  a  scriea  of  years  there  were  head- 
acheiii  tvhosc  cause  could  not  be  made  out,  and  whoae  violence  wasH 
so  great  us  to  make  life  unendurable,  ^^ot  a  day  passed  without 
them,  and  much  of  the  time  the  hced-pain  wait  an  agony.  In 
this  case  the  headaches  finally  became  ajssoctated  with  attacks  of 
loss  of  consciousneaSr  which  closely  resiembted  petit  nial,  so  that 
I  ivuH  kil  to  the  diagnosis  of  an  organic  leaiou  of  the  brain  or 
its  membranes.  Finally,  all  the  small  joints  of  the  body  and^f 
many  nf  the  lar^  were  simultaneously  attackwl  with  a  furion* 
sudden  general  gout,  with  enormous  deposits  and  permanent  dis- 
ablement. The  headaches  were  greatly  relieved  by  tlits  outbreak, 
but  have  reappeared  from  time  to  time,  although  the  joint-lesions 
have  progressed  so  that  the  patient  is  entirely  crippled.  My 
own  belief  is  that  there  was  originally  a  gouty  thickening  of  the 
dura  mater  with  depoeit,  so  that  the  headaches  were  not  dimply 
the  result  of  gouty  irritation,  but  were  due  to  a  gouty  orgonnj 
leftion. 

tTrsDoic  Hoadache. — The  ursetnie  headache  tnay  take  alt 
any  form,  and  the  diagnosis  must  be  mude  out  by  detectiog  the 
kiilney -disease.  Some  years  siniv,  a  patient  was  brought  to  me 
who  wae  suffering  from  n  unilateral  frontal  headache,  which  al- 
ways commenced  from  one  to  two  hours  after  rinJng,  and  oontinncKl 
to  grow  mure  inteniie  until  the  mau  went  to  bed,  when  it  dis- 
appeared. Examination  of  the  urine  revealed  the  nature  of  the 
trouble.  In  the  |>re-albnrtiinuric  stage  of  gouty  kidney,  when 
the  heart  is  aomewliat  hypcrtrophicd,  the  vessels  more  or  less 
rigid,  and  the  arterial  tension  raised,  headache  is  a  common  symp- 
tom. How  far  under  these  circuraKtances  the  headache  is  due  tofl 
retention  of  matters  in  the  blood  which  ought  to  be  excreted, 
how  far  it  is  the  result  of  the  increaseil  arterial  tension,  how  far 
it  i»  gouty  in  its  nature,  often  caDDot  be  made  out.  Dr.  S.  Weir 
Mitchell  spt-akssoiiiewiiere  of  having  seen  oases  in  which  rej>eated 
headaches  prece<led  hemiplegia.  It  seems  probable  that  tbeae 
headaches  were  either  gouty  or  uremic,  and  were  only  by  accident 
asBocialvd  with  the  subsequent  rupture  of  a  blood-vessel. 

AloohoUo  Headache. — Headache  ia  a  common  aymptom  itt^ 
clironic  aluuhotisni ;  in  some  cases  it  may  be  due  to  the  direct  irri- 


ZXALTATIOKS  OF  SEN8IBIIJTY. 


305 


tion  of  the  hnkin-m«mbrAne!<  by  the  nloohol ;   bnt  usually   it 
appears  to  be  seouudary  tu  the  godlro-iiiteslinal  imlatioD. 
H    Caffeixkio  Headache. — A  very  common  headanhe  is  that  which 
^1  have  dillrti  curTfiiiic,  booaiisp  it  is  the  result  of  ihn  exwssive  use 
i^f  eoffw?  or  tea.    The  subjects  of  these  headnchea  are  almost  always 
^bT  neumtic  terajKrament;  not  rarely  they  sufi*er  from  migraitie 
^Bgr  Bomc  form  of  nervous  headache.     It  must  Ite  borriR  in  mind 
"that  even  a  small  anioimt  of  cnjSee  miiy,  in  such  pereona,  pro- 
duce disabling  head-pains.    Overworked  sGumstroiwefi  and  wewing- 
wonien  often  supply  a  lack  of  food  and  strength  hy  an  excessive 
use  of  lea.      Under  these  circumstances  severe  cephalalgia  ami 
I     Qtbcr  nervous  symptomg  are  certain  to  occur.    There  m  no  method 
^bof  determining  in  any  individual  case  that  the  ticadaclie  is  due  to 
the  use  of  tea  and  coffee  except  by  notielng  tbo  effect  of  atispend- 
ing  these  beveratjes.     Before  a  decisive  result  van  be  considered 
^fttD  have  been  reecheil,  total  abstinence  must  have  been  enforced 
Hibr  at  least  three  weokK,  ainc^.  when  the  train  of  morbid  HvmptnmH 
Vhw  once  been  set  in  motion  very  small  amounts  of  the  beverage 
suffice  to  keep  it  moving. 

Gtastrio  H0a<lache. — Headache  from  disorder  of  the  liver  is 
frequent.     It  can  hardly  be  separated  from  that  which  is  pro- 
duced by  giLstric  derangement,  although  in  some  catte.^  tlie  gastric 
headache-pain  is  evidently  rt'flex,  due  to  irritation  of  the  periph- 
eral nerve-filaments  in  the  stomacli  by  enwedingly  acid  and  acrid 
cnntcDt^.     This  acid-stomach  headache  is  usually  frotitat,  and  ia 
often  accompanied  by  sudden  blifidness  and   dizziness  and  aoid 
eructations,     lis  true  nature  is  n-vcaled  by  the  immediate  relief 
whicii  is  afforded  by  the  use  of  large  doees  of  aromatic  spirits  of 
■liartehorn.      On  tlie  other  hand,  a  dull,  heavy  headache  which 
often  accora]»aniea  indigestion  and  hepntio  torpor  is  probably  the 
^result  nf  the  absorption  or  retention  of  poisonous  organic  products. 
^It  is  usually  frontal,  but  occasionally  is  referred  to  the  region 
behind  the  eairs  or  to  the  occiput.      It   may  be  associatefl  with 

I  defective  vision,  giddiness,  and  great  depression  of  spirits. 
Diabetic  Headache. — Headache  is  not  rarely  jiremiit  in  dia- 
betes. When  it  occurs  in  an  advanced  utage  with  great  severity 
it  is  of  s{)ecial  importance,  because  it  is  frequently  prodromie 
of  diabetic  eoma.  Under  these  circumstances  it  is  oeually  ao- 
^bompBiued  by  dizziness,  muscular  {laius,  gat^trie  distress,  and  dis- 


306 


DIAGNOSTIC  NEt'BOLOOY. 


ordered  mental  action,  as  showu  by  incoherent  talk  or  hy 
delirium. 

Cardiac  and  Pulmooic  Headaches. — Violent  headache  oiiea 
acoom|)aiiies  di.souwH  of  the  hcai-t  aiul  Iiiii^  whii:h  Hre  stiflicteiitl] 
severe  to  interfere  either  ivith  ozidatiou  of  the  blood  or  wJt 
the  circulation.  Id  csmsi  of  obtKure  chrouio  headache,  es|>ecia]lj 
in  children,  practitioners  should  always  carefully  examine  the 
ooudiiion  of  tlie  heart. 

SjfmpaUteiic  ITeadnchai. 

Paim  in  the  head  are  in  rare  In.stauce»  the  result  of  comi 
tively  diMaut  irritations:  tliiis,  ilwrc  am  i-aum  nii  record  in 
laneiug  the  gums  or  removing  a  diseased  tooth  has  relieved 
severe  and  perhaiw  long-ex istj tig  headache. 

Headaches  of  Eye-Strain. — Severe  headaches  frequently 
Bult  from  eye-strain.  The  head-|»ain  \&  produced  by  a  disonic 
of  aecommodatJon,  or  by  un  iiiHufliirii'iKy  of  one  of  the  ocuUr 
muacJe?.  Although  very  frequently  the  facts  connected  with  the 
pain  are  euggcfttive  of  itn  cause,  yet  the  Iteadache  of  ej'e-sttaio 
has  no  fixed  determinate  charader.  It  \s  usually  frontal  or  in 
the  region  of  the  eye,  but  this  position  is  not  always  Bclectei]. 
In  A  rase  reported  by  Dr.  William  Thomson  (Med.  and  Surg. 
Reporter,  1874),  the  headache  finally  aetiunied  cbaraot«r»  exactly 
simulating  th(.>i*e  of  the  most  typical  migraine,  the  |>aroxysm8 
onmineucing  with  an  attack  of  [lartial  blindnei^  involving  half 
the  visual  field,  followed  by  severe  pain  in  the  heud  lasting  man] 
honrx,  fl<^cini]>ai)ied  by  nauscn  and  great  general  dcpre^ion.  In 
almost  all  ca^ea  the  pain  is  greatly  aggravated  by  the  use  of  the 
eyes,  and  in  the  earlier  periods  of  its  history  only  follows  such  use ; 
finally  it  may  onmo  on  nt  nil  titn^,  ami  often  apparently  spon- 
taneously. It  is  apt  to  be  very  severe  in  the  raoruioga  after  an 
evening  spent  at  the  theatre  or  oiher  place  of  amusement  where 
tiie  lights  are  very  brigbi.  Someiimes  the  pain  is  nut  confined  to 
the  head,  but  ru<liates  down  the  back.  The  difficulty  of  diagnosis 
M  oOen  aggravated  by  the  fa(rt  that  the  headache  of  eye-stntin 
b  especially  common  in  neurotic  subjects,  and  that  it  not  rarely 
ooexistB  with  head-pain  of  other  character.  The  conjunctival 
syniploniN,  although  not  oouHlant,  arc  cliuraoCeristio:  they  consist 
of  chronic  irritation,  with  intense  redness  and  velvety  appearanoaj 


KXALTATIOS8  OP  SEWSIBrLITY. 


I 


of  the  EDUoous  membrane  and  of  the  tarsus.  Although  in  many 
OSses  the  »tymptom»  are  siiificiently  definite  to  leai]  to  a  ^^tron^ 
nSfMciou  of  tli«  cau^e  of  the  Iieadaches,  a  [KMilive  d«ci)«ioii  <r^n 
be  reached  only  by  a  careful  examinatioD  of  the  eye  by  the  ocu- 
list, and  the  i-oiiiiteractiun  of  any  defects  timt  may  be  found. 

Nasal  Headache. — Headaches  may  be  tlie  result  of  disease 
of  the  nasal  mnoons  membrane.  Prof.  Harrison  Allen  ooncsludes 
that  lliere  are  three  kinds  of  thc«(e  na»al  hcad-palns,  uhieh  lie 
denominates  respectively  the  reflex,  the  neurotic,  and  the  iuflani- 
matory.  The  reflex  hfsuluche  i^  almost  entirely  ruHtricteil  to  tlie 
forehcul,  the  temple,  and  the  vertex.  By  drawing  the  index 
finger  a<Toss  the  face  from  the  middle  of  the  nose  to  the  temple, 
and  thence  iu  some  cuaes  to  the  parietal  emiueuce,  the  patient 
odea  indicates  the  seat  of  the  pain.  In  severe  attacks  pain  some- 
times rndiat(4  U^  the  vertex  and  i^von  to  the  na[)e  of  tlie  neok, 
and  then  oAeii  naU5«itcs  and  ^imulalc^  migraine.  Sometimes  the 
point  of  pniii  iii  narroweil  to  a  minute  focus  or  spot.  A  very 
diaracterii^tic  sympt^xn  i»  the  marked  lucreaMe  of  the  headache 
upon  the  slightest  exaoerhalion  of  the  catarrh.  A  diagnostic 
l^mptom  is  tenderness  of  the  inner  wall  of  the  orbit  when  pres^d 
upon  by  the  finger ;  or  a  probe  pa-ssed  into  the  nose  causes  an 
imaiediale  access  of  pain  when  it  reaches  the  ri|^ht  middle  turbi- 
nate bune.  The  disappearance  of  the  catarrhal  reflex  headache 
when  the  uasal  catarrh  is  cured  is  the  strongest  proof  of  ita  na- 
ture. The  neurotic  nasal  headache  of  Prof  Harrison  Allen  cora- 
prite*  tta^  in  whicli  highly  neurotic  individuals  roniplaiu  of  vio- 
leot  pain  in  the  throat,  the  ears,  the  back  of  the  head,  or  even  the 
pharynx,  or  of  various  distresses  about  the  head,  as  a  result  of  a 
moderate  degree  of  local  na^tal  or  pharyngeal  diiwa.sc.  Dr.  Allen 
farther  says  that  he  has  i>ever  seen  catarrhal  headaches  of  inflam- 
matory origin  except  in  acute  congestion  or  inflammations  of  the 
I  {roatal  sinuses:  the  pain  is  of  high  grade,  is  as  a  rule  confinnl  to 

[  one  ride,  and  euhaides  after  the  local  application  of  leeches. 


P 


NervoUM  Heniiactie, 


Doder  the  title  of  nervous  headache  I  shall  group  the  so- 
oalleil  antemic  heudnche,  congestive  headache,  the  headache  of 
brain-exbttiution,  the  hystoical  headache,  migraine,  and  certain 


308 


DlAOiroeTlO   NKUBOIXXIY. 


rare  lieadaebet  whose  nature  is  ootnpletely  obsuure,  \yat  whicli  maj 
be  ilesij;nnl«I  by  the  misnoraer  of  idiopotliic  headache. 

AnsBinic  Headache. — The  hcndarJie  which  ib  i^^ren  in  th<ii 
who  are  .suflerinj  from  well-mnrkcd  anietnia  following  malnria, 
bleeding  piles,  etc,  has  iii  itself  natbiiig  that  is  pccaliar  or  t:bar- 
ftcteri^tic.  It  iH  oneii  brought  on  or  aggra\*ale<]  bv  um>  of  the 
brain,  and  in  this  way  is  related  to  the  headache  of  brnin- 
erhnustion.  Very  frequently  during  the  attack  the  faoo  will 
flu^li  and  the  eye*  rudden,  and  the  patient  oomplaiof  of  a  sense 
of  fulness  in  the  head.  In  these  symptoms  the  headache  reBcm- 
blen  the  cimgei'live  headache.  Ah  in  inniiy  odier  of  tliese  forms 
cf  headache,  the  diagnosis  is  to  be  made  out  by  discovering  the 
existence  of  the  disease  or  condition  which  produces  the  heul> 
ache,  and  by  the  relief  which  follows  the  cure  of  the  parent 
affection.  The  hemlache  nhich  h  sometimes  a<«ociated  wiih  fattv 
heart  is  prolwibly  due  to  an  improper  supply  of  blood  to  the 
brain,  and  may  properly  be  considered  to  be  a  variety  of  annmic 
headache.  It  must  be  borne  in  mind,  however,  that  [lalpitation 
of  the  heart  and  «mlialgic  diiiturbauce  may  be  prominent  symp- 
toms in  amcmia,  and  mislead  the  diagnostician  into  aupposing 
that  a  cardinc  Ipsion  cxi-ttR. 

Congestive  Headache. — Congestive  beadiiches,  or  lieadachea 
from  active  bypermmia,  are,  I  think,  extremely  rare,  unless  after 
exposure  In  (he  sun  or  some  nther  immediate  exciting  ranse. 
They  are  to  be  distinguished  by  the  severity  of  the  throbbing 
pail),  by  the  8en.se  of  pressure  and  weight  in  the  head,  by  tho 
(fufiutiiun  in  the  fiiL'e  and  eyes,  and  by  the  strong  pulsation  in  the 
cnrntid.  The  \m\m  is  usually  full  and  strong,  and  the  cephalic 
symptoms  may  go  on  to  the  ap[>earance  of  hallucinations,  and  even 
to  the  production  of  coma  or  delirium.  ^ 

Hysterical  Headache. — In  many  caws  of  hysteria  the  patient 
suffers  much  from  violunt  paiuN  in  the  head,  uf  varied  character. 

AhnoftirharacterisLicof  the  tcmpemmcnt  is  the  so-called  (i/<nnu, 
a  pain  situnte<3  in  the  middle  of  the  top  of  the  head  in  a  point  so 
small  that  it  can  almost  be  covered  with  (he  point  of  the  finger. 
The  hysterical  bcadaebc  is  apt  to  be  increoRetl  at  the  men- 
strual periml,  and  to  be  suddenly  removed  by  pleasurable  mental 
excitement. 

Headache   of  Exhaustion. — In  exhaustion  of  the  geueral 


A 


EXALTATrONS  OF  SENStBriJTY. 


309 


Den'oas  system,  from  such  generally  acting  causes  as  severe  con- 
Joinei]  mental  and  bodily  exertion,  niirsinji^,  rlcpressing  pmntions, 
sexual  exc«NKS,  etc.,  or  in  the  limited  cxhaustioD  of  the  brain- 
centros  from  excessive  iotellectaal  work,  tbe  patient  commonly 
■ufiera  from  a  sense  of  weight  at  the  lO[i  of  the  vertex,  or  from 
K  heavy,  dull,  opprcasive,  deep-seated  cephalic  distress.  This 
form  of  hefiJaclie  is  of^n  associated  with  insoninin,  and  h  aUvays 
increa^  by  auy  intellectual  effort. 

Mijirraine. — Under  the  name  of  migraiue,  or  megrim,  are  in- 
olnded  very  numerous  caee*,  whiirh,  while  they  have  much  in 
oommon,  vary  greatly  in  the  development  of  their  symptoms. 
The  oaeeiitial  feature  of  the  affection  is  a  paroxy<;mat  headache, 
whidi  ill  the  great  majority  of  cases  appears  6rst  at  early  puberty 
aod  continues  id  women  up  to  the  menopause,  or  in  men  to 
adxTinced  middle  life.  In  its  details  the  piiroxysm  varii'it  in 
different  individuals,  but  usually  conforms  more  or  leas  to  the  fol- 
lowing type.  For  some  hours  before  the  attack  the  patient  suffers 
from  malaise,  often  with  chilliness  and  a  teuse  of  languor,  ur  in 
rare  casehex|>eriericcsacondilion  of  peculiar  cmottomil  and  mental 
a^-iiviiy.  The  attack  may  or  may  not  be  ushered  in  by  distinct 
prodromes.  The  pain  is  unilateral  in  the  great  majority  of  caH>es, 
■otl  ia  referix>d  to  ttie  frontal  region.  Iiaviug  the  focus  at  ur  about 
tlw  sopra-orbital  foramen,  or  more  rarely  in  the  eye  itself.  It 
eomea  on  gradually,  becoming  more  and  more  intenae  for  hourS| 
antil  6nally  it  is  unbearable.  It  is  generally  dcacribed  as  boring 
in  cbaraeter,  often  throbbing,  and  only  in  very  rare  instances  H 
•liooting  into  the  jaws  and  the  neck.  Sometimes  the  occipital 
region  may  be  the  feat  of  the  pain.  About  (he  time  that  the  pain 
r<a^e»  ita  greatest  intensity,  nausea  followed  by  vomiting  rle- 
vclops.  The  vomiting  is  usually  repeated,  and  is  attended  with 
great  bodily  depression.  The  matters  ejected  are  the  contents  of 
tlie  »ioniach,  followed  by  mucus  and  bile.  App.irent  relief  ofieu 
follows  Uie  vomiting.  In  some  cases  the  patient  now  falU  aisleep, 
■lid  wakes  free  from  the  headache;  in  other  cases  the  headaohe 
pwloally  subsides.  The  whole  paroxysm  lasts  from  live  hours 
to  two  or  even  three  days.  During  the  height  of  the  attack  of 
migraine  there  is  generally  intolerance  of  light  and  sound  ;  and 
yet,  according  to  K.  Souila  { TAtU*?,  Paris,  1884,  No.  35),  oocasion- 
ftlly  there  is  an  intense  craving  for  light,  and  even  for  noiw. 


i 


k 


DIA0N08TIC    KEDROLOOT. 

AltKough  the  general  fealures  of  an  attack  of  migrain<>  confrtna 
to  the  act^ount  just  givwi,  there  are  certain  sviuptoms  wbicb  are 
occasionally  present,  and  deinand  more  detailed  dcfioription.  Id 
some  cases  the  prodromes  are  very  marked,  and  inrlmJe  distinct 
disturbance  of  a  special  tiense.  The  sight  in  the  roost  frequently 
affected,  and  next  aflcr  it  the  smell.  Possibly  a  peculiar  bitter 
taHte  in  tite  mouth  which  soems  frequently  to  precede  an  attack 
of  inijjrainp,  and  which  is  generally  referred  by  most  patients  to 
disordor  of  the  stomach,  should  be  notett  as  among  the  sensory 
prodromes.  This  taste  hay  seemed  to  me  to  be  closely  coonected 
with  a  peculiar,  exoesaively  disagreeable  odor  of  the  breath,  which 
in  tnrn  appears  to  be  due  to  the  excretion  of  some  milpliurclted 
comimundH.  Jewelry  abi^ut  the  i>crson  may  be  very  distinctly 
tarnished  during  an  attack. 

More  usual  and  more  distitictly  prodnimic  is  the  pheDomeoon 
which  M.  Galezowaki  has  df^eribed  under  the  head  of  miffraine 
opfiiJuitmiea,  or  hrmtopia  periwlioa.  The  most  freqnent  form  of 
this  is  an  amblyopia,  necompanied  by  vivid  sointillationa  passing 
ziguig,  like  the  lines  of  a  forti6catton,  over  the  6eld  of  vUioii, 
When  hemiupia  ucvtirs,  it  may  be  either  monocular  or  binocular; 
sometimes  it  is  lateral ;  iu  other  eases  it  occupies  the  superior  half 
of  the  visual  field.  In  the  binocular  form  a  lateral  half  of  the 
field  is  attacked.  The  visiou  is  completely  abolished  in  the 
affected  portion  of  the  Held,  although  the  total  acuity  of  vision 
may  remain  normal.  This  seoHory  disturbance  very  rarely  occurs 
except  in  persons  who  have  long  Huffercd  from  the  miffraine.  In 
imnie  c&ses  it  is  preceded  by  headache,  bnt  usually  it  develops 
suddenly  as  the  beginning  of  the  piiroxysm  ;  occaaionally  instead 
of  heniiopia  a  central  Rcolonxa  la  the  dominant  symptom.  Rarely 
this  scotoma  merges  itself  finally  in  a  heniiopia.  In  rare  coses  ■ 
these  distui'l>!incc«  of  sight  arn  rejiIaceH  hy  distinct  visions  or  hallu- 
cinations. The  olfactory  disturbance  wliicli  ui^here  in  a  migraine 
is  generally  of  a  peculiar  odor,  like  that  of  osmic  acid,  etc  Tlie  ■ 
auditory  prntlroriie  hw  lieen  variously  described  as  like  the  sound 
which  is  produced  when  n  marine  shell  is  applied  to  the  ear,  or  as 
a  guttling  similar  to  that  which  is  heard  when  water  entent  the 
ear  during' washing.  It  is  stated  thai  in  very  rare  cases  a 
comftarable  to  that  produced  by  {wLssing  nn  electric  current  throu 
the  mouth  is  prodromic  of  a  parox\'sm  of  migraine. 


I 


taste    1 
■ougli     I 


EXALTATIONS  OF  SENBFBn.ITY.  311 

Tho  pftyt^it^l  ajmptnniA  which  acmropany  a  migrnine  arc  usu- 
ally n«t  aevere;  but  in  mro  cases  they  are  very  marked,  nficctitig 
especially  the  emotional  nature,  causing  in  one  instaooe  profound 
melancholy  and  depression,  in  auother,  vivacity ;  in  cither  nase 
there  is  commonlv  nn  exoessive  irritability.  During  the  attack, 
•jceording  to  the  mra-inremejits  of  <).  Bci^^,  there  in  a  rendition 
<^  hypenestheeia  of  the  skin  of  the  Tacc,  at  least  so  far  as  the  senate 
of  locality  and  the  electric  sensibility  are  oonoerned.  Certainly 
ID  mwt  cases  there  is  m>  excessive  sent^ihiUty  to  preasure,  and 
indeed  commonly  the  pain  is  more  or  !««  distinctly  relieved  by 
firm  preswurp.  There  is  usually  no  tertdernctvt  either  during  nr 
after  the  attack  at  tlie  point  of  emergence  of  tlia  nerve  from  the 
bone,  although  in  i^onie  coses  a  certain  degree  of  general  tender- 
ness of  the  face  is  prodnoeil  by  a  violent  [lamxyHm.  A  itunark- 
able  bnt  very  rare  compliration  of  migraine  \f  an  aphasin  during 
tlie  height  of  the  Rttai-k.  Thiw,  in  a  ca-*  re(»ort*<l  {GozetU  tUt 
HOpUattx,  May  17,  1884)  b)-  Prof.  Charcot,  there  was  habitu- 
ally t-omplete  aphasia  for  about  an  hour  during  the  crisis  of  the 
paroxysni.H. 

An  the  affection  has  come  under  my  notice  iu  this  country, 
nso-motor  disturbance  m  not  usually  pronounced  ;  but  Euleuburg 
diatiuguMfaeii  two  varieties  of  migraine  which  be  eays  are  typicaL 
In  the  one,  during  the  height  of  the  paroxysm,  o|>oo  the  aflbded 
aide  the  face  Is  pate,  the  pupil  dilated,  the  temporal  arter}'  hard, 
and  the  temperature  of  the  external  an(lttor>-  canal  i.i  re>(:lu(«d 
one  to  two  degrees  Fahr.  Pressure  of  tbe  carotid  upon  the 
aide  of  the  paiu  now  increases  the  pain,  whilst  presure  upon 
the  artery  on  the  opp<wite  side  of  the  uerk  tends  to  relieve  it. 
Towards  the  end  of  the  paroxysm  the  face  and  car  become  red, 
with  a  senisition  of  beat  and  ao  alwotute  Hue  of  the  temperature; 
at  tbe  aame  time  there  in  in  Honie  cai%s  a  oontratiion  uf  the  puptl. 
In  the  second  variety  of  migraine  described  by  Kulenburg  tlicre 
are  throughout  the  paroxyfim  evidena^  of  vaso-mntor  depreeann. 
Always  at  tbe  height  of  the  attack  the  face  is  red  and  hot,  the 
oonjanctiva  injected,  and  tlie  lachr>'mal  scrretlon  increased.  Tbe 
ear  of  iJic  80e<-te<l  side  t»t  di^inctly  hotter  thau  i(h  fellow,  and  the 
mat  IB  very  iU)UDdant  at  the  immediate  aitc  of  die  pain,  or  somc- 
tiicA  the  sweating  in  unilntr-ral.  By  compression  of  the  carotid 
npoo  tiie  affected  side  the  pain  is  leaseDcd,  but  it  is  iDcreoaed  by 


DUOMutrrio  N£Uuui.M}r. 


I 


pressure  upon  tlie  urtery  of  tbe  opposite  »ide.  It  m  affirmed  tliaC 
ill  Sfiiue  cases  the  dilatatioii  of  the  arteries  and  vcJos  caa  be 
detected  In  tlie  fundtu.  TowardH  iiie  close  of  tlic  attack  the  face 
becomes  pale. 

The  existence  of  these  varietits  of  migraine  I  have  uot  been  able 
to  verify.  A  very  extraonliuary  phenomenon  which  is  vouclie<l 
for  by  the  late  Dr.  Anstie,  of  Ijondoo,  is  tliat  in  certain  cbms  of 
migraine  an  al>soliite  change  in  the  color  of  the  hair  of  the  cye- 
bn.AV8  in  the  immediHte  neighburliood  of  the  pain  can  be  »eea  to 
occur  duriDg  tbe  paroxysm,  the  hair  beoomiiig  wliitc,  but  reguii-  ■ 
ing  it^  <w]or  after  the  pain-stomi  is  |)ast :  by  a  succession  of  these 
paroxysms  tJie  hair  is  gradually  bleached  permanently,  so  that  ^ 
a  white  lock  appears  in  tbe  eyebrow  or  eveu  in  the  Iiesl.  H 

The  peculiar  features  of  a  paroxysm  of  mignUDc  are  usually 
repealed  in  tht'  next,  tbe  same  type  of  attacJt  being  perwistcnt  ia 
tile  one  individual. 

There  have  been  a  number  of  theories  brought  forward  as 
explauator>'  of  the  attack  of  uiigraiiie.  As  these  tlieoneti  slill 
remain  theories,  it  is  beyond  the  province  of  the  present  work  to 
discuss  them.  Clinical  experience  shows,  first,  that  migraine  is 
in  some  way  related  tu  gout ;  stcondly,  that  in  tbe  great  majority 
of  caaca  it  h  an  iiiheritetl  disorder,  which  has  cloac  relaliuux  with 
Other  Kcrious  neurotic  ailments. 


Faee-Pahu. 

Probably  owiug  to  its  great  development  and  to  its  ex|)o»ed 
[KNiiliou,  the  trigeminal  nerve  i»  especially  prone  to  suffer  from  fl 
functional  and  organic  disturbance.     The  sensory  root  arises  from  " 
a  nucleus  near  the  floor  of  the  fourth  ventricle,  and  emerges  from 
the  pons  to  euter  quickly  the  Gai»vi-iau  ganglion,  which  it  leaves 
^in  three  bmuchcs.  the  ophthalmic,  tlie  superior  maxillary,  and  the 
_  iferior  iniuillary.     The  first  of  these  furnishes  braiichet>  to  the 
eyeball,  to  the  lachrymal  gland,  to  the  mucous  membranes  of  ■ 
the  uoee  and  eyelids,  to  the  skin  of  the  nose,  upper  eyelid,  and 
forehead,  and  U>  tbe  upper  part  of  the  hairy  scalp.     The  superior 
maxillary  nerve  supplies   the   intt^ument  above  and  over  the 
maxillary  boue,  that  of  the  lower  eyelid,  that  of  the  nlde  of  the 
ii(>6e  and  upper  lip^  also  the  upper  teeth,  the  mucous  membranes 
of  the  nose,  of  the  up|>Gr  part  of  tlic  pharynx,  of  the  aotrum, 


R3CAI.TATIOKS   OP   SENBIBILrTY. 


313 


and  of  the  posterior  ethmoidal  <.'el1 ;  tt  also  sendi^  \ta  branohiis  to 
th«  soft  palate,  the  tonsil,  tlie  uvula,  and  the  glandular  and   mu- 
^L  Dous  strncturee  of  the  roof  of  the  mouth.     The  inferior  maxiU 
^B  hay  nerve  supplies  the  lower  jaw  and  teeth,  the  tongue,  the  inu- 
H  voxt&  tnembrane  of  the  mouth,  and  the  salivary  glands,  and  sends 
'        Elaments  to  the  side  of  the  head,  the  external  ear,  tlie  external 
ADdtlory  canal,  the  lower  lip,  and  the  lower  part  of  the  face. 
Much  has  already  been  ^id  in  this  book  in  regard  to  ]^ain- 
H  ati>nii8  which  afiect  the  trjgeraitial  nerve.     In  addition  to  these 
^1  we  must  recognize  four  classes  of  pain  in  the  nerve: 
V       ^inU  Neuralgic. 

Sewnd.  Reflex. 
K        Thini,  Neuritic. 
H       Fourth.  PriMopalgic. 

H       By  nemrafyia  affecting  the  trigeminal  nerve  Is  meant  violent 
H,2iain  oocurrliig  in   the  nerve  whii'h   h  not  due  to  any  known 
V^organic  affection,  and  which  i^t  simply  an  expression  of  a  gen- 
eral neuralgic  temperament,  either  hereditary  or  acquired.     By 
^Lannst  authoDi  the  term  neuralgic  in  regard  to  the  trigeminal  nerve 
^BH given  H  vcr}'  much  wider  fligiiitiuince,  m>  that  almo8t  any  form 
^Nf  trigcmtDal  pain  is  s|token  of  as  neuralgic.     Trigeminal  neu- 
nlgla,  using  the  term  in  it»  restrlctetl  sense,  is  to  be  reoc^ized 
Liy  the  cocxifiteuce  of   the    neuralgic  teiuperarneut,  and    by  llie 
absence,  between  the  paroxvi^m.'^,  of  the  tender  poinla  of  neuritis. 
(See  page  314.)    The  neuralgic  lcm|)eranient  is  itself  to  be  made 
oat  by  knowing  the  history  of  re|>eatcd  attack'^  of  pain,  afTti'ting 
now  this,  now  that  r^ion  of  the  body, — iucoustaut,  shit'tiug,  ap- 
^«mitly  ooiiselete.    These  [niiiis  are  the  expreHsion  of  a  general 

IDeuratic  vice. 
RifUx  trigeminal  pains  are  the  result  of  some  more  or  leas 
permrnnent  irritation  situated  at  a  distance  from  the  nerve,  and,  it 
may  be,  in  a  position  having  no  direct  connoctiou  with  the  nerve. 
ThcEe  reflex  pains  usually  do  nut  have  the  histoty  of  long  oon- 
tinnaiioe  that  is  characteristic  of  dental  and  prosopalgic  |>ains. 
They  are  also  usually  ruuch  less  severe ;  but  they  are  especially  to 
In  not^ized  by  the  diM^very  of  a  point  of  irrilntion,  niid  by 
the  lemoval  of  the  irritant.  They  have  Uvu  nuted  a»  following 
injaries  to  distant  nerves,  as  due  to  the  irritntioos  produced  by 
luBibriooids  or  tapeworms,  and  to  over-«xcitation  of  ihc  uterine. 


314 


DIAONOffnC   NKtIROI-OOY. 


» 


ovarian,  or  other  orgawt  of  generation,  as  well   as  to  heranr- 
rhoids  and  other  rectal  diseases. 

Ttifftminal  nmrith  i»  a  very  frequent  affection.  In  a  larjre 
pmjmrtion  of  oa.set  it  is  gouty  or  rlieiimatic.  The  pain  is  violent, 
affecting  perhaps  the  whole  diBtribution  of  the  nerves,  eertainly 
a  larjte  territorj-,  and  usually  associated  with  a  dUtiitct  history  of 
rbeumHtisni  in  the  past  or  with  other  evidences  of  a  general  dis- 
order in  the  present.  Trigeminal  nenritirt  may  be  suddenly  pro- 
duced by  excessive  exjMWiire.  It  may.  under  these  eirenmstanees, 
he  rheiimnlic;  but  it  seemA  to  me  prolnbic  tlmt  there  \»  a  iioii- 
Hieumatic  neiiritia  directly  caused  by  oxpoeure.  A  very  important 
form  of  trigeminal  neuritis  is  that  which  is  prttduced  by  decayed 
teeth,  through  t!ie  proiugatiim  of  an  inflaninmtion  of  the  pulp 
alonji;  the  smaller  twigs  until  the  whole  nerve  is  involved.  Of 
similar  nature  to  siifh  neuritis  la  that  \rhich  has  been  deflcrilN-<i 
by  Prof.  Grues  m  u  pvculiuc  neuralgia  uoeurriug  in  the  toothleae 
remains  of  the  alveolar  pri>ce8ses  of  old  people,  and  due  to  the 
irregular  or  exeetwive  de|KKit>^  oomprtHAing  and  irritating  the 
nerves.  Dental  neuritis  is  essentially  chronie,  h  a^^ociated  with 
horrible  suffering,  and  when  once  established  has  little  or  no  ten- 
dency to  get  well,  although  in  the  earlier  stages  it  may  be  arresled 
by  removing  (he  point  of  irrilation, — that  is,  the  affected  tonth. 
A  neuritis  arising  from  a  decayed  tooth  is  nanally  confined 
throughout  its  oourse,  or  at  lea»t  for  many  montlis,  to  tlie  inferior 
or  fsuiKrior  maxillary  branch  ;  and  such  isnlntion  of  a  ncuritic 
should  alwa^-s  give  ritie  to  a  suspicion  of  dental  origin. 

Trigeminal  neuritis  is  to  be  distinguished  from  neuralgia  of 
the  nerve  by  Ihe  persistent  tenderness  felt  at  the  point  of  emer- 
gence of  the  nerves  from  the  bones  of  the  fuix*.  As  these  points 
were  first  pointed  out  by  Dr.  F.  h.  I.  Vallcis,  tliey  are  frequently 
spoken  of  as  Valleix's  points. 

In  the  ophthalmic  branch,  the  most  imjKtrtant  point  h  the 
supni-orbital  foramen.  Less  commonly  to  be  recogiiixed  are  the 
palpebral  points  of  the  upper  eyelid,  the  nasal  ou  the  nose,  where 
the  ethmoidal  nerve  emerges  from  the  naaal  cartilage,  the  inner 
angle  of  the  eye,  corresponding  to  the  snpra-trochlear  nerve,  and 
the  (larietal  prominence.  In  the  auiierior  maxillary  bmnch,  the 
mt>st  im|Htrtanc  point  is  over  the  infra-orbital  foramen;  next  in 
order  ts  that  in  tlie  upper  lip,  Iheu  those  in  the  gutns  ur  in  the 


EXALTATIONS   OP  SESSIBILITT. 


316 


alveolar  proccascs  of  the  upper  jaw.  In  the  inferior  mflxiltary 
branch,  the  point  on  (he  chin  is  the  most  frequent,  next  i»  one 
in  front  of  the  ear,  while  ver^  iDcoostant  and  rarer  are  pointa 
OD  the  lower  Up,  on  the  side  of  tlie  tongtie,  and  on  Uie  alveolar 
prooesses  of  the  lower  jaw. 

Under  ilio  terra  proaopaftpa  T  inolnde  all  trigeminal  pninn 
which  are  neither  neuralgic,  reflex,  iior  ueuritic.  The  (tuffering 
in  prosopalgia  ia  apt  to  be  iutolerable ;  pains  of  the  most  furious 
character  slioot  witli  ligbtniag-liicc  rapiditv  along  Llie  courne  of 
the  nervew,  follow  one  another  in  incessant  floahcs  for  a  few 
seoooda  or  minutes,  and  then  abruptly  eeaso.  In  manj  cnses  these 
pains  are  aironi[ianie<l  by  furiou>j  clonic  uud  tonic  a>utractiou»  «f 
the  uiuschis  uf  the  Bide  of  the  f^aoe,  giving  nse  to  the  congeries 
of  symptoms  known  as  Ho-dotUouraix.  In  some  ca-'^w  paroxysms 
occur  only  a  (ew  times  a  tlay,  hot  more  frequently  they  repeat 
themselves  at  short  intervals.  The  lower  jaw  and  cheek  are 
pn^bly  the  most  frequent  seats  of  the  pain ;  somewhat  more 
rarely  are  (he  branches  of  the  u))per  maxillary  and  even  of  the 
opbthairoic  nerves  afTeotcd.  Only  in  excejitional  cases  do  tlie 
raiMous  membranes  softer ;  but  frightful  bnming,  shooting,  sting- 
ing, darting  pains  may  be  felt  in  the  mouth,  and  become  exee»- 
Bi»-«ly  severe  as  they  ruu  tliroitgh  the  tongue.  Often,  impelled  by 
an  irresistible  impulse  to  do  something,  or  |>erlia{is  led  by  a  slight 
feeling  of  relief,  the  patient,  during  the  paroxisms,  inoeseantty 
mbs  the  affbctod  part  with  the  hand,  cither  naked  or  armed  with 
a  handkerchief,  and  it  is  not  uncommon  under  these ctrcumstaueea 
to  Bee  the  cheek  bare  of  skin  fnim  incessant  rubhiog.  These 
severer  forms  of  prosopalgia  are  ca]wiblG  of  being  arranged  in  two 
groups,— those  in  which  a  lesion  can  and  those  in  which  it  cannot 
be  demonstrated.  I  have  seen  a  violent  trigeminal  antofOitgia 
doloromi  immediately  follow  an  apoplexy,  and  due,  without  reason- 
able doubt,  to  the  involvement  of  (he  sensory  nnclcuit  or  fibres  of 
the  trigeminal  nerve  in  the  pons.  Crnveilhier  found  a  cancerous 
growth  attacking  the  nerve-sheath  in  a  case  of  obstinate  proso- 
palgia. Laveran  noted  a  6brous  degeneration  of  the  (lastieriiin 
ganglion  ;  Lippic,  caries  of  the  Ixme  immedialely  below  the  nut- 
going  nerve-root ;  and  syphilitic,  cystic,  and  gtiomaloua  tumors 
hi%*e  been  found  in  the  neighborhood  of  the  On>)serian  ganglion. 
A  progressive  lesion  ninuinganot  too  ra)>id  course  and  involving 


S16 


DIAONOffnC  NKUEOMOY. 


the  sensory  roots  or  nucleus  of  the  tri^minal  nerve,  either  beforel 
or  after  tliey  enter  the  Qiuserian  ganglion,  is  o(^a  the  c»u:«e  of 
an  obscure  proeopalgia.  To  cases  of  prosopalgia  witliout  obvioas 
le^ioti  Pmf.  Truusieaii  gave  the  name  of  epileptiform  neuralgia, 
because  of  hJA  belief  that  the  affection  is  related  to  epilepsy.] 
This  opiuion  was  foumled  on  his  liaviug  seen  disorder  of  tht*  intel- 
ligence in  eome  esses,  and  having  noted  in  ottiers  that  the  attacks 
were  uabered  in  by  vertigo  or  other  aura-like  sensatiou,  whilst 
one  or  two  epileptics  sufieriuj;  from  violent  prosopalgia  had  come 
umier  hw  notice.  Olistinivte,  apparently  causeless  prosopalgia 
oocars  especially  in  uKl  i>cople:  it  is  probable  that  it  is  the  result 
of  atrophic  or  nutritive  degenerations  of  the  nuclei  or  of  the  root 
of  the  nerve,  such  degenerations  often  being  cauned  by  alterations 
of  the  walls  of  the  blood-vessels.  I  can  see  no  suffieient  rensoa 
for  believing  that  a  [Miroxysm  of  tJcxlouloureux  ever  represents 
one  of  idiopathic  epileptiy. 


KoR  testing  the  hearing  the  neurologist  usually  relics  upon  the 
onlinanr  watch  or  a  tunin|^fork.  In  ntauy  cavee  the  acuteoestt  of 
MuditioD  is  to  be  determined  by  comparing  the  two  esr»t  of  the 
patient.  If  both  sides  are  equally  affwtwJ,  it  iH-coraes  necessary  to 
ooroparc  the  hearing  of  the  individual  with  that  of  another  ]>ersori. 
The  varyingloudnewof  the  ticking  of  wntcheeand  the  gn-at  natu- 
nU  diftl'rences  in  the  acuteiieus  of  hearing  in  different  individuals 
reader  an  accurate  estimation  of  the  amount  of  a  double  deafness 
difBcnlt.  There  is  an  instrument  known  as  the  tonometer,  used  by 
otologists,  which  is  supposed  to  give  always  a  sound  of  a  definite 
intensity  ;  Imt  it  is  probable  tliat  even  this  inalrumeut  as  made  by 
diffcretit  iDi<tru men t- makers  varies  in  the  intensity  of  its  souod. 
Moreover,  I  know  of  no  studio  in  wliieh  the  range  of  normal 
audition  has  been  detcrmineil :  so  thut  the  ordinary  practitioner  ia 
uAially  forced  to  take  his  own  hearing  as  the  normal  ntandard. 

Id  examining  a  ca8«  of  deafness  the  neurologist  must  Brvi 
determine  whether  the  existing  deafness  ii^  <lue  to  disease  of  the 
middle  ear  or  is  neurotic.  In  doing  this  it  ia  custuniar}'  to  em- 
plov  the  tuning-fork.  If  the  deafness  be  unilateral  and  be  duo 
to  obstructive  disease,  either  of  the  middle  or  of  the  internal  car, 
vben  a  tuning-fork  In  vibration  '\fi  placed  ii|M)n  the  vertex  the 
noise  is  heard  much  more  itttensetv  in  the  deaf  ear.  Under  rarh 
eiream9lAncct(  the  neurologist  knows  ihat  the  Iors  of  hearing  is,  at 
least  in  part,  due  to  wax  in  the  external  meatus,  stoppage  of  the 
Eustachian  tubes,  or  other  obstructive  disease;  Unfortuiuilely,  in 
certain  middle-ear  dimuses,  inucli  as  andiyloeis  of  the  bones,  the 
tuning-fork  is  not  heard  more  loudly  on  the  deaf  side.  A»,  how. 
ever,  these  cases  are  comparatively  rare,  it  is  a  general  rule  that 
when  the  tuning-fork  is  not  heard  more  loudly  on  the  deaf  side 
the  deafness  is  probably  due  to  a  lesion  of  the  nerve  itself  or  of  its 
eoDtTF.     We  have  no  way  of  determining  with  certainty  whether 

817 


DIAO?rOSTIC  WBTBOI-OOY. 

such  loss  of  lieariug  b  due  to  a  lesion  in  the  labyrinth,  tn  Uie 
trunk  of  the  nerve,  or  in  tlie  nerve-centres:  labyrinthine  disefl.se 
is,  however,  )j;enerally  <H>nneicte<I  with  wvere  gtdtliues»,  whilst  iu 
disease  of  tho  nerve  or  of  it«  centre  gitldinoss,  if  il  exist,  is  not 
eevere. 

The  eightii,  or  auditory,  nerve  has  its  principal  nucleus  in  the 
floor  of  the  fourth  vcnlricte,  cloee  to  the  nuclei  of  the  vagus,  the 
glcwso-pharyngtal,  and  the  hypoglossal  nerves.  From  this  nucleus 
the  inferior  ro4)t  arisen.  The  M^und,  outer,  superior,  or  minor 
auditory  nucleus  lies  between  the  inner  nucleus  and  the  rcstiform 
body,  and  givcfl  origin  to  the  superior  nmt  of  the  nerve.  Tht? 
roots  past  obliquely  outward  and  unite  into  a  aiugle  trunk,  which 
appeani  at  the  lower  edge  of  the  pons  on  the  outer  side  of,  and 
<doae  to,  the  fa>c!ia1  nerve.  After  leaving  the  medulla  oblongata 
the  nerve  is  directed  outward,  in  conipRoy  with  the  facial  nerve, 
to  the  internal  aiidilory  meatui^. 

Deafu'estt  froui  disease  ui'  the  auditory  nuclei  is  very  rare: 
Peripheral  neunitie  deafnets  is  mucli  more  coraraon.  Tho  audi- 
tory nerve  is  liable  to  be  prease*!  upon  by  syphilitic,  tubercular,  or 
other  exudations  at  the  base  of  the  brain,  and  is  especially  exposed 
to  paralysis  from  disease  of  the  mastoid  processes  of  tiie  temporal 
bone.  It  may  therefore  Ije  laid  (htwn  an  a  general  diagniM>tio  rule, 
the  exceptions  to  which  arc  very  rare,  that  n  nervous  deafness  not 
associated  with  marked  giddiness  is  dependent  upon  a  lesion  of  the 
nerve-trunk. 

Hyperwsthceia  of  the  auditor)'  uervc  prodaoes  a  Iosb  of  hearing 
which  is  characterized  by  exoeasive  susceptibility  to  Bounds.  The 
normal  »timuli  of  the  nerve  produce  pain  rather  than  normal 
functional  excitement,  so  that,  allhuugli  unable  to  |>erceive  minute 
differencea  In  sounds,  the  patient  suffen?  acutely  from  loud  noises. 

SIQHT. 
In  discussing  the  relation  of  the  eye  to  discaacsi  of  the  n^voui 

Byslem,  I  shall  take  up  first  its  movements,  next  alterations 
the  pupila,  and  then  internal  oondittons. 


MOVKMENTi   OF   THE    EYE. 


Strabismus. — When  one  or  more  of  the  eye-muscles  are  |«r-' 
alyzed  or  cxccasivcly  contracted,  the  axis  uf  the  eye  is  drawn 


» 


* 


ont  of  its  normal  direction, — in  the  one  case  by  the  ttount)  mus- 
cle, which  are  no  longer  oontrolled  by  their  normal  antagonists; 
ID  the  other  ease  by  the  uveractiiig  muscle  ur  ti)u»cles.  When 
froiu  any  cause  die  axes  of  the  eyes  do  nut  correspond,  the  paticat 
is  Boid  to  suffer  i'roiu  strabismus,  or  squint.  A  8tnibismud  may 
be  either  pamlrtiR  or  <!oncomitsnt.  Paralytic  Mrabi.imu.'t  in  almost 
tD%-artably  the  result  of  disease  of  tlie  oervoiw  system ;  coiteoaii- 
taot  EtrabiKmus  is  the  outcome*  of  ou  ocular  defect.  In  the 
hypernietropie  eye  the  Hquiut  is  usually  (■uuvergcnt-  \a  the 
myopic  or  near-sighted  eye  it  is  usually  divergent. 

In  any  individual  c&ie  the  fiRtt  t>oint  in  the  dingnmis  is  to  de- 
teruiiue  whether  the  existing  squint  is  paralytic  or  ouiieomitant. 
The  diagnosis  as  to  which  muscle  is  affected  is  to  he  made  by 
studying, — firei,  the  raoveinentHof  the  eye;  rtecondly,  the  so-called 
secondary  deviation ;  thirdly,  the  absence  or  presence  of  double 
vision,  and,  as  part  of  this,  the  false  projection  of  the  field  of 
viitiun  of  the  paraiy/^  eye. 

I'wwt.  With  the  [latienc  sitting  before  him,  the  practitioner 
holds  up  the  finger  or  the  point  of  a  i^ncil  and  requires  the  sub- 
ject (0  follow  its  movements  wJlli  the  eye,  the  head  l>eing  kept 
etUl.  Under  these  oirctinutauc^,  il'  the  t^guiut  be  jmralyliu  the 
movements,  of  the  ball  will  be  found  to  be  restrictctl  on  the  side 
of  the  jMiralyiwii  mnsi'le.  This  tent  Kcems  u  very  simple  one,  but, 
owing  to  the  complicated  relations  of  the  ocular  muscles,  in  some 
cases  judgment  h  dillicnlt. 

Seoottdly.  Il  in  well  known  that  one  eye  habitually  follows  the 
Bovemems  of  the  other  eye,  so  that  if  the  left  eye  be  directed 
towartis  an  object  situated  on  the  extreme  left  the  right  eye  fol- 
loH-s  it  even  though  covered.  The  movement?  of  the  !«econd  eye 
depend  upon  the  tact  that  when  a  nerve-cenlrc  is  calte<t  ufiun  to 
move  one  eye  it  Kendg  an  equal  and  parallel  amount  uf  foroe  to 
the  other  eye:  thus,  if  the  external  rcctui)  and  ussm^iated  muwiea 
be  called  upon  in  one  eye,  the  intemnl  rectus  and  associated  muscles 
in  the  otlier  eye  receive  an  equal  amouut  of  nerve-force.  When 
a  partially  [laralyzed  musulc  is  required  to  turu  the  eye  in  a  certain 
dinctioD  up  to  s  certain  amount,  it  is  plain  that  a  muuli  greater 

*  The  explsQktiuQ  of  the  connoctioti  betwaen  oculmr  dofecU  and  tlntlHuniti 
WoDgi  to  woriu  on  dU«u«»  of  th«  aye,  u  il  is  k  purely  Inosl  mattw. 


DZAOKoenc  neokolooy. 


eicrtion  on  the  part  of  the  Dcrvc-ccntrc  controlling  tlie  niovenoetit 
will  be  required  to  produce  the  desired  uiovemeut  than  would 
be  nwesmry  if  tlie  niu»:le  %ven<  not  paralyzed.  The  amoaut  of 
nerve-force  discharf^  from  the  centres  being  equal  in  the  two 
e\"es,  it  follows  under  the  circumslanoes  just  i»|ioI(cn  of  that  the 
muscle  of  tlie  normal  eye  will  receive  a  greater  amount  of  nerve- 
force  than  is  nofxesairy  to  carry  the  eyeball  over  the  required  diB- 
taiiw:  (he  eye  will,  therefore,  be  drawn  beyond  the  object  which 
is  to  be  looked  at.  If,  iiftcr  such  rinvcmcnt,  tlic  normal  eye  be 
directed  towards  the  objert,  the  ball  wtti  have  to  return  towards 
itif  central  position, — the  anmuiit  of  return  tieing  exactly  the  excess 
of  movement  first  producol.  This  return  is  the  measure  of  the 
"  Htvontiari/  iltrvuition" — the  ceoonckry  deviation  being  the  distance 
which  the  sound  eye  has  l>ocn  drawn  beyond  the  position  which 
it  normally  chould  have  assume*!.  Primary  deviation  i»  the  d^ 
viation  of  (be  eye  M'hoKC  muscle  h  paralyzed,  from  its  normal 
position,  when  the  object  ih  looked  at  with  the  sound  eye. 

To  make  this  nmttcr  clearer,  let  us  supjvose  that  a;  represents  the 
amount  of  force  required  to  move  the  normal  left  eye  a  giveo 
distance  towards  the  left,  and  that  the  muscles  of  the  left  eye 
become  so  fur  pnrnly^KMl  that  "Ix  is  requirei]  to  execute  the  neocssarv 
movement.  When  such  movement  is  executed,  the  sound  eye  will 
receive  ix  instead  of  *  nerve-force,  and  will  therefoi-e  ho  drawn 
twice  as  far  from  it«  central  position  as  is  required.  The  t<ocoDd- 
ary  deviation  will  therefore  be  the  amount  of  movement  wbtofa 
ia  prodnoed  by  the  expenditure  of  x  force  in  the  eye.  In  order 
to  make  clear  the  method  of  te-sting  the  presence  of  secondarj 
deviation,  let  us  suppose  tlie  patient  has  a  defect  in  the  left  eye. 
The  right  or  sound  eye  is  covered  M'ith  the  hand  or  a  piece  of 
paper,  whilst  iht?  left  or  afUn^ted  eye  is  directed  towards  an  object 
8itunte<i  at  the  distance  of  a  few  feet.  When  the  left  ere  baa 
been  fociiascd  upon  hucH  an  object,  the  jwitient  is  told  to  look  at  ic 
with  the  right  eye,  and  the  cover  hastily  removed:  the  right  or 
sound  eye  will  now  be  seen  to  move  in  a  direction  opposite  to  that 
cowards  which  the  p:iralyzpd  nuiscle  ilrawa  the  boll.  Thus,  if  it 
be  the  external  rectus  of  the  left  eye  that  i»  affected,  the  rigbt 
eye  ulien  uncovered  will  move  backward  towards  the  right, 
becant^e  its  internal  rectus  lias  originally  received  an  excess  of 
nerve-force  and  drawn  it  too  far  tuwards  the  left. 


i 


I 

I 

i 


L 


DIST0RBANCES  OP  TH£  SPBCtAL  SENSES.  321 

Thirdly.  If  by  pressure  upon  the  ball  Ihc  axis  of  one  cyo  is  dis- 
torted, two  objects  are  seen,  because  the  visiml  Belds  of  ttie  eyes 
no  louger  txirrespoml.  Double  vlrtion  19  equally  pruduccfl  wlieu 
the  distortiou  of  the  axes  u  tlie  i-eeult  of  a  paralysis  and  when  it 
is  caused  by  an  overactinn  of  one  or  more  muKcIee.  Wlien  Uih 
lesion  of  the  mu-seic  and  consequent  distortion  of  the  axea  has 
been  very  gradually  developed,  the  patient  as  grndnaily  loses  the 
peroeptioD  of  one  of  th«  two  iiuagetft  or,  in  other  words^  habitu- 
ally sees  with  only  one  eye.  The  concomitant  squints  due  to 
defects  of  tJie  eye  are  verj*  slowly  developed,  no  that  the  second 
image  is  habitually  lo<tt  and  the  patient  has  conscious  vision  only 
of  tbe  single  ot^ect.  On  the  other  band,  paratylic  quints  are 
usually  suddenly  or  rapidly  developetl,  and  the  habit  of  not  heed- 
ing niie  image  \\an  not  time  to  form  itivlf,  ho  that  double  virion 
results.  For  these  reasons  we  are  able  to  frame  the  diagnostic  rule 
that  K^M  a  pfiraltftie.  xjuiiit  ui  almaM  invariaf>ly  aeeompanif/l  fty 
diMbU  visioin,  a  concomitant  s^piint  tg  rartly  $0  accompanied,  lu 
meet  of  the  ca^es  in  M'hich  the  second  iniag«  has  been  loeit  through 
habit  it  can  he  develo[>ed  by  placing  a  colort-^l  glam  before  (he 
sound  eye,  .so  an  to  liut  one  of  llie  inmgeg.  When  the  imager  are 
so  near  together  tliat  they  overlap,  the  result  in  a  blurred  image, 
which  by  the  colored  glass  is  resolved  into  two. 

Double  virion  may  be  cra^Aef]  or  simple.  Oowwd  diphpia 
oocnra  in  cases  of  divergent  squint:  the  image  seen  bv  the  left  eye 
if  to  the  right  of  that  »een  by  the  right  eye.  In  other  wokIs, 
the  image  seen  by  the  left  eye  is  ctrried  beyond  or  crossed  over 
liiat  «>cen  by  the  right  eye.  Simple  or  bomontfmoua  diplopia 
existn  in  convet^nt  K^tiint.  In  it  the  image  seen  by  the  left 
eye  'i»  to  the  left  of  the  other  image.  A  great  aid  to  the  memory 
in  regard  to  this  diplopia  is  afforded  by  remembering  the  rule  laid 
down  by  Gowers  in  his  lecturer, — namely,  that  when  the  pro- 
longed axes  of  the  eyes  would  cross,  the  images  are  not  crossed  ; 
whilst  when  the  prolonge<l  axes  would  not  croits,  the  imager  are 
cnMMd.  In  other  words,  convergent  )>quint  cauaes  simpli;  diplo- 
pia, divergent  squint  causa  oroawd  diplopia. 

In  Inag-exiattng  cases  of  paralytic  squint,  aecondary  oontractures 
of  the  Doa-paralysed  mnscle  may  give  ri^  to  diplopia  of  peculiar 
^MrHter.  For  the  discussion  of  these  ^ncr  points  tbe  reader  is 
referred  to  works  upon  tlie  eye. 

21 


The  foist  prt^fdum  nf  the  visual  Jiefd  is  ft  f(ubJG«t  which  secmi*  at 
firet  very  abstruse,  but  whicli  may  readily  be  simiilified.  Accunliog 
to  my  thinkiugi  it  really  is  neillier  more  nor  le^  th»Q  diplopia, 
fllthoiif^h  Gowcre  speaks  of  it  as  thou|;h  it  were  a  distinct  STnip- 
torn.  We  jndgp  of  the  positions  of  objects  In  regard  to  oor  own 
body  by  their  rehitiotix  (c  our  visual  fields.  This  relation  depends 
apon  the  positioQ  of  ih<.'  head  and  of  the  eyes,  so  that  the  degree  > 
of  contraction  of  the  iniiscles  of  the  head  and  of  the  eyes — Ce.,  fl 
the  amount  of  nervc-fonx'  which  is  given  off  to  them — nnron- 
flcionsly  becomes  to  onr  oonMrionsness  a  measure  of  the  position 
of  objects.  If  the  muscles  of  tlie  eye  are  at  rest,  the  ball  is  in  fl 
mid-poaitioii,  and  we  know  that  an  object  n]wn  which  wh  are 
fociiasing  the  eye,  or,  in  other  words,  at  which  we  are  intently 
looking,  is  directly  in  front  of  the  face;  that  is,  vre  know  that  a 
line  drawn  from  the  centre  of  the  object  at  which  we  are  looking; 
to  the  centre  of  the  (ield  of  vision — i,e.,  to  the  visual  centre  of 
the  retina — would  be  at  right  angles  to  the  face.  If  the  pye  is 
now  focnssed  n|)on  an  object  to  the  left^  the  degree  of  movement 
of  the  eye— that  is,  the  amount  of  nervo-force  given  lo  the  mus- 
cles of  the  eye"t8  the  basis  of  tJjc  uneonsciona  judgment  which 
leads  to  the  recognition  of  the  position  of  the  object  relative  to 
our  own  bodies.  Experien**  has  shown  us  that  the  exp4>nditiire 
of  T  force  on  the  appropriate  muscles  in  turning  (he  eym  to  the 
\eft  is  requiretl  if  the  \iv*ly  looked  at  is  situated  at  a  certain  angle 
in  rcf^rd  to  ourselves.  If  the  object  looked  at  is  fiufliciently 
close  for  us  to  lay  our  hand^  upon  it,  we  unconsciously  throw  into 
the  ncrvc»  of  the  arm  force  which  in  amount  and  direction  cctf- 
res|Kii)ds  to  that  given  to  the  eye-muscle,  so  that  ibc  hand  is  placed 
directly  upon  the  object  seen.  If  the  eye-rauficle  is  partially 
paralyzed,  and  an  increased  amount  of  nerve-fort^  is  required  [o 
produce  the  necessary  contrnctions  of  the  eye-muacles  in  looking 
towards  the  object,  the  lower  nervous  syfitem  throws  into  the  hand, 
which  is  put  forth  to  touch  the  ubject,  foix'e  which  in  amount  and 
direction  corres|}onds  to  the  abnormally  large  force  required  to 
move  the  weakened  *'ye-mnscle.  The  hand  is  therefore  projected 
too  far  to  one  side  of  or  beyond  the  object,  according  as  this  or  that 
ocular  muscle  is  paralyzed.  The  false  direction  of  the  arm  will 
actwrd  with  the  direction  of  the  secondary  deviation  of  the  sound 
eye ;  that  is,  if  the  normal  eye  goes  too  far  to  the  left  the  arm  will 


I 


DI6TURBANCEB  OF  THE   SPECIAL  SENSES. 


323 


■ 


go  too  far  to  the  lefl,  etc  The  disoord  which  thus  arises  hetwcea 
tlie  face  of  thiugs  as  ecea  aud  as  felt  often  producer  vertigo  or 
gidilineH^:  hence  Uie  so-called  ocular  vertigo.  (S<ee  article  on  Ver* 
i^go.)  In  sonic  cases  the  nerv-c-ocntres  Hnalty  learn  to  accnmmu- 
date  themselves  to  the  altered  circiim.9tanoed.  In  other  cases  the 
patient  may  try  to  avoid  the  vertigo  by  holding  his  head  in  such  a 
position  that  the  affected  nutficics  arc  not  lulled  into  action,  or  by 
ctoBing  the  affected  eye,  either  with  the  hand  or,  more  generally, 
by  a  contTflottire  of  the  orhioulnr  muscle.  As  pointed  oQt  by 
Gowers,  the  affected  eye  is  always  the  one  clo*^,  because,  althong^h 
closing  either  eye  would  remove  the  diplopia,  only  closure  of  the 
■fleeted  eye  removes  the  vertigo  or  uncertainty,  by  removing  the 
diaoord  between  the  visual  and  other  sensations. 

This  scientific  explanation  of  tlie  false  projection  of  the  visual 
firid  is,  of  course,  iuterestiog,  but  after  all  it  amounts  only  to  this, 
that  the  patient  neeti  the  image  of  the  object  looked  at  in  a  false 
pgeiiion,  and  that  he  natnrally  puts  his  hand  forward  to  seize  the 
image  at  the  position  in  which  he  sees  it  Thus,  if  in  a  case  of 
diplopia  two  distinct  inkstands  are  seen,  although  only  one  exists, 
and  tlie  secoodarj'  inkstand  lu  perceived  to  the  left  of  the  true  one, 
when  the  sound  eye  is  closed  the  patient  sees  only  tlie  secondary 
or  left  iniuge.  If  now,  witli  the  sound  eye  closed,  he  should  at- 
tempt to  take  hold  of  the  inkstand,  he  would  of  course  :^ize,  not 
tlie  iokstJiud  pro|>er,  but  the  secondary  image  which  alone  he  toes. 

Ocw/cHnnofor  PcUxy. — A  pamty tic  divei^eut  squint  is  due  to  patsy 
of  Uic  tliini,  or  oculo-motor,  nerve,  which  supplies  all  the  muscles 
of  llie  orbit  except  the  sU|ierior  ol)Iii|Me  and  external  rectus.  As 
it  ii  poanble  for  certain  fibres  uf  the  oculo-motor  oerve  to  be 
paimlyzed  aud  the  remainder  to  preserve  their  normal  a(rtivity,  one 
of  the  muscles  supplied  by  the  eye  may  be  alone  affected.  Thin 
netOBitates  a  brief  ooiisidcrution  of  the  varieties  of  stmhismns 
ooonected  with  each  muscle. 

When  the  internal  rectus  is  |uinilyzed,  there  is  defect  of  the  in* 
ward  movement  of  ilic  eye,  and  cni^sed  diplopia,  the  false  image 
being  oblique  above  and  below  the  horiEontal  plane;  when  die 
•nperior  rectus  ainnc  is  |«ralyzed,  the  movement  upward  and 
outward  is  affected:  a  certain  amount  of  upward  aud  inward 
movement  is  preserved  in  the  ball,  because  the  inferior  oblique 
moaele  hnhitually  acts  with  Uie  su|K:rior  rectus  iu  causing  tlioee 


334  DiAONoenc  neurolooy. 

movements:  <1ouhle  vision  oocuns  on  looking  upward,  Uie  false 
image  lieing  above  tlw  true.  When  the  inferior  rwtns  mnscl*^ 
is  paralyzed,  there  ia  loss  of  the  downward  and  outward  move- 
ments :  the  Beoondary  deviation  is  produced  by  tJic  nppoeite 
recttts  moving  the  ball  too  much  downward  and  outward,  so 
that  the  return  movement  ifi  upivard  and  inward.  This  form 
of  strahis^mus  is  apt  to  be  confoiindei)  with  tliat  which  results 
from  paralysis  of  the  superior  oblique  (fourth  nerve :  see  p.  325). 
Paralysis  of  the  inferior  oblique  musele  riu<ieA  defect  of  the 
upward  movementa:  the  secondarj'  deviation  is  produced  by  ex- 
oeeeivn  action  of  the  inferior  oblique  and  inleroal  rectos  mmcles 
of  the  sound  eye,  so  that  the  liall  ia  farrie<I  ioo  much  upward 
and  inward  and  the  return  movement  is  outward  and  do^'n- 
ward :  double  vision  occurs  with  tlie  false  image  oblique  and 
situated  above  the  true,  the  obliquity  being  greatest  la  liwkiog 
outwani,  llie  ciefoot  in  height  in  looking  inward. 

The  third,  or  octtUt-vioior,  nerve  emerges  from  the  inner  mde  of 
the  erus  cerebri  cIorc  to  the  upper  border  of  the  pons,  and  extend* 
outward  and  upwanl  between  (lie  posterior  cerebral  and  supe* 
rior  cerebellar  arteries  to  the  outer  side  of  the  (KKiterior  cliooid 
process,  a  little  anterior  to  which  it  penetrates  the  dnra  maler 
close  to  the  outer  boundary  of  the  cavernous  sinus,  and  paft«ea 
through  the  sphenoidal  fissure.  Its  deep  root  Is  situated  in  the 
gray  matter  of  the  floor  of  the  Sylvian  aqueduct,  in  tlio  rv^ion  of 
the  superior  corponi  qundrigeminu,  ju5t  above  tite  nucleus  of  the 
fourth,  or  troehlrar,  nerve.  The  fibres  pass  forward  from  the 
nucleus  thntugb  the  tegmentum  and  the  tegmental  nucleus,  and 
partly  through  the  substantia  nigra  to  tbc  point  of  emergence. 
Owing  to  the  position  of  its  nuolens,  the  itculo-mator  nerve  is 
liable  to  be  jMiralyzod  by  lesions  of  the  crus  cerebri.  Under  tlieM 
circumstances  the  symptoms  of  the  oculo-motor  paUy  are  upon 
tlic  side  of  tJie  Ixxly  opposite  to  the  hemiplegia  or  liemianiesthesio- 

.49  the  oculo-motor  nerve  supplies  not  only  Itic  muscles  of  the 
eyeball,  but  also  Clie  elevator  of  the  upiter  eyelid,  the  levator  palpe- 
br«B,  its  complete  palsy  is  followed  by  ptosis,  jMiralysis  of  uccoiu- 
modation,  and  dilatation  of  the  pupil,  as  well  as  by  paralysis  uf  the 
muscles  of  the  ball.  The  dlscusetoii  of  the  relations  of  the  oculo- 
motor nerve  to  the  pupil  will  be  found  under  the  head  of  Pupil. 

Partial  paralysis  of  the  oculo-motor  nerve  has  a  significance 


DISTCKBANCES  OF  TH£  SPECUL  8EN8E&. 


325 


similar  to  tlie  sarae  phenomenon  in  the  abduccns,  vritli  the  ex- 
oeptioo,  at  least  ia  my  «x[>eri«iic-e,  that  functional  palsy  is  more 
rare.  Owing  to  its  prolougod  course  at  the  liase  of  the  skull, 
it  in  eBpecially  liable  to  l>e  presi^l  upon  hy  syphilitic  or  tu- 
bercular exudations.  An  acute  oculo-motor  palsy  which  is  not 
Theumntic  is  in  the  adult  generally  syphilitic,  aad  in  the  cbllil 
«i»ually  tubercular. 

According  to  the  statisticg  of  Eulcubut^,  tiie  oculo-motor  nerve 
K  more  frequently  aSetrtecl  in  locomotor  ataxia  than  are  thc^  other 
«icular  nervefl.  Under  thfsti  circum<ttnnocs  the  poralj-sis  is  nearly 
ailwayii  partial ;  very  rarely  is  there  ptosis,  usually  the  muscles 
mnci  the  pupiLs  alone  being  affbctocL  On  the  contrary,  it  is  not 
Tare  in  syphilis  for  [Amif>  to  exist  without  marked  disonlcr  of  the 
pupil  or  of  the  muscles  of  the  eyeball. 

IParaiytit  of  IVo^dtar  Ntrvf. — Loss  of  movement  of  the  eye 
downwani  itnd  inward,  with  the  convergent  strabismus  mnr.t 
marked  when  the  patient  looks  down,  in  dite  to  the  puralysis  of 
the  superior  oblique  muscle,  which  is  supplied  by  the  fourth,  troch- 
IttU",  or  pathetic  nerve.  Care  mny  be  necessary  to  distinguish 
{nralysis  of  the  superior  oblicjue  muscle  from  that  of  the  inferior 
Rctu£,  in  which  the  loss  of  movement  is  downward  and  outward : 
the  distinction  is  readily  made  by  paying  attention  to  the  position 
of  the  imaj^  in  double  vision.  In  paralysis  of  the  inferior  nctus 
tlie  diplopia  is  croese<1,  and  the  false  image  is  placed  below  the 
true  and  is  oblique.  The  greater  the  attempted  movement,  the 
lower  it  is  situated  and  the  mart>  ohtiquc  it  is.  In  iwraljrsis  of 
the  superior  oblique  niwicle  the  diplopia  in  simple,  and,  the  false 
toiag«  being  lateral,  the  distance  between  the  two  images  is  greatest 
in  tliu  middle  line,  and  les.suns  when  the  object  i.s  moved  inward  or 
outward.  The  diplopia  occurs  especially  when  the  patient  looks 
downward,  and  often  gives  much  trouble  in  going  down-staira, 
the  patient  being  unable  to  distinguiab  the  falM  from  the  true 
iin^Q  of  the  descending  flight.  The  trochlear  or  pathetic  nerve 
hma  its  saperficial  origin  jiint  below  the  corpora  qaadrigemino,  and 
is  directed  at  first  outward  across  the  superior  peduncle  of  the 
eerebellam,  and  then  turns  forw.-ird  around  the  outer  ^ide  of  the 
enw  cerebri,  between  the  pfisterior  and  nufieriur  cerebellar  arteries. 
Its  nooleus  is  situated  between  the  superior  and  inferior  quadri- 
gminal  bodies^  immediately  below  tliat  of  the  third  aerve.     A 


326  DUomMTic  XEintoLOGr. 

partial  docussatioa  of  this  nerve  is  eaid  to  occur  in  the  anterior 
iDedullary  velum  at  the  oommcnoement  of  tlie  aqueduvt  Pan- 
lytic  aflections  of  the  troclilear  nerve  are  very  rare,  but  may  oeew 
under  circumetances  stmllar  to  those  of  the  nculo-motor  nerves. 

Paralysis  of  Abditceng  Nert'C. — Paralytic  convergent  squint  ii 
due  to  iianilvKiR  of  tlie  external  rectus  ruuiwlc.    The  antmutl  move- 
menta  of  the  eye  are  restricted ;  the  diplopia  is  simple.     The  twn 
imngpa  are  pantllpl  and  on  the  iwme  plane  when  on  the  hnrizoatil 
,      plane  of  tlic  centre  of  vision,  but  they  mm  usually  more  or  leei 
I      oblique  and  on  a  difierent  plane  when  they  are  situated  above  gr 
below  tlie  horiKonta)  visual  plane, — j.«.,  when  the  eye  has  to  bt 
moveil  npward  or  downward. 
I  The  external  recli)<i  is  .supplied  by  the  abduoens,  or  sixth  cranial, 

'  nerve.  This  nerve  arises  in  the  groove  between  the  pons  and  th« 
medulla  oblongata,  immediately  external  to  the  upfwr  end  uf  tbe 
pyramid, and,  jroing  outward,  lies  close  to  the  floor  of  tlic  eavemniu 
sinus,  in  contact  with  the  outer  side  of  the  internal  carotid  arierjr; 
finally  it  pafls&s  through  the  sphenoidal  ftii>iure  to  the  muscle.  Xu 
deep  root  is  situated  in  the  floor  of  the  fourth  ventricle;  a  few  fibra 
are  believ<.-d  to  pasH  upwani  and  acrosn  the  raph6  to  join  the  tliird 
nerve  of  the  opposite  side.  In  tliis  is  to  be  found  the  explanation 
of  a  few  recorded  cases  in  which  atrophy  of  the  nucleus  of  tbe 
sixth,  or  abduoens,  nerve  has  been  followed  by  paralysis  of  the 
internal  rectus  of  one  side  and  tlic  external  rectus  of  the  other 
side, — i.e.,  by  u  convergent  h<quint  on  the  side  uf  the  leaion  and 
a  divergent  squint  on  the  opposite  side. 

l^irtial  paralji^is  of  the  external  rectus  not  rarely  occurs  from 
simple  neurasthenia,  especially  when  the  cerebral  exhaustion  is 
largi'ly  manifestetl  by  drsoi'dfir  of  vision.  In  such  cases,  and  alao 
in  «Ls^  of  locomotor  ataxia  with  stnibiti>mu8,  double  vision  fron 
disorder  of  tJic  optic  axis  may  occur  although  the  strabismus  ii 
not  sufficient  to  be  ea^iily  noticeable.  Paralysis  of  the  extcroul 
rectus,  as  of  other  eye-muscles,  may  be  rheumatic.  In  such  eases 
there  is  usually  a  liistnry  of  cxptkauiT,  ]>ain  in  the  eyeball  or  its 
neighborhood,  swelling  and  pain  in  the  face,  and  various  c\H- 
dences  of  a  rheumatic  diatlietiis.  Attempts  to  move  the  eyeball 
I      also  rauHC  |Hiin. 

A  complete,  non-rheumntic  paralysis  of  the  aljduceits  nerve 
always  depends  ujx>n  an  organic  lesion  either  of  the  nerve  itself 


DtBTURBANCFS   OP  THE  8PBCUL   8BNSKS. 


tm 


I 


I 


I 


I 


or  of  i\e  centre.  In  cases  of  tubercular  or  syphilitic  basal  nieDingitH 
the  nerve  is  very  ape  to  he  presse<I  upon  ;  and  it  may  be  laid  down 
as  a  sufficioDtty  accurate  rule  that  (rA^te,  ccmpteie,  nun-rhtvmutio 
'  foralytit  of  the  ademal  reetius  in  the  child  is  tubercular  or  aypiiilitio, 
m  the  aduU  e^philiUe,  xaUeas  due  to  cerdfro-irpinal  menint/itis. 

In  oerlain  cai<es  of  poliomyelitis  the  DUcleua  of  the  abducena 
niidergocri  wasting,  and  the  muscle  suffers  from  atrophic  palsy.  A 
eonvet^nt  atrabisnnia  from  jiaralysi^  of  the  sixth  nerve  is  al»o  an 
oocastonal  plieaomenon  in  [K>stenor  bclerosis.  It  was  present  in  &ix 
of  thetwciily-fiveca.suiof  t{KX>niotoraLixia  witlibtnibi!iiiiti»n!(ii>rdtxl 
by  Eiilenburg.  This  form  of  convergenoe  ia,  like  all  other  fortos 
of  strabinmus  due  to  locomotor  ataxia,  apt  to  occur  at  first  in  parox- 
y»mii — i.e,,  to  come  and  go — and  to  be  associated  with  giddtneiis.  It 
may  be  a  very  early  phenomenon,  preceding  tlie  more  pronounced 
symptoms  of  {Htetcrior  strlerosLs.  When  the  Bolernsiii  conimcnoes 
high  up,  strabismus,  atrophy  of  the  optic  disk,  and  fulguraut 
pains  in  the  distribution  of  the  fifVh  nerve  may  long  precede  the 
usual  symptoms  of  locomotor  ataxia.  (See  Clozier,  Rtcual  d'Oph- 
Ukzlmoio^,  1880,  ii.;  alfiu  Galezowski.  ihid.,  1884,  vi.  334.) 
Pkralysis  of  eye-mtiscles,  with  or  without  allenitions  of  the  pupils, 
is  iMtniewhat  common  in  multiple  Kclerosis,  having  been  noted  in 
thirteen  of  the  fifty  cases  observed  by  R.  Guauck  (iVfuro/ogr.  Oen- 
taiUaUf  ISS*!,  iii.  314).  In  some  cases  of  iwlerwus  nystagmus  is 
presenL 

Ophthalmoplegia  Interna. — Under  the  name  of  ophthalmo- 
plegia interna  Mr.  Jonathan  Hutchinson,  deacrilici;  {ifiul.-Chir. 
TVtxtu,,  vol.  Ixi.  p.  215)  au  aflection  of  the  eye  which  he  believes 
10  lie  the  result  of  paralysis  of  the  clliar)*  ganglion.  In  this  gan- 
glion the  fibres  of  tlic  oculo-motor  nerve  meet  with  tlxcec.  nerve- 
fibres  which,  originally  springing  from  the  cilio-spinal  axis  of  the 
cer\'i(ml  cord,  pasa  upward  through  the  superior  cervical  sympa- 
thetic ganglion  to  the  brain.  From  the  ciliary  ganglion  the  oiui- 
joined  sympathetic  and  oculu-motur  fibres  ]ias*  outwanl  to  supply 
all  muivular  fibres  within  the  eyeball.  DeMruction  of  the  ciliary 
ganglion  is  consequently  followed  by  tridople^Ut,  or  paralysis  of 
the  iria.  both  as  to  the  circular  and  the  radiating  fibres,  and  by 
ofdbp&jTKh  or  paralysis  of  tlie  ciliary  muscle.  I  have  never 
reoogoized  a  case  of  opiithulmoplegta  interna,  aud  I  think  there 
is  difficulty  in  its  positive  diagnosis.     Unfortunately,  I  luive  not 


!Q  able  to  find  tn  any  of  the  various  papers  of  Mr.  Htttehinam 
upon  this  subject  a  M)luttoD  of  the  difficulties-.  Either  the  ocolo- 
motor  nerve,  which  supplies  the  circular  fibres  of  the  pupil,  w 
the  R^'mpathetic  nerve,  which  supplies  the  nuliaiin^  fibr^  nay  he 
^t>Qrately  jjaralvzed,  or  the  two  may  be  conjointly  paralyzed.  In 
either  esse  the  popil  is  immovable  to  light  or  other  iaflaem. 
Whr-n  the  oculo-motor  nerve  ulunc  is  pHratyzed,  the  pupil  ia 
dilated.  When  the  sympathetic  nerve  alonp  is  affected,  Uie  popil 
18  contracted.  When  both  nerves  are  ]>aralyiK<l,  tlie  pu[Hl  nnit 
be  of  medium  size.  The  degree  of  dilatation  iu  the  ocuto*iD(>uir 
palsy  varied,  however,  greatly,  and  I  strongly  suspect  that  aaaH! 
of  the  recorded  cascH  of  ophthalmoplegia  interna  were  aimplj 
iustanoes  of  oculo-motor  paralysis. 

OphthalmopLoffia  Externa. — Ophthalmoplegia  extenia  ii  ■ 
name  apiiUed  by  Mr.  Ilntoliinson  {Med.-Onr.  Traits.,  vol.  Ixii.) 
to  those  cases  in  which  all  tiie  external  muscles  of  the  two 
eyON  nre  more  or  leas  completely  |Mralyxed.  I^ong  before  the 
name  was  given  by  Mr.  Hutchinson  the  condition  was  described 
by.  Von  Graefe  att  ophUiahito^itfxfia  /ti-offranva.  If  the  palt>y  is 
neirly  eompleto,  there  is  marked  drooping  of  the  upper  lid,  with 
complete  immobility  of  the  eyeballs,  giving  rise  to  a  very  pw^- 
liar  expression  of  the  face.  Usually  the  internal  muscles  of  the 
eye  are  also  implicated,  but  w^ciisioually,  according  to  Mr.  liut- 
chioBon,  they  csca{ie.  The  causes  of  the  affection  are  variviu. 
Paralysis  of  all  the  muscles  of  a  single  eye  is  in  the  mnjoriiv  of 
cases  due  to  pressure  upon  the  nerves  at  the  bftee  of  the  brain : 
in  adults  sucli  pressure  is  usually  caused  by  syphilitic  exudation. 
A  double  ocular  paralysis  may  evidently  be  cau>«d  by  a  sypliilitk 
or  other  growth  of  such  sixe  and  situation  as  to  press  upon  the 
nerves  of  both  lyes.  Oj>hiliiilmo]>]<^ia  externa  may,  however, 
be  of  ceutrie  urigin.  A  ciue  i«  reported  by  Mr.  Hulc-hinson  iu 
which,  at  the  autopsy,  was  found  degeneration  of  the  nuclei  of 
the  affected  nervcH  apparently  idoulical  with  l.hHl  which  wrnns 
iu  progressive  muscular  atrophy.  Dr.  Thomas  Buzzard  (Brain, 
vol.  v.  p.  34)  has  recorde<]  the  case  of  a  syphilitic  woman  in 
whom  ophtlmlnioplegia  externa  coexixtiid  with  Rymptomn  of  loco- 
tnotor  ataxia,  and  in  whom  there  was  found,  after  death,  degener- 
ation of  the  nuclei  of  the  ocular  muscles  and  of  some  portion  of 
the  gray  matter  of  ilie  cord,  and  also  pronouoocd  posterior  scle- 

I ^ 


DZflrrURBANOES  OP  THE  SPECIAL  8EX8ES. 


339 


is,     Aeoordinp^  to  Dr.  Edward  NettlwKip  (Dltt^Mft  of  ihf  Etfi, 

*hila<Iel[)liia,  1863,  p.  39^),  iu  vouti^  uclulis  a  fuiietioDal  oph- 

Imoplegia  externa  sometimes  devclo])^,  with  HymptoniM  which 

>inc  nn  quickly  am!  p»m  ofT  oompletdy  ;  in  mme.  casm  there  are 

^fKatett  attackfi. 

Associated  Paralysis  of  the  Eye.* — In  oerlaia  oases  U)«re 

paralysis  of  the  vyi'-nnim-U'v  wliit-h  arc  associated  vnth  one  an- 

rotlier  in  tlieir  iiiovcments.     ThuH,  the  vertical  movemoiit  may  lie 

Iloet  in  each  cyr.  Inftnchacase  the  obvioiiR  explanation  oBera 
Itself  that  the  nuclei  of  the  affected  nerves  are  aymmetrically 
diseased.  When,  however,  the  associated  paralyais  iuvolve«  the 
lateral  nioveiui!nis  of  the  eye,  the  nit)@de.s  whicli  are  iinpliiialed 
are  not.  supplied  by  the  same  nerves.  ThiM,  in  the  left  eye  there 
would  be  loss  i^f  power  in  the  external  reclii^  muscle,  whilst 
io  the  right  eye  the  iiiterual  ret-tus  would  be  aOected.  Tn  such 
■a  case  a  post-niorteni  examination  by  M.  F6r6o]  demonsti-ated  the 
^Pleston  to  be  (situated  on  the  level  of  the  eminenita  teres  and  to 
V«j&ct  the  nucleus  of  the  sixth  pair,  which  is  joined  by  a  band 
of  fibre.4  witli  the  oculo-motor  uucleua  of  the  other  side.  (See 
page  &7.)  AsBouiale<i  jMralj'sis  of  the  eye  is  asserted  tn  !« 
frequent  in  multiple  ccrttbro-apinal  scleroais  (Parinaud.  Proffret 
Mfdlail,  xii.  641);  but  as  that  disease  wrurs  in  this  country  it 
mittt  be  a  very  rare  ooui plication,  since  I  have  never  seen  it. 

(.\mjtigatetl  Ikriatimi  of  Head  nnd  Kyes. 

As  long  ago  as  IBM,  M.  Andral,  la  the  third  edition  of  his 
Oinkal  Medicine,  ca\lvd  attention  to  a  symptom  occasionally  oc- 
curring iu  apuple^cy  whicli  has  nxrcutly  been  much  commented 
np(Hi.t  In  ordinary  hemiplegia  the  tendency  of  the  head  is  to  fall 
pttMtvely  towards  the  [jaralyzcd  side,  but  in  certain  cases  the  head 

*  For  ao  elaborklo  papftr  on  tbiB  tubjcdt  by  Jl.  Virinaui,  *<e  Arehivet  rf« 
NturoU^t,  Tfll.  V.  p,  H6. 

t*rbe  rCadnr  detiroiiii  of  following  up  this  subject  will  find  mott  of  ihe 
nlWrencM  ap  la  Ibe  dBt«  of  it*  publiuilon  In  the  inono;>rK[ih  by  I>r.  J.  L. 
Pr»vo»t,  De  In  J>Maiwt  eoi^git  dta  Vntx,  et  dr  ia  Kctation  rf«  la  Titt  dans 
eertaini  Ou  d'Hhni^ffk.  Sinc"  tliat  d«t«  Uio  pupcrs  of  Dr.  Brondbent 
(London  Lantti,  Tol,  H..  1879,  p.  861),  I>r-  Lutidwiiry  ith-nyrlj>  Midioal,  187«, 
Tol.  Til.  p.  967),  and  Dr.  R«cl»tcrew  {St.  feUftburffer  Jtfw/iWn.  Woahenachri/t, 
MMcb  14,  1881)  »n  th*  nKxl  Importanl  on  the  iiibject. 


330 


Duosoanc  iteuroloot. 


in  Hrawn  forcibly  from  the  puralyzed  extremities,  and  the  eye* 
with  tlieir  axeetparaHel  ai%ul»u  A>ix-ibty  directed  towaixU  th« sound 
limbfi.  This  Bo-caII«d  conjugated  deviation  of"  the  head  and  eyes 
varies  in  intensity.  The  s^wsn}  of  the  aflected  muscle*  »  Rome- 
times  80  intent  that  it  la  atmoift  impossible  to  restore  the  head  to 
its  norma!  poeitioii.  Usually,  however,  the  bead  can  be  put  back, 
but  returns  (o  Its  abnurmnl  [itistiire  tlie  itmUnl  the  forou  is  witb- 
drawn.  In  milder  rases  it  may  be  very  easy  to  retore  the  head, 
and  no  immediate  movement  may  follow  letting  it  go,  but  slowly 
the  hend  returns  Co  its  original  puetilioa.  When  cOD»oiou»neas 
coexists  with  this  symptom,  except  in  very  mild  cases,  tbe  patient 
hiis  no  wntml  over  the  head  and  ej'es. 

Conjugated  deviation  of  ihc  head  and  eyes  is  much  more  apt 
to  develop  when  the  hemiplegia  come*  on  suddenly;  and  in  severe 
cases  of  apoplexy,  wheu  all  the  limbs  are  mo  flucxiid  that  it  may  be 
difficult  to  discover  the  cxis^teuce  of  the  local  palsy,  the  diagnosis 
of  cerebral  hemorrhage  may  oocasionally  be  made  out  by  noting 
the  dbtortcd  position  of  the  bead  and  eyes.  Jt  is  true  that  in  the 
b^inning  of  an  epileptic  couvuUion  drawing  of  tlie  bead  and 
eyes  may  occur,  but  it  titsts  only  for  a  minute  or  two.  Jacktwniau 
epilepsy  often  begins  with  omjugated  deviation,  and  when  the  con- 
vidnive  seizures  follow  one  another  very  closely  the  spasm  of  the 
nock-  and  eye-muscles  may  be  persistent  (Bechlerew). 

The  pupil  may  be  drawn  into  the  caotbus  of  tbe  eye.  Ordinarily 
the  balls  are  entirely  quiet;  but  market!  nystagmus  is  not  very 
rare.  ConJHgatcd  deviation  is  commonly  fugitive.  It  may  oeaae 
immediately  after  the  development  of  the  full  a[ioplectic  syni|K 
toms,  but  it  commonly  disappeur^i  in  a  few  hours,  or  ut  most  iu  a 
few  days.  In  fatal  cascm  it  is  not  uncommon  to  sec  it  ocasc  Just 
before  death.  This  fugitive  character  is  not,  however,  universu], 
for  in  some  recorded  cases  the  distortion  lias  [icrsisted  for  a  month 
or  more,  or  even  for  a  whole  year.  Occasionally  during  an  attack 
of  apoplexy  tlie  deviation  of  the  eyea  and  lieail  may  return  after 
having  disappeared,  or  the  symptom  may  be  6rst  developed  to 
tlic  midst  of  tbe  apoplectic  storm  :  under  these  circumstunoes  it 
marks  the  renewal  of  the  hemorrhage. 

Although  in  tbe  majority  of  instances  the  face  and  eyes  are  di- 
rected away  from  the  paralyzed  side  nnd  towai-ds  the  lesion,  there 
are  exceptional  cosca  which  are  not  at  prcr^ent  readily  explained. 


I 


DISTURBANCES   OP  THE  SPBdAL.  SBX8EB. 


331 


Among  the  cases  collected  by  Frevost  there  are  tliree  in  which  the 
fiirrotion  of  the  head  was  towards  the  paralyzed  Rtde.  In  each  of 
the**  cases  tlie  lesion  wat*  in  the  peduncle  of  either  the  cerebntna 
or  tlie  oerebellum.  Od  the  ottier  hand,  in  a  ^imilur  case  reported 
by  Dr.  Bernhart  {Vtrehow^e  Arehiv,  vol.  Ixix.)  the  lesion  was  a 
very  Ul^  raeDinj»eaI  homorrhnge,  niid  in  the  reported  case  by 
Dr.  Nothnagcl  {Duiffnofi.  dm  Qfhimh^tnkhntfn,  p.  682)  it  was  a 
aofieaing  in  th«  cortical  motor  zone.  These  exceptional  cases 
would  soem  to  show  that  the  law  formulated  by  Vulpiao  and  Pre- 
Tosc,  that  iu  lesions  of  the  hemisphere  the  head  is  drawn  towards 
the  lesion  and  away  from  the  ^mrnlysis,  whilst  in  lesions  of  the 
meseucephaloQ  it  is  drawn  away  from  the  lesion  and  towards  the 
paralysis,  has  exceptions.  According  to  Dr.  Laudouzy,  wlien  there 
are  unilateral  convulsions  with  conjugated  deviatioo,  if  the  head 
vA  eyes  look  towards  the  convulsed  extremities  there  is  an  irri- 
tative lesion  of  the  hemisphere,  but  if  the  head  is  turned  away 
from  the  convulser)  linilM  the  iiTitative  lesion  is  in  tlie  mesen- 
cephalon. 

INTERNAL  OCULAR  CONDITIONS. 
The  internal  conditions  of  the  eye  which  it  is  necessary  to  study 
in  their  relations  to  the  nervous  system  are — first,  alterations  of 
the  optic  disk,  or  end  of  the  optic  nerve;  secondly,  alteratioiu  Id 
the  retinal  |iower  of  rceeiving  impression. 

ABNOKUAI.rrit^»  OF  THE   DISK. 

Five  years  after  the  discovery  of  the  opht)ui1maeoo|>e  Von 
Gncfc  called  attention  to  the  marked  alterations  in  the  intra- 
ocular ends  of  the  optic  nerve  which  frofjuonttv  itn-ur  in  intra- 
etaniul  disease.  Of  these  altcnitioriFi  he  described  two  main 
varieties. — the  one  in  which  there  is  intense  swelling  of  the 
intraocular  end  of  the  nerve,  and  ihe  other  in  which  there  is 
a  dull  suffusion  of  the  disk.  To  tlie  6rsi  of  these  he  gave  the 
name  of  tUtM»  papilla:  It  is  now  generally  known  as  "choked 
disk,"     The  second  he  de!>ignated  as  descending  neuritis. 

In  cliuked  disk  the  end  of  the  optic  nerve  projects  into  the 
ejre  bb  a  small  protubcraixt-  or  umlKination.  Its  height  luay  be 
ei)iial  to  ita  own  diameter.  Through  its  oxleniatous  and  o[Hiquc 
ucrve-5bres   run  the  tortuous,  enlarged,  and  sometimes   newly- 


formed  orular  vessels,  vliicli  hide  the  arteries  and  allovr  oaly 
the  branches  of  the  tortuous  and  dilated  retinal  veins  to  be  Been 
sloping  down  from  the  Kwollen  papilla  to  their  normal  le\'cl  in 
the  rctnia.  In  deeceiiJing  neuritis  the  dti^k  is  slightly  swoIleD, 
dull  red,  with  an  opocity  of  its  nerve-Gbrcs  which  oompletely 
hides  JtM  normal  boundaries.  The  tortuou.«  veins  find  arteriw 
are  often  diminished  in  size.* 

Typical  cases  of  choked  disk  and  descending  Deuritia,  seen  at 
the  height  of  the  disorders,  are  siid  to  he  dbitinguiHliable^  but 
usually  they  shade  off  so  impercL-ptibly  one  into  the  other,  and 
terminate  in  atrophies  which  present  so  ahaolutely  the  name  ap- 
poamnce,  that  it  i»  impossible  to  di^liugulsb  l>et«reeti  them. 

Choked  disk  in  moat  cases  develops  slowly,  requiring  from  a 
few  days  to  a  month  to  attain  its  maximum.  After  this  tt  may 
remain  unchanged  for  a  year,  or  even  more.  Ordinarily,  however, 
atrophy  begins  in  the  course  of  a  few  mouths.  It  is  remarkable 
how  nearly  perfect  vision  may  be  even  when  the  disk  is  etior- 
mousSy  swollen;  but  when  atrophy  is  fairly  established  almost 
invariably  the  amblyopia  becomes  np|Kireiit.  In  the  diagnosis 
of  neuritis  some  cire  on  the  part  of  the  beginner  is  necessary  not 
to  mistake  for  descending  nenritts  the  neuro- retinitis  due  to  eye- 
strain from  inoorreot  visual  defeetu  or  from  local  congestion  from 
other  causes. 

Von  Graefc  explained  the  choked  ciisk  by  supposing  that  the 
returned  blowl  in  ihe  cerebral  sinuses  ia  damme«l  up  by  the  gross 
lei^ion  (if  the  brain  and  causes  an  impeded  circulation  with  in- 
creoaed  blood -pre^ure  in  the  oplithaliuic  vein  and  itfi  branches, — 
the  effect  of  this  damming  bafk  being  increased  by  the  rigid  tissue 
of  the  lamina  cribrosa  acting  like  a  multiplier  .nnd  increasing  the 
pressure  at  tlie  head  of  the  nerve.  This  theory  of  Von  Graefe^ 
however  ingenious,  bos  l>cen  abandoned  by  ophthalmologists  iu 
favor  of  one  or  the  other  of  two  theories.  The  first  ami  the  least 
probable  of  tlicite  is  that  the  choked  disk  is  due  to  {Miralyaia  of 
tha  vaso-motor  nerves  connected  with  the   blood-supply  in  the 


*  The  Huthor  acknowledga  liis  mpcciRl  iiid«btftdncM  lo  tbv  able  vticlea 
by  Prof.  Wlllitim  Norrii  {"  Medical  Ophthalmolouf ,"  in  the  ftUi  vol.  of  Itie 
SyaUm  of  Practieal  ifcdteinr,  by  Amcriran  Aitthifrt,  Pliilad«lpbiit,  188S)  nnd 
Prof.  R.  0.  H«guin  ("  Hcmianopeis,"  Jatimal  of  IVervoiu  and  Maitat  DiS' 
ea»et,  Janusry,  1886). 


DISTURBAXCBS  OP  TUB  SPECIAL  SENSES.  333 

papil.  TJic  second  is  the  so-callctl  lyntph-spaoc  theory.  As 
abowii  by  the  nnatomical  researches  uf  Schwalbe,  Retziu!^,  and  later 
ADarnraisIs,  ihe  sheaths  of  tho  optic  nerves  communicnlc  freely 
with  lUe  pin  niater  and  the  arachnoid  spaces  of  the  bmm,  which 
are  in  turn  portions  of  (he  lymphatic  aystem  of  t]ie  cerebrum. 
When,  therefore,  owing  to  a  gross  lesion,  the  Iyn»phati»s  of  the 
brain  become  chokei],  tliere  is  an  exceseive  pressure  upon  all  tiic 
lymphatic  spacer,  which  especially  expresses  itself  in  the  lymph> 
«{Moes  of  the  optic  disk,  a  free,  unsnpported  portion  of  the 
sjritem. 

The  latter  view  is  confirmetl  by  experiments  upon  the  lower 
animals  and  upon  the  human  cadaver,  and  also  by  a  large  unm- 
ber  of  autopsies,  whieh  have  shown  that  choking  of  the  disk  has 
been  accompanied  by  dilatation  of  the  outer  sheath  of  the  nerve 
by  lyropb,  pus,  or  blooil  wliitrh  has  found  ila  way  down  from  Uie 
cranial  cavity.  It  has  also  been  pmve<l  that  growths  in  contact 
with  the  distal  end  of  the  nerves  may  proiluce  chok«l  disk  bv 
caiuitng  a  local  accumulation  of  fluid.  The  fact  that  in  certain 
OMK  of  choked  di^k  no  distinct  lymph>1e«ions  have  been  found 
lAer  death  is  explaiiml  by  the  supposition  that  sucli  dilatation  of 
the  vessels  has  disnpfieared  in  the  setvndary  inflammations  and 
chfeoenitions  which  have  been  set  up. 

"Whatever  theories  we  may  adopt  to  explain  the  production 
fif  oboked  disk  ami  of  optic  neuritis,  clinical  ex{)criencc  shows 
that  iloublc  choked  disk  is  generally  ilejiendent  iifmn  brain- 
tumor,  abeicees,  nicMingiti.<i,  or  oilier  gross  lesion,  and  iliat  de- 
soending  neuritis  may  be  produced  by  a  basal  meningitis.  For 
practiral  purposes  we  may  consider  the  two  lesions  as  identical, 
shfaoagh  if  in  any  case  a  typicnl  descending  neuriib  is  found  tho 
pralMlbilitif^  are  in  favor  of  ihc  cxiotcnce  of  a  Itasal  meuin;;ili» 
imther  than  of  any  other  form  of  gross  brain-lesion.  A  bnral 
meningitut  may,  however,  pr»jduce  a  typical  choke<J  disk.  One 
disk  may  occasionally  be  nfltvlcd  earlier  than  the  other.  Under 
these  circumstanoes  the  lesion  ia  usually  on  the  side  of  the  nerve 
attarke<l.     A  double  optic  neuritis  sometimes  occurs  in  ad- 

loetl  Bright's  disease.  It  is  probable  that  in  such  cases  there 
ii  always  serous  eflTnsion  into  the  Biibarachnoid  space  of  the  brain, 
or,  in  other  wonls,  (hat  there  is  gross  lesion  of  the  brain.  It 
hm  already  been  elated  that  tumors  nud  other  diseases  far  hack 


OIAGX06TIC  NEfTROLOGY. 

in  the  orbit  may  produce  a  choked  disk,  such  choked  disk  beJug 
usually  unilatem).  If  a  clioked  disk  be  unilateral  it  is  probably 
dac  to  local  di&ease:  nevertheless  it  may  be  the  outi^ome  of  n 
onnrAe  hrnin-lesioii. 

Althougli  ill  a  gceat  msjority  of  csjtes  optic  neuritis  is  the 
result  of  gross  cerebral  disease,  it  may  bo  a  primary  affi^tion, 
rollowiiig  typliUJt,  typhoid,  scarlet  fever,  measles,  variola,  and 
other  constitutional  diiwoses.  There  U  also  a  form  of  it  whi^-h  is 
rheumatic,  or  at  least  h  directly  produced  by  exposure.  It  may 
also  develop  without  dl^x>verable  cause,  as  in  a  case  which  I 
watched  for  many  months  without  bciug  able  to  detect  any  evi- 
denoes  of  rhetimatitim  or  of  cerebral  or  kidney  disease.  Sudden 
blindness,  with  neuritis,  U  auild  to  have  been  produced  by  the 
arrest  of  meustniatiou  by  exposure,  and  to  have  beeo  recovered 
from  by  the  restoration  of  the  flow.  For  details  of  tliis  and  other 
caaes  Uie  reader  is  rcf(!rr(Kl  to  tJie  paper  by  Dr.  H.  F.  Han^Kill 
[ifedioat  Netrs,  vol.  xliz.  p.  144).  This  idiopathic  or  rheumatic 
optic  neuritis  is  frotjiienlly  monocular. 

The  absence  of  choked  disk  does  uot  prove  the  non-exisleoce 
of  gross  brail) -lesion.  In  a  case  under  my  care  the  eyes  were 
examined  two  davH  before  death  by  one  of  our  moat  eminent 
ophthalmologists,  and  the  nerve  pronounced  absolutely  healthy  ; 
yet  a  large  tumor  of  the  frontal  lobe  was  found  at  the  au- 
tO)>8y.  Tliia  is  in  accord  with  the  general  cxpericuco  that  legions 
of  the  frontal  lobe  are  espcdalty  apt  not  to  give  rise  to  changes 
in  the  optir  jiapilla.  Gowcra  believes  that  disk-changes  oocTir 
in  eighty  per  cent,  of  all  eases  of  cerebral  tumors.  In  a  series 
of  cighty-eii^ht  coses  quoted  by  Nurri;?,  tlie  disk  was  altered  in 
ninety- til ree  per  cent.  Hnghlings  Jackson  caXls  attention  to 
the  fact  that  optic  neuritis  is  essentially  a  transient  8)'mptom, 
which  often  occurs  early  in  the  disease,  but  may  be  developed 
ouly  in  the  lust  weeks  before  death.  A  slowly-growing  tumor  ur 
exudation  which  does  not  affect  the  opdc  chiasm  or  the  optic 
nerves  may  remain  for  niimilis  or  years  without  causing  an  uptic 
neuritis,  because  it  docs  uot  materially  increase  the  pressure  upon 
tlic  braiu  or  set  up  iuflamtnatiuu  of  the  lymphatics.  When  the 
alteratiunH  vi'  tlic  brain  arc  rapidly  progressive,  or  wheu  they 
arc  accompanied  by  much  irritation,  intiltnition  of  its  nerve  and 
ghcath  with  lymph  or  inflammatory  products  must  rapidly  eusue. 


k 


I 


DISTURBANCES  OP  THE  SPECIAI.  SENSES,  336 

When  a  cerebral  tumor  presses  uiwn  tlie  intm-cranml  portion  of 
the  optic  uerves,  or  when  the  chiasm  is  comproiawl  and  atro- 
phied by  the  protuberant  and  bulging  floor  of  the  third  ventricle, 
as  in  cases  reiwrted  by  Foerster,  opttu  atrophy  may  occur  without 
precedent  chohe<I  disk. 

Atrophy  of  the  Opiie  PapiUa. 

Atrophy  of  the  optic  papilla  may  be  prodtiee<1  by  choked  disk, 
W  certain  diseases  of  the  cerebro-apiiial  axis,  especially  «clcrosiR, 
and  by  aflectiuns  of  the  eye  itself. 

After  a  choked  disk  has  continued  for  a  greater  or  Ic9«  length 
of  time,  the  swelling  liegios  to  subside  and  the  reddish  tint  to  pase 
slowly  into  a  dull,  opaque,  grayisb^white  color.  The  peculiar 
(Edematous  look  of  the  papilln  also  fades  into  a  faiiitly-eloiided 
apf>earance.  The  outline  slowly  becomes  aomewhat  more  sharply 
defined,  but  may  remain  obscure,  passing  inseatibly  iuto  a  faintly- 
clouded  retina  until  the  papilla  ha*)  returned  to  nearly  its  normal 
level.  The  changes  c«ut)ime  to  prt^nas;  the  disk  becomes  con- 
tinually whiter,  with  more  »<liarply  defined  oiitlinei^,  until  at  last 
it  IB  of  a  dead-white  color,  with  hard  margins  which  look  as 
though  cut  by  a  punch,  and  with  both  arteries  and  veins  atmphied. 
Hie  retinal  veins  change  much  more  slowly  Ihau  do  the  arteries, 
umJ  may  remain  dilated  and  tortuous  even  when  the  atrophy  is 
onnt^idembly  advanced. 

Atrophy  of  the  optic  nerve  may  result  from  a  Ie«on  of  the 
optic  centres,  or  from  prewure  u|>on  the  optic  nerye-trunk,  dtiasm, 
or  tracts,  an  by  a  tumor,  an  injury,  a  local  inflammation,  or  a 
distention  of  the  thinl  ventricle.  Kven  meningitis  may  produce 
atrophy,  in  rare  inAtancM,  without  antecedent  intraocular  inflam- 
matioD.  Tliese  atrophies  are  white  or  gray.  When  gray,  the  tint 
may  closely  reeembte  that  which  is  supposed  to  be  more  or  less 
characteristic  of  sclerotic  spinal  di^ciise.  Primurj'  atrophy  not  in- 
frequently appears  without  known  cause.  Sometimes  it  is  heredi- 
tary: in  one  instance  it  aftcctwl  all  the  males  of  a  family.  Such 
maw  have  been  studittl  by  Leber,  and  more  recently  by  W.  F, 
Norris  {JVam.  Amtr.  OpUhdmol  Soe.,  1884). 

The  atrophy  of  the  Dptiu  nerve  which  accompanies  sclorotic 
cottditions  of  the  ncrvc-ccntrcs  is  not  preceded  by  any  stage  of 


S36 


DIAQNrK«TIC   N'EaROIXKJY. 


avcUing  or  of  demonstrable  inflammntiun.  Thi?  normal  grayish' 
pink  lint  of  the  clUk  begina  to  change  into  a  pecaliar  hliiUh 
or  bluish-green  color,  and  at  the  same  time  the  tniiispareucy  uf 
the  disk  diminifilies,  90  tlial  the  retinal  vensels  are  less  reaclilr 
traced  into  the  suhcttance  of  the  i>apiiia.  As  the  atrophy  progrcMes, 
the  didooloration  of  the  papilla  gets  more  marked  and  its  size  may 
ap|>ear  to  be  dtniiniebeil;  the  vutliue  growH  continually  harder 
and  mora  sharply  defined,  and  the  choroidal  border  beooni{»  ex- 
cessively diatinc-t,  while  within  it  the  iwlenil  ring  grows  Dnnata- 
rally  disthict  and  whiter  than  the  adjacent  nerve.  The  blond- 
vessels  may  diminish  in  size,  the  small  ones  upon  the  di^k 
disappearing  entirely.  Jitit  tiuch  changes  take  place  very  slowly  ; 
and  only  in  rara  casen  ts  there  aensible  le^i^cning  in  the  size  of 
either  the  main  arteries  or  veins.  On  the  other  hand,  in  other 
atrophies  the  arteriet  become  very  narrow,  and  at  last  are  reduced 
to  minute  threada,  and  the  veins  slowly  diminish  in  calibre. 
Greenish  atrop))y  is  developed  ho  gradually,  and  the  chaises 
which  it  proiiuecs  in  the  nerve  are  at  first  tui  Alight^  that  its  early 
recognition  may  be  a  matter  of  great  doubt  To  illustrate  the 
di£Bculti€s  of  the  situation,  I  may  say  that  I  ooce  sent  a  patient 
to  two  of  the  best  ophthalmologists  of  the  country,  and  receive 
absolutely  antagouistic  opinions. 

Atrophy  of  the  jMpilla  from  centml  nervous  afTectiona  w 
compaiiied  hy  <'oiitraction  of  the  field  of  vision,  and  the  dlscussi< 
of  the  diseases  in  which  it  occurs  is  deferred  until  the  oonsit 
tion  of  that  symptom. 

PUPILS. 

In  the  examination  of  the  pupils  the  first  point  to  be  attended 
to  is  their  size.    The  norm  of  pupillary  uulurgemeut  varies  almost 
indefinitely  in  different  individuals,  so  that  it  is  ira|>»i«ib[e  to 
detect  slight  departures  from  health.     A  pupil  which  is  abnor-      . 
mally  contracted  is  said  to  be  miotic,  the  condition  of  oontraction^f 
being  known  as  viyogis.     The  corresponding  terms  for  eularge-^^ 
ment  of  the  pupils  are  mydriatic  ami  mi/driasin.     From  the  ad- 
jective? myotic  and  mydriatic  are  formed  the  terms  myotics  audit 
mydriatic!(,  denoting  classes  of  drags  which  piwduce  correspond*! 
ing  changes  in  the  pupil. 

Inequality  of  the  pupils  is  of  great  diagnostic  imi>ortauce  toj 


DIS'mtBA>XES  OF  THE  SPECIAL  BEKSES. 


337 


I  tho  neurologist,  althongh  it  is  occasionally  present  in  normal  eyes. 

P  I  UaT«  also  aeeo  mistakea  arise  from  one  pupil  being  accldent.ill}' 
Quder  tbe  influence  of  s  drug.  The  inequality  of  the  pupiU  may 
be  due  to  ai)  excessive  nmtraction  or  an  excessive  dilatation  of 
one  pupil.     Which  of  these  factors  is  the  cause  of  the  allcnition 

119  to  he  judged  of  by  comparing  the  size  of  the  pupils  with  tliat 
of  the  pupils  of  other  persons.  Exofwlve  mobility  of  the  pupil, 
■  constant  to-and-fro  play  without  obvious  cause,  is  an  indiua- 
tion  cX  nervous  weakness,  and  especially  of  that  kind  of  nervous 
mobility  which  is  oasocinted  with  hysteria.  It  is  also  seen  in  oer- 
tnin  persons  with  a  tranisparent,  tine  skin  who  arc  predigpo8«d  to 
taberculoMs. 

The  normal  pupil  contracts  rapidly  on  exposure  to  light,  and 
dilates  with  equal  rapidity  when  the  stimulus  of  the  light  is 
removed.  When  the  eye  is  dii'ected  from  a  near  to  a  distant 
object  the  normal   pupil  dilates,  this  dilatation  beiug  au  a^eK)- 

(ciated  movcrueut  with  accoimuodatioti.  Piuehing  the  shin  of 
the  neck  causes  dilatation  of  the  pupil,  a  phenomenon  which  is 
known  as  the  gtnn  pupUlary  r^lrx.  A  very  peculiar  series  of 
pupillary  phenomena   is   that  which  was   first   pointetl  out  by 

»Dr.  Argyll  Kobert&on  as  occurring  io  locomotor  ataxia.  In  the 
ArgyU  Robertson  pupU  there  is  no  movement  when  the  skin  of 
the  neck  in  pinched,  and  no  (?ontraclion  or  dilatation  with  the 
varying  intensities  of  light,  but  the  relations  between  the  pupil 
and  accommodation  are  prescrvotl.  In  other  words,  a  pupil  which 
remains  immovable  when  the  skiu  of  the  ucck  is  pinched,  or 
when  light  is  allowed  suddeidy  to  shine  into  the  previously  dark- 
ened eye,  does  move  when  the  gaiie  of  tlie  fiatient  is  suddenly 
directed  from  a  near  to  a  distant  object, 

ILcMB  of  the  light-raiction  of  the  pupil  when  there  is  no  poison 
io  (be  blood  nor  evident;  of  cerebral  congestion  is  often  looked 
upon  as  proof  of  the  existence  of  organic  disease  of  the  braia. 
As  has,  however,  been  shown  by  Thomsen  {ChariK  Annaien^ 
Berlin,  1885),  after  the  epileptic  paroxysm  the  pupil  may  be 
fixed  for  many  hours,  although  oonsfnousBeBs  has  been  com- 
pletely recovered.  Tniuiobility  of  the  pupil  is  also  occusionally 
present  in  hystencal  states,  and,  according  to  the  researches*  of 
UhthofT  (quoted  by  Thomsen),  it  occurs  in  a  small  perc£ntag« 
of  tlxMC  who  are  iuetane  but  not  paralyze<l. 

33 


A,  nMT»-BbrM  froai  Uts  embran.  B.  opUe  «mUn.  i,  optic  nam.  B,  papO. 
T,  m.taa.  II.  oculonvJor  nprra,  G,  QCiili>-niiiliH  MDtra.  D,  oeaWr  Mntna  In  dM 
WTTiol  ■plBBl  wnl  (cIlLMplnkl  &xii  of  Duilca].  IK  nd  IL,  ajvpaifciils  uM>t. 
M.  H.  um  K,  mumit  OAtTM. 

MyosJB. — Excessive  contraction  of  the  pupil,  ormyoeU,  may  be 
due  tojuraly^isof  the  roots  of  the  syiupatlictio  nerve  in  the  cervical 
Bpioal  region,  or  uf  the  sympathetic  nerve-fibres  in  the  neck  ;  or  . 
it  may  be  the  mult  of  stimulation  of  the  oculo-motor  derve-^| 
centres  iu  tLe  brain.  In  cervical  spinal  disease,  such  as  pachv-^^ 
DieningitU,  myelitis,  or  chronic  sclerosit;,  inyoeis  may  occur  if  the 
leBiou  M  ftuffieieot  to  paralyze.  1  have  r^eon  excessive  uDilatcml 
myosU  due  to  the  pressure  exerted  upon  the  sympathetic  nerve- 
fibres  hy  enlarged  cervical  glands.  Aneiiriams  and  other  tutuura 
iu  the  neck  may  have  the  same  effect.  If,  in  such  a  case,  by  the 
interference  M'ith  circulutioii  in  (lie  carutid,  any  cerebral  Rvmptoius 
are  pnMiuccd,  or  if  lliere  is  hysteria,  a  mistake  in  diagnosis  might 
readily  be  made, 

A  spasmodic  rayoeis  may  be  caused  by  an  irritation  of  the 
oculo-motor  centres  or  nerves.  The  contracted  pupil  of  opium- 
pcuBoning  and  of  cerebral  congestion  is  due  to  centric  irritation. 


DISTCnBANCES  OF  THE  SPECIAL  8STI8E8. 


339 


I 
I 


whilst  that  couwd  by  Cal&bor  bean  is  probably  produoed,  at  least 
in  part,  by  a  peripheral  action. 

Mydria«ia. — Mydriasis,  or  dilatation  of  the  pupil,  may  l»e  due 
lo  irritation  of  the  sympathetic,  as  in  inflammatory  lesions  of  the 
eervicul  spinal  cord,  but  m  the  inujority  of  vasts  it  is  the  resuU  of 
a  centric  or  a  peripheral  paralj-sis  of  the  ocolo-niotor  nerve.  The 
etuaes  of  such  affections  of  the  nerve  have  already  been  sufficiently 
diacttswd, 

Actioa  to  Iiiarht. — The  presence  of  the  normal  relations  of  the 
pupil  lo  light  provwi  in  any  cam  that  tlie  ari'  E  C  R  F(Fig.  21)  is 
intact, — Lr.,  that  the  optic  nerve  and  tract  to  the  corpora  quad- 
rtgemina  and  thence  to  the  oculo-motor  ntioleue  and  thence  through 
the  oculo-motor  nerve  to  the  iris  are  fuuclionally  active.  It  must, 
however,  be  borne  in  mind  that  the  two  eyes  act  in  association,  so 
that  cuniraction  nf  both  pupils  occurs  when  light  falls  apun  one 
•fe.  In  this  m-ay  a  blind  eye  in  which  the  optic  nerve  is  p«ni- 
tysed  niay  have  movements  of  the  pupil.  In  examining  an  eye 
U  id  tliL-refore  ci»ential  that  the  other  bo  covered, 

Skill-Reflex. — It  is  believed  that  the  skin  pupillary  reflex  is 
producol  ihrniigh  the  spinal  region.  Thus,  the  impult^e  tnivel- 
hng  up  the  cervical  nerves  stimulates  the  cervical  spinal  centres, 
which  in  tarn  send  an  impulse  to  the  iris.  This  being  the  case, 
the  preservation  of  tiie  skin  pupillary  reflex  shows  that  the  arc 
M  I)  I  E  is  functionally  active. 

MoTements  of  Aooommodation. — Movements  of  the  pupil 
with  accommodation  are  brought  alioiit  through  the  oculo-motor 
nerve,  and  arc  probably  of  the  nature  of  habitual  associated  move- 
ments. They  denote  the  integrity  of  Uie  oculo-motor  nerve  and 
its  nticleiis. 

Argyll  Robertson  Pupil. — In  the  Argyll  Robertson  pupil 
the  failure  of  the  pupil  to  contract  under  the  stimulus  of  light 
shows  that  there  \>i  u  k«ion  iu  the  arc  £  C  B  F,  or,  in  other  words, 
that  either  the  optic  nerve  or  its  centre,  or  the  connection  iKtwcen 
the  optic  centre  and  the  oculo-raotnr  centre,  or  the  ocuto-inotor 
centre  or  its  nerve,  is  diseased.  The  retention  of  normal  vision 
•bows  that  the  optic  nerve  and  its  nucleus  arc  fierfcct.  Tlie  oocur- 
renoe  of  niovemcuts  during  the  process  of  accommodation  proves 
that  the  oculo-iDotor  nerve  and  its  centre  are  active:  the  interntp- 
tioo  iu  tlie  arc  E  C  B  F  must  therefore  be  between  the  optic  auJ 


340 


DiAosoeric  keurology. 


tlie  ooulo-motor  centre,  or,  in  other  wonU,  in  the  commiHunil 
fibres  wliieh  connect  tlie  oplic  and  the  oculo-motur  oeiitre.  Tbe  loss 
of  the  skin  ]mpil!arv  refies  proves  that  there  is  aome  iDtcrruptioa 
in  the  arc  M  D  L, — thut  interruption  prohably  being  in  the  .spinal 
conl  and  due  to  the  lesiotmhich  iuterrupts  the  continuity  of  tlie 
pathway  between  the  oculo-motar  and  the  optic  centre. 

DvteaneH  in  vhieh  Ute  Pupils  are  tieranffal, — ^There  are  certain 
ocDtric  nervoua  diseases  uf  whicli  the  pupillary  symptoms  require 
more  detailed  dKoti-ssion  thnn  hn.^yet  been  given  them.  Prominent 
among  the^  affections  is  locomotor  ataxia^  in  which  tbe  pupiU 
may  be  altered  duriug  the  earlieet  stages.  They  may  be  eitlier 
dilate*!  or  abnormally  corilrai.Tted.  Tliey  may  Im>  ixjiuilly  af- 
fected, or  one  may  l»o  contracted  and  the  other  dilatet),  or  one 
may  be  dilated  and  the  other  normal.  According  to  Kulenburg, 
tlie  ainiuUaueou!^  oeeurreuce  of  tiiyuni^  and  mydriafiiit  liap]>euE( 
only  in  tbe  late  stages  of  the  disonler.  Mvimis  is  much  more 
iVequent  ttian  mydriasis:  tlius,  Eulenhiirg  in  Aixly-four  ea.<^t^ 
oote4:l  mydrinsis  in  nine,  myosis  in  twenty-eight.  In  the  rare 
C8*es  in  which  the  cervical  spinal  oord  is  fimt  atiarke<l,  myofii* 
occurs  very  «irly.  Tbe  degite  u(  contraction  vanes  greatly  in 
different  coses,  but  is  often  cxceasive:  it  is  usually  greater  oa 
one  side,  and  often  varies  from  time  to  time  in  the  same  case. 
T.  Grainger  Stewart  states  that  he  had  Keen  the  uiyo-ais  incresM 
during  a  gastric  crisis,  whilst  Charcot  affirms  that  during  tbe 
|>ain  of  u  crisis  tlie  pupil  enmetini(>s  dilates. 

In  multiple  cerebral  spinal    sclerosis   the   pupil   is  \'HriousIy 
affected.     With  or  without  ptosis  there  may  be  dilatation  of  the 
pupil,  or  myoais  may  exist;  in  some  cases  there  va  iuetjuality  of 
the  pupils.     It  is  affirmed  by  Parinaud  (Frogi'^  Mfdical,  vol.  xii.  ^j 
p.  642)  that  there  is  a  8tage  of  the  disonier  in  whiob  the  pupil-  ^M 
lary  reflexes  ore  exaggerated,  and  that  if  at  the  aame  time  one       ' 
vye  is  affected  more  than  the  other,  mouocular  myoais  may  be 
pnxluued  whenever  the  pativut  gow  into  tbe  light.     Aouurding 
to  tlic  same  author,  whenever  myosis  exists  in  a  pcrsou  presenting 
symptoms  of  central  nervous  disease,  if  tlie  pupil  still  reacts  to 
light  tbe  cause  is  probably  multiple  solerosis,  aud  not  locomotor 
ataxia. 

The  Argv'II   Robertson   pupil  is  probably   pntliognomonia  of 
degeneration  of  the  u])pcr  spinal  conl,  including  in  thi^t  term  the 


I 
4 


I  toe        I 


DntTTTHBAXCES   OP  IHE  SPBCUX.  8EK»BS. 


mednllfl.  It  lia-^  been  cejiet-iallr  nnial  in  locntnotnr  ataxia,  of 
which  disease  it  is.  vcrr  characteristic  It  also  occurs  io  pro- 
greeaive  p«rsl}^8  of  the  insane.  A».  however,  descending  spinal 
degenerations  are  very  rommon  in  general  paralpia,  the  Argyll 
BobertBon  pnpil  is  pn^bly  produced  by  these  secoodary  spinal 
lesioDfl,  and  not  by  the  afTection  of  tltc  lirain-cortex. 

In  genera]  paralysis  of  tlie  insane,  the  pupils  may  be  et^ual 
and  normal ;  or  equal  and  contracted  ;  or  equal  and  dilated ; 
or  tin«qua)  on  aocount  of  one  lining  con  tract  tnl  and  tlie  other  di- 
lated, or  on  aoooant  of  one  being  normal  and  the  other  dilated 
or  contracted.  Of  all  these  plienomena,  inequality  of  the  pupils 
ia  oiObt  frequent  and  muet  characterUtic.  It  may  vary  from  day 
to  day.  One  day  the  pupils  may  be  equal,  the  next  day  they  may 
be  unequal ;  or  to-day  the  pupils  may  Ik  unequal  l>ecauBe  the  rigbt 
is  contracted,  and  to-morrow  they  may  be  unequal  because  the 
right  is  dilated.  This  shifting  inequality  of  the  pupils  is  especially 
cliarauti-ristio  of  the  disease,  and  may  be  a  prodromic  eymptom. 

Dr.  K.  Mendel  {randyae  der  /rren,  Berlin,  18«0,  p.  147) 
states  that  lie  has  seen  inequality  of  the  i>U]>iU  w>.  lung  as  three 
and  a  half  years  before  the  outbreak  of  meutal  disturbauoe,  whilst 
Foereter  (quoted  by  >'orns)  relates  the  case  ot'  a  colleague  who, 
while  yet  of  sound  miud,  jokingly  said  tliat  uu  accouut  of  his 
pupils  having  become  unequal  he  thought  of  taking  quarters  in 
an  insane  asylum,  and  who  actually  died  a  few  years  later  in 
such  an  institution.  Along  with  the  dilatation  of  the  pupil  the 
shape  .of  the  eyeball  may  be  affected.  Mob^he  and  Mondol 
noted  an  increatied  convexity  of  the  ball  and  a  narrowing  of  the 
opening  of  the  eye.  The  whole  eye  may  also  appear  to  be  amallfir 
than  normal,  on  account  of  the  paralysis  of  Mueller's  muscles 
or  of  spasm  of  the  orbicular  muscle.  In  some  cases  ptosis  or 
strabismus  and  double  vision  occur.  After  the  epileptic  attack 
of  advanced  progressive  ponitysiH  cniijngiited  deviation  of  the  eyes 
(Prevoflt's  symptom,  so  called)  is  occasionally  present. 


I 


I 


DISTtmSANCES  OF    VISION. 


Mdhod  of  Testing  T^ion. 

In  order  to  determine  the  acntcncss  of  sight,  test-tyjws  are 
employed,  in  which  the  letters  are  of  various  sizes,  and  numbered 


acoording  to  the  distance  at  whidi  each  stae  fiubteDda  a  visual 
angle  of  five  minutes,  and  the  strokes  of  the  letters  ao  angle  of 
tme  niiniit«.  This  m  considered  to  be  a  standard  for  average 
uomial  visiou.  The  typeii  coutitructeil  by  Suvllen,  made  upon  this 
plan,  are  in  common  use,  although  many  other  aeries  of  testrtyjiee^ 
equally  u.4efnl,  es|>ec!a]ly  those  in  which  the  nccesary  alterations 
have  been  made  to  render  thera  conformable  (o  the  metric  system 
of  measurement,  are  employed.  When  it  ia  desired  to  test  the 
acuity  of  virion,  the  patieut  t^hould  b(*  planed  twenty  feet  from  the 
type-canl,  in  a  well-lighted  rtium,  and  each  eye  tried  eepsrately. 
If  the  letters  of  No.  XX  are  read,  vision  is  normal,  or  1,  bQt 
if,  standing  at  tlic  same  distance,  no  smaller  letters  than  lhw>e 
Dumbt^red  XL  can  be  tliscerned,  vit^ion  is  ^.     It  is  usual  to  ex- 

press  these  results  acconliug  to  the  formula  V  ^  j,,  in  wliich  V 

stands  for  vleiual  acuteuess,  d  for  the  distance  of  tlie  patient  from 
the  card,  and  I>  for  the  number  of  the  type :  so  that  in  tiiese  io- 

slauces  the  viaion  would  be  recorded  ^v  and  ^-:  •     Twenty'  ft-ei 

hsa  been  fuund  to  be  a  useful  distance:  any  other  may  be  chusun, 
provided  it  does  not  place  the  patient  closer  to  the  tcst^nrd  tbon 
ten  or  twelve  feet. 

It  often  becomes  a  tuatter  of  importance  to  test  tlie  field 
of  vision,  or  that  space  throughout  which  the  eye  is  able  to  see 
while  it  remains  statiunar^'  at  a  given  diHtanw  fn>m  a  fixed  point. 
This  may  bo  roughly  done  by  following  the  ap[icDded  directions. 
Place  the  patient  with  his  baclc  to  the  source  of  light,  and  have 
him  fix  the  eye  nuder  observation,  the  other  being  covered,  n[>oa 
the  centre  of  your  face,  at  a  distance  of  two  feeL  Then  move 
your  fingers  in  various  direutions  midway  lietween  yourself  and 
him  on  a  plane  with  yonr  own  face  until  you  determine  the 
limits  of  hU  indirect  vision,  controlling  at  the  same  time  the 
extent  and  direction  of  your  movements  by  your  own  field  of 
vision.  This  plan  of  examination  may  he  improvetl  by  plaoitig 
small  wjuare  pieces  of  white  or  cf,ilore4i  iwjwr  on  the  end  of  a  rod, 
and  proceeding  with  the  examination  as  before. 

Altliough  the  field  forms  part  of  a  hemisphere,  it  may  be 
pnijeiiCeLl  upon  a  Hat  surface  and  a  useful  uiiip  of  the  visual  field 
obtained.    Thus,  let  tlic  patient  be  placed  twcuty-five  centimetres 


I 


DISTUBDASCES  OP  THE  6PECIAI  SENBES. 


343 


rrom  a  blactilMKtnl,  wliirli  may  be  conveniently  niled  in  squares, 

lad  fix  the  cvc  under  obaervntioo  upon  a  small  while  miirk.    Tlien 

Biove  the  test-object,  either  a  piece  of  white  chalk^  fastened  in 

«  bUck  hamlle,  or,  better,  pieces  of  wliito  and  colored  paper  one 

<*nliDKtr«  square,  from  the  periphery  towards  6xation,  until  the 

°^M  is  seen  or  the  wtlor  naiucd ;  then  mark  tliis  position.     If 

^'glil  peripheral  points  l>o  marked  and  afterwards  joineil  hy  a  line, 

*  fair  map  of  the  Beld  of  vlKinn  will  be  obtained,  and  may  be 

'Wnscribed  upon  a  chart  ruled  for  the  purpose.     This  metho<l  is 

'^ot  eniirely  accurate  if  the  field  is  larger  than  45*',  because  beyond 

^'"^  ongte,  on  flat  surfaces,  the  object  is  too  far  away  from  tlie  eye 

"  Bnaltc  the  examination  exact. 


Fifl.  22. 


I 


Pifl.  211. 


Fig.  22  rcprcscnta  the  normal  field  of  vision  of  the  right  eye 
taken  on  a  flatsur&oe:  the  outer  marking  is  the  biHindary  for 
white,  aud  die  others  reapectively  for  blue  and  red.  For  accurate 
mcasarementa  of  tlio  field,  aud  for  any  measuromeots  beyond  4d°, 
an  ioBtniment  known  a**  a  [lerimeter  must  be  employed.  Thisoon- 
Uts  eflsentinlly  of  an  arc  marked  in  degreefl,  which  rotates  around 
■  oeDtnil  pivot  that  is  at  the  same  time  the  fixing-point  for  the 
patient's  e^'e.  The  test-object,  square  pieces  of  white  and  colored 
paper  affixal  upon  a  piece  of  dead-black  canlUmrd,  U  moved 
from  without  inwanl,  and  the  point  in  each  meridian,  where  it  ia 
recognired,  noted.     The  result  is  transcribed  U|>on  a  chart  prepared 


*  Ib  kmblyofJe  t^M  th*  Held  ma;  bn  Ukea  In  i  dark  room  and  m  candlo  b« 
mUtlUilCM]  Tor  lli«  pi«c«  of  cbalk.  In  tbis  wky,  «>  long  m  the  patient  cui  we 
at  l]l,  tbe  leld  may  bo  napped. 


344  DIAGNOSTIC  KEUROUWY. 

by  hftviug  ruled  upon  it  radial  Uaea  to  correspond  to  the  variooSI 
poHitions  of  the  arc,  and  ooDceiitric  cirolet;  tu  denote  the  degrees. 

Fig.  23  repreRentfl  tbo  field  as  taken  with  the  perimeter.  The 
fields  for  color  are  smaller  than  the  field  for  white,  and  are  green, 
red,  yellow,  and  blue  from  witliiu  outward.  Landolt's  investiga- 
tions— those  usually  quoted — make  tiie  normal  fields  for  color  «e 
foUows : 

ITppor - fty  *6»  W* 

Ouler - „ W  70"  6*» 

Lower _ —..56"  46°  88" 

Inner 60°  40»  W 


Ah  majiy  meridians  may  be  tested  as  are  needful:  foar 

usually  sufficient. 

DUorden  of  Sight. 

The  cliaorclera  i)f  vision  wliich  require  siiidy  by  the  neurol 
arc — amaurosis,  or  nervc-blindneas,  including  amblyopia,  or  im- 
paired vision  ;  hemianopsia,  or  loss  of  vision  over  oue-half  (lateral 
or  vertical)  of  the  eye;  soutuinaUi,  or  }Nitohes  of  blindnesa;  tax- 
contraction  of  tlic  field. 

Anaiomy  of  Opttt  Ti-ati. — Before  discnssing  these  various  vbnti 
distiirbaoces  it  Is  perhaptj  well  to  Humniarize  briefly  the  anatomy 
of  th<i  optic  tract.  The  band  of  white  fibres  known  as  the  optic 
tract  arises  from  the  posterior  (>art  of  the  thalamu!?,  the  geniculate 
bodies,  and  the  su]>crior  qnadrigcminal  ItodicM.  From  the  under 
part  of  the  ihalamus  it  suddenly  bends  forward,  and  as  a  flattened 
band  passes  obliquely  inward  across  tJie  up|>er  anterior  surface  of 
the  cerebral  peiluiicle,  to  which  it  Ik  closely  altachetl ;  a^er  this  it 
adheres  to  the  tuber  cinereum,  from  which  and  from  the  lamina 
cinerca  it  ia  said  t«)  reoeive  fibres.  In  this  way  it  reaches  the  optic 
chiasm,  uti  oblong  Qutteued  body  Kttuuted  upon  Uiu  olivar)'  emi- 
nence of  the  sphenoid  bone.  In  the  chiasm  the  fibres  of  the 
nervcfl  [uiming  from  tlie  triirt  divide :  tlie  larger  or  outer  ImuuI  de- 
cussates with  its  fellow,  or,  in  other  words,  crosses  over  to  enter  the 
optic  nerve  as  it  emerges  from  the  opposite  side  of  the  chiasm  and 
tu  be  finally  distributed  tu  the  hbhuI  half  of  the  retina.  The  inner 
or  smaller  band  of  fibres  passes  on  through  to  the  chini^m,  without 
decu$«&tiou,  to  the  outer  side  of  the  retina  of  its  own  eye.  These 
fibres  are  tlie  only  gnes  that  have  direct  relations  with 


1 


th  vision,— ^H 


I>ISTUItBANOBU  OF  THE  SPtXHAL  fiEN8E8. 


345 


the  hiftrior  commiitiiure  of  Giidden  (tlie  |M)sterior  loop  of  Hannover) 
ft  being  oompoaefi  of  fibres  wliioli  pass  through  the  optic  tracts  and 
the  posterior  portion  of  the  chiasm  toconnect  the  two  inner  genic^- 
iilate  bodies^  whilst  the  existence  of  the  iiiter^reliual  fascicule, 
vhieti  Ilanuovcr  believed  to  pass  through  the  anterior  edge  of  the 
chiasm  ami  to  be  a  reticml  ctiinrniR^tire,  la  denied  hy  miv^t  recent 
Mnatomwfci.  Although  the  optic  tracts  are  closely  connected  with 
"the  corpora  geoicniata  and  the  anterior  corpora  qnndrigomina, 

I  it  9eeoi5  clearly  made  uiit  that  these  centres  have  not  tlie  fiinctioo 
of  vision.  The  conscious  pereeptiou  of  retiual  images  takes  place 
in  the  brain-oortex.  The  exact  [KM^ition  at  which  it  occurs  has 
been  tnuch  di$cnwed,  but  the  consideration  of  this  \s  so  closely 
bound  up  with  the  (juesliou  of  heraiauopsia  that  it  is  better  po'-t- 
puDed  for  the  present. 
^B  Amanroeds. — Amaurotits  was  the  term  cmp1oye<l  by  the  old 
floigeons  to  d»ignate  coses  in  which  they  could  find  no  pause 
In  the  eye  for  the  Ki.-^  of  «ight.  In  i-ecent  times  it  haif  come  to 
s^ify  blindoeH)  from  disease  of  the  nerve  or  of  the  uerve-ccntres. 
Amblyopia  is  a  partial  loss  ofvisioa  of  aervous  origin.  The  two 
terms  are  sometimes  rendered  synonymous  by  means  of  adjectives: 
thos,  partial  amaurosis  is  ufied  to  signify  amblyopia,  and  complete 
amblyofHa  is  sometimes  employed  inetead  of  amaurosis.  There 
is  ftt  present  sufficient  clinical  evidence  to  show  that  a  tem[)orary 
imauraais  may  be  produced  by  a  distant  irritation.  The  niscarches 
of  Dr.  Brown-.S^uard  {London  Lancet,  July,  1861)  proved,  many 
years  ago,  that  amaurosis  may  occur  in  diseases  of  the  cerebellum 
without  alteration  of  the  nerve.  Dr.  Davaine  is  said  lo  have 
H  reported  twelve  cases  of  amaurosis  produced  by  intestinal  worms. 
Dr.  Brown-SAqiiard  has  seen  it  in  animals  following  injury  to  the 
spinal  cord,  and  has  noticed  its  occurrence  in  man  as  the  result  of 
B   irritation  of  the  nerves  of  the  stomach. 

^1      Aouurusis  may  uI.-tO  lie  an  hysterical  symptom.     Under  these 

^m  iiiznuii8taDcca,  its  true  nature  ts  usually  rcvcalc<l  by  the  sudden- 

^B  MM  with  which  it  develops  and  disappears,  as  well  as  by  the  co- 

'  existence  of  other  pronounced  hysterica)  symptoms.     (See,  alMi, 

page  259.) 

Otffcmie  AmM^tipia, — Partial  or  complete  neurotic  blindness 
may  be  due  to  lesions  of  the  peripheral  visual  nervous  s\-8tem  or 
to  oefltric  diseases.     For  reasons  that  will  become  manifest  during 


348  DiAaxosnc  neuroloov. 

the  study  of  hemianopeia,  a  lesion  of  tlie  brain  which  directly 
causes  la's  of  vthtoti  by  acting  ou  the  vUiml  reutres  almost  in- 
variably affects  only  a  portion  of  the  field  io  botb  eyes,  raosiag 
heinianopsifl,  A  central  lesion  which  produces  general  ambly- 
opia, affecting  the  whole  6eld  of  each  eye,  must  be  double  and  fm- 
plicalG  iioth  cerebral  hemispheres.  Such  a  lesion  is  so  excessively 
rare  that  it  may  be  laid  duwn  as  »  diagtiuHtic  rule  that  un  itrgauie 
nmhlyopia  h  due  to  peripheral  disease.  Sooh  dtscoac  may  be  n 
guinmntoiis,  gliomatons,  or  »nrooniato(is  tumor  w  sittutted  as  to 
press  upon  the  optic  chiaam  or  the  optic  tract  at  tlie  ba«  of  the 
brain.  It  may  be  an  inflammation  of  the  optic  nerve,  either  a 
true  neuritis  or  a  choke<l  disk.  Almost  invariably  inflammatioOB 
of  the  optif;  nerve  are  symmetrical  and  affect  alike  both  eyes. 

ThacFHite  Amblyopia. — ^Toxsemic  amblyopia  is  usually  of  or^nic 
origin,  but,  as  the  lesion  is  diret-tly  produced  by  the  poiaouing,  and 
is  likely  to  be  reoovored  from  on  removal  of  the  poison  from  the 
system,  the  separation  of  toxemic  amblyopia.-*  is  of  practical  im- 
portance. The  most  ooraraon  and  the  most  important  of  the  claas 
is  the  loss  of  vision  produced  by  tobacco.  In  a  large  proportion 
of  cases  the  ex<ie8H  in  tlie  use  of  tolwoco  has  been  associaied  witJi 
an  czcesB  in  the  use  of  alcohol,  and  there  has  been  mncb  discus- 
sion as  to  which  of  these  agents  wn.i  the  cause  of  the  optic  de- 
rangement. The  amblyopia  id  frequently  present  iu  those  who 
smoke  excessively  bat  do  not  driuk,  and  tobacco  seems  to  exert  I 
the  more  [wtent  influents.  The  vit^tini  of  tobocoo  amblyopia 
shows  no  diflSoulty  or  awkwardiieas  in  going  about,  but  especially 
complains  that  vision  is  very  Vwd  in  direct  sunlight.  He  almost 
invariably  sees  better  on  dull  days,  and  in  the  early  morning  and 
evening.  If  this  be  not  noted  by  the  patient  himself,  it  may  be 
shown  by  testing  vision  with  ty[w  in  full  daylight  and  again  in 
a  darkened  room.  An  examination  of  the  visual  field  will  show 
thai  a  great  functional  defect  is  in  the  centre  of  the  field,  occupy- 
ing an  uUuug  or  oval  patch  which  extends  from  the  fixiug-point 
(corresponding  ta  the  macula  lutca)  out  towards  and  often  imme- 
diately Iwyond  tlie  blind  spot  (corresponding  to  the  disk).  This 
central  scotoma  is  relative,  and  not  absolute;  Le.,  loss  of  Tisiou 
in  it  is  never  complete.  It  is  especially  marked  for  the  pcroeptiou 
of  colors,  fur  green  and  red  in  particular:  the  former  is  usually 
described  by  the  patient  as  "  white"  or  "gray,"  and  the  latter  as 


I 


DI8TCRBANCEB  OF  THB  SPECUL  BBNSE6. 


347 


» 


I 


"  brown"  or  "  no  color  at  all."  Id  most  caees  the  sootoma  is 
siualler  tJian  the  visiul  field  for  centra)  rolors,  green  ami  red,  and 
hence  a  zone  is  prcaent  beyond  the  scotoma  in  which  these  colors 
are  ohAerve<l.  This  it  pspccinlly  tlio  reawn  that  the  patient  will 
recognize  the  color  of  a  large  body  and  mistake  that  of  a  very 
small  one. 

The  scolomn  of  tobnoco  amblyopia  Is  invariably  anatomically 
Hymmetrical,  oocupyinjf  exactly  the  some  position  in  each  retina. 
It  is  Iwlieved  by  ornlist-s  to  Iw  chiefly  tliie  to  the  change  in  the 
periplieral  portion  of  the  nerve-axis.  It  has  been  atwerted  in 
the  rare  cases  in  which  the  scotoma  is  central  and  surrounds  the 
fixaiinn-s[>ot  equally  on  all  sides  that  the  muse  is  alcohol.  Dr. 
Edward  Nettleship  [i^.  Thoma^g  Hoitpltal  Reports,  vol.  ix.) 
states,  however,  thnt  in  all  the  aae^  of  such  scotoma  which  he  hns 
seen  the  patients  were  smokera.  And  Dr.  G.  De  St^hweinitz  has 
reported  {Philadvlphia  Jledical  Itme^,  188G)  an  example  of  such 
scxitoou  in  a  wnnian  who  used  neither  alcohol  m>r  tobacco,  but 
mode  cigars,  and  in  whom  the  eyes  beeiimc  normal  after  iJic  left 
her  rtocnpation.  In  investigating  a  case  it  sliould  be  remembered 
that  chewing  tolmcco  is  more  injurious  than  .smobing. 

Cues  of  blindness  directly  pri^luced  by  itad  are  stated  tu 
occar.  Such  cases,  however,  must  be  verv  infrequent,  since  I 
have  seen  a  great  many  cawst  of  lead-poi^ning,  but  never 
such  a  one.  More  frequent  is  the  indirect  production  of  blind- 
nen  by  lead.  Thutt,  the  saturnine  Bright's  disee.se  may  cause  a 
nnemic  degeneration  of  the  retina,  and  in  cases  of  violent  Halur- 
oine  brain-disease  [enreftfuilopaUiia  eatumina)  choked  disk  ia 
usually  prewnl,  with  consequent  low  of  vision.  According  to 
Norris  {System  of  Fracticat  Sfedicine,  Philadelphia,  1886,  vol. 
iv.  |i.  804),  "  excessive  overduees  uf  quinine  impair  the  ^ight, 
■nd  in  sonic  cases  have  produced  icmfiorary  but  nlviotute  blind- 
neee.  The  nsunl  symptoms  are  a  deterioration  of  the  central 
vision,  with  contraction  of  the  field.  The  ophthalmoscopic  cx- 
ainiuation  reveals  a  pallid  <Itsk,  with  marke<l  diminution  in  the 
size  of  the  retinal  arteries  and  veins."  Many  veurs  ago  I  saw  a 
complete  blindness,  la'iting  eight  or  ten  hourx,  prcxluoed  in  t 
yonng  Udy  by  fifteen  gmins  of  sulphate  of  quinine  :  that  the  alka- 
loid was  the  cause  of  the  symptoms  was  proved  by  their  recur- 
rcooe  on  a  repetition  of  the  dose.    Sanlon'tn  in  toxic  doses  pro- 


348 


DtAQyoenc  keubdloot. 


duces  dilatation  of  tbe  pupil  and  great  dmturbanoe  of  vimoo. 
(See  author's  treatise  on  Tfieraptuiivg ;  also  VTrcAoic'*  Aixhiv, 
Bd.  XX.,  I860;  IJd.  xxviii.,  1863.)  The  action  of  salicylate  of 
sorUum  so  cloeely  resembles  that  of  quinine  that  it  is  probable 
amblyopia  might  be  caufied  by  it;  and  Gntti  (quoted  hy  Norris) 
reports  a  case  of  transient  amblyopia  attributed  to  tbe  ingestion 
of  one  hundret.!  and  tweuty  graiDii  of  salicylate  of  sodium. 

HemianopBia. — Hcmiano|>ftia  ii'  a  lu»«  of  vision  in  one-half  of 
the  eye.  Since  tbe  rays  of  light  eroeB  in  the  eye,  the  part  of  the 
retina  wbi(^  is  blind  is  alwayit  opposite  to  the  object  whieh  cannot 
be  Men.  Thus,  when  the  eye  sees  no  objects  to  the  left  of  it,  the 
^ymptom  is  termed  Icfl  hemianopsia,  although  the  blind  spot  is 
on  the  right  side  of  tbe  retina:  in  otlie.r  wnnln,  when  an  objr^ 
in  front  of  the  line  of  the  nose  is  not  seen,  the  hemianopsia  is 
s|)okcn  of  as  nasal,  although  the  temporal  half  of  the  retitia  is 
paralyzed. 

Hemianopsias  are  best  divided  for  our  purposes  into  horizontal. 
in  which  the  dividing  line  between  the  paralysed  and  the  active 
portion  of  the  retina  is  hori7x>ntal,  and  vertical,  in  which  the 
dividing  line  U  vertical.* 

Horizontal  hemianopma  may  be  inferior  or  su])erior.  It  is  al- 
most always  due  to  disea^  of  the  eye.  The  only  known  nerve- 
lesion  wpable  of  ]iro4hicing  it  is  a  tumor  or  other  alteration  of 
the  hemisphere  so  situated  and  developed  as  to  press  downward 
upou  one  optic  irnct.     Such  cases  have  been  recorded. 

VeriictU  hemianopsia  is  almoet  invariably  due  to  uerve-lesion. 
A  large  nucnber  of  terms  have  been  employed  to  designate  tbe 
varieties  of  vertical  hemianopsia.  Of  these  the  following  seem 
worthy  of  adoption : 

a.  Tempwal  hemianopsia,  in  which  both  temfKiral  fields  are 
involvcil. 

6.  NawU  kanianopeia,  in  which  both  nasal  fields  arc  involvetl. 

c.  Lateral  or  Aomoaymous  hemianopsia,  in  which  corresponding 


*  Tbe  term  kemiopta  liat  bcoa  UE«d  by  eoow  writan  ■«  tyaonf  moiu  witEi 
bominiiu^wJB  ;  but  Dr.  St^guin  dednei  it,  "tn  nov  toeapted/'  to  sig^nlfy  lo«*  of 
perceptive  [lower  in  one-hnlf  of  ibo  retina,  wtiJInt  hcniiKno|»ia  m^niu obscura- 
tion  of  cvnc-half  uf  the  visunl  field.  A  right  hemiopin  is  oquivalctit,  there- 
fore, to  »  left  hominnopoin.  To  avoid  oonfatron,  I  Bhall  not  tu«  the  t«rm 
hamiopia. 


Iitigmii  a(  tho  B-ildt  at  Tliion  la  ■  mm  of  iMniKinl  li«inlikii<>i>*lA.  l*(ic  thiuJInji 
ilboaraucf  aUmlTUIaD;  tlk*  onur  boDDdarr  ^"l>*  »li4iUn£  I*  tli*  HbjI  of 
IkaasrMBl  IWM.  Tlia  inUlaiil  km  bcv^  iO,  li»ib<mlii-«j|<Iilll>,*ii>l  {imtiaM/ ■  dvpcjaU 
■^■t  tha  ctiiaan.    V  —  }^    Boib  cipttg  bvtvm  ynij'grvaii  lu  filar  mil  alniplil)^ 

Both  tem]K>ral  and  naRal  lipmiatiu|i8ia  are  exclusively  caused,  iUt 
ikr  as  our  present  knowledge  goes,  by  lesion  of  the  optic  chiasm. 


Fig.  20, 


INac>MD  of  tlie  Aolili  or  ilsluii  111  ■  oM  of  1*ri  UUnJ  hvmlaDOiMla.  Tlir  miter 
boandaryofUia  dwdln(li  iUb  II  mil  of  Ui*  miraki)  (litil ;  lbs  tbadJag  n-tmvpiil*  irbara 
vUoB  <rM  to*1. '  Tb«  1(11  liftif  vl  nan))  n*ld  !•  atiHiit,  and  Ilia  rP|hc  lial*>«  an  con- 
tncled.  The  iiallcul  Kaa  a  itoDUii.  at*d  ifi.  T  — i,^.  OtKM  Btrtw  oral,  era;  In 
ttwltilH[«r  iDjsn.lial  •ii|Mrn'-U)1)>c*pi11ar7.  Cvnlnl  clmnktlun  ti[iiliaii(iil.  Bvw^a 
■Kmtli*  Mure  «sanlnat1on  ilia  patlani  had  a  lampuTarr  1*fl-«ldod  bwiilp1a|li. 

Lfltera!  hetuiannpsia  a|ii>ears  to  Iw  alwayw  priKJut^  by  lesions 
of  one  optic  tract,  or  of  the  more  central  parts  of  the  optic  appa- 
ratus as  Car  |«wU;rior  as  the  cortical  centre  for  vision  in  one  hemi- 
sphere. Central  lesions  causing  lateral  hcmiauopsia  are  usually 
embolic  or  hemorrhagic,  and  hence  are  apt  Ui  lie  sndtlenly  de- 
reloped.     Lesions  of  the  optic  tract  causing  lateral  hemianopetia 


3fiO 


DIAGK06TIC   HEUROLOOY. 


are  probably  always  slowly  progressive,  being  of  the  nature  of 
the  growtlit)  or  exiKiali<)n& 

A  aiudy  of  the  (tiagrani  on  the  op]H)sitc  page,  after  Prof.  Sc^ia,] 
will  show  the  correctness  of  the  following  dedactions: 

1.  When  a  lesion    involves   one  optic   tmct  it  causes  lateral 
hemianopsia,  the  side  of  the  hemianopsia  being  opposite  to  the 
side  of  lesion.    Thus,  if  the  right  tract  is  pressed  upon,  »  \eH\ 
lateral  heminnopsia  results. 

2.  A  lesion  aclinig  upon  one  side  of  an  optic  tract  so  as  to  com- ! 
press  only  some  of  it«  fibres  might  produce  one-sidwl  hemianopsia, 
either  nasal  or  temporal,  according  (o  the  fibres  involved.  Jf  the 
presHtire  lie  upon  tlif  outer  .side,  tJie  hemianojiKia  will  lie  na-^al; 
if  it  be  on  the  under  side,  the  hemianopsia  will  be  temporal. 
Thus,  tumor  T  1,  in  the  diagram,  acting  only  feebly,  would  cause 
a  unitiileral  nasal  hemiuuo])»ia ;  T '2,  a  unilateral  temjwral  hemt- 
anojisia;  although  citiicr  tumor,  if  sufficiently  large  to  compreea 
the  whole  traot,  would  cause  an  homunymou:?  right  hemian-' 
op!tia. 

3.  When  both  sides  of  the  optic  chiasm  are  pressed  upon  by  a 
Icsiou  nut  suPEiciently  jtuwerful  to  obliterate  tlie  function  of  tlie 
chiasm,  both  lateral  fasciculi  arc  prc&'ted  upon,  ami  a  double  nasal 
hemianopsia  results.      Thus,  the  tumors  T  3  and   T  4  acting  h 
together  would  cause  a  double  uasal  hemianopsia.  fl 

4.  When  the  lesion  involves  the  frontal  and  posterior  bordcre 
of  the  ohiasni  it  injures  the  decussntiug  nerve-Bbrcs,  and  thcrebjr 
causes  double  temporal  hemianopsia.     Thutt,  the  tumors  T  5  and 

T  6  acting  together  would  cause  a  double  temporal  hemianopsia,  fl 

These  forms  of  hemianopsia  are  almost  invariably  accximpuniet] 
by  changes  in  the  optto  disk  and  oilier  eviilenco  of  pressure  or. 
change  in  the  basal   nerves,  which  symptoms  ara  very  apt  to 
wanting  in  legions  that  involve  the  cortical  centre. 

The  most  elaborate  study  whtcii  has  been  made  of  lateral,  cor- 
tical heinianu[>sia  is  that  of  Prof.  E.  C.  Seguin  (Journal of  Scrvoug 
and  Mental  Diseases,  vol.  xill.).  In  this  |>a|>cr  sixteen  cases  are 
analyzed,  leading,  as  Dr.  Seguiu  believes,  to  a  6nHl  drierminntioD 
of  the  position  of  the  c<.>rtiail  centres  which  are  oouoected  with 
vision.    These  cases  show —  ^ 

"  That  Icfiioos  of  the  corpus  fr<'"i«"ltituni  laterale,  pulvinar,  and 
latero-caudad,  etc.,  of  the  thalamus  may  cause  hemianopsia, — 


or 

1 


t.ll  1  I.   u.o 

IKt(nuD  of  Tliuat  ^dui;  dddinwl  lo  IlIatltBia  •ipaolBtlj'  Lnfl  LaCand  Bainluinpila 
bna  ki>7  l«*i°ii.  I^  T.  P.,  I«n  t*iD[K>nJ  tmlMl'liI.  R.  M.  F.,  risbl  iiaMl  b*ir-ai>1d. 
It  S..iiciilniilii.  0.  P.,  Acutiia  dsitnT.  K,  T,,  Dlw*l  anil  lampural  hallraof  raltiu 
V.  0.9.,  Bama  opUcna  ain.  N.  O.  n.,  iivrvu*  oplk'ua  drxl,  T.  C.  8^  faiKlriiltw  eni< 
iWnadB-  F,  L.  D^htckalua  WaraJlidtxL  C,  clilumft,  ord«cuHallon  ot  (Mdcall 
cnicMI.  T.  O.  n.,  Uacluaopikuailoil.  O.  O,  L,  oiipm  Kantculatkrnt  latarnl*.  L  0., 
taU  ejillcl  (curpni  qoail.).  P.  O.  O.,  priouirj'  o(>Ui:  cnnimt,  liicluillug  luLiu*  vptlca*! 
Mfp.  (Nile,  tot,  ftod  iia3TlMtr  or  not  aid*.  P.  O^  faickulut  oiilicuA  (GratlclM]  In  lb« 
iNlanMI  *>[«tt1a.  <!.  P..  ciirnu  luateiinr.  G.  A,  rtfimi  at  f  jni*  aURitUtla,  K  0.  S., 
tobna  oBdp.  ain.  L-  O.  D^  lulm*  otpIii.  Ant,  Co.,  cunrm  ajiil  (ultliaci-iil  |Q-ii  ciia- 
MIIMbc  III*  cortical  Tjnul  tantr*  la  man.  TAa  haoiy  ar  ^W«d  liiM  njprcMnl  faria 
I  ■«>  lb  r^M  Um  <■/  hMJVnMkB. 

"That  a  IcAinii  of  the  whit*"  mitwlance  of  the  (Kcipital  loW 
in  the  caudal  radiotions  of  the  inlcTtml  capsule  may  cause  hemi- 
anopsia, alone  or  with  hemiansesthesia. 

I  "That  lesions  of  the  supra- marginal  gyrus,  angular  gynw,  and 
inferior  parietal  lobule  with  ihc  subjacent  white  substance  may 


362 


oiAaxosnc  nkuboixuy. 


i 


I 


k 


cau.w  hemianopsia,  with  or  without  other  gymptoms  (h«nip] 
low  of  luuaeular  aeuae,  wurU-deaftie)^,  etc.). 

"That  a  lesion  of  greater  extent,  Involving  the  speedi-ranti 
the  motor  convohitionn,  aTid  the  parts  enumerated  above  (4),  doe 
usunlty  to  embolism  ur  throtiilx>8iit  of  the  entire  Sylvian  arlerr, 
will,  when  existing  ou  the  \cii  side,  produce  aphasia,  alexia,  hemf 
anopsia,  and  hemiplegiii, 

'*  That  Iftiiona  of  thti  oocipital  lobe,  wirtex,  and  subjacent  white 
matter  prothmc  hlindnesn  when  bilateral,  and  hcmiano[Mia  wlieu 
unilateral.     This  oonclueion  \%  in  accord  witli  Exner's  (1881)."     fl 

It  will  be  remembered  that  there  arc  two  distinct  views  held  bf™ 
pliysiologistH,  Muuk  teauhing  that  the  centres  for  oonsdous  visual 
perception  are  in  the  occipital  lobe,  and  Ferrier  that  tliey  are  ia 
the  angular  gyrus.     The  elaborate  dij^cusaiou  of  the  phyciiological, 
evidences  is  out  of  tiie  province  of  the  present  article,  but  the 
explanation  of  these  apparently  discordant  results  as  given  by 
Dr.  K.  C.  Seguin  is  probably  correct, — namely,  that  the  while 
band  of  conducting  tibrcs  known  as  the  optic  fa^iciilus  of  Gni- 
tiolet  and  Wernicke,  whilst  passing  from  the  posterior  port  of      ' 
the  tlmlamuiii  to  the  cuneuM  of  the  occipital  lube,  lies  m  close  lu 
the  inferior  parietal  lobule  and  the  angular  gyrus  that  a  lesion  of^J 
the  angular  gyms  or  of  the  supra-marginat  g>'ru»,  or  even  of  thfli^l 
inferior  |>arietai  lobule,  might  prww  upon  or  otherwise  involve  this 
conducting  fasciculus,  and  thus  interrupt  the  communicatiou  bi- 
tween  the  percejiiive  visual  centres  and  the  eyes.     Both  Ferrier 
and  Munk  may,  therefore,  be  correct  in  their  views, — the  loss  of 
eight  in  Ferrier'a  ex^Kriments  being  dne  not  to  the  wounding  of 
the  angular  gyrus  itself,  but  to  tlie  interferenoe  with  the  huntl 
conducting  the  white  matter  beneath  the  gyrus.  ^M 

The  following  rules  for  tlic  diagnosis  of  the  scat  of  the  lesion 
in  cases  of  hemianopsia  are  those  of  Dr.  Seguin,  aod  seem  to  am. 
correct : 

"  1.  Lateral  hemtaDo}>^ia  always  indicates  an  intrn-cranial  Icsi 
on  tlie  opposito  fiide  from  the  dark  ficldw. 

"  2.  Lateral  hemianopsia,  with  pupillary  immobility,  optic  neu- 
ritis, or  atrophy,  especially  if  joined  with  symptoms  of  basal  di8»- 
ease,  is  due  to  Icf^ion  of  one  optic  tract,  or  of  the  primary  op(io 
centres  on  one  cide. 

"  This  diagnosis  may  be  further  strengthened  and  rendered 


'J 


DIBTURBANCEB  OP  TUB  8PBCIAL  6GN8ES.  363 

certain  by  .seeking  for  and  finding  onesided  itupillary  reaction, 
ae  retiently  eugg<'Ste<l  by  Wernicke.  He  ingeniously  predicts  tliai 
ooly  one  larerol  half  of  each  iris  will  tx^  found  to  contract  by  the 
refiex  eS«ct  of  light  wbcn  one  optic  tract  has  been  iDicmipted. 
He  designates  this  ns  '  heniiopic  pupiUarj'  reaction.' 

*' 3.  lateral  ]iemiaiio{wia/or  sector-like  defects  of  the  same  geo- 
metric order,  with  bemiantesthesia  and  ehoreifonu  or  ataxio  move- 
ment of  onc-hnlf  of  the  l>ody  without  mai-kcd  hemiplegia,  is 
probably  dne  to  legion  of  the  caudo-lateral  [posterior  lateral]  part 
of  the  thalamus,  or  of  the  caudal  division  of  the  internal  cap- 
sule. 

'M.  Lateral  hemianopsia,  with  complete  hemiplegia  (spastic 
aj^er  a  few  weeks)  and  hcmianassthena,  is  probably  caused  by  an 
extensive  lesion  of  the  internal  capsule  in  ita  knee  and  caudal 
[poeierior]  port. 

"6.  Lateral  heminnopsia,  with  typical  hemiplegia  (silastic!  after 
a  few  weeks),  aphasia  if  the  right  side  be  paralyzed,  and  with 
little  or  no  antesthesia,  Is  quite  cerrainly  due  to  an  extensive 
superficial  lesion  io  the  area  supplied  by  the  middle  cerebral 
arter>' :  we  would  expect  to  find  (as  in  Case  26  by  Weatplial)  soften- 
ing of  the  motor  zone  and  of  lEie  gyri  lying  at  the  extremity  of 
the  69»ure  of  Sylvius, — viz.,  the  inferior  parietal  tobnie,  thesupra- 
nui^inal  gyrus,  and  the  gyrus  angularis.  Embolism  or  throm- 
bosis of  the  Sylvian  artery  would  be  Uie  must  likely  pathological 
fluise  of  the  softening. 

"  6.  Ldteral  hemianopsia,  with  moderate  loss  of  power  in  one- 
half  of  the  body,  especially  if  associated  with  imjiairment  of 
muscular  sense,  would  probably  be  due  to  a  lesion  of  the  inferior 
parietal  lobule  and  gyru!^  ungularis,  witli  their  subjacent  white 
aubstanoc  penetrating  doi'ply  enough  to  the  visual  centre. 

'*7.  Lateral  hemianopsia,  without  motor  or  common  sensor^' 
Bymptom^,  this  symptom  alone,  is  due,  I  believe,  from  the  con- 
vincing evidence  afforded  by  Cases  28,  29,  41,  and  4b,  to  lesions 
of  the  cuneiia  only,  or  of  it  and  the  gray  matter  immediately  sur- 
twiuding  it  on  the  mesal  surface  of  the  occipital  lobe  in  the  liemi- 
qibere  opposite  to  the  dark  half-fields.  Most  sui^jical  cases  come 
at  onoe,  or  afier  convalescence,  within  this  rule,  or  in  No.  9 
(Ctac  3)." 

Contraction  of  the  Field  of  Vision. — Contraction  of  the 

28 


^M          field  of  vision  occurs  in  eoveral  forms  of  sclerosis  of  the  oervooa 
^1          sT'Steni,  and  i<i  prolxtbly  the  result  of  woondary  oi^iiic  clianges 
^^^     lu  the  optic  Derve.     It  i»  especially  frequent  in  locomotor  ataxia, 
^^^1    but  muy  occur  in  multiple  sclerosis.     The  oontroctioD  isooocen- 
^^1         trie,  and,  acjiording  to  Forstcr,  in  a  majority  of  cases  Is  generally 
^M          more  marked  on  the  outer  side.     The  curve  llmt  bounds  the  field 
^M          of  vision  is  usually  irregular  with  emarj^^iDalions,  which  have  a 
^M          tendency  to  take  the  form  uf  sectors  wIiom*  centre  is  the  optic 
^1          papilla.     The  coutractiun  of  the  field  progresses  steadily  and  with 
^M          greater  rapidity  than  the  Iosk  of  sight,  so  that  vision  may  be  «at- 
^M          isfactory  although  the  sensitive  [lortion  of  the  retina  vs  almost 
^M          limited  to  the  macula.      Microscopic  studies  of  the  optic  nerve 
^M          have  shown  that  the  contraction  of  the  fieh)  in  connected  with  a 
^M          degeneration  of  the  nerve-fibrea  which  commences  in  the  oater 
^M          portions  of  the  optic  nerve  ami  travel*  towards  its  centre.     Die- 
^M          onler  of  the  colur-senm  utiually  accompanies  the  coutractioo  of 
^1         the  field.     The  power  of  |iercciviug  yellow  and  blue  is  prescrvi>d 
^M          for  B  long  time,  whilst  l)lindnej»  for  green  and  red  is  early  de- 
^M          velopcd.     According  to  M.  Abadic,  it  is  past^iblc  to  dijttinguLili 
^M          between   parcnchymatou.^   and   interstitial   atrophy  of  tlie  optic 

^B                                                                      Fin.  fi7. 

i 

^^U                        DlafKua  of  il>a  fl*ld*  of  t 

^^M                                fllktlODkUd  tbf'liliuil  IpOt, 
^^^1                            Bulb  u|>llo  n<?rTni  tl-invnl 
^^M                        barm  *  wwk.itnd  ilniili  ' 
^^M                     produdni  lb«  *"■*■''!"**  a 

^K          nerve  by  a  study  of  t 
^1          the  color-sense.     Whe 
^1          ^1  >^  greeu  is  no  longe 
^1          nized   with  diEHculty, 
^^^^    the  other  hand,  with 

n 

.  , 

_^_ 

1 

/ 

r- 

-.> 

■\ 

\ 

f 

< 

*• 

' 

^^ 

— 

J 

1 

/ 

/ 

1 

liiuD  for  wlilu  «iid  rvl  and  can 
rram  o  okH  of  lueonMtor  atulk. 
nj  ilmiibj.    Iriumucb  ma  h* 
*  a  frw"  llaana  of  wktakt?  Mlj 
DiiBt  b* rnUrvIr  Moludod.    For 
11,  ric.  io. 

iG  relation  between  t 
n  the  loss  of  vision 
r  perceived,  and  red  a 
there  ia   [mreiichynia 
an  acuteness  of  visiu 

ml  «oni««niiu,  MiiifMUc         ^^1 

PattNitaCCd^i  V— A-           ^H 
•iiiakail  two  oniiioaa  of  lo-          ^^H 
,  till  lallnfana  tS  ibM«  In          ^^| 
a  rimilaf  omb  m*  Oowon.         ^^| 

he  general  sight  amf^" 
is  still  greater  than 
nd  yellow  are  rccog- 
tous  atrophy;    if,  on 
n  inferior  to  •^^  *i>^^ 

I>l8TrBBANCE8  OF  THE  8PEC1AI.  8E.N8ES.  355 

pemeptioD  of  color  ia  satisfactorily  maintained,  there  is  probably 
interstitial  atrophy. 

Multiple  sclerosis  may  produce  di!;turliati(!^  of  vision  giniilar  tu 
those  caused  by  locomotor  ataxia.  Out  of  tifty  cases  olxservcd  by 
Dr.  R.  Gnauck  {Nfurotog.  Omlralhlatt,  1884,  iii.  315),  vi&ion  was 
affected  in  twenty-two.  In  some  cfises  the  disturbance  of  vision  i« 
monocular,  probably  as  tbc  result  of  the  development  of  a  focus 
of  sclerosis  iu  the  nerve  itai-If.  Acconling  to  Pariuaud  (Proffrfi 
Mfdicalf  xii.  642),  the  amblyopia  of  multiple  sclemsin,  unlike 
that  of  posterior  sclerosis,  very  mrely  ends  in  tolnl  blindrieas ;  but 
in  two  of  Ouauck's  caites  tJie  lo6s  of  sight  was  oomplt^te. 

SEXSE  OP  TASTE. 

The  function  of  taste  is  shared  by  two  nerves, — the  glosso- 
pharyngeal and  the  lingual  branch  of  the  fifth, — the  first  supply- 
ing the  posterior  half  or  two-thirdi'  of  the  tougue,  llie  lixsi  tlie 
anterior  half  or  third  of  the  organ.  Owing  to  this  double  ncrve- 
sapply,  it  is  necessary',  in  testing  the  condition  of  ilie  taste-seninc^ 
that  the  tongue  I>e  protnidcd  from  the  mouth  and  be  kept  f|ui«'t 
after  contact  with  the  sapid  substance  until  time  has  elapsed  for 
the  penetration  of  the  latter.  The  gutitatory  filameuts  of  the  lin- 
gual brarifli  of  the  fifth  leave  the  nerve  with  ihe  chonla  tympanJ 
and  pa^  to  the  facial  nerve.  Paralysis  of  the  lingual  branch  of 
the  fifth  ner^-e  after  it  receives  the  chorda  tympani  is  therefore 
followed  by  Ioks  of  ta^le  in  the  uuterlor  part  of  the  tongue;  as  is 
also  a  lesion  of  the  trunk  of  the  facial  nerve  between  the  genicu- 
late ganglion  and  the  point  at  which  the  chorda  tympani  se|Minite8 
from  the  facial  nerve.  There  have  been  cases  of  paral^'sis  of  the 
fiuaal  nerve  above  the  geniculate  ganglioD  in  which  there  has  been 
no  inierfereuve  with  the  sense  of  taste,  and,  ou  the  other  hand, 
fluea  have  been  reported  in  which  oompreseiun  of  the  trigeminus 
nerve  above  the  position  at  which  the  [>elrosal  norvc^  join  it  has 
been  followed  by  loss  of  taste.  It  is  therefore  probable  that  Oie 
gustatory  fibres  of  Ibe  lingual  nerve  return  through  the  petrosal 
nerves  to  the  trunk  of  the  trigemious.  There  are,  however,  oases 
on  rcconi  in  which  the  taste-symptoms  are  very  difficult  of  ex- 
planation, and  it  is  possible  that  tlte  courae  of  the  filaments  varies, 

Tbe   glosso-pltaryngoal  nerve  arises  from  the  nucleus  in  the 


356 


■DIAQSOBTIC  KEDBOIXtOY. 


in«liilla  close  to  the  nucleus  of  the  vngus.  The  trunk  emerga 
in  the  groove  Iwtwetn  t-!io  nli\'ary  body,  and  eacai>es  fmiu  the 
skull  through  the  jufi;ular  roramen. 

Hyperaifitheaia  of  the  sense  of  ta^te  is  sometimes  Men  in  tyv 
teria.  HalludiiHtionH  occur  iu  insanity,  and  with  extreme  niriw 
are  pmduccd  by  organic  disease  of  tbo  nervous  apparatus  iovolvol. 
They  are  very  frequently  present  as  the  result  of  disorders  of  tbe 
intestinal  tract:  whether  under  Iheie  circumstances  they  should 
bti  hioktil  upou  as  reflex  or  as  the  development  of  abaomuJ 
mouth-secretions  is  doubtful. 


HESSE  OF  3UELL. 

It  18  neoesssary  iu  tet^ting  the  senile  of  suiell  that  such  odl 
snfaetances  be  selected  »s  are  not  irntiuit  to  the  muo^nis  meml 
of  the  nose,  lest  tbe  subject  shouki  detect  their  presenoe  by  their 
effect  upon  the  branc^hes  of  the  trigeminal  nerve  in  the  nasal  mu- 
cous muiubrutiu.  Ky{>erwg(hesiu  of  the  senseof  smell  is  sometimes 
seen  in  hysteria,  aud  theoretically  should  occur  in  inflammatory 
conditions  of  the  oliiictor)*  tract,  but  I  have  never  known  of  sucli 
a  case.  HaUuciuatious  of  the  sense  are  sometimes  soeo  in  iu* 
sanity,  and  also  occur  in  diseases  of  the  olfactory  tract,  when  they 
are  apt  to  usher  in  aa  epileptic  convulsion.  I  have  seen  sucli 
symptoms  produced  by  a  gliomotous  tumor  involving  the  olfactory 
lobes.  Loss  of  smell  usually  dejwnds  upon  disease  of  the  raucous 
membrane  of  the  uose,  but  it  may  be  caused  by  an  afTection  of 
the  olfactory  lobes,  and  is  occasionally  seen  in  organic  hemiani: 
tbesia  produced  by  a  lesion  involving  lite  internal  ca|]uule. 


DISORDERS   OF  MEMOET  AND    CONSCIOUSNESS. 

Ali^  functional  acts  are  accoinpniited  by,  or  dependent  upon,  a 
itrittve  dUturbBDce.  It  matters  itot  whotLer  tha  functional  act 
13  connected  with  tliougtit,  TOiisriousncss,  or  secrelinn,  the  pinem- 
don  of  ner\*c-fr>rce  b)*  th«  ganjrlionip  oell  and  ite  transmiiwion  by 
nerve-fibre  are  accompanied  by  nuiritive  cbango**  in  the^e  bodies. 
A  nutritive  act,  althongU  temporary,  has  a  distinct  tendency 
to  impreafi  permanently  tlie  part  iniplic^ted  •  and  tins  tendency 
18  especially  pronounced  in  nervous  tissue.  All  nervous  tltsuc  is, 
therefore,  liable  to  be  permanently  afftcted  by  its  own  functional 
actions.  This,  it  roust  be  remembered,  applies  equatly  to  normal 
and  to  pathological  activities.  ThiLS,  the  child  in  learning  fo  walk 
by  re|ieated  efforts  trains  the  lower  ner%'e-ei?nti'eK  until,  in  response 
to  appropriate  stimuli,  a  definite  wries  of  nervous  discharges  and 
trans  missions  oocnr  independently  of  the  will,  and  walking  b«- 
comes  automatic.  Tbitf,  iu  short,  »  the  hixtury  of  all  training, 
mental  and  physical.  All  nervous  tisHue:^,  therefore,  have  memory, 
— !.«.,  the  faculty  of  being  ]>ormancntly  inipraweti  by  remjwmrily 
acting  stimuli,  the  thing  remembered  Ireing,  in  fact,  the  functional 
excitement. 

The  recognition  of  the  uuiversality  of  memory  in  nerve-tissues 
is  of  great  importance  in  the  considenitiun  nnil  treatment  of  dis- 
ease. Thus,  an  epileptic  fit  U  produced  by  a  perijihenil  irritation. 
If  that  )>eriphenil  irritation  l>e  at  once  removed,  the  fit  does  not 
recur,  ami  the  patient  is  cured.  If,  however,  the  Irritation  be  not 
stHin  taken  a^vay,  but  produce  a  twncs  of  eonvulsioiift,  the  fits 
may  continue  after  the  removal  of  the  irrilatiou,  simpiv  because 
of  the  j>ermaiient  impre«i.s  which  has  been  made  upon  those  ceils 
in  the  brain-cortex  whose  discharge  of  nerve-foroe  is  the  imme- 
diate cause  of  the  epileptic  pai-oxy.sHi.  The  nutrition  of  the  cells 
has  l)een  so  altered  that  at  irrc^lar  intervals  they  fill  up  and 
discharge  nerve-force. 

Owing  to  this  power  of  memory,  a  physical  habit  may  become 


857 


S68 


WAGNOenC  NEUROLOGY. 


90  permaDently  engraOed  upon  the  nervous  sjTAtem  tlint  the  {utienl 
18  unable  to  cuutrol  it.  An  example  of  this  is  seen  in  the  so-l 
called  habit/Kiborens :  luoveraents  at  iir&t  controllable,  mere  bad' 
habits,  become  at  last  fixed,  not  to  be  altered  by  any  power. 
The  liysterical  woman  who  gives  vray  to  hysterical  nen'Oiis  im-  | 
pulMs  thereby  streogthens  tlietr  hold  upon  the  tiysteni,  so  tliat  ia  ■ 
time  she  may  \om  all  power  of  control  over  the  lower  nerve*  ^| 
oentres.  Moral  habits  are  formed  in  obwlienoe  to  the  same  law.  " 
Self-oontro),  (enforced  at  first  by  discipline,  may  become  ut  la.'*!  io  ^ 
the  child  an  int^ral  fuuctiOD  of  the  nervous  centre,  by  a  method  fl 
parallel  to  that  by  which  an  accidental  epilepsy  is  converted  into  ^ 
a  |icrniiinent  diseii^e.  In  tlic  progno»ii>  and  treatment  of  diAeabe,  ^ 
as  well  as  in  the  training  of  the  young,  the  full  recognition  of  the 
power  of  habit — ix.,  of  uiiconf«cious  memory — U  a  matter  of  vital 
importance. 

What  is  true  of  the  lower  nerve-centres  and  fibres  is  true  of 
tlie  upper  ones.  Intellectual  acts  or  thoughts  and  peroeptioos 
tend  to  stamp  themselves  uiMin  the  centres  connected  with  them, 
and  when  the  function  of  the  nerve-oell  is  coniiecte<l  witli  coo- 
acuoaeuees  the  ohangee  which  ocxnir  in  the  nutrition  give  origia, 


I 


t4>  conscious  memory, — i.e.,  to  memory  in  the  umial  sense  of  tbaj 
term. 

The  methods  of  ordinary  mental  action  aeem  to  indicate  either 
that  special  gunglionic  cells  are  set  apart  for  special  forms  of 
meunury,  or  el&t;  that  the  single  ganglionic  cell  i«  ca]»able  of  dis- 
tinf^t  acts  of  memory.     Thim,  one  individual  will  remember  one      , 
class  of  facts  with  great  ease,  to  the  exclusion  of  other  matt«rg^«^ 
whilst  the  second    person   may  readily    remember   those  afiuira^^ 
which  the  first  naturally  forgctfl.     Disease  aonictiiues  diseects  out, 
as  it  were,  the  different  forms  of  memory,  isolating  one  from  the 
other.     It  is  well  known  that  in  the  loss  of  memory  which  ac- 
companies senile  changes  of  the  brnin,  or  is  a  prominent  symptom 
in  the  first  stage  of  general  pare»is,  the  power  of  remembering 
recent  evcnt.«  may  Ix;  lo^t,  although  the  recollection  of  affairs 
which  happened  in  childhood  days  is  far  more  vivid  than  in  the 
normal  condition  of  the  individual.     Under  tbeee  circumstances 
it  may  be  considered  tliat  the  ganglionic  cells  have  Inst  theil 
capability  of  receiving  impressions,  but  not  of  reoognizing  tmpres-'' 
eiooB  which  were  made  long  before     The  iieparatiou  of  different 


I 


forms  of  memory  is,  however,  distiuct  from  this.  Thus,  in  a 
CAM  of  dementia  recently  under  my  care  memory  for  ordinary 
ertiiiis  wa«  almost  entirety  latt,  and  yet  a  joke  or  a  ludicrous  ntory 
would  be  remembered  in  all  il6  details  without  apparcni  elTurt. 
It  is  well  CBtabliHlied  that  one  forni  of  memory' — namely,  that 
connected  with  liu)gtia|re — hft.4  in  mnnt  individuals  a  doflnile  lirain- 
location ;  and  it  may  be  that  each  variety  of  memory  has  its  own 
lerritory. 

In  oonfiidering  the  disorders  of  memory  I  shall  dij%ui»,  first, 
dieturbanoes  of  specialized  forms  of  memory  ;  secondly,  disturb- 
ances of  tJie  gcnenil  fimotion.  This  arrang^'ment  may  appear  to 
be  a  revereal  of  the  natural  urder^  but  tliu  peculiar  relatious  of 
memory  to  consciousness,  and  the  directnffls  with  which  a  dis- 
cussion of  either  of  tliese  functions  leads  to  a  consideration  of 
tlic  other  functions,  render  the  plan  whicli  I  have  selected  ihc 
more  convenient.  Of  the  special  forms  of  memory  which  pre- 
sumably exist,  tlic  only  one  whose  syraptumatology  is  sulficiently 
worked  out  to  ucccs^aitate  discussion  here  is  tliat  connected  with 
Iviguage. 

WORD-MEMORY. 

The  power  of  speech  may  be  lost  by  an  individual  from  pnra- 
lytic  or  other  aficctionsof  the  larynx  preventing  the  formation 
of  sound ;  fmm  parah'sis  of  the  tongue  and  lips  (causing  tnabiU 
ity  to  pronounce  words  or  letters;  and,  finally,  from  derangement 
of  the  mental  functions  immediately  connected  with  word-thought. 
To  tiie  voiwiifwness  of  laryngeal  disease  the  name  of  Ajffumia 
may  be  applied ;  b>  that  which  Ls  the  result  of  affM^lona  or  [uiral- 
-jRa  of  the  tongue  or  mouth,  Aphtrmta ;  whilst  for  the  meiitnl 
Sculty  may  be  reserved  the  term  Apfutsia.  These  terms  have, 
liowever,  been  employed  with  various  significations  by  various 
autliors.  Ajihieniia  has  heeu  used  to  ingtiify  apliosia,  nod  the 
ooodition  which  1  have  called  aphoemia  is  known  by  some  writers 
H  ataxic  aphasia, — a  term  which  is,  however,  used  by  other  writers 
to  denominate  a  |>eculiar  variety  of  aphasia.  With  aphonia  and 
aphiemia  we  have  at  present  no  comxfn. 

Aphaaia. —  In  aphasia  the  jiower  of  verbal  expression  or  of 
won! -percept ion  is  affcsotod,  although  the  general  intelligence  of 
tht  {Mitient  may  be  intact.     Id  the  completest  form  of  aphasia, 


860 


DIAGNOSTIC   NEUROLOGY. 


I 

I 

I 


when  the  patient  can  neither  understand  spoken  or  wntten  Ino-I 
guagc,  nor  express  liimgclt'  either  in  words  or  iu  writing,  tlte  iotel- 
ligcnce  is  to  be  judged  of  by  the  acts  of  the  patient :  thu«,  such 
an  aphasic  will  iindersinnc]  the  use  of  tlie  pen,  and  perhaps  at- 
tempt, if  he  be  not  paralysed,  to  write,  or  he  will  use  properly      . 
a  ipoou  or  a  knife,  although  he  bos  no  knowledge  of  the  hm^H 
gaage  or  written  symbols  habitually  employed  to  represent  snch^ 
articles. 

Apbainia  is  in  many  cases  not  complete, — that  is,  it  does  not] 
affect  all  the  mental  functions  conne*.:ietl  with  K|)<ech.     In  1880j. 
Dt.  Magnan  divided  the  cases  of  ajihasia  into  two  groups:  firs^' 
those  cases   in  which   all   connection   lietween   words  and  their 
meanings  is  lost,  so  that  the  aphasia  is  complete;  to  these  cases 
he  gave  the  name  of  Vei-bai  Amnfxia:  secondly,  cases  in  which 
the  subject  in  able  to  comprehend  spoken  language,  but  has  lustj 
the  power  of  expressing  himself;  thus,  wJien  asked  to  pick  up  a, 
pen  from  the  table,  the  patient  does  st),  hut  holding  the  pen  is 
nnabic  to  name  it :  to  this  partial  or  incomplete  aphasia  Magnan  ^, 
gave  the  name  of  LogopUgia.  ^H 

Ati  long  ago,  however,  as  1843,  Dr.  Lordat,  of  Montpellier,  ^H 
reporte*)  cases  of  a[)h:asia,  nitd  clearly  recognized  the  cxistenoc  of 
much  more  partial  and  distinct  forms  of  the  affection  than  those 
outlined  by  Magnan  ;  and  In  ]}j74,  Wernicke,  under  the  name  of 
Sautory  Aphasia,  descrilied  certain  peculiar  cases  similar  to  thoec 
noted  by  Lunlat.  In  1874,  Kussmaul  also  rcporied  cases  of 
aoisory  aphasia.  Magnan  and  Kussmaul  have  disputed  much 
conoernitig  their  rights  to  priority,  but  they  each  were  long  ante-^_ 
dated  by  Dr.  Lordat.  ^| 

Kussmaul  {j^enwsen'H  OtjclopfFdiay  vol.  xiv.),  in  an  extraordina- 
rily elaborate  and  diilicult-to-be-read  article  upon  speech,  divide 
aphasia  as  follows: 

Fir-a.  Aiaxie  Aphasia,  or  that  condition  in  which  the  patient 
has  an  entire  lost  of  sj>eecli,  although  written  and  S[}okcn  lan- 
guage is  understood.  In  pure  ataxic  aphasia  there  is  no  affraphiaj 
or  loss  of  the  power  of  writing,  so  that  the  subject  may  be  able 
to  transact  by  writing  the  ni»>t  complex  business.  When  agra- 
phia is  added  to  ataxic  aphiisia  the  patient  ts  entirely  unable  to 
t-ommunicate  with  his  fellows  except  by  rude  signs.  Agraphia 
ia  not  dependent  upon  any  loas  of  control  over  the  finer  move 


'°1| 


DISOBDEKS  OF   HEMOBT   AKD  OOlfSCIOVSKBSS. 


361 


mciits  of  the  hand.  Thus,  in  r  case  rt-ported  by  Spamcr,  a  young 
woman  completely  agraphic  vftv^  etill  a  skilful  seamstress.  The 
facial  exprewiiona  of  emotion  are  usually  proaorvetl,  so  that  anger, 
sorrow,  etc.,  are  expressed  in  the  face,  and  sign- language — 'indeed, 
the  whole  mimetic  faculty — may  be  normal.  In  very  rare  cases 
sigij-«pwi^li  i«  also  lost,  so  that  the  patient  ia  no  longer  able  to 
oomoiDuicate  by  pantomime. 

Second,  Amnetio  Aphasia,  in  which  the  idea  is  present  but 
the  won)  '\s  wanting,  although  aitieulation  is  "  at  the  service  of 
the  word."  Under  these  eircumstaoces  the  patient  is  unable  to 
talk,  althongh  he  can  ftill  repeat  and  also  write  out  words  which 
are  i$pukcn  to  him.  In  ]>artial  amnesic  apliasia  proper  uames  are 
the  first  to  be  lost,  next  names  of  things,  and  finally  nouns  in 
general.  The  patient  will  often  pumpliraiic  the  noun  which  ha 
cannot  remember.  Thus,  a  pair  of  soisaors  may  be  called  "  that 
with  which  one  cuts;"  the  window,  "thnt  through  which  one  sees." 
The  early  forgetful  riess  of  proper  names  in  evidently  founded 
upon  their  isolated  arbitrary  character,  which  fails  to  link  them 
with  the  world  nf  word-thought,  and  renders  them  even  in  health 
apt  to  be  forgotten.  In  some  cases  of  amnesic  aphasia  it  is  only 
certain  letters  that  are  left  out.  Thus,  L.  Schlessinger  details 
the  oise  of  a  boy  who  invariably  oniittetl  the  initial  oonsnnants, 
l>oth  in  writing  ami  in  s^ieaktng. 

Third.  Word'dmfriegs  and  toord-hlmdnegfi,  constituting  the  >Sm- 
•ory  Apiiosia  of  8<«ne  authors.  The  subject  of  toord'bUndneitit  is 
able  to  express  his  ideas  in  conversation  with  his  normal  fluency, 
and  to  underslnnd  all  that  is  8i]i(l  to  Inni,  also  to  oopy  written 
language  and  with  the  pen  to  put  down  upon  paper  hia  ideas,  yet 
he  is  unable  to  read  printing  or  wTiting.  Tbu»,  in  a  case  reported 
by  Charcot  the  patient  sutlering  with  purliul  right  hemiplegia 
was  unaware  that  he  had  any  disorder  of  word-thought  until  be 
wished  to  give  certain  orders  about  his  business  affairs.  These 
he  wrote,  and  afterwards,  in  order  to  be  sure  of  their  correctness, 
undertook  to  read  what  he  had  written,  when  he  fonnd  that  he 
could  not  recognize  a  single  word. 

In  trord-4leafnea»,  although  the  sense  of  hearing  is  intact,  and 
although  the  individual  is  able  not  only  to  express  himself  in 
coovemattou,  but  alsto  to  write,  to  read,  and  to  umlerstand  writing, 
he  comprehcndB  uothing  that  is  said  to  him  by  word  of  mouth. 


832 


SIAONOSTIC  KEinWLOOY. 


I 


He  hean  distinctly,  but  cannot  connect  the  souod  of  the  word 
with  tbe  object  which  it  t^ymbolizes. 

Fourth.  I'arajiiuma,  ur  ihtit  condition  iu  M-hich  the  peraoD  is 
onable  to  use  words  in  their  proper  sense,  speaking,  it  may  be, 
with  considerable  flnency,  but  perpetaally  using  one  word  for 
another. 

Fifth.  Agravimaiisma  or  Akaiaphagia^  in  which  all  the  rolfls 
of  grammar  ore  lont,  ho  that  tJie  |>arls  of  speech  are  hopeleaely 
intermingled.  ^J 

It  seems  Ingical  to  consider  tbe  fourth  and  fifUi  varieties  of  ^| 
aphasia  of  Kuasmaul  a&  siiuply  |>artial  aphiu^ias,  io  which  the 
relatione  of  words  with  ideas  have  become  dislocated  but  not 
completely  di'rJoEned.  If  all  pecuLinr  forms  of  partial  aphasia  must 
be  defined  and  named,  the  list  will  have  to  be  much  extended 
beyotn]  that  of  Ku88maul.  Thus,  I  might  iustance  a  ca»e  reported 
by  Dr.  Grashey  {Hilzii-ngsbenehte  Med,  Geseli.  H'iirzbun/,  1884, 
"No.  9),  in  which  the  patient  understood  conversation,  and  read 
and  wrote  fre^^ly,  but  in  attempting  to  talk  was  frequently  un- 
able to  remember  wortU,  exoefit.  by  writing  and  then  reading 
them.  It  waA  hiti  uoinmon  practice  to  write  with  his  fore6ngcr 
upon  the  palm  of  his  kTt  hand  each  word,  letier  by  letter^  and  then 
immediately  pronounce  it.  1  have  lu'ard  or  read  of  a  cose  in 
which  the  patient  repeated  backward  the  sentence  that  he  was 
trying  to  uLter,  beginning  at  the  end  of  the  tfentence  and  at  tbe 
end  of  each  word.  Instcnd  of  "  John  is  a  bad  boy,"  the  patient 
would  Bay,  "Yob  dab  a  s-i  nhoj." 

As  was  pointed  out  by  Dr.  Hiighlings-tlacksou  in  1864  (ZondL 
Sogp.  Report,  1864),  the  faculty  of  iutellccttial  speech  may  be 
lost  whilst  cmotiuiml  speech  remains  to  a  greater  or  less  extent.  ^ 
Thus,  a  pet^oii  who  ha.i  been  ('■onsidered  completely  ai^hasio,  after  ^| 
obstinate  silence  to  nil  questions  and  remarks,  will,  iu  a  burst  of  ^ 
anger,  suddenly  swear  violently.  Or,  a.^*  in  a  case  seen  by  Dr. 
•Jac'ksou,  uu  uphaKic  who  is  unable  to  respond  "no"  to  an  ordi- 
nary question  blurts  out  tbe  monosyllable  when  the  qutvtion  is  so 
wonlal  ii-s  Io  provoke  his  nnger.  Dr.  Brondlwnt  rf[Kirts  a  case  in 
wliich  the  power  of  volutilar^-  speech  was  entirely  lost,  but  in 
which  under  emotion  a  large  number  of  words  would  be  forced 
out  rti|)idly  like  m  many  iiiterJL-<rlions.  Rrown-S^Vpiard  states 
that  aphasic  persons  sometimes  recover  their  speech  during  de- 


I 
I 


I 


PIBURDERS  OF  UKAIORY  AND  CONSCIOC8XE&S. 

Hrium,  and  Jaclutoit  relates  ao  instance  frotu  the  experieooe  of 
Laugttou  Dowu  in  which  u  apeechtuM  idtot  duriug  the  dtilinum 
oi'  fever  spoke  fredy. 

When  the  aphasic  has  hahitiially  spoken  more  than  one  lao- 
gtuge,  certain  word^  iimy  remain  in  each  language.  Thus,  a 
woman  under  my  own  care  would  frequently  answer  "no"  aa  the 
only  Euj;li&li  word  at  her  cotiituaiul,  hut  would  expresB  her  emo- 
tion by  '*  Qott  in  Himrael,"  the  sole  remaining  fragment  of  her 
native  tongue. 

FMndtoned  Aphimia. — Although  commonly  an  aphasia  is  due  to 
an  organic  lesion,  yet  it  may  be  purely  functional.  It  is  notorious 
that  nnder  great  excitement  the  power  of  speech  may  be  loet.  In 
the  Host.  Mcfi.  and  Surg.  Journ.,  December  17, 1885,  is  an  account 
of  a  case  in  which  aphakia  was  produced  in  a  child  by  fright.  In 
hysteria  aphonia  h  mucli  more  frequi^l  tliuu  aphasia,  and  yet 
undoubtedly  there  is  an  hysterical  apJiasia  which  may  remain  for 
many  montlis,  if  not  years,  although  not  dependent  ii[K>n  any  groes 
lesion  of  the  brain.  Dr.  Hacrtz  (i5emMen*»  Oyclopmiiaj  vol.  ii.  p* 
601)  states  that  a  paroxysm  of  aphasia  may  replace  the  ordinary 
symptoms  of  malarial  iwiHiming.  After  epileptic  attacks  there  is 
iomctimea  a  temporary  aphasia.  The  symptom  has  also  [leen 
Tutted  in  a  large  number  of  acute  diseases,  hut  proljahly  in  the 
majority  of  ihetie  vasdf  it  Iia»  rested  upon  a  dbstinct  lesion.  It  'u 
certainly  capable  of  being  produced  by  reflex  irritation.  Prof. 
rSernhardt  afBrniit  that  in  children  indigestioni?,  eiitozoa,  and  |Hy- 
chieal  irritations  occasionally  produce  aphasia  (London  Medical 
Record,  October  16, 1886).  Kiiasmaul  states  that  cases  have  been 
reported  in  which  collections  of  fteoes  in  the  large  intestine  or  lum- 
bri(^)id  worms  have  been  suppascd  to  he  the  caiiec  of  an  aphasia 
which  has  ilisuppcared  on  the  expulsion  of  the  irritant.  In  u  case 
which  came  under  my  notice  several  temporary  attacks  of  aphasia 
were  the  result  of  an  overloaded  &tomach,  and  were  relieved  at 
onoe  by  vomiting. 

Functional  aphakia  can  usually  be  diatiuguishod  from  the 
organic  affection  by  its  tem|)orary  or  paroxysmal  character,  but 
in  hysteria  the  Iosb  of  speech  may  persist  for  a  great  length  of 
time.  Under  these  circumstances  tlie  |iositive  diagnosis  may  long 
be  impossible,  although  the  nature  of  the  aphasia  may  lie  surmised 
from  the  hysterical  history  of  the  patient  and  the  ahscoce  of  evi- 


I 


I 


364 


PIAQNOBTIC  NEUROI.OOY. 


dences  of  serious  organiu  brain-diftease.  The  sudden  recovery  of 
such  a  case  would  decide  its  natare. 

Lesions  nf  Apka/tfa. — la  1836,  Dr.  Dax  first  made  known  at 
Montpcllier  that  in  or^nic  aphasia  the  left  cerebral  hemisphere  is 
at  fault.  !5inoe  his  earliest  publ  ication  a  large  number  of  cases  have 
[been  re[Mirteti,  which  prove  that  in  the  great  majoritr  of  ineitanoefl 
it  if*  the  left  hemisphere  that  is  diseased:  thus,  out  of  two  hun- 
dred and  sixty  cases  of  aphasia  collected  by  Dr.  Seguin,  of  New 
York  {QttarUrl^  Jotimal  of  Pet/chotogi&d  Medicine,  Janiiarr, 
1868),  iu  two  hundred  and  forty-three  there  was  right  hemi- 
pl^ia  and  in  seventeen  lell  hemiplegia,  the  pruporiiuu  being  as 
14.3  is  to  1. 

The  connection  between  disease  of  the  left  hemisphere  and 
aphasia  is  even  closer  tlian  is  iudiuated  by  Uiese  figures  of  Dr. 

'uin,  for  there  is  reason  to  believe  that  in  a  considerable  pro- 
portion of  the  cases  in  which  \eft  hemiplegia  has  been  associated 
with  aphasia  there  have  been  two  lesions.  The  most  satisfactory 
explanation  of  this  connection  yet  given  is  theeu^wrior  develop- 
ment of  the  left  cerebral  hemisphi^re,  due  to  tlie  habitual  exoes- 
sive  use  and  tmininj;;  of  the  right  hand,  which  acts  not  only  upon 
the  individual,  but,  from  the  laws  nf  heredity,  upon  the  race,  the 
perpetual  training  of  generation  after  generation  resulting  in  ut 
habitual  excessive  development  of  the  centres  presiding  over  the 
right  hand, — i.e.,  of  the  left  cerebral  hemisphere.  Kspeeially  is 
the  habitual  act  of  expressing  thonght  in  writing  vritJi  the  right 
hand  believed  to  lead  to  the  great  development  of  the  speech- 
centres  in  the  corresponding  brain-region.  In  a  certain  propor- 
tion of  ca^eti  rhe  human  iiiilivldnal  is  Ixrrn  with  a  su|>enur  deveU 
opment  of  the  left  hand,  or,  in  common  parlance,  is  left-handed. 
In  sucli  ]>er«ons  it  must  l»e  ackimwiedged  that  the  right  cerebral 
hemisphere  is  the  most  highly  orgauined.  If  the  theory  which 
has  just  been  enunciated  be  correct,  wc  should  expect  to  find 
that  aphasia  In  lot^-hstudcfl  pi^ople  Is  Imbitually  assooiated  with 
left  hemiplegia. 

Drs.  Pye  Smith,  ITughlings-.Tack8on,  and  John  Ogle  have  re- 
ported a  number  of  ti\iv\\  cases.  (See  Kufismauj,  p.  740.)  In  a 
very  extraordinary  case  reported  by  Wadhara,  a  vonng  man,  who 
wrote  with  his  right  h.in(t,  but  was,  like  his  brother,  in  other  re* 
spects  left-handed,  sufiered  with  left  hemiplegia  with  aphasia.     It 


• 


DISOnDRRS  OP    UEUORY   AND  CONSCIOn»XKKS. 


365 


Id  seem,  therefore,  that  he  used  the  left  hemisphere  in  writing 
and  the  right  iu  spcakiDfi;.  In  this  case,  according  to  Dr.  Bate- 
man  (see  London  Latuxt,  April,  1880),  the  lesion  foiiud  after 
death  was  a  complete  destrurlion  of  the  inland  of  Reil  on  the 
ri^ht  side,  the  left  hcmiaphcre  of  the  brain  being  healthy.  The 
association  of  aphasia  with  left  hemiplegia  is  nsualty  dependent 
upon  iu  occurrence  in  lelVhanded  peoplt,  hut  this  explaiialiou 
will  not  suffice  for  all  cases.  Thus,  Dr.  Michel  Catsaras  (La 
f)rance  i((d.,  1884,  vol.  ii.)  reports  a  lase  of  otnuplex  aphaftia 
with  left  hemiplegia  in  a  man  wlio  was  tiol  left-handwl.  Hugh- 
liug^Jackson  {Lemdon  Lnrnvt,  April  24,  1880)  has  recorded  a 
similar  case.  I  have  not  been  able,  however,  to  find  any  cose  of 
tlie  cliarai-ler  just  spoken  of  iu  which  there  hu8  hcf-n  an  nutopey, 
and  the  possibility  remains  that  in  these  cases  a  double  lesion  hoa 
existed.  Even  if,  however,  an  exceptional  case  should  be  clearly 
made  out,  it  would  have  to  be  viewed  Bimply  as  au  exception  to 
tiie  general  law,  that  the  speijcli -centres  of  the  left  hemisphere  arc 
active,  whilst  thoee  of  the  right  hnniisphcn^  are  ilnrtiiaut. 

The  connection  between  the  frontal  lobes  and  word'thought  was 
originally  pointed  out  by  the  celebrated  Prof.  GoU  iu  1825.  His 
pupil  Boiiillaud  lociited  the  speech-centres  in  the  divisions  of  the 
cerebrum  over  the  fissure  of  Sylvius  and  in  front  of  ttie  fissure 
of  Rolando,  In  1861,  Broca  affirmed  that  (he  integrity  of  the 
le/l  lliirtl  frontal  convolution,  and  i)erhap9  also  of  the  second, 
is  essential  for  the  development  of  articulate  speech.  The  cases 
of  organic  aphasia  which  have  been  rtporLLil  iu  the  last  twenty 
years  are  far  too  numerous  for  analysis  here.  They  undoubt- 
edly, however,  show  that  tlie  thinl  fnmtal  convolution  and  the 
island  of  Hell  in  the  left  hemiKphere  arc  closely  couuectcd  with 
the  speech- function.  The  conclusion  reached  by  Kussmaul  is 
that  the  left  frontal  lobe,  and  aspefrlally  the  third  frontal  convo- 
lution, possess  by  no  means  a  monopoly  of  aphasia,  althou^^h  it  is 
most  fi-equeutly  brought  about  by  lesions  at  this  point.  The 
island  of  Reil  uomes  uext  Ju  frequency  to  the  frontal  lobe. 

It  seems  to  me  that  we  must  consider  it  [irovetl  that  perma- 
nent complex  cortical  aphasias  are  <luc  to  disease  of  the  third 
frootal  convolution  or  the  island  of  Reil  in  the  left  hemisphere, 
and  that  tu  tliis  position  are  hwaitcd  the  centres  of  word-thought. 
Xnssmaul  states  that  he  has  been  able  (u  discover  only  two  ob- 


see 


urAoxosnc  seuholooy. 


8ervatio[ia  io  literature  iu  which  a  lesion  of  the  third  left  cot 
vnluttna  haH  occainionefl  no  apha-sia,  anil   that   in  the  reports 
these  caacB  h  in  not  f^tated  whether  the  {latJent  was  right-handed.^ 
It  has  not  been  the  habit  of  most  obeervcra  to  examine  micro- 
scopically the  convolutions  of  the  island  of  Reil  in  cases  of  aphasia 
without  iipimrent  lesion,  and  without  sncli  examination  no  weigtit 
can  be  uttiK^hetl  to  u  case  in  which  HphoBiii  has  existed  without 
latinn  of  thespccoh><!i^nvnhition<;.    In  one  case  of  my  own,  in  whidl^| 
to  the  nakwl  eye  the  8peech-con volutions  were  healthy,  thp  micnv^l 
scope  showed  that  their  vessels  had  umlergone  d^ncmtion  and      ■ 
the  vcUe  atrophy.     I  have  alfto  had  opportunity  to  examine  speci^H 
mens  from  an  unrefjorted  case  which  occurretl  in  the  practice  of  Dr.^i 
A.  V.  Mcig3.  in  which  the  only  grais  Iwion  found  wan  a  large  patch 
of  sofleiiing  in  the  neigh borhootl  of  the  left  corpus  striatum,  but  in 
which  the  micn>fioi)i}e  showed  that  the  bliKxl- vessels  ami  gnngliunic 
celltt  of  the  tliird  frontal  convolution  were  profoundly  aHccted, 
there  being  even  minute  peti^cs  of  softening  and   microacopie 
hcmorrhagefi.     Tn  tho  light  of  such  cases  an  thene  the  scientific 
accuracy  of  much  of  uur  aphastc  literature  iKcumos  very  doubtful, 
and  I  do  not  think  that  there  is  a  properly-observed  case  do 
record  in  which  a  permanent  nphasin  htm  existed  iind  the  third 
frontal  convolution  region  been  uormat.     If  such  a  case  should  he 
reporteil,  the  aphasia  would  have  to  be  considered  as  due  to  u 
anatomical  variation  or  as  produced  in  some  indirect  way.     It  l^| 
well  known  that  the  effects  of  f^oss  lesions  of  the  brain  oOen  ex-^i 
tend  far  beyond  their  immedijite  cnnlines,  and  if  a  gastric  irritation 
may  inhibit  tlie  action  of  the  speech-centres,  It  is  not  strange  that 
a  tumor  or  softened  mass  of  brain-tissue  may  sometimes  have  a 
similar  jHiwcr.     It  must  altio  he  remembered  that  aphasia  should 
be  produced  by  lesions  of  the  white  matter  which  interrupt  the 
passage  downward  of  the  fibres  from  the  speech-centres.  ^^ 

In  regard  to  word-blindness  and  wonl-deafness,  the  number  of^ 
autn)isies  which  have  been  made  is  not  as  yet  sufficient  to  allow  ns 
to  consider  the  conclusions  reached  as  fixed.  The  centres  for 
MDBOty  aphasia  are  located  by  Wernicke  along  the  margin  of  the 
fissure  of  Sylvius  iu  the  iirst  temporal  <x>nvolutiou.  The  r^oo 
of  sensory  apliasla  Is,  iiuwever,  proliably  a  much  wider  oti<lj^| 
Gra«*ct  {Mfintpellifir  MMitwii,  1884,  p.  52)  makes  three  central 
positions  for  the  aphasic  alterations : 


d 


PI901U>ERS   OF   MKUOnV    AND   OONSCTODSNESS. 


367 


Fir^.  Centres  of  verbal  dcafiiesa  m  the  first  left  terajwral  ood- 
volntiou. 

Second.  Centres  of  verbal  blindttG^  in  the  inferior  parietal 
lobalp. 

Thtrd.  Centres  of  tmnsniission,  or  ataxic  aphasia,  at  tlic  foot 
[■of  the  third  tcmp<mil  convolution. 

Dr.  AmidoD  (A'<w  York  Maiicfil  RMortl,  Novptnlwr  15, 1884) 
eted  twenty-four  cases  of  wnwry  aphoaiat  id  eight,  with 
afievtiug  the  visual  and  auditon,-  r^ions  of  the  left  hemi- 
gpbere,  there  were  both  word-hlindnoas  ami  deafneaa;  in  two, 
in  which  the  area  of  vi-tion  alune  was  affected,  there  was  wonJ- 
Uliodoees;  in  fonrteen,  with  the  tension  in  the  auditory  region, 
there  was  word-<]eafuess.  Wernicke  locates  the  lesion  in  i»ara- 
phasia  In  the  medullary  tmct  connecting  the  sensory  aphasio 
region  with  the  island  of  Reil.  In  a  (lase  reported  by  Dr.  8.  G. 
Webber  (Boston  Mtd'tcal  and  SurgicalJonmaly  December,  1883) 
the  hemorrhage  was  situated  so  close  to  this  tract  as  to  act  readily 
upon  it  by  pressure.  In  this  case  tlie  recovery  of  the  speech- 
function  during  life  showed  that  tlio  effect  of  the  lesion  was  tem- 
porary, and  therefore  probably  an  indirect  pressure-effect. 

The  oour*c  of  the  fibre*  which  rnn  from  the  spccoh-^-ent-res  of 
the  frontal  lobe  ia  not  known;  undoubtedly,  however,  a  clot  iu 
the  neighborhood  of  tlie  ctaustrum,  which  duen  not  directly  impli- 
(«te  tlie  centre!*,  will  pro<luoc  aphasia,  pn>lmbly  bv  dividing  oon- 
dncting  6bres  and  isolating  the  centres.  I  have  made  antopsies 
upon  two  liuch  caws,  and  Drs.  Farge,  Popliam,  and  Jaoooud  have 
eacb  reported  similar  instances. 

The  lesion  of  aphasia  varioa  greatly  in  its  nature.  It  may  be 
a  dot,  a  tumor,  an  abscess, — indeed,  any  form  of  acute  or  chronic 
localized  alteration  of  the  brain-subatanoe.  Very  frequently  it  is 
a  narrowly-defined,  syphilitic,  gummatous  meningilis.  The  ar- 
terial liupply  of  the  cunvobuiuns  tK  receivetl  through  terminal 
branches  which  pass  through  the  pia  mater  and  do  not  anas< 
tnraone:  hence  an  exc&wive  thiclcenin;;  or  inllammation  of  the 
rnembranea  may  so  interfere  with  the  circulation  iu  the  cortex  as 
to  afflwt  its  function.  In  this  way  arc  to  be  explained  at  least 
■mne  of  the  ewes  of  apha»ia  without  obvious  lesion  of  the  tem- 
poral convolutions. 

In  a  large  proportion  of  the  caaes  of  aphasia  the  lesioo  ia 


m 


DIAGNOSTIC  NEUROLOGY. 


embolic  The  region  of  the  brain  involved  is  sapplicd  by  ihe 
middle  cerebral  or  Sylvian  arterj-,  the  line  of  whose  course  so  cor- 
reBpoods  willi  tliul  of  ibo  carotiil  art«ri(s  that  the  blood-cumut 
ia  very  likely  to  carry  inlo  it  any  foreign  matters  which  may  reach 
the  brain.  The  Sylvian  artery  on  the  surface  of  the  ialand  of 
Keil  divides  into  four  branches:  of  these,  thelirst  is  distributed 
to  the  outer  portion  of  the  orbital  surface  of  the  hemisphere  and 
the  adjacent  inferior  frontal  cxxivolutioii ;  the  se<»n<l  supplies  tlie 
chief  part  of  the  second  osceoding  convolution  ;  the  tiiird  passes 
through  the  fi»<tiire  of  Rolando  to  the  remainder  of  the  ascending 
frontal  convolution,  to  the  ascending  parietal  couvolotion,  and  to 
the  inferior  part  of  the  superior  parietal  lobule;  the  fourth  branofa, 
lying  in  the  posterior  port  of  the  fissure  of  Sylviu«,  supplies  the 
inferior  parietal  lobule  and  the  superior  temponvsphenoidal  con- 
volution. 

The  three  speeeh-ceutres  of  Qraaset,  although  conjointly  sup* 
plied  by  tho  middle  oorebml  artery,  arc  reached  by  distina 
branohe»  of  thin  arter}*,  so  thai  whilst  an  arterial  lesion  of  tlie 
main  trunk  involves  all  the  speech-centres  and  j^ivcs  rise  to  a 
complex  aphasia,  a  lesion  of  one  of  the  branches  may  lavolvs 
either  of  the  apliasic  regions  separately  and  ^ve  rise  to  one  of 
the  special  forms  of  the  affection.  ^^ 

In  children  aphasia  sometimes  exists  without  hemiplegia.  sf^M 
may  be  due  to  an  artest  of  development,  whioli,  I  believe,  may 
be  caused  by  an  emotional  storm.  A  cose  whicli  died  under  ray 
care  li»d  the  history  of  the  child's  having  b^n  well  and  strong 
until  it  was  nearly  two  years  old,  at  which  time  it  was  beginning 
to  talk  Hucce-ssfully.  It  was  then  taken  into  a  i-ailway-lrain,  was 
exoetMtivcly  frightened,  aud  screamed  for  two  houra.  From  this 
time  it  ceased  to  talk,  developed  convulsions,  and,  after  several 
years,  died.  At  the  autopsy  the  only  lesion  I  oould  find  was  ooni- 
plete  failure  of  development  of  the  convolution  of  the  left  island 
of  Reil.  The  brain  looked  as  if  this  had  been  abruptly  gouged 
out  of  it. 


GENERAL  MEMOKT. 


J 


Like  most  functions  of  the  organism,  memory  may  be  stimu- 
lated, jHjrverled,  or  depressed. 

Exaitalion  of  Memory. — A   distlnctj   indisputable  stimulatiou 


^ 


V  iacrease  of  the  memory  under  the  iofliieDce  of  pathologicnl 
prooeawa  i»  a  phenomeuoit  rarely  to  Im;  distinctly  recogni/^I. 
Forbes  M'inslow  iletalls  cases  in  which  an  extniordiniiry  excitA- 
tion  of  the  memory  and  of  other  taeutal  funotions  preceded  an 
attack  of  a[io|>]cxy ;  and  tt  is  prohatile  that  in  the  nicut&l  exalta- 
tion which  precedes  a  general  mania  or  occurs  in  thtj  peculiarly 
dan^rous  form  of  insomnia  due  to  excitation  of  the  cerebral 
cortex  tiie  memory  may  share  id  the  geoeral  functional  excnte- 
ment  of  the  braio. 

Fitilure  vj  Memory, — Ixws  of  memory  is  au  exccedinj^ly  fre- 
qaent  symptom  of  organic  brain-disease.  It  cannot  be  said  to 
b«  characteristic  of  any  particular  form  of  hrnin-diwaM,  but  ir 
Uable— iudeed,  almout  certain — to  occur  iu  organic  aSTectious  of 
the  cerebml  cortex.  Its  diagnostic  importance  comes  from  the 
fact  that,  unless  due  to  obvious  acute  disease  or  connected  with 
insanity,  it  h  n  strong  indication  of  an  organic  affection  of  the 
brain.  A  degree  of  failure  may,  however,  arise  from  simple 
brai  u-cxhaustiuQ. 

Usually  the  patient  or  his  friends  reco^ize  even  a  slight  Ions 
of  memory ;  bnt  sometimes  very  careful  swirch  is  required  for  lis 
dldcovery.  Under  these  circumstances  the  physician  must  quentliou 
the  {latient  as  to  the  small  events  of  the  last  twenty-four  hours, 
and  not  be  misled  by  that  viviilnens  of  recollection  of  the  long  {xist 
which  sometimes  causes  the  sufferer  to  declare  that  his  mcraor)'  is 
even  stronger  than  normal.  In  doubtful  Cflses  of  general  paralysis 
of  the  insane,  failure  of  the  memory  is  of  special  value  in  en- 
abling us  to  distinguish  the  oi^nic  insanity  from  fmietional 
mental  disturbances  which  may  simulate  it.  According  to  my 
own  experience,  failure  of  memory*  which  is  not  acoorapanied  by 
paralysis  for  tUe  time  being  of  all  the  functions  of  the  mind,  as  in 
insanity,  is  of  serious  im{>ort  iu  propi>rtiou  to  its  completeness. 

OOBBELATED  DLSORDSRS  OF   MEMORY   kSTi  OONSCIOUSNEfiS. 

As  has  already  been  stated,  a  memory  is  [Ktsseased  by  all  va- 
rieties of  ganglionic  nej-ve-ectls,  but  that  intellectual  function  lo 
which  the  name  is  usually  restricted  is  so  closely  related  with 
consciousnew  that  we  can  scarcely  conceive  of  its  existence  with- 
out conacioueness :  nevertheless,  the  connection  of  memory  witli 
dreaming  shows  thai  it  is  a  separate  function  from  conaciousaees. 

'li 


J 


370 


DIAGN06TIC  XEUROLOGV. 


There  are  a  good  many  i-easons  for  believing  that  tbe  impra*- 
sioiis  of  all  events  with  which  au  iuiUviilual  has  been  €on- 
nectcd  ore  indelibly  recorded  upon  bis  bntia-tissue,  althoagb 
be  may  not  Ik  able  to  bring  niich  imprrssionA  into  oonsciotu 
peroepliun.  At  tbe  approach  of  death,  or  under  the  stinialatioD 
of  disease  at  a  time  when  oonsciouoness  is  wanting,  penona  will 
frerjuently  speak  in  foreign  tx)nguw>,  recile  {latiuageK  of  prose  or 
poetry  long  since  forgottcnj  or  give  detailed  acoouots  of  events 
that  occurred  in  their  earliest  childhoofi  and  of  which  th^ 
have  in  their  normal  condition  nut  the  sligbtwt  renieoibraoce. 
It  would  therefore  appear  that  two  diatinot  fonctioag  or  ada 
are  involved  in  oonncious  memory, — one  the  preservation  of  the 
records,  the  other  the  dragging  out  of  such  records  into  the 
light  of  couscioi»nes»  and  their  reooguitioo  by  the  personality  of 
tlie  uiau.  In  eerUiin  diEseaaeH  when  oonaoiouancBa  ia  obliteratol 
the  oomiectioQ  between  tlie  stored  records  of  the  cerebral  oortex 
and  the  automHtic  speeeh-ccnu-ea  ts  so  cloee  that  the  latter  act 
in  obedience  to  the  records,  and  the  uncooscious  patient  iipeak«  in 
an  unknown  tongue,  or  relate*  oocurrenoes  of  which  he  baa  do 
conscious  memory. 

When  the  link  that  binds  oonaciousncas  to  memory  is  broken 
by  disease,  conscioiLsnesa  may  exist  without  memory.  Under 
these  circumatances  cottaciouanees  is  isolated  from  the  past,  al- 
though the  past  may  still  be  connected  with  tlic  present  by  an 
automatic  iinconwiious  memory. 

This  \a  illustrated  by  the  case  {Rose,  NermuK  DineoMcn,  vol. 
ii.  p.  $80)  of  a  man  who  was  wounded  dnriug  the  Franoo-Oermau 
war  in  such  a  vnxy  aa  to  lay  bare  the  brain  for  about  two  and  a 
half  inches  in  the  leil  parietal  region.  Ah  the  rcsnlt  of  this  he 
was  suhjiHit  lo  aitacliH  ladling  from  twenty-four  to  forty-eight 
honrfl,  in  which,  although  in  a  condition  of  apparent  [>artial  coo- 
BciousDt**,  he  tiad  no  sensitiveness  of  any  part,  and  wa»  unaware 
of  physitail  [lain.  Never tlieltsa,  his  will  wai^  at  once  influenced 
by  external  objectf^.  If  »el  upon  hiH  feet,  the  contact  with  the 
ground  etartetl  him  to  walking,  when  he  marched  slmight  on, 
quite  steadily,  with  fixed  eyes  and  without  saying  a  word.  If 
he  met  with  an  ol)6tai:le,  he  wuultl  Iniich  it  nnd  try  to  make  out 
what  it  was,  and  then  get  out  of  its  way.  A  pen  placed  id  his 
band  started  liim  to  writing.     Dr.  lioessays  of  him, — 


DIHOROEItS  OF  MEMORY   AND  CONSClOUSNEaS. 


371 


Give  him  cigarolte-paper  aud  he  will  take  out  iiis  tobacco, 
roil  a  cignrette,  and  light  it  with  a  match  from  his  uwn  bux.  But 
ijl^itn  a  match  yourself  ami  give  it  hlni,  he  will  not  use  it,  but 
let  it  bum  between  h!»  fiiiffcra.  If  his  tobacco-box  be  filled  with 
any  trash,  he  will  roll  his  cigarette  and  smoke  without  perceiviug 
the  hoax.  Tf  a  ]>:itr  of  gloves  l>e  put  into  his  band,  he  will  put 
them  on,  and,  being  reminded  of  his  profession,  will  look  for  bis 
mtuic    Tf  a  roll  of  paper  then  be  given  to  him,  he  will  assume 

■  the  attitode  of  a  public  i>erforraer  aud  begin  to  siog." 
Lo»8  of  Personal  Identity. — Ad  attribute  of  tlie  human  under- 
standing wiiich  iri  de)H!ndeiit  upon  the  existence  of  memory  and 
consciousness  is  the  sense  of  personal  identity, — i.c.,  the  conviction 
of  the  individual  that  he  i^  the  same  per^n  as  he  has  been  in  the 
[tast.  The  uiibrokeu  chaiu  of  events  reconled  from  an  indeBnite 
past  correlated  with  ilie  cousciouHnesti  of  the  present  glveii  the 
realization  of  the  unity  of  the  pn^ciit  with  the  past.  This  scuHe 
of  personal  identity  13  destroyed  by  a  tomplete  losa  of  memory, 
which  leas  may  be  abrupt  and  be  unaccompanied  by  impairment 
of  consciousness  or  of  ratiouHlity.  I  have  seeu  this  association  of 
sjrmptoms  continue  for  several  (hiys  utlter  a  sunstroke,  no  that  the 
patient,  who  had  been  brought  by  ambulance  into  the  lionpital, 
was  unable,  after  he  had  recovered  his  mental  faculties  and  was 
perfectly  mtionnl,  to  give  any  clue  to  his  personality  which  could 
lead  to  hiti  identification. 

Double  Peraonaliiy. — Hasheesh  and  perhaiKt  some  other  drugs 
have  tbe  power  of  producing  a  sense  of  daubfe  personality, — a 
condition  in  which  tlio  aubject  feels  as  though  he  were  two  dis- 
tinct personalities,  one  holding  intercourse  contiuuaUy  with  the 
otlier.  In  iuftanity  this  feeling  of  double  personality  may  be  the 
basis  of  delusion.  Such  delusion  usually  takes  the  form  of  an 
alisolute  belief  in  a  dual  existeuce:  thus,  tn  a  case  of  my  own,  an 
iusaoe  nmti  believed  that  he  and  all  others  of  the  human  race  had 
their  "doubles,"  which  were  not  to  be  distiuguiBhwl  from  their 
proper  persoualities.  The  life  of  the  patient  was  overwhelmed 
by  the  constant  fear  that  he  was  not  himself,  but  his  own  double. 

Ikniltte  Cbngcioiimeim. — Double  personality  is  to  be  distinguished 
from  the  extraordinary  plieuomenou  to  which  the  names  of  double 
oonaeiouKMaBj  periodic  failure  of  menwry,  and  periodic  amnesia 
have  been  given.     Id  this  state  there  is  audoubtally  a  disorder 


I 


I 
I 


372 


ClAONOenC  NEOTtOLOOY, 


of  memory,  but  in  most  cues  all  the  intelleottul  fuuctions  ar« 
deeply  involved.  Before  attem|)ting  an  analyeis  of  doable  con- 
BciousiiefiM  I  shall  briefly  sketch  some  of  the  more  important  re- 
corded instances.  The  earliest  record  of  Bunh  a  case  that  I  have 
been  able  to  find  19  by  Dr.  Mitchell  (JW.  Rrpog.,  p.  185,  Nev 
York,  1817).  A  very  highly  edurateil  ynuiig  woman  foil  withoat 
warning  into  a  deep  sleep,  whicli  lasted  for  mauy  hours.  Oa 
waking,  she  hail  loat  all  her  former  knowledge ;  her  memory  had 
become  a  tofnda  rasa,  every  tmee  of  her  paat  culture  having  dis- 
appeared. It  was  necessary  for  her  to  releflrn  everything.  After 
extreme  effort  she  became  familiar  with  surrounding  persons  and 
thiuga,  acquired  the  alphabet,  then  learned  to  read,  then  to  write, 
and  finally  to  reckon.  Some  months  later  she  again  fell  intoi 
deep  sleep,  and  awoke  in  her  normal  state.  She  now  knew  alt  thit 
she  had  learned  in  her  original  condition.  Fur  many  years  after 
thia  she  alturnatetl  l>etwe€ti  the  first  and  second  conditions,  lo 
each  Rtatc  knowing  only  wliat  »he  had  learned  in  the  previous 
{>erio(Is  of  the  same  ftate.  M'^hen  she  made  acquaintances  she 
rec^^nizcil  them  agfiiit  only  when  she  waa  in  the  state  In  whidi 
she  had  been  at  the  time  of  the  first  meeting.  Her  handwriting, 
which  was  very  good  in  her  first  condition,  was  very  bad  in  her 
Rooond  state. 

Dr.  Azam  {AniialM  M(d.-Pgych,,  1876,  vol.  xvi.)  reports  a  owe 
of  double  coDscio useless  occurring  in  an  h}'sterical  girl.  Jd  this 
patient  the  change  from  one  state  to  the  other  was  always  pre- 
ceded by  a  profound  sleep  lasting  three  or  four  minutes,  this 
period  of  repose  being  n;^}iered  in  by  an  intense  headache.  Id 
her  abnormal  state  the  girl  was  extremely  gay  and  vivacious, 
and  remembenKl  perfectly  all  that  had  passed  both  during  pre- 
vious similar  abnormal  eondirioiia  and  during  tier  normal  life. 
There  was  no  delirium,  no  hallucination,  do  faUc  appreciation, 
but  the  intellectual  faoulties  were  more  develo{)ed  than  during  her 
normal  oondition.  After  this  condition  had  lasted  a  varinble  length 
of  time,  her  gayety  suddenly  disappeared,  her  head  dropped,  and 
she  fell  into  a  deep  sleep,  out  of  which  she  awakened  in  a  oon- 
dition of  great  sadness.  She  forgot  all  thosK  things  that  hsd 
happened  during  her  abnormal  period,  but  remembered  perfectly 
everything  that  she  had  known  or  that  had  been  done  during  the 
preceding  normal  states.     Having  been  seduced  and  become  pr^- 


1 


i 


DtSOnDERS  OP  ME3I0RV  AND  O0NSCIODSXB8S. 


373 


nant  during  one  of  her  abnormal  periods,  she  was  entirely  ignorant 
of  the  flflRiir  during  her  normal  stnte,  althongh  fuHv  aware  of 
it  during  8uca;a8ive  abnormal  jrerioda.  Finally,  whilu  in  her 
normal  condition  she  was  made  to  uu<lcr8tand  that  she  was  preg- 
nant, when  she  was  seize*!  with  violent  hysterical  convidsions. 
After  ihe  birth  of  the  child  she  had  no  menial  trouble  for  several 
years,  and  was  njarried.  Somewhat  later,  after  a  very  painful 
H  and  exhausting  accouchement  she  had  hysterical  letliarg;y,  followed 
by  ecBtasy  and  violent  hysterical  manifestations.  At  thirty-two 
she  was  the  mother  of  a  family,  and  an  active  biisinefln  woman. 
The  child  which  had  been  couc«tved  during  an  abnormal  period 
was  very  intelligent,  und  no  excellent  musician,  but  of  a  highly 

t  nervous  ten)|K!rament,  luitl  liable  to  ncrvoui^  attacks. 
A  case  somewhat  similar  to  this  is  reported  by  Dr.  James  Mayo 
(London  Medical  Gas^c,  vol,  i.,  1^45).  A  young  girl  passed  re- 
peatedly through  two  alteruatiug  di^ereuL  states  of  mental  exiat- 
euoe.  During  the  abnormal  periods  she  was  extremely  excitable, 
H  and  had  mental  attrihute.s  much  abtive  her  normal  condition.  She 
made  progress  iu  nee<lle-work  and  in  intellectual  acquircmenta 
for  beyond  what  was  possible  with  her  natural  talent,  tibc  also 
H  l>ecaine  very  vivacious  in  conversation,  hut  did  not  recognize  her 
relations  to  her  father  and  mother,  colling  them  by  wrong  names. 
On  the  subsidence  of  her  abnormal  state  her  retxillecttion  of 
kindred  and  friends  returned,  and  iihe  resumed  her  quiet,  dull 
character.  In  the  abnormal  state  she  retucmhered  without  the 
aligbteat  coufuHiou  all  that  had  happened  in  previous  abuurmal 
periods,  and  what  she  had  Icarncil  cither  nianually  or  intel- 
lectually, but  knew  nothing  of  what  had  occuri-ed  in  her  normal 
»  conditions.  Iu  her  normal  conditions  she  had  no  knowledge  of 
anything  that  Imd  happened  or  of  anything  that  had  been 
learned  during  the  abnormal  states. 
I  have  Acen  one  ca.sc  which  otiered  symptoms  reaembling  those 
of  double  consciousness.  They  were  produced  by  a  depreasui.!  frac- 
■  lure  caused  by  a  blow  u]>on  tlie  head.  Previous  to  trephining 
there  were  at  least  four  of  tlie  abnormal  states,  hut  since  the  o(»er- 

•  ation,  over  a  year  ago,  there  has  been  no  return,  although  the 
patient's  mental  condition  is  not  good.  Id  the  first  of  his  spella 
he  went  to  a  railroad-d6[)6t,  bought  a  ticket,  travelled  on  ilic  cars 
two  or  three  hours,  and,  afler  getting  out,  met  an  acquaintance, 


374 


DIAGSOenC  XEUBOLOGY. 


who  expressed  great  iturpnae  at  seeing  him,aud  a^ikerl  why  he  had 
come,  reoeiving  tlie  reply  that  be  had  comw  to  try  to  get  work. 
The  man  them  went  to  a  friend's  house  to  dinner,  where  he  tiilk«] 
and  ate,  antil  suddenly  he  waked  up,  ^Tith  an  ioqutrr  of  iRtei»e 
surprise  as  to  how  he  had  got  there.  He  appeared  to  have  no 
recoUeelion  of  his  trip,  except  of  a  few  luinotes,  hh  remem- 
brance  of  whicli  was  kg  vivid  as  to  imltcittR  that  he  had  then  liad 
a  wAking  spell.  During  the  nboormal  period  the  man's  beha- 
vior su^;es.ted  to  his  arqnaintanres  only  that  he  wnR  di.^tmtigbL 
I  was  unable  to  obtain  evidence  that  lie  exhibited  during  the  spells 
any  memory  of  acts  performed  in  previous  simihir  periods. 

It  docs  not  seem  necessary  to  abetrart  any  more  of  the  few 
recorded  cases  of  double  eon3cioa<!Dej»  for  the  purposes  of  pres- 
ent illustration.  lu  a  typical  case  there  in,  first,  ao  abrupt  Ion 
of  memory  at  the  b^uuing  of  each  paroxysm  for  everything 
that  has  happenetl  during  paroxysms  not  of  the  same  scries; 
secondly,  a  change  in  the  personal  character  of  the  individnat, 
the  disposition,  tlie  hahiti<  of  thought,  and  even  the  intellectnal 
powers  being  altered. 

Double  oonf<ciousoesa  m^y  exist  in  various  degrees.     Thus,  in 
a  case  reportol  by  Dr.  Samuel  .lackson  {Aitur.  Jour.  Mfd.  Sei^ 
18G9,  p.  18),  the  character  was  affected  rather  than  the  memory. 
An  hysterical  young  lady  was  attacked  with  nausea  and  vomit- 
ing, followed  by  a  complete  alteration  of  cJiaraeter  and  change  of  J 
voicfi.     Formerly  mitd  and  gentle,  she  became  abrupt  and  ru<le, 
and  yet  would  so  perform  her  houaehold  diitiei)  th.it  it  wak  oAen 
difficult  to  determine  in  which  condition  she  was.    The  attacks 
came  on  daily,  without  apparent  cause.     The  symptoms  in  tliis 
case  »eem  to  repr(«ent  only  an  exaggerated  form  of  moodiness; 
and  there  can  be  no  doubt  that  even  the  most  complete  double 
consciousness  in  elnsely  related  on  the  one  hand  to  epilopay  and 
on  the  other  to  hysteria  and  to  insanity.     In  roy  case  detailed 
above,  the  cause  of  the  attack  was  a  blow  upon  the  head, — a  not.i 
rare  caune  of  epile^wy, — and  there  waB  uo  binding  memory  betwoea^^f 
the  spells.     In  that  form  of  epilepsy  in  which   there  are  anto-  " 
tuatic  movements,  and  also  in  cases  of  epileptic  dehrium,  the^J 
paroxysm  is  in  many  ways  related  to  the  second  period  of  douhl8.^| 
consciousness,  but  diflcra  in  that  the  individual  docs  not  preserve 
any  reasonableness  or  capability  of  being  affected  by  other  persons, 


DrSORDERS  OF   ME5I0BY   AUD  CON8CIOC8yE98. 


375 


and  does  not  remember  what  has  occurred  during  previona  spcUa 

■  of  similar  type.     On  the  other  hand,  in  a  large  proportion  of  the 

H  cases,  double  cousclouaaete  hus  'Kx-urred  in  hyslericul  womtin,  and 

^  the  phenomenn  pass  almost  iuacnsibly  into  thasc  of  hysterical 

ftemi-coTtKionsnesA  and  delirinm. 

In  insanity  there  is  oHen  a  change  in  the  whole  manner  of 
thought  and  diameter  of  the  individual.  In  acaseof  mcluucholia 
H  long  under  my  care,  the  patient  after  recovery  was  subject  to  fre- 
qacnt  attacks  of  trniiaitory  melancholia,  which  lusted  fron]  a  few 
to  many  hours:  whilst  |>eriect.ly  content^l  and  happy,  she  would 
my, ''It  18  coming/* and  in  a  few  moments  would  be  covered  over 
as  it  were  with  a  wave  of  emotional  deprc^ion  which  would,  for 
the  time  being,  completely  alter  her  habits  of  thought  imd  her 
behavior.  In  a  case  of  profound  apathetic  melancholia  recently  at 
Burn  Brae  Asylum,  near  this  city,  the  patient  one  day  suddenly 
said,  "I  have  hud  a  revelation:  my  sinet  are  forgiven  me,"  and, 
ailer  weeks  of  aheolute  voicelesBoess,  became  talkative,  rational, 
and  aetive  in  all  hia  .sympathies,  without,  however,  being  unduly 
excited.  Not  long  after  this  the  man  relapsed  into  his  insano 
condition.  It  is  said  that  similar  sudden  changes  have  prc- 
K  viously  occurred  several  times.  This  man  appeara  to  carry  bis 
memon-'  over  from  one  state  to  the  other,  and  in  this  only  do  his 
symptoms  differ  from  those  of  typical  double  consciousness.  If 
in  sueh  a  caw  of  insanity  as  thin  the  continuity  of  memory'  should 
be  broken,  there  would  l>e  a  typical  double  consL^oiutness. 

The  cloee  relation  between  insanity  and  double  oonactousness 
is  further  itltii;trated  by  a  case  reported  by  Dr.  David  Skac,  in 
which  a  man  after  eighteeu  mouths  of  typical  melancholia  de- 
veloped a  twofold  life,  being  on  alternate  days  sane  and  insane. 
On  melanehoHo  days  he  neither  eats,  sleepit,  nor  walks,  but  tuta 
inoeaaantly  turning  the  leaves  of  the  Bible  and  complaining 
ptteoitsly  of  hi«  misery.  At  this  time  he  hft.**  no  remembrance 
of  the  days  in  which  he  is  well,  nor  of  any  eugagementij  made 
during  them :  he  docs  not,  and  cannot  be  made  to,  recognize  the 
existent*  of  such  days,  but  contemplatCH  the  future  with  hofielcss 
de::«pondeDc>-.  On  the  alternate  well  day  he  denies  that  he  has 
any  cause  of  complaint,  Iwlieves  that  he  was  well  the  previous 
day,  transacts  businese,  takes  food  and  exercise,  and  is  entirely 
^-free   from  delnsions  or  despondency.      He  also  anticipatee   no 


376 


DIAQNOfrriO  nBtTROLOGY. 


return  of  liia  illoass,  and  has  no  memory  of  b\s  ba<l  daya.  He 
remembers  exactly  the  transacliODs  of  his  previous  well  days, 
and  persists  in  making  basiness  eogagcments  for  the  fullowitig 
day,— !.«.,  for  his  melaDohoIic  day, — although  repeatedly  ammd 
tliul  at  the  time  named  he  u'ill  be  unable  to  attend  to  basiDeas. 

There  is  a  very  rare  mental  condition  known  by  German 
writers  as  DoppeUwahmehmunff,  or  dmthU  peroeption,  which  is 
liable  to  be  confounded  with  the  condition  I  have  just  described 
under  the  name  of  double  consciousness.  The  pecidiarities  of 
this  aflectiou  arc  well  portrayed  iu  the  report  by  Dr.  H.  Bup- 
pert  {AUffenieine  ZeiUchri/i  fur  Pst/cJtiutrie,  I8(>9,  vol.  xxvi.  p. 
531)  of  a  caAc  in  wliich  whenever  the  man  read  to  himself  be 
would  plainly  bear  each  word  repeated  as  though  a  ofaorus  of 
fifly  or  sixty  female  voices  were  speaking  to  him,  and  when  be 
ceased  to  read  he  would  bear  the  ]a.st  wxihIa  reail  after  him. 
This  reading  after  htm  disappeared  as  soon  us  he  spoke  aloud, 
and  waa  prevented  by  his  reading  aloud.  In  one  sense  of  tbe 
term  coaactouaness,  this  patieut  hatl  a  double  cousciuusDcsg ;  but 
it  is  plain  that  his  symptoms  were  much  more  closely  relokd 
to  hallucinations  than  to  the  state  commonly  known  as  double 
consciousncas. 


CHAPTER   X. 


DISOBDEBS  OF   GOMSOIOUSNESS. 


preeent  bd  elaborate  discussion  of  the  so- 
called  ph^'ijialogUnl  tiieories  of  sleep  wuuld  be  out  uf  place.  It 
seems  to  me,  however,  that  a  few  words  upon  ttic  subject  arc 
required.  Ao(y>rHing  to  some  physiologists  anrl  neurologists, 
natural  e<leep  is  iiiduc'ed  by  the  witlulrawul  of  blood  from  the 
bnun.  It  must  bo  allowed  that  the  concordant  results  of  experi- 
ments show  that  during  sleep  there  i»  a  more  or  less  pronounced 
cerebral  anEemia,  which  on  awaking  is  replaced  by  turgescence 
of  the  cerebral  vessels.  This  is  not,  however,  proof  that  sleep 
is  induced  by  the  withdrawal  of  tlie  blood.  It  is  a  universal  law 
that  cessation  of  functional  activity  is  iniTUodiatcly  followed  by 
leflsening  in  the  Hinonnt  of  blood  In  the  part.  I  conceive,  there- 
fore, tliat  the  sleep  m  the  cau»e  of  the  blood les&uewj,  ami  not  the 
bioodlcssness  the  cauac  of  the  sleep.  This  is  certainly  iu  accord 
with  cUnical  experience,  which  to  my  mind  proves  that  insomnia 
may  be  connected  either  with  cxoeasivc  aniemia  or  with  cxccseive 
congestion  of  the  cerebral  cortex.  Thns,  the  wakefulness  of 
aniemia  is  well  known,  a»  !»  also  the  insomnia  of  acute  mania. 
Some  physiologists  have  attempted  to  explain  the  production  of 
sleep  by  Huppusing  that  <,-erlatn  cliemical  compounds  are  formwl 
during  the  activity  of  the  day,  which,  circulating  in  the  blood  of 
tlie  brain,  act  as  hypnotics  on  the  cerebral  cells.  There  is  no  evi- 
dence worthy  of  attention  establishing  any  theory  of  this  character, 
and  to  ray  thinking  eueli  chemipal  thifiories  are  upon  their  face  so 
improbable  that  thev  should  be  receive<l  only  after  the  clearest 
[proof.  Concerning  sleep,  as  conwrrning  other  functions  of  the 
human  organism,  the  simplest  explanation  is  the  most  probable. 
In  the  greater  portion  of  the  active  tissues  of  the  organism  rest 
alicmatca  with  activity,  and  the  brain  in  its  sleep  conforms  to  this 
general  habit.  The  beat  explanation  of  sleep,  then,  Is  tliat  when 
exhausted  by  elfurt  the  cortical  brain-cells  pass  into  a  condttioD  of 
fuQctiooal  inactivity,  during  which  their  power  of  further  eSbrt  is 

877  " 


378 


DtAOXosnc  NBtmoLoor. 


recuperated.  Becaiiae  ounddousoeK}  ts  the  exprcaeiioD  of  functtonal 
activity  id  these  cells,  therefore  when  these  cells  tlo  not  exercias 
iheir  fiinrtifm  there  is  unconsciouMneHe, — i.e.,  sleep.  That  sleep, 
or  functional  rest,  should  be  more  or  ]e»!$  periodical  Mems  eMealial 
from  the  very  nature  of  the  case.  Throughout  a  healUiy  nervous 
aysteiu  a  ti.-ndency  to  jHiriodicity  uf  action  la  marked.  In  dti^eaiv 
this  tendency  beoomes  even  more  apparent.  Pain-storms  reoir 
with  more  or  less  regularity,  habits  of  periodical  discharge,  at  first 
aecidenlal,  become  fixed,  convulsions  develop  at  intervaU,  «tc 
The  daily  rhythm  iu  the  productiou  and  di^ipatiou  of  animal 
heat  during  health  is  a  forerunner  of  the  marked  diurnal  swing 
of  tomperaturo  so  common  in  fevers. 

The  bearing  upon  the  practice  of  mediciue  of  our  belief  as 
to  the  imraediut«  cau.satiou  of  sleep  is  very  apparent.     If  we 
think  that  insomnia  la  due  to  cerebral  ansBmia,  we  munt  treat  tbe 
anffimia  to  remove  the  insomnia.     Out  of  such  error  have  grown 
other  theories,  which,  though  absurd,  have  been  largely  domirunt. 
A  notable  example  of  these  is  the  belief,  at  one  time  wide-spmd, 
that  bromide  of  potassium  produces  sleep  by  afiectiug  the  blood- 
vessels.     Again,  largely  in  order  to  sustain  their  theories,  certain      I 
neurologists  have  distinguished  sleep,  stupor,  and  coma  aa  easea- 
tially  diverse  conditions  readily  to  be  diagnosed  io  the  sick-room. 
These  states  are,  however,  simply  the  out(»me  of  difKTent  de- 
grees of  completeness  to  the  suspension  of  the  functions  of  the 
cerebral  cortex :  su<'ii  a  nuspcn^on  findi)  it8  lightest  cxpresAion  in 
ft  doze,  and  its  profoundcst  development  in  a  coma.     No  rules  of 
diagnosis  can  be  laid  dowu  which  will  enable  as  to  draw  any 
practical  lines,  sharp  and  fixed,  between  the  lightest  clumber  and 
the  most  complete  untunaciousness.     Nor  is  the  unconscionsnesi^J 
of  ansBsthesia  an  ii^olated   thing.     It  i^  simply  a  suspension  oP^M 
cerebral  function  in  which  a  chemical  ageut  is  the  cause  of  the 
paralysis.     In  the  sick-room  every  grade  can  be  found  between 
light  and   heavy  slumber,  iMtlwcen  heavy  sleep  and  t>tupor,  and 
between  stupor  and  coma.     For  the  purposes  of  discussion  we 
must,  however,  arbitrarily  separate  thei^e  states.     I  would  define 
these  terms  a^  follows:  ttteep  is  tliut  troiidilioii  of  uiiiTuuseiuusDeai      i 
in  which  the  subject  is  readily  amused,  aud  when  aroused  is  easilj^f 
kept  awake  by  ordinary  external  stimulations  or  by  his  will-power;  " 
stupor  is  that  coudition  in  which  tbe  subject  is  aroused  wJtli  great. 


fiTSORDEBs  or  cov^cxovsint^ 

difficulty,  and  wlt«n  lefl  to  liimself  r«la]>!«es  into  uoconsciousDeas; 
coma  m  that  slate  in  which  it  is  ioipossible  by  external  irritation 
to  restore  consciousnesH. 

I      In  the  present  chapter  I  pro]>o6c  to  treat  of,  first,  sadden  loss 
of  oonsciooBDeae ;  .secondly,  sleep,  its  abnormalities  and  accidents. 


SUDDEN  LOSS  OF  CX>NSCI0U8XKS. 

Sudden  loss  of  oonsciousness  is  a  symptom  of  sut^  varying  im- 
port that  it  if(  Rcarcely  susceptible  of  scientiBe  arranf|;enicnt  in  a 
t  treatise  like  the  prvBeuL  Nevertheless,  it  is  one  of  such  practical 
importance  as  to  demand  discuiwiou.  A  blow  upon  the  bead,  or 
even  upon  a  distant  part  of  the  body,  may  produce  immediate 
insensibility ;  but  tJie  study  of  such  cases  belongs  to  surgery,  and 
I  ihall  in  the  present  comtidenttion  of  the  causes  and  collateral 
Bjmptonis  of  sudden  unconscious  nets  ouiit  trauniatisoi  and  its  re- 
soltBL  lioas  of  consciousness  is  an  essential  part  of  the  epileptic 
oonviil^'on;  bnt,  as  this  oonvubinn  has  already  been  aiudiod  in 
detail,  I  shall  at  present  consider  only  affections  in  which  there 
are  do  convulsive  syniptonui,  or  in  which  if  the  convulsion  occurs 
it  is  not  an  essential  feature  of  the  disease,  but  an  incident  of  the 
attack.  ThiLs,  in  ppilepey  the  oonvulsiou  is  an  essential  feature, 
bnt  in  a  cerebral  bemurrhagc  or  a  sunstroke  it  is  not  of  snch 
character ;  and  if  a  convulsion  occur  in  an  apoplexy  it  belongs 
to  tlie  individual  case,  because  it  is  uot  neoessarily  present  in  the 
disease. 

H  The  ortlinary  non-traumaiin  causes  of  the  sudden  luiS  of  con- 
MMNisiHSB  are  epilepsy,  hysteria,  s3mcope,  sunstroke  in  Its  various 
fonm^  apoplexy^  various  forms  of  poisoning,  and  malignant  sys- 
temic dtaaaee. 

The  symptoms  which  attend  the  hytiteriont  and  the  epUfptie  loai 
of  consciousness,  ami  the  methods  of  recognizing  the  nature  of  such 
tttackst  have  been  thoroughly  di«uus)K<(l  in  a  previous  chapter. 
Bffiteopai  loss  of  consciousness,  due  to  a  failure  in  the  supply  of 
Mood  to  the  brain,  Is  to  be  recttgnizeil  by  the  extreme  pallor  of  the 
Bot^ect,  by  the  absence  of  the  pulse,  or  Its  excessive  threadinem 

Hor  weakness,  at  the  wrists,  and  by  the  greatly  enfeebled  action  of 
ibe  heart,  as  shown  by  the  w<,mkness  of  the  cardiac  sounds  and 
impalse.     Its  diagnosis  is  fudlitatod  by  noting  that  it  occurs  after 


380 


DIAGNOenC  NBUBOLOOr. 


exertion  or  during  great  excitemeDt,  and  in  a  subject  alreatly 
enfeebled  by  disease,  Iienmrrliage,  or  atxident,  or  else  of  a  mtu- 
rally  weak  coiiiitttncion. 

Sunstroke. — During  the  samiuer  montba  sunstroke  is  a  verr 
fr»)uent  oautie  of  Htidden  loss  uf  cuosciousiieaB.  It  develops 
only  after  eiposurc  to  beat,  either  natural  or  artificial.  It  may 
happen  in  the  day  or  in  the  night,  and  is  especially  fatal  in  m^ar- 
refiiKnes  and  other  places  where  the  heated  air  is  saturated  with 
moisture.  It  occurs  most  frequently  in  unaccHuiated  races,  and 
is  very  rare  in  negroes,  HinduoH,  and  nlher  tnipifal  peoplcB. 
There  are  two  distinct  forms  of  it, — one  of  which  niay  be  known 
as  Ihermio  fever,  the  other  m  lieat-exhaustion. 

The  animal  organism  is  consLrueted  to  run  upon  a  oertaia  plane 
of  lu-at,  and  whenever  tliia  level  is  deitarted  from  all  the  fauetioos 
of  the  body  suffer.  The  ner\'0U3  rtysteni  ia  tlie  most  su«ie|itible 
portion  of  the  organism,  and  therefore  the  nervous  symptoms  are 
always  prominent  when  there  is  a  great  disturbance  of  the  bodily 
temperature.  It  ap{>eani  to  make  little  difference  whether  the  t«ui- 
peraliire  be  elevated  aivovtt  or  depnissed  below  llie  norm,  so  far  aa 
the  nervous  system  ts  concerned.  lu  either  eaee,  if  the  departure 
from  the  norm  be  sufficient,  oousciousness  is  loest,  the  lower  braio- 
fum'tioiiH  are  iinplicalcd,  m  that  the  respiratory  and  cardiac  action 
both  Iiccomc  irregular,  and  death  occurs  at  lust  usually  fmui 
paraly(=iis  of  the  rpspimtory  functions,  lu  thermic  fever  the  tem- 
perature of  the  body  is  greatly  elevated.  In  heat-exhaustion 
the  bodily  temperature  is  depressed. 

Heal-txhawition  is  very  oHen  fell  in  a  mild  degree  by  feeble 
workers  in  hot  weather.  There  is  a  sense  of  weariness  and 
distress,  pallor  of  the  countenance,  failure  of  the  muscalir 
forw,  and  finally  failure  of  the  pulse.  Severe  examples  of  the 
afiection  are  rare.  In  these  the  symptoms  may  develop  almost 
as  suddenly  as  in  tliermic  fever.  Thu»4,  in  a  case  brought  into 
the  Centennial  Hospital  during  ray  service  in  1876,  there  was 
sudden  iiuconsciousneas,  with  muttering  delirium;  great  rest- 
lesHntwt;  a  facial  expretviion  uf  uollaiise;  profuse  perapiratlou 
bedewing  the  whole  surface;  rapid,  feeble,  scarcely  jwroeptible 
puke;  and  a  mouth-temjicrature  of  95''.  Although  in  their 
general  a-'pect  the  ayniptoms  of  beat-ex haustiou  resemble  those 
of  thermic  fever,  the  true  character  of  the  case  should  be  at 


I>IS0irDER8   OP  OONBCIOCSXKBS. 


381 


I 


once  reoogniEed  on  touching  the  ioe-ook)  surface  oF  the  bod^. 
The  only  diaeasc  or  condition  readily  confounded  with  heat-«- 
bamtiou  is  collapse  from  other  candies.  I  hnve  »eeii  ca^es  of  in- 
ternal aneurism,  of  pemiciouA  malarial  fever,  and  of  other  affec- 
tions picked  up  in  the  streets  and  brought  into  the  hospital  in 
ooliapse  in  which  a  mistake  in  diagnnsis  would  have  been  very 
excusable.  If  sucli  a  case  should  bapjien  u|>on  an  intensely  bot 
day,  and  the  bodily  temperature  be  much  below  tlie  norm,  tite 
diagnosis  tutgbt  have  to  tie  reserved.  Except  m  regard'?  }H?rnidoas 
malaria,  however,  tliis  is  a  matter  of  little  im[>ortanco,  bocaUM 
the  treatment  of  heat-exhaustion  is  the  same  as  that  of  co1]a[)ae 
with  h>wered  temperature  from  other  otu^es. 

Thermic  jerrr,  heat  fever,  or  coup  de  mIeU  (sunstroke)  usually 
comes  on  without  distinct  prodromes,  although  frequently  there  ia 
a  great  wdm  of  diatreaa  or  of  a  general  burning  heat  before  the 
loss  of  coosciousneas,  which  may  also  be  immediately  ushered  in 
by  elironiatop«>ia,  or  colored  vision, — the  wliole  landsfSiK!  being 
deluged  in  a  blue,  yellow,  or  red  light.  The  unoniisciouanees 
ordinarily  deveIo|w  abruptly,  and  is  complete,  although  very  fre- 
quently it  K  associates!  with  muttering  delirium.  There  Is  usually 
great  muscular  restlesHUGK,  which  in  some  cases  bccomea  oonvul- 
sive  or  ia  replaced  by  violent  epileptiform  convulsions.  Some- 
times the  patient  is  profoundly  relaxed  and  quiet  The  sur- 
face of  the  body,  at  first  dry,  often  later  in  the  attack  galhere 
upon  itself  an  excesj^ive  perspiration,  whioh  doev  not,  however, 
reduce  its  burning  heat.  The  face  is  finshc*},  and  tlic  eyes  are 
mffbaed.  The  rapid  pulse  is  sometimes  bounding  and  apparently 
strong,  although  almost  invariably  oompreiHiiible;  frequently  it  is 
feeble  and  even  thready,  eejtecially  if  the  symptoms  have  last^ 
for  some  hours.  Vomiting  is  very  common;  purging  is  in  Imd 
cases  almost  aln'aya  present.  The  whole  body  is  apt  to  exude 
a  peculiar  odor,  which  is  eaiieirially  strong  in  the  fa^caI  dischargea. 
The  cliaracteristic  symptom  is  the  high  tempeniture,  which,  as 
measured  in  the  mouth  or  rectum,  may  reach  112"  or  113*^,  and 
is  rarely  below  IDS'*  in  cases  severe  enough  for  nnconsciousnesfl  to 
be  present  The  urine  ia  scanty,  wmetimea  albuminous,  not  rarely 
finally  suppressed.  The  breathing  is  more  or  lees  labored,  and 
often  insular,  and  towards  the  last  generally  becomes  mora  and 
lore  shallow.    Although  at  times  the  patient  suRbrtag  from 


382 


DtAo.voarnc  keurolooy. 


thermic  fever  may  be  iiarlially  aroused  bv  shoutiDg,  ahakiag,  etc., 
the  uiiooQEtciouauetjif  is  ofum  absulute.  The  pupils  are  variable, 
sotnetinifs  oontmctod,  gomctimcs  dilated. 

The  dia^osis  of  this  form  of  thermic  fever  la  usually  free  frooi 
difficulty :  the  Icdowh  exposure  to  heat, — i.«.,  to  the  cause  of  sun- 
stroke,— the  uuooDsciousDcs^,  and  other  symptoins,  and  the  veiy 
higli  temperature  botli  of  the  surface  and  of  the  interior  of  the 
body,  are  ciiaractoristic.  If,  however,  an  apoplexy  ahould  ooenr 
upon  a  ver)'  hot  day  and  be,  fn  it  might,  associated  with  a  sudden 
rise  of  temperature,  the  diagnosis  would  not  be  easy ;  indeed,  if 
the  oiouth  wore  not  drawn  and  the  general  relaxation  prevented 
the  reoc^ition  of  hemiplegia,  the  diagnosis  might  be  impossible. 

In  this  country*  the  profe^on  has  been  flccustnme^l  to  recogniie 
as  suustrotce,  or  thermic  fever,  only  the  severe  cases  which  approach 
to  the  symptoniH  that  have  just  been  detailed.  For  many  deoadcs, 
however,  medical  practitioners  in  India  have  known  that  liiere  is 
a  form  of  continued  fever  due  to  heat  which,  under  treatment, 
may  gradually  subeide,  or  whicti  may  at  any  time  end  in  a  and- 
deu  exploeiou  like  that  of  true  sunatroke.  Dr.  John  Guit^rat 
{"nterapmlie  Gazette^  March,  1885)  has  shown  tliat  this  mild  form 
of  thermic  fever  occurs  in  the  suhr,ropical  portions  of  the  United 
States.  These  cases  have  usually  been  supposed  to  lie  inataooesof 
typhoid  fever,  from  which,  according  to  Dr.  Guit^ras,  they  are  to 
be  separated  by  the  suddeuDCSs  of  their  onset,  the  temperature  of 
the  first  day  reachiug  103"  F.,  or  even  higher ;  by  the  course  of 
the  fever,  which  i.4  extremely  irregular,  indefinite  as  to  duradoD, 
and  almost  always  has  the  morning  remissiou  more  accentuated 
than  in  typhoid  fever;  by  the  absence  of  petechia,  miliaria,  rose- 
colored  spots,  tenderneiix,  and  gurgling  in  the  iliac  fossa;  by  ihc 
tonjl^e  remaining  moist,  with  only  a  light  creamy  coating,  inler- 
rapted  by  a  clear  streak  along  the  cdge^  and  median  line;  by 
the  absenue  of  cerebral  syuiptotus,  except  at  limu»  when  the  fevet 
rises  ver}'  higli ;  and  by  the  mental  ulerlnes!;  in.stend  of  hebetade. 
Diarrhoea,  although  often  absent,  may  lie  present,  and  even  be 
severe  and  bloody. 

Many  cases  of  obscure  indispoeition  during  intense  hot  weather, 
especially  in  children,  are  really  mild  iii^itaiices  of  derangement 
of  function  of  the  body  by  heat, — that  is,  of  thermic  fever. 
Dr.  C.  Comegya,  of  Cincinnati,  was  the  first  to  call  attention  to 


DISORDF.BIS  OF  CnNSCIOnHNESS. 


S8S 


t^ 


the  fact  that  cases  of  cliolera  infantum,  so  called,  are  frequently 
instances  of  thermic  fever  and  yield  at  once  to  the  iiso  of  the  cold 

th.  It  hns  long  been  known  that  in  cholera  iiiraatuni  there 
b  often  B  siid<iou  increase  In  tlje  fever,  with  or  without  lo^iscn- 
ing  in  the  number  of  the  [lassages,  but  with  a  rapid  lo«s  of  cod- 
scionsDess.  which  is  likely  to  end  in  death.  Under  these  circnm- 
Manceti  the  lause  of  Uie  oerebral  symptoms  is  the  elevation  of  the 
temperature.  As  it  occurs  in  onr  large  cities  in  hot  vrcather, 
cholera  infantum  Is  frequently,  if  not  usually,  a  form  of  thermic 
fever,  and  yields  with  great  readineaa  to  the  sy^teuiatic  use  of  the 
cold  bath.  In  all  oases  of  this  character  the  physiciaa  should  use 
a  thermometer,  and  if  tlie  temiKratnre  be  found  dL<)tinctIy  above 
the  norm  it  should  be  reduced  by  systematic  cold  bathing.  (See 
article  on  ''  Smwtroke,"  Eue^-ioptrdia  of  Medicitit^  vol.  v.,  Phila- 
delphia, 1886.) 

Apoplexy. — The  term  apoplexy,  as  used  in  this  work,  applies 
to  cases  in  which  conscioastie»B  is  suddenly  lost  us  the  result  of  dls- 
torfaancc  in  the  circolation  of  the  brain.  Scientific  accuracy  would 
require  thnt  cases  of  arrest  of  the  cerebral  circulation  should  be  s«p- 
mted  from  m^es  of  oongestiuu  or  hemorrhage:  the  diaguosia,  hoir- 
rrer,  between  loss  of  oousciousneas  which  Li  the  result  of  am?st 
of  circulation  in  the  brain  by  au  embolus  and  the  unconscious- 
H8i  which  is  due  to  a  sudden  rupture  of  a  vessel  and  hemorrhage 
into  the  bruin  U  frequL>ntly  uot  jKJssible.  Moreover,  it  is  by  no 
neue  oertaio  that  even  in  hcraorrhogio  apoplexy  the  suspension 
of  oerebral  functions  is  the  result  of  a  coi^estion  or  of  an  excess 
of  blood  in  the  brain.  For  theee  reasoos  it  seems  to  me  wisest  to 
consider  under  one  heading  all  lasses  of  conacionsneas  cunneoted 
with  circulatory  brain-disturbanoe,  and  afterwards  to  potut  nut  the 
few  facts  of  value  that  we  have  as  guides  in  separating  between 
the  forms.  Again,  it  should  be  said  that,  except  by  the  prcseuoo 
of  paral^nis  or  convulsions,  we  have  no  way  of  distinguishing 
between  au  apoplexy  which  is  simply  due  lo  wiiigestion  of  the 
brain  and  one  which  is  connected  with  more  or  leas  permanent 
o^nic  ehaogcA.  It  ha^;  been  denied  that  there  is  such  a  thing  as 
HiDpU  eongedive  apopUxy;  but  there  can  be  no  doubt  of  its  occur- 
tcoee.  I  have  seen  it  developed  witliout  obvious  cause,  tu  be 
raoovind  from  without  sequelte,  and  never  to  recur  in  after-life. 

oongestive  apoplexy  may  be  due  to  a  brnin-tnmor,  or  to  a 


384 


OIAOKOBTIC  NSI7B0L00Y. 


syphilitic  diseaso  of  the  braia  or  its  membraocs.  For  a  detailed 
discussion  of  tliese  comas,  see  article  on  Organic  Coma. 

For  description  and  i^tudy,  cartes  of  aimplnxy  may  be  amu^ 
in  two  claaaes,  to  which  the  names  of  sthenic,  or  coogestive,  aod 
istbenicj  or  syncopal,  may  be  given. 

There  are  no  etiolo^cal  diflfercuces  between  these  tvodaMBi 
Extreme  typical  cases  differ  widely  and  characteri^tiealljr  bi  Arfr 
symptoms,  although  they  rest  ii|Kin  similar  structural  chan)^. 
Moreover,  overy  possible  iDtorrae<liate  variation  occurs  in  nature 
between  an  extremely  sthenio  and  a  typioLtly  astlienic  apoplexy, 
so  that  the  two  classes  are  not  naturally  Mtporated  from  each  other, 
but  are  artificially  characterized  for  the  purposes  of  discusBion. 

The  apoplectic  attack  may  come  Dn  with  great  suddenness.  It 
may,  however,  be  preceded,  by  prodromes,  which  are  lu  some  cases 
affirmed  to  have  lasted  for  some  hours.  SomeLimes  without  dis* 
tinct  warning  the  patient  dmp>>  unconscious,  or  he  may  become 
confused  iu  speech  and  manner,  and  then  suddenly  be  stridceo, 
or  else  gradually  grow  more  and  more  heavy  and  finally  sink  into 
nnooDsciousuess.  At  the  height  of  the  attack  the  unconscious* 
ncas  is  complete.  The  pupil  is  6xed,  dilated  or  contracted,  as 
the  case  may  be.  In  the  congestive  form  the  faoe  and  conjaDo* 
tivn  are  intensely  sufTui^ed,  dark  purplish  red.  The  breflthing 
is  loud,  snoring,  and  stertorous.  The  pulse  is  usually  full  and 
bounding.  It  may  be  slower  or  more  rapid  than  normal;  oc- 
casionally it  is  aiuall  and  hard.     The  surface  is  warm. 

In  the  syncopal  form  the  face  is  pnle,  and  the  breathing  quia, 
or,  if  stertorous,  not  loud  and  hanih  in  ite  sound.  The  surface 
is  coolish,  and  the  pulse  rapid  and  feeble. 

Paralysis,  oonvnlsions,  and  great  rise  of  temperature  may  occnr 
in  either  variety  of  apoplexy.  They  are  proof  of  the  presence 
of  an  organic  lesion.  The  apoplexy  may  end  in  death,  which  is 
commonly  developed  by  a  mon,*  or  less  rapid  increase  of  the  symj^* 
tomu.  Tlie  unconciousness  remains  complete ;  the  pulse,  whether 
originally  strong  or  feeble,  continually  falls  in  force;  the  respira- 
tion grows  more  and  more  shallow,  or  more  and  more  irre^lar, 
and  may  at  last  gradually  die  away  or  suffer  sudden  arrest.  Tbe 
cerebral  reflexes  are  frequently  lost  early  in  a  ease  of  severe  apo- 
plexy, especially  when  the  basal  region  is  invaded  by  the  Icsioo. 
Tlius  it  is  that  the  power  of  swallowing  is  affected.     Complete 


DISORDERS  OF  CONSCIOUSNESS. 


366 


P 


4em  of  this  function  ts  a  very  flerious  if  not  a  fatal  symptom. 
When  recovery  orcars  it  is  usually  gratJual,  although  in  rare  cases 
the  patient  may  aroii«e  him»«lf  stutdeuly.  Kveu  when  the  patient 
Beenis  rational,  mental  action  may  siill  be  very  imperfect. 

Unconsoiousnees  troxa  Indirect  Causae. — UnwnAoiousness 
more  or  less  closely  resciublinj;  that  of  apoplexy  occurs  from  a 
multitude  of  ratises.  Such  nnconscionsncss  is  usually  develo|jed 
gradually,  and  is  accompanied  by  other  symptoms  which  at  once 
dletingaish  it  from  the  unconsciousnesa  of  apoplexy.  With  a  clear 
history  there  it>  rarely  any  difficulty  in  distinguishing  these  vari- 
ona  fonns  of  unconsciousness  from  that  due  to  disturbances  of  the 
cerebral  circulation.  "Very  frequently,  however,  in  hospital  prac- 
tice the  physician  U  called  upou  to  make  immediately  ench  ding- 
Doeis  as  may  be  necessary  for  treatment  without  having  knowletlge 
of  ihe  autecedentK  of  the  attack.  The  importance  and  difficnitiea 
of  such  diagnoaia  seem  to  me  to  justify  the  consideration  in  this 
place  of  the  more  important  forms  of  unconsciousness  which  are 
I        likely  to  be  brought  into  a  hospital. 

I  In  the  fir4t  plane,  the  patient  should  always  he  earefnlly  ex- 

^_  amined  for  the  evidences  of  traumatism, — cuts  about  the  hcnd, 
^Bbmises,  etc.  I  once  sau*  at  an  autopsy  upon  &  man  who  had 
^M  been  brought  into  the  llo^pita1  unconscious,  and  in  whose  ca.«e 
^K  there  was  do  suspicion  of  traumatism,  a  knife-blade  projecling 
^H  two  inches  into  the  brain,  and  broken  off  close  to  the  outside  of 
^H  the  skull.  A  traumatism  maybe  present  without  the  ph}tuctan 
^^  being  able  lo  detect  it,  but  usually  some  local  iiidit-ations  of 
the  injury  will  be  revealed  by  close  inspection.  In  the  cai^e 
jnM  spoken  of  the  wound  was  very  narrow  and  small,  and  was 
•ottrely  ooncealed  by  the  bu.sliy  hair. 

IxNs  of  consciousness  may  be  caused  by  poisoning  and  by  great 
eokotiona]  disturbauce,  or  it  may  be  an  early  ^mptom  of  acute 
Uood-disBaseB.  Uncoosciou«nes8  from  acute  alcolifiliKm  is  very 
freqaent  in  lai^  oitiee.  Not  very  nirely  |>ersons  supjiosed  to  be 
only  dead-drunk  are  put  into  station-house  cellH,  to  be  found  dead 
BotDC  hours  aHerwards.  Even  when  suspicion  is  aroused,  the 
diagnoBts  between  apoplexy  and  deep  intoxication  may  be  very 
diflSeult.  The  oilor  of  alwhol  about  the  breath  or  the  penon, 
and  its  presence  in  tlie  urine,  [X)int  towards  alcoholic  poisoning, 
but  cerebral  hemorrhage  may  ocmr  after  either  moderate  or  im- 

25 


386 


DIA0X06TIC  NEDBOLOQY. 


moderate  (Irinkiug,  It  U  in  siidi  cases  thut  mMtak«  u« 
liable  to  oocur.  Wlietiever  by  simkiug,  shuuliug  in  Uie  «at,  tttJ^ 
a  druiikei)  person  caunot  l>e  arousfxl,  the  prubabilitios  of  cerebral 
hemorrhage  are  Htrong  enough  tu  jiialify  tlie  tern|K)rar3*  dtagnams 
and  the  iiiutitutioii  uf  pro|wr  ineitHures  of  relief.  A  very  otrefal 
ttxaiiiiuatiou  should  be  made  for  evidences  of  paralyBis.  Under 
the  oonjoint  inlliieiive  o(  aloohul  and  cerebral  hemorrhage  the 
uoiveraal  muscular  relaxation  is  so  complete  thai  the  detectioa  of 
a  local  palsy  m«y  be  a  matter  of  the  gre-atest  difficidtjr.  Drawing 
of  the  face  to  one  side  is  of  ouunse  decisive,  and  if  iu  breathing  tti* 
air  ottmes  out  with  a  sort  of  pufl"  aud  pulliii[5  of  one  corner  of  the 
mouth,  the  aim  is  one  of  cerebral  ht'niurrliage.  If  the  jKitient  be 
at  all  reAtlewt,  the  motioul««ne88  of  the  arm  or  1^  of  one  sid« 
will  usually  betray  a  hemiplegia.  If  the  pupils  are  unequal,  the 
probabilities  are  in  favor  of  uereUral  hemorrhage,  Iu  any  doubt- 
ful case  the  phy«cian  should  be  very  earefui  not  to  ofiirm  thai 
the  patient  is  HufTering  simply  from  drnnkennesa,  but  shoold 
reserve  his  opinion. 

Cjumnt-poisouitig  produces  symptoms  very  similar  to  those  of 
apoplexy,  and  I  have  seen  cases  iu  which  the  diugnosiu  was  simph 
irapoewihic.  The  presence  of  heniiple^ie  or  juonoplt^ic  jMlfy  ii, 
of  course,  decisive.  But  I  have  seen  inequality  of  the  pupils  pri>> 
duced  by  opium.  The  remarks  made  iu  regard  to  distinguishiog 
alcoholic  uummsciouKuesg  ajiply  with  equal  force  to  opium-|x>isoB- 
iug  in  its  aJvaneed  stage. 

Urcemie  poli^oninf;  is  a  very  frequent  cause  of  unoonsciouines, 
aud,  unlike  alcoholic  and  opium  poisoning,  is  oAen  aasociaicd 
with  convulsions.  The  diagnosis  between  unemic  and  orguio 
convulsions  has  been  alreaily  discussed.  (See  {Mge  118.)  It  is 
sometimes  im)Mssible  to  make  an  immedrale  'liagno^is  between  the 
quiet  form  of  ursetnia  and  cerebral  hemorrhage,  especially  siaoe 
iu  uraemia  serous  etfu-^ion  into  the  cerebral  ventricles  is  oommoii. 
Cerebral  hemorrhage  itself  is  not  rare  in  advanc«l  kidney -disease. 
In  every  case  braught  into  a  hospital  uncrousciiiuK  the  nriiif 
should  he  at  owk  examine«I.  If  it  l>e  normal  in  specific  gravin' 
and  free  from  atbuiuen,  the  proljabilities  are  strongly  agautst  urs- 
inia.  If  the  urine  be  scanty  and  of  low  hfHKiific  gravity,  mudi 
more  if  it  Iw  albuminous,  the  patient  is  probably  su0cring  from 
kidney -disease.     The  presence  of  local  palsy,  even  though 


I  then    j 


DISORDERS  OF  COtiSniOCSNEBS. 


3«7 


be  advaooed  renal  dej^eneration,  is  deoiunatrativc  of  either  hemor- 
rhagic or  serous  exudation  into  the  brain.  A  temperature  above 
tli«  normal  without  convuUions  would,  according  to  the  teaching 
of  the  French  clinical  school,  prove  that  the  patient  is  sufiTer- 
iog  from  something  else  Uiau  uneraia.  I,  however,  doubt  veiy 
rouc^  the  correctness  of  this  teaching.  (See  )Hige  121.)  Usually, 
but  not  always,  the  patient  in  simple  uncmia  can  be  orou^^ed  to 
some  tftight  extent 

A  partial  nnconsciousnesa  may  result  from  various  irritative 
jM>isonM  which  do  nut  commonly  affect  the  cerebrum.  I  have  seen  a 
marked  stupor  amounting  to  almost  complete  unconaotonsness  the 
chief  aymptom  of  poi^ning  by  Paris  green,  and  there  are  nnmer- 
OU5  cases  on  record  iu  which  the  ingestion  of  larg«  doses  of  tartar 
emetie  or  other  violent  irritant  has  been  followed  by  symptoms 
similar  to  those  of  my  case.  In  some  of  these  caitca  when  no 
hiatory  is  obtainable  a  correct  diagnosis  may  be  almost  impos- 
Mble:  nevertheless  a  trilling  circnm.stance,  if  the  physician  be  suf- 
Gcieutly  alert,  may  give  tlic  neceasary  clue.  The  circumMtuuces  of 
the  case,  the  friends  of  the  ]>utieut,  and,  if  he  be  at  all  sensible, 
the  patient  himself,  sJiotild  be  nuint  mrcfiilly  examined. 

A  very  important  clans  of  cases  is  those  in  which  collapw  with 
more  or  less  complete  unconsciousness  occurs  as  an  early  symptom 
of  aevere  iitiatml  dv^ea$e, — either  a  local  affection,  »ucli  as  a  gas- 
tric or  an  intestinal  perforation,  the  rupture  of  an  aneurbim,  etc.^ 
or  a  general  blood -disease. 

With  a  clear  history  the  diaguosU  may  be  very  eaay ;  but  oflen 
in  practical  life  the  hiatory  is  misleading  or  altogether  abeeut. 
The  suspidon  of  the  physician  should  Ik  aroused  by  noticing  that 
(he  toss  of  coDiwaousncss  is  not  complete  and  in  acnomfiaiiied  by 
•ridences  of  cardiac  failure,  coolness  of  the  skin,  and  a  |>eculiar 
"docnmpoaed"  expreasion  of  the  countenance  seen  only  in  mortal 
iI1ne«4,  and  Uftually  known  as  the  Hip[KKTatic  coiintcnum-e.  It 
is  impo:«ible  to  describe  exactly  ihia  facial  exprcssiou,  but  to  the 
experieoccd  eye  it  is  sufficient  for  the  recognition  of  the  gravity 
of  tbe  disease.  In  any  cjiae  offering  the  symptoms  just  described, 
very  carvful  examination  should  be  made  to  detect  the  exii«teuoe 
of  a  local  lesion,  and  if  evidouec  be  found  of  a  [wrforation  or  of 
any  sufficiently  severe  local  affection,  the  diagnosis  becomes  clear. 

Wb«a  coUapae,  with  more  or  less  incomplete  unconsciousnc^,  i» 


3S8 


j>iABJi08no  NEUBOTjOGnr. 


an  early  symptom  of  a  malignant  syi^temic  disease,  we  are  foronl 
to  make  llie  (liagn<iH)»  l>y  tlic  prixttea  of  exdiismn.  Usiinlly  it 
cstt  be  determined  tliat  the  attack  is  due  to  some  blood -disease, 
allbou^h  ofteo  it  is  impossible  to  know  the  exact  nature  of  such 
aflection.  Kxc«|>t  in  the  case  of  a  {leraii^imiH  malarial  jiarosysm, 
an  aucuratc  diagansis  is  not  of  great  importance,  because  it  has 
little  bearing  upon  the  treatment.  It  is,  however,  vital  to  rceo^- 
nize  the  true  nature  of  a  malignant  chill.  This  can  usually  be 
done  by  excluding  other  causes  of  collapse  and  by  paying  atten- 
tion to  the  folluwing  putiitive  iudioalioiis: 

First.  The  unconaciousneaa  is  partial :  the  patient  can  be  aroused, 
and  when  arouse<1  i^fK^ak^  in  a  feeble,  UHunlly  whii^pering,  voice. 

Seccudlif.  There  are  evidences  of  iaterual  cuugesUons,  such  as 
alnioHi  com]>lete  absence  of  respiratory  murmur,  vomiting,  gas- 
tric or  alwlominHl  tendernehR,  incpeas^i  perai#ion-dulnen  over 
the  liver  or  splwn,  suppreasjon  uf  urine,  etc. 

JTiirdly.  The  temixrature  19  disturbed :  it  may  be  dtstincdy 
lowered ;  or  in  Home  ciues  there  is  a  low  external  tem]>eraltire 
with  a  high  internal  temperature. 

Fourthly.  A  history  of  previous  malarial  attacks  or  of  exposore 
to  malarial  iuflueiices  can  be  obtained,  and  the  season  of  the  year 
is  usually  that  at  which  malarial  fevers  prevail. 

FyUily.  The  piiticjjt  is  an  adult,  and  i\ws  not  present  panihlil 
or  other  syraplonia  cliaracteriBtic  uf  cerebral  hemorrhage.  In  chil- 
dren malignant  malarial  paroxysms  do  not  occur,  at  least  !n  iliilj 
climate  (thut  of  Peinii^ylvHnia),  whil^  primaty  collapse  trom 
acute  malignant  constitutional  affections,  not  malariali  is  in  adiilb 
execaiivcly  rare. 

In  any  doubtful  case  the  patient  should  be  given  the  beneGtof 
the  doubt,  and  wlieu  the  collapse  has  been  recovered  from,  fifty 
grains  o(  the  sulphate  uf  quinine  should  be  administered  during 
the  next  twelve  to  eighteen  hours. 

Collapse  with  more  or  less  complete  loss  of  consciousness  taiy 

lit  from  fmotional  txctiemoii.  Many  years  ago,  during  a  chol- 
era epideuiic,  In  auMwer  to  a  sudden  professional  mil,  I  fuumla 
man  in  cullajjse  and  partially  unconscious,  who,  when  aroused, 
said  in  a  suppre?«&d,  whispering  voice  that  he  had  had  a  sudden 
furious  attack  of  vomiting  and  purging,  M-hi<-h  had  ceased  but  li^ 
lefl  bim  in  his  present  condition.     I  supposed  that  the  case  wu. 


DISOBDEBS   OF   CONSCIOUSNESS.  389 

ooe  of  cholera ;  but  the  sequel  jtroveil  lliat  shortly  before  I  saw 
him  the  man  had  cut  the  throat  of  a  prostitute  after  cnhabltation 
with  her  ami  left  her  Head  in  her  lied.  The  colliipse  I  witnojwed 
wa*  caused  by  the  emotional  reaction  which  developed  when  the 
nudoess  of  his  oi^  liad  passed  off  sufBcieutly  to  allow  blin  to 
reoi^nize  the  rebutts  of  his  actiunK. 


SLEEP— ITS  DISORDERS  AND  ACCIDENTS. 

Id  treating  of  sleep  and  its  disorders  T  shall  divide  the  subject 
into  three  )>arm : 

jPrrt^.  Aboormal  wakefuliieds. 

Second.  Abnormal  somnolence.     Morbid  sleep. 

Third.  Accidents  or  groups  of  symptomn  which  occur  during 
sleep,  and  which  are  not  elsewhere  spoken  of  in  tins  book. 

.IBNORUAL   WAICEFULN'ESS. 

In  cases  of  aimj^e  intomnUt  the  form  of  the  sleeple«nes8 
varies.  In  soEue  instances  the  subject,  is  timpty  unable,  when 
bedtime  comes,  to  go  to  !<leep.  In  other  cases  he  goes  to  sleep 
Kodily,  but  in  the  oourw  of  two  or  three  huiirs  wakes,  and  t» 
unable  to  slumlier  agnin.  The  latter  form  of  insomnia,  in  m3r 
experience,  is  not  commonly  the  precursor  of  severe  mental  aflec- 
tion.   This  form  of  insomnia  is,  on  the  other  band,  often  obstinate. 

Insomnia  may  be  prodromic  of  various  diseases  of  the  brain. 
It  itt  very  common  in  the  insanities.  It  is  also  pre^nt  not  rarely 
io  euch  general  organic  hraiu-diseasee  as  general  |>aralysis  of  the 
inane,  but  is  seldom  a  symptom  of  tumor  or  other  focal  brain- 
ledoa.  It  may  be  priKluced  by  various  diseaneK  of  organs  other 
Uun  the  cerehrum.  It  may  exist,  however,  in  its  most  aggravated 
fiirm  without  other  evidences  of  cerebral  disturbance,  and  in  some 
caaea  cerebral  exhaustion,  and  even  more  severe  mental  !>yniptoms, 
ara  without  doubt  produced  by  the  loss  of  sleep.  The  dtagurisiA 
of  Uie  muse  of  an  iit»omnia  it;  tu  be  made  by  exclui^iun.  If  otlier 
sympt^>ins  of  cerclmil  diwasc  arc  wanting,  the  condition  of  the 
heart  and  kidneys  should  he  carefully  examine<l,  Itecause  latent 
diaeaae  of  these  organs  occasionally  has  sleeple»sneas  for  its  chief 
laaDifcatatioo.     When  no  disease  of  tlie  brain  or  otlier  fiortioDs 


I 


390 


DIAONOfirnO  NEUnOI<OOY. 


of  the  organism  can    lie  made  out,  the  diagnosis  of  simple  or 
functintial  iasotania  mimt  )>c  settled  upon. 


UORBn>  SLBEP. 


4 


In  studying  the  phenomena  of  disordered  or  abnormal  sleep,  I 
sliati  first  consider  those  disarran^'mcnts  of  the  function  which 
ooc-ur  in  flrnte  fevers  or  other  di**€at4e9  not  directly  connected  with 
the  brain. 


I 


Dimrd^x  of  Slrep  connected  trifh  Aetitr  Ftrrrt. 

It  does  not  accm  necesaary  to  occupy  space  in  the  proaeat 
ume  with  any  elaborate  description  of  the  various  derangement* 
of  sleep  which  occur  in  arute  fevers.  Sneli  derangements  may 
consiHt  of  morbid  wakefulness,  or  of  a  pcoiiltar  wakefulnees  with 
delirium  and  partial  unconsciousneas,  or  of  true  (>tnpor  or  coma.' 
In  some  oa<ieA  these  nunifefltntion?  dejiend  upon  high  bodily 
temperature;  they  may  also  be  produced  by  an  excessively  low 
bodily  temperature.  In  other  ca^es  of  fever  the  disturbaoceE  of 
Bleep  are  proVwMy  the  renult  of  imjiaired  hrain-nutrilion,  doe  to 
the  aljeration  of  the  Woijd.  An  improper  aeration  of  the  vital 
fluid,  such  OB  occurs  in  severe  pneumonia,  may  for  a  time  came 
aggravaled  wakefulness,  but  more  usually  it  manifests  itself  in- 
Btupor  and  coma. 

In  some  eases  of  fever  the  polient  will  awaken  from  a  sleep  of 
several  houre'  duration,  and  insist  (bat  be  has  never  closed  his  evcit 
during  the  time,  probably  because  his  dreams  have  been  so  vivid 
that  they  have  conveyed  the  feeling  of  wakefulness.      To  this 
state  the  name  of  coma-Hf/H  was  given  by  Ohomel  in  1834.     In 
1819  the  term  wa^  applie<l  by  Dr.  Jenner  to  a  condition  entirely 
diflereiit  from  that  just  spoken  of.      In  the  coma-vigil  of  Dr. 
Jenner  the  patient  liea  with  his  eyes  wide  open,  gazing  into 
vacuity,  his  mouth  partially  opened,  and  his  face  pale  and  devoid 
of  expression.     The  pulse  is  rapid  and  thready  or  imperceptible;  j 
the  movements  of  respiration  can  scarcely  be  made  out;  whilst H 
the  cold  moist  skin  marks  the  presence  of  a  deadly  oolhipse.  ^ 
The  patient  is  awake,  but  is  absolutely  indifferent  to  everything  ^J 
that  is  going  on  about  him.      In  some  cs^es  this  state  is  pny^^ 
ceded  by  somnolence.     It  is  much  more  frequent  in  typhus  than 
in  typhoid  fever,  and,  according  to  Murchisooj  in  typhus  fever 


J 


DISORDERS  OF  COSSCIOUKNKSk. 


sn 


it  is  an  iovariatily  fatal  symptom.      I  have  aeea  it  in  typhoid 
fever  in  a  «ngl«  case  followed  by  recovery. 

Nelav&n. — N'e!8\*an,  or  ilie  so-called  A^friran  fitepmg  duvaae 
(^ipiUM«  of  Drs,  Uo^uairc  and   Nicolas),  is  an  acute  fevpr  in 
which  excemive  Romnolence  is  the  most  cbaracteristic  symptom, 
and  18  protiably  dejteiKleiit  u)x>ti  the  direct  action  of  the  )x>i!H)n  in 
the  bhxid  upon  the  braiu-oortex.     First  degcribed  in  1819  by  Dr. 
Wiaterbotl'ini.  tliis  affeLiion  has  of  reirent  years  had  numerous  ex- 
positors.    It  is  endemic  on  the  west  coast  of  Africa,  but  appears 
to  occur  epidemically  in  some  of  the  West  India  islands.     It  at- 
tacks the  negroes  e»peoia)]y,  but  has   in  a  number  of  instances 
decimated  regiraenisnf  French  troops.    In  nin^t  cases  it  oomcH  on 
jjrradually,  but  it  may  l)egin  brusquely.     There  is  at  first  a  flight 
frontal   bewlache,  with  a  sense  of  constriction  in  the  forehead, 
attendei]  by  a  mild  fever.     The  vision  may  at  this  period  be  dis- 
oniered.     The  ^it  becomes  irregular,  and  not  very  infrequently 
there  is  a  distinct  ataxia.     Even  during  the  Rm  hourH  nf  the 
headacbe  an  intenae  desire  for  sleep  is  manifested.      This  con- 
tinually increfl.**  antil  the  patient  is  overpowt^retl  by  an  irresist- 
ible somnolence.     During  Ibe  period  of  sleepineis  the  strength 
fails,  thes|)iritHare  depre^e<l,and  there  is  some  fever,  but  usually 
neither  diarrh<efl  nor  constiimtiou  develops  and  the  forces  of  the 
circulation  are  well  maintained.    The  somnolence  when  once  dcvcl- 
0|ied  Dontiimfs  to  bt^eome  more  and  more  intenn*,  and  the  patient 
{gradually  ginks  into  a  profound  coma,  out  uf  which  be  canuot  be 
■rmMed.     There  is  at  this  time  complete  loss  of  sensibility.     The 
OOaui  may  intn-i  quietly  into  deiilli ;  but  fretpiently  there  arc  more 
or  less  violent  convulsions,  and  in  some  cases  stougliing  be«I->wre« 
mark  the  failure  of  nerve-power.     There  are  no  patbi^nomunio 
po^'miirtem  Inions,  but  in  1873  Dr.  Aliuartliy  culled  attention 
to  swelling:  of  the  glands  in  nelavan  as  chanu!teristic.     In  this  he 
i»  confirmed  by  Dr.  Nicolas  {R^c.  Mfd.  lU  la  France  ft  tie  FEtmii' 
gtr,  1880).     The  disease  is  very  fatal :  uul  of  one  liuwlred  and 
forty-eigbt  (lu^es  seen  by  Gtiirtu  at  Martinique  but  one  recovered 
(Th^,  Faria,  18f}t),  Ho.  201). 

Abnormal  iiltvp. 

Tbe  discussion  of  morbid  somnolence  ir>  in  the  present  stale 
of  our  knowledge  attended  by  much  difficulty,  aa  it  Menis  impns- 


392 


UIAOSOSTIC  NE(TIWM/)QY. 


sible  to  draw  (he  lines  l)etween  the  diflfurent  varietiee  o 
griou<>nefts,  and  tt  ut  not  always  possible  to  give  a  clear  explanation 
of  tlie  cause  of  the  eymploms.  In  its  simplest  form  the  srmp- 
tom  oonsifits  of  aii  exceseive  ilru\v'8tne<«,  which  causes  the  suh-  ! 
jcct  to  fall  asleep  at  any  time  during  tlic  twenty-four  hours,  even 
when  in  the  midst  of  u-ork  or  ooDversalion.and  leads  to  his  pac- 
ing many  hours  daily  in  bed.  Wheu  the  morbid  tend^Hry  i.« 
a  little  stronger,  the  impulse  to  sleep  becomes  irret^istible,  and 
iIa  itifluenoe  k  ko  continual  that  the  waking  periods  may  he  re- 
dui>ed  to  only  a  few  hours  out  of  a  wet-k.  No  disiiuction  can 
be  made  between  the  sleep  that  occurs  in  many  of  these  cases  and 
that  of  normal  slumber.  The  ca.seg  gmde  regularly  from  the 
periion  who  is  simply  known  as  a  profound  sl<«pcr,  to  the  sub- 
\fM  who  passes  most  of  bis  time  in  unconsciousness.  In  lighter 
ca-wfi  the  jMitlent  can  be  awakened  out  of  thei^teep,  but  in  the  more 
severe  forms  of  the  disorder  it  is  not  ]ioiKiblu  to  arouse  tbe  sleeper. 
Here  also  a  i-egular  scries  of  cases  exists  between  the  sleep  out  of 
wliicli  lite  subject  is  easily  aroused  and  that  out  of  which  be  cannot 
be  awakened  at  all. 

iu  the   more   prolonged  eases  of  excessive  sleep  the   patient     i 
remaiuH  iu  a   condition  of   inseusibility  for  weekS]  mouthy  o^H 
years.     Dr.  Guf-ntau  dc  Muksv  reported  to  the  French  Academy" 
of  Medicine  the  ease  of  a  woman  who  w»s  »iid  to  Imve  gone  to 
sleep  in  1808,  and  to  have  been  still  sleeping  at  the  lime  of  the 
report,  January,  1838.    Diiriug  this  time  tiie  woman  remained  im- 
movable LiiMJU  her  bed,  with  her  limbs  drawn  up  over  herstomacL 
At  firet  she  took  foo<l,  but  soon  she  ceased  to  receive  any  nourish- 
ment except  the  sacrament,  which  was  adniinisterwl  on  the  first 
Sunday  of  every  month.    As  this  case  iippeare  to  rest  solely  ujwa 
the  authority  of  a  French  eur6,  and  not  to  have  been  seen  by  the 
doctor  himself,  the  acouunt   mtisl   be  accepted   with   allowBDce. 
There  are,  however,  similar  instances  in  literatore.     Thus,  a  caae 
in  recorded  iu  the  AVio  YorL   Moltad   GazcUe,  iv.,   1853,  in 
which  a  man  slept   five  yeans;   oue  in  the   likKmond  Mnikal 
Journal,  1H67,  in  which  a  girl  slept   eighteen  years;   and  the 
"sleeping  girl"  of  Turville  is  affirmed  to  have  not  awakened  for 
ten  years  {lancei,  Juue,  1880).     Dr.  Qsiulkv  {Vtcrtttjahrgch.  Jw 
GericJiUiche  Metiicin,  vol.  xxvi.,  1877)  gives  an  aocouut  of  a  pris- 
oner who  for  two  years  had  been  in  a  deulb-like  stupor. 


J 


DISORUEBS  UF   CONSCIt]USNB88. 


393 


Blnndet  details  tbe  history  of  a  youtig  womau  who  slept  twelve 
months.  Although  thcoorrectneseof  some  of  these  reports  is  open 
to  donbt,  other  cases  might  be  citoti,  and  it  winnol  I»  gninmid 
that  the  uuconjKnoiuneiis  may  last  for  years,  either  imbrokeo  or 
interrupted  by  brief  intervals  of  consciousness. 

Morbid  somnolence  of  a  miUl  ty|)e  luu^ser;  by  insensible  grada- 
tions into  that  condition  known  by  some  English  authors  as  /ranoe, 
and  UMially  spoken  of  by  French  writers  as  iHhar^y.  Trance, 
or  letharg)-,  may  or  may  not  be  tisherwl  in  by  marked  hysterical 
nniptoffls,  saeh  as  immoderate  depression  or  excessive  gayety, 
convub.iuns,  hallucinatiuns,  etc.  Usually  in  the  course  of  a  very 
abort  time  the  symptoms  arc  fnlly  developed,  and  the  subject  is 
in  ahsobite  rejwise.  The  face  may  be  red  and  hot,  espciually  in 
the  first  dayK  of  the  attack,  but  usually  it  is  pale.  The  pulse 
at  first  may  be  regular  and  slow,  but  after  a  long  sleep  it  Is  rapid 
and  feeble;  the  respirations,  generally  quiet,  may  at  times  become 
hurried,  irr^rular,  and  even  stcrtontus.  In  severe  cases  the 
movements  of  the  tliorax  may  be  so  slight  as  to  be  traceable  vritli 
diffieulty.  The  muscular  system,  oHen  thoroughly  rclaxctl,  may 
be  rif^d,  and  in  many  rases  muscidar  relaxation  alteniates  with 
muscular  contractions,  or  even  contractures.  The  eyes  are  0{)ened 
or  doeed ;  very  frequently  minute  tremors  affect  both  tbe  lids  aod 
ibe  eyeballs.  The  jaw^  are  ofWn  set,  and  sonietimea  an  exocsa  of 
aativa  or  even  foam  gathers  almut  the  mouth.  In  the  profound- 
cases  tliere  is  complete  ansesthosiaof  both  the  ouramon  and  the 
apeeial  senses,  so  that  neither' pinching  nor  cutting,  neither  wld 
uor  heat  applied  to  the  skin,  clioita  response.  The  jiiipils  arc 
usually  dilated;  tliey  oHen  respond  to  a  powerful  light,  wbicbi 
however,  calls  fortli  no  other  signa  of  life.  Sometimes  the  pa- 
tient can  l)e  readily  fed  by  means  of  a  siHxm,  but  generally  in 
severe  ca»es  it  is  necessary  to  use  the  a»ophagenl  tube.  Usually 
digestion  is  good,  but  the  stools  are  at  long  intervals  and  scainty. 
The  uritic  is  iu  most  casee  scantily  secreted,  and  is  pasBe<l  invol- 
untarily. QiDsidering  the  small  amount  of  nourishment  taken, 
tiie  botlily  nutrition  ts  of^en  surprisiugly  maintained,  but  in 
proloogtd  CBH«  there  oomes,  sooner  or  later,  great  emaciation. 
Tbe  bodily  temperature  may  in  the  earlier  |»rls  of  tlie  attack 
be  somewhat  elevated,  but  ordinarily  tt  is  distinctly  subnormal. 
The  awaking  is  usually,  but  not  always,  sudden.     During  the 


394 


DIA0N08TIC  XEDROLOOY. 


ooaneof  such  a  lethargy  the  subject  m&y  pans  into  a  oonrlitmn 
which  has  been  umlakeii  for  <le8tb.  The  Ixxlily  temperatitre  falls, 
the  respiration  becomes  so  passive  that  do  movement  of  the  tho- 
rax or  fibdomen  is  perceptiltle,  and,  nntess  a  feather  or  oilier  lighl 
objed  be  held  to  the  moath,  breathiog  mar  seem  (o  bare  ceand. 
The  beats  of  the  heart  diniintsh  in  frequener  and  in  force,  w 
that  they  lieoome  tmpero<*])tible  even  upon  au<4ciiltalion.  The 
fare  takes  on  the  waxy  whiteneatt  of  a  corpse.  The  miiscnlar 
system  is  in  complete  resolution,  the  dilated  pupil  no  hinger  reacts 
to  lighl,  and  even  the  cornea  is  filmy  as  in  a  corpse.  Tlii»  death- 
like condition  may  last  for  only  a  few  hours,  or  may  contitiue  from 
one  to  several  days,  aftxr  which,  little  by  little,  respiration  h  re- 
e«tabliahed,  the  puUc  reeurn.<i,  and  the  circulation  briiig«  new  life 
into  the  limbs:  after  such  a  crtaia  the  subject  may  awuke  iio- 
tue<liutely,  or  may  continue  to  sleep. 

A  condition  which  \»  allied  to  that  of  hysterical  lethargy  m 
trance  has  long  been  known  as  catalepsy,  a  term  to  which,  how- 
ever, so  many  meaniniipi  have  been  attached  an  to  give  riae  to  an 
almost  hopeless  confusion  iu  literature.  lu  its  correct  use  it  sig- 
nifies a  form  of  morbid  sleep  which  is  charncterizeil  by  I<B9  of 
oonscioiianeas  and  of  volnntary  motion,  and  by  a  peculiar  condi- 
tion of  the  muscles,  so  that  the  body  or  the  liml>s  take  without 
retrislanoe  any  ]>D»ition  in  which  they  are  placed,  and  ])re$erTe 
without  apimrent  effort  such  position  for  an  indefinite  time.  In 
some  cuses  of  insanilv  an<l  in  other  neuroses  the  muscles  pasB 
into  a  Rtate  somewhat  rcsemiiling  that  of  catalepsy.  These  are 
not,  however,  instances  of  catalejwy,  to  which,  in  truth,  the 
of  oonsciousneai  is  as  necessary  as  is  the  peculiar  condition  of 
musics.  To  designate  muscutar  symptoms  resembling  thiue 
catalepny  oocurring  in  other  conditions  the  term  oaUiteptaid  nus 
well  bo  used. 

Crttalepey  generally  develops  gradually,  but  it  may  come' 
abruptly  a.x  the  result  of  a  powerful  emotion.  As  au  instance 
of  such  sudden  development  may  be  cited  the  case  recorded  in 
1415  by  Lafaille  {Annaffs  de  TmUoune,  1st  part,  1415)  of  two 
Gray  friars  who,  during  a  sermon  ou  the  Passion,  were  struck  ^ 
immovable  in  the  attitude  r>f  devotion.  Usually  the  cataleptiafl 
fttatUH  m  preceded  iiy  letharg}',  oonvnlsione,  or  other  pronounced 
hysterical  symptoms.     It  last*  from  two  hours  to  a  day,  and  may 


i 


DISOBDERB   OP  COXBCIOU8>' ESS. 


396 


oontiuiially  recur,  so  tliat  the  patient  \s  t^iid  to  be  caUlepfio  for 

nuiny  days  or  even  for  weeks.     The  facial  expresaion  may  be 

that  of  apathy ;  in  some  cases  it  is  that  of  devotion,  of  rage,  or  of 

vbatever  {ladsion  the  subject  was  in  at  the  time  of  the-  fixation 

of  the  mnscles.     The  eyes  arc  wide  open,  with  qaiet  lids.     The 

body  IB  motiunless,  in  Uie  {KWtiire  in  which  it  has  been  plaiMxl 

or  in  which  it  has  settled  during  the  arrest  of  active  motion.   There 

i»  DO  power  of  voluntary  movement,  but  the  limbe  are  not  rigid 

or  contracted.     When  taken  hold  of,  they  lumd  with  the  plasticity 

of  wax.     In  any  position  in  which  the  body  or  limbs  are  placed 

tb^  remain  for  a   long  time,  and  Bergi;r  (quoted  by  Barth)  is 

Mid  to  have  seen  the  moAt  biKarre  and  difficult  attitudes  steadily 

mainlaiued   for  seveu   consecutive  hours  by  a  young  cataleptic 

Woman    who   was   coiii^tantly   under  ob>wrvatiun.      During   the 

whole  of  the  cataleptic  state  there  ts  complete  anasthcsia  of  both 

the  common  and  the  3|H!cial  senses,  so  that  the  most  violent  irri- 

tattons  of  the  skin  produce  no  reaction.     Respiration  i.s  regular, 

the  pulse  maiutains  its  normal  rhythm  and  rate,  aud  the  general 

iMidily  funrtions  appear  to  go  on  unaflected. 

A  condition  resembling  that  of  tninoe  or  catalepsy,  in  which 
consciousness  li  preserved,  although  the  patient  has  no  control 
over  the  voluntary  movements,  may  develop  as  the  result  of  a 
Kvere  acute  disease  or  from  other  cause.  It  is  affirme^l  by  Berth 
that  in  some  cases  which  in  other  rcs|>ccta  entirety  resemble  those 
of  attnlepsy  the  patient  after  coming  out  of  the  condition  has 
recited  alt  that  occurred  during  the  crisis.  To  thow  cnseo  o(  leth- 
trgy  in  wliich  conaiioiisncsis  has  been  prerarved  the  terra  lucid 
Uharffjf  has  been  applied.  If  in  a  lucid  lethargy  the  death- 
like condition  spoken  of  on  page  394  has  developed,  the  patie-nt 
majr  be  thought  to  be  dead.  There  can  be  little  doubt  that  under 
circumataucw  premature  burial  of  a  conscious  person  has 
ned.  In  my  childhcKxl  I  well  knew  an  old  and  enieeraiKl 
minister  of  the  Hociety  of  Friends  who,  in  one  of  the  epidemics 
of  yellow  fever,  after  on  attack  of  the  disease,  pafvie«)  into  iIma 
ooadition  aud  waa  prejNired  for  burial.  Although  i>erfectly  cog- 
niaot  of  his  danger,  he  could  give  no  sign,  until  by  a  supreme 
tflbrt  he  siiccee<lei1  in  making  some  slight  movement  of  the  eye- 
which  indicatwl  life. 

If  in  imanity  a  cnlaleptoid  condition  appears,  the  tme  ebaraoter 


Bbbcu 


396  DIAGNOSTIC   NEUROLOOV. 

of  the  apparent  catalepey  cqd  usually  be  dctermiDed  by  Duticing 
that  tlie  body  ami  limlis  wticn  placed  in  bizarre  fxisitious  show 
tremors  or  other  evidences  of  fati)2;nc.  In  cntaJepsy  the  limb 
vhen  it  falls  folia  like  a  wax  arm  which  lias  been  bent  and  eluwlj 
straightens  by  itB  own  weight. 

According  to  my  thinking,  it  is  not  at  present  possible  to 
range  the  various  caaes  of  morbid  somnolenoe  into  symptomatic 
grou[>s  which  can  be  distinguished  from  one  another  by  the  symp- 
toms. In  a  prcvion.'i  chapter  ehoreic  movements  were  showa  to 
be  due  to  a  peculiar  condition  uf  the  ganglionic  nerve-oella,  capa- 
ble of  being  produced  by  various  causes.  It  seems  to  me  that  It 
must  also  be  considered  that  the  condition  of  morbid  sleep  m  diie 
to  an  altered  nutrition  of  nerve-cells  conuccted  with  coincioiu 
life,  which  altered  condition  cannot  always  be  recognized  by  the 
microscope,  and  may  be  produced  by  various  causes.  The  parallel 
between  morbid  somnolence  and  chorea  is  fnrther  evinced  by  the 
fact  that  the  best  classification  tliat  we  can  make  of  it  is  etio- 
logical. It  will  at  once  strike  the  reader  that  most  of  the  groups 
which  are  separated  in  the  following  sohcrae  are  represented  in 
chorea : 

Group  first,  those  cases  in  which  the  unconsciousness  is  due  lo  a 
distant  reflex  irritation. 

Group  second,  those  cases  in  which  it  is  on  outcome  of  a  pecu- 
liar nervous  condition  of  unknown  nntnre,  to  which  the  name  of 
narcolepsy  is  applied. 

Group  llilnl,  thoBc  cases  in  which  it  is  liyeterical. 

Gronp  fourth,  those  cases  in  which  it  is  connected  witli  insanitj. 

Group  fifth,  those  eaacA  m  which  it  is  due  to  an  oi^nic  dtsmse 
of  the  bmiu. 

Before  taking  up  the  oonsideratJou  of  tliese  etiological  groap*, 
it  is  ncceissary  to  call  attenlion  to  the  fact  that  epileptic  attacks 
may  closely  simulate  morbid  sleep. 

EpiUpiic  fUtcp. — A  sleep  of  some  houra*  duration  out  of  which 
the  imtient  cannot  rtiudily  be  awakened  is  a  jjortiou  of  a  typical 
epileptic  attack.  In  rare  cases  the  whole  epileptic  imroxy^m  may 
l)C  comprised  in  a  sl(*p  which  may  be  ]>ro!onged  for  seveml  da; 
The  following  case,  rejwrted  by  Surgevn  M.  Chabert  {RtctuU 
MHnoira  de  Mideoine  c<  de  Chirurffie  miiitairts,  1867,  vol.  xviiJ 


* 


DISORDEBS  OF  OOKSCIOfSXESS. 


397 


p.  1 6),  was  probably  epileptic,  A  soldier,  twcnCy-eix  years  o?  age, 
soddeoly  disnppearet].  and  wns  marked  &s  a  deserter.  Eighteen 
days  later  lie  was  found  deeply  buried  in  a  pile  of  straw  lying  in 
au  out-house,  the  door  of  which  is  asserted  to  liavc  bccQ  lookal  for 
seven  day^  Tde  roan  was  completely  uiiponscious  and  appareutly 
dead.  The  face  was  deadly  pale,  with  dilateil  pupil.*,  the  limbs 
were  relaxed,  the  surface  was  «y>Id  and  without  sensibility,  the 
respiratiuns  were  completely  cusipendwl,  and  even  on  auscultation 
no  evidence  of  cardiac  action  could  be  made  out.  After  half 
an  hour's  work  with  frietions,  external  heat,  etc.,  an  inspiration 
was  taken :  in  a  short  time  respiration  and  circulation  were  r^ 
establiehed,  and  on  (be  next  day  the  ntan  was  couseious.  Inquiry 
showed  tliat  at  the  age  of  twelve  years  the  ]>utient  hiul  bctui  seized 
with  a  forious  migraine,  had  disapjwarcd,  and  was  found  twenty- 
four  houTB  afterwanis  asleep  in  a  granary.  Two  months  later  he 
bad  a  scooud  similar  attack.  In  the  twelve  or  fourteen  years 
afler  this  be  had  seven  or  eight  attacks,  during  whieli  he  would 
be  deprived  of  oousciousne^  foriseveral  days. 

Another  case,  which  .may  have  been  hysterical,  hut.  poKsiblv 
'■was  epileptic,  is  that  recorded  by  Dr.  Marduol.  The  soldier  was 
admitted  to  the  Military  Hospital  of  Lyons  ou  the  2l9t  of  March, 
1870,  profoundly  unoon&cious  and  insensible,  but  with  a  full  reg- 
ular pnlt%  of  eighly-four,  and  mill)  respiration.  In  spite  of  ilie 
oae  of  cold  aSiisions  and  violent  electrical  currents,  the  sleep  oon- 
tinned  for  seventy-four  hours.  Snlise^juentty  the  patient  had 
aootlier  attack  of  deeping,  during  which  there  was  a  violeut  oon- 
vubinn.  The  fact  that  in  one  of  these  sleeping  pcriwls  there  wns 
general  hyperiesthesia  of  hucIi  character  that  touching  of  the  ttltlu 
would  immediately  produoc  a  violent  tetanus  or  opisthutouuH, 
points  towards  hysteria. 

Reflex  Unconeoioutfnees. — It  is  well  known  that  in  pois<ining 
by  gastro-intestinal  irritants  stupor  or  insensibility  may  he  so 
pronounced  ns  to  mask  the  unlitmry  symptoms.  I  have  seen  this 
in  a  case  of  poisoning  with  Paris  green.  I  was  once  called  to  a 
cliitd  who  was  in  profound  insensibility,  with  very  alarming  ool- 
lapse,  apparently  without  cnuiTe,  but  whu,  I  tnhortly  leumed,  had 
eaten  stale  cream  pufls  a  few  hours  before.  By  tlie  use  nf  a  hot 
bath  and  emetics  consciousness  was  soon  restored.  Tlie  following 
may  be  cited  as  instances  of  refiex  unoonsoiousneas. 


—^  case* 


398 


DIAONOOTIC  NEITROLOGY. 


In  the  Bodon  Medieat.  and  Surgical  Journal,  1863,  xJix.  36.1, 
is  reported  the  ca4e  of  a  pitient  who,  as  the  result  of  the  ing^«- 
tiou  of  iiuligestible  food,  passed  luto  u  semi-coaiatoee  oondiiiou,  io 
which  he  rcmaioed  ior  two  weeks  aud  then  died.  At  the  autop^ 
tile  legions  found  were  severe  inflammation  of  the  smalt  intestineg 
and  tubercular  degeneration  of  the  abdominal  glandti.  A  more 
aatisfootory  case  is  reported  by  Dr.  Katerbau  {Maffosin  Jur  Gt- 
sanmUe  JfcUkutuh,  Berlin,  1S25,  p.  157);  a  seventeen -vear-old 
Jewess,  who  had  alept  for  four  days  and  night»,  under  th«  inflncnce 
of  nierliclne  pas^  a  knot  containing  twenty-four  round  worai& 
and  immediately  awoke.  ^H 

That  the  reflex  sleep  may  take  the  form  of  eatalepey  la  diowtf^ 
by  a  caae  rejwrted  by  Dr.  Mayer  (,'lnn.  de  la  Soe.  MM.  d'Ayicenf_ 
May,  18631,  in  which  a  boy,  nine  years  old,  for  five  or  six  coa- 
aevutive  days  had  a  diurnal  attack  of  oitalepey  lasting  sevettll 
hours,  and  waa  at  once  curvd  by  the  expulaiua  of  a  Urge  nomt 
of  intestinal  worms. 

Narcolepsy. — The  cases  of  morbid  sleep  which  are  here  groat 
together  under  the  name  of  naroolepay  vary  in  the  intensity  of' 
their  symptoms  from  drowsiness  to  a  sleep  which  cods  in  deaiii. 
It  is  most  prububle  that  the  caut?e  of  the  steep  varies,  and  that 
Beveral  distinct  aBcctions  are  rcprcaeutei]  in  the  group.  The  best, 
however,  tint  can  be  done  at  present  is  to  separate  tbe  cases  into 
three  BLib-grou|}s,  which  are  not  very  clearly  di«tiaguiabable  and 
indcoil  are  probably  closely  oonnccted  by  intermediate  cases.  In 
the  lirst  of  tlietw  grou)>»  the  8tibjeiil  [la^iHeij  many  lioure  in  wliat 
secmn  to  l>c  ordinary  slumber.  In  some  cases  the  sleep  comes  on 
daily,  iu  others  at  longer  intervals.  In  some  instances  there  is  a 
perpetual  dro^vainesti,  in  oLhers  the  jHitieut  wheu  awake  is  not 
sleepy.  As  illustrating  these  various  facta  I  cite  the  following 
cases.* 

Dr.  J.  W.  Qloninger  reports  in  the  AmtritMn  Medical  Reoordf, 
vol.  v.,  1822,  a  case  in  which  a  man  gradually  passed  into  a  eou-j 
(tilion  iu  M'hich  he  wiuj  ejcuessively  <lrowsy  all  the  time,  perpetu-' 
ally  falling  a.slcep  when  at  work,  and  habitually  spending  eigh'| 
teen  hours  out  of  every  twenty-four  iu  profound  slumber.     Dr,  i 


*  For  ■  lar^  Goll«ctton  of  c»ci  of  morbid  ab^i  Ha  paper  by  Dr.  Daos, 
Journal  oj  It«rv«ua  and  MtnUU  IHauua,  April,  1884 


DLSORDERS  OP  CaN»CIOU6N£S8. 


399 


^ 
^ 


^ 


HanGeld  Jones  {Lancd,  Januaiy,  1870)  detatte  the  history  of  k 
porter  who  was  never  free  froiii  drowsiness^  falHiig  asloep  at  all 
times,  and  habitually  spending  fourteen  hours  of  the  twenty-four 
in  (deep.  Dr.  T.  Brady  (.\ffdu^  (Mtaerwttiona  and  J7iquirUg, 
Ijoodoo,  1867)  records  the  case  of  a  woman  who  for  many  years 
had  blept  eighteen  hoiin*  a  day,  except  four  months  iu  one  year, 
during  which  she  was  like  other  j»eo])le,  aud  tweuty-one  days  iu 
another  year,  when  she  hud  a  tertian  fever  and  slept  not  more 
than  two  hours  at  a  time.  This  woman  oould  not  lie  aroused  out 
of  her  sleep.  G.  Ballet  reiwrts  {Rcmi^  de  JIM&yhWf  ii.,  1882}  the 
case  of  a  wioe-merchont  who,  when  three  yeare  old,  had  an  at- 
tack of  lethargy  lasting  seventeen  days  after  typhojil  fever,  and  at 
the  age  of  twenty-six  began  to  suffer  from  excessive  drowsiness, 
which  cau^  him  to  fall  afileep  in  all  sorts  of  placoi  and  at  all 
times,  although  his  nightly  sleep  was  very  long  and  profound. 
Dr,  Rudolph  {New  Orlf^ins  Jfedktii  ami  Sun/ical  Journal,  1883, 
xi.)  iclU  of  a  young  ranchcro  who,  after  having  been  tivuhled  by 
exoenive  somnolence  during  the  day,  had  spelts  of  sleep  lasting 
from  twenty-four  to  forty-eight  hours. 

The  seixMid  chi8s  of  c&iies  comprises  Ui08e  in  which  the  parox- 
ysoui  of  sleep  come  on  at  im^lar  intervals  and  continue  for  days. 
Afl  an  in.Htanoe  of  this  form  of  narcole|»y  I  cite  a  case  refiorted 
by  Dr.  Uuirepont  {Seiu  Zeitschrift  fur  Gchurtgkunde,  1844).  A 
Jeweati  shortly  after  her  marriage  fell  into  a  prtdonged  sleep,  which 
had  ever  afterwards  recurred  jK.'riodically.  The  average  length 
uf  the  sleeping  period  was  6vc  and  a  half  days,  the  longest  time 
titat  she  htui  ever  slept  l>eing  seven  days.  The  intervals  of  wake- 
Ailneas  lasted  from  two  to  twenty  days,  during  which  time  she 
did  out  sleep  at  all,  or  had  ouly  a  very  little  restlots  slumber. 
The  bleep  would  come  on  suddenly,  sometimes  in  the  night 
and  sometimes  in  the  middle  of  the  day.  At  the  end  of  the  first 
twenty-four  hourw  she  would  nwake  with  a  very  tiry  mouth  and 
put  out  lier  tongue  as  though  slie  wanted  a  drink,  when  an  at- 
tendant would  give  her  fluid  oourishment,  af^er  which  she  would 
immediately  gu  tu  sleep  again.  She  apiteareil  to  have  no  oon- 
sL-iousDois  of  this  brief  awaking.  &ihe  could  not  Ito  aroused,  bat 
would  awake  spontaneously  and  suddenly  in  a  y«:vy  weak  oon- 
ditinn.  The  puhie  during  the  sleep  was  about  sixty-aix,  regular; 
tba  respiratious  were  so  feeble  that  the  raovementa  could  scaraely 


fOO 


DIAGNOSTIC  WEPROLOOT. 


be  obBcrved,  and  the  temperature  was  imrnial.  Neither  the  urine 
nor  the  (bsccs  were  passed  during  sleep.  The  pupils  were  normal, 
but  did  not  respond  to  light.  Dp,  W.  G.  Gimson  (lirituh  .Vwi- 
ical  Journal,  1863,  i.  616)  rcporte  u  ca^  in  which  a  nmn  after 
a  severe  oold  had  attacks  of  profound  sleep.  The  sleep  would  la^l 
from  twelve  to  twenty-fonr  hours;  the  respirations  nrure  eighteen, 
qniet,  the  pulse  sixt^'-four,  regular,  feeble;  skin  warm,  hands  and 
feet  cold ;  he  uould  not  be  awakened,  and  waked  suddeoly  at  last. 
At  the  time  he  was  seen  by  ttie  doctor  tlie  man  lutssed  forty  out 
of  forty-eight  hours  in  sleep;  oooe  he  slept  eighty-four  hours. 
He  never  took  food  nor  had  a  paxaage  from  the  bladder  or  tbafl 
rectum  during  sleep.  When  awake  tlie  mental  action  was  » 
good  as  ever. 

A  third  class  of  cases  is  that  in  which  the  sleep  ooniee  on  witb^| 
ont  apparent  cause,  and  hecomes  more  and  more  profound  imlit^^ 
the  patient  diofi.     Tims,  in  a  ease  reporte<l  by  Dr.  S.  Weir  Mit- 
chell to  the  College  of  Physicians,  a  woman   suddenly  became 
giddy  and  fell  insensible;  from  this  condition  slie  soon  arousal, 
but  three  days  later  she  jMiaseil  into  a  condition  of  sleep,  durin^^ 
which  she  could  be  momentarily  aroiiseil  and  would  answer  simpl^f 
questions.    For  eleven  days  she  remained  tu  this  state,  with  socae 
oonvulsive  luovemcntK,  and  then  died  quietly.    Careful  {Hjst-mor 
tern  examination,  with  a  microscopic  study  of  the  brain,  failed 
to  detect  any  cause  of  death.    Some  of  the  cases  of  the  present 
group  are  probably  instances  of  intense  cerebral  congestion,  and 
might  be  relieved  by  venesection.    Thus,  Dr.  Charles  S.  SptlraaD 
reports  in  the  Transylvania  Medi<xU  Journal  the  history  of  a  boy, 
fifteen  years  of  ago,  who,  after  the  death  of  hia  father,  fell  into 
a  condition  of  profound  sleep,  with  occasional  slight  oouvuUive 
movements  aud  a  slow,  laboring  pulse.    He  could  nut  be  aroused; 
but  after  seventy-two  hours  of  sleep  forty-four  ounces  of  blood 
were  taken,  and  the  lH>y  at  once  awukenal.     In  some  fatal  cutea^— 
of  apparent  Darcolc[My  distinct   Ici^iona  after  death    have  bcd^f 
found.    Thus,  Dr.  Ilaine  reports  {Oa:xtfe  des  IldpUaux,  vol.  llii,, 
1869)  the  caiK  uf  a  girl,  tiiuuteen  ycant  of  age,  who  died  after  tm^ 
profound  sleep  which  had  come  on  suddetdy  and  continued  fnel 
fifly-stx  days.     At  the  autopsy  a.  small  and  very  circumscribed 
spot  of  soflenicig  was  found  in  the  cerebrum. 


VI^RDERS  OF   CONeCJOUSNBSS. 


401 


I 


Hyst«rieal  61«ep. 

The  niof^t  coniiuou  variety  of  morbid  sleep  is  that  wbicti  ii4 
oonnei-leil  with  hysteria.     The  flvmptoma  usaally  take  the  furm 
of  lethal^  or  tranrc,  with  or  without  ratulepsy.     Tnie  narco- 
lepsy may,  however,  be  closely  simnlated,  the  patient  beinjy  con- 
tinaally  drow-«y,  and  falling  asleep  at  all  times,  but  paiwing  only 
the  nights  in  profound  sliimber.     The  preseooe  of  othn-  hysterical 
Bymptoms  cnnitunnly  Iwlrayn  the  nature  of  the  wmiKiK>n(w.     As 
illustrating  the  maniHT  in  which  the  various  symptoms  of  hysteria 
are  usually  intermingled,  I  ctte  the  following;  case  reported  by  W. 
T.  Gairdner  {Brit.  Med.  Joura.,  October  ^0,  1875),  in  which  a 
girl,  after  hysterifial  fits  and  hysterioal  chorea,  suddenly  became 
unconscion-j,  with  wide-open  eyes  and  dilated  pupib,  at  the  same 
time  speaking  and  singing  incoherently,  nppai-cntly  as  the  result 
of  hallucinations  and  delusions.     This  eonlinued  for  about  two 
weeks.     A  month  ur  two  later  she  fell  into  a  deep  sleep,  which 
lasted  eight  days  with  an  intcrraption  of  a  few  moments.    During 
this  sleep  she  could  not  be  aroused,  and  hafi  no  passage  from  the 
bowels  or  the  bladder.   Some  mont1\)«  later  she  had  a  second  eight- 
day  sleep:  after  awaking  from  this  she  passed  into  a  condition  in 
wliich  she  slept  persistently,  unless  aroused,  when  she  would  get 
up  and  dre!94  henwlf,  Init  would  remain  awake  only  so  lung  as  she 
VBs  in  active  exertion. 

A  caw  of  hystericsil  lethargy  which  nhow^  the  clo*  relation 
beCweeo  it  and  insauity  is  recorded  by  Dr.  F.  R.  Mueller  (JourruU 
dtr  FrakHaehe  Heiihindt,  1829,  vol.  Ixviii.),  A  young  woman  who 
had  had  slight  melancholia  was  suddenly  seizorl,  whilst  at  church, 
with  intense  sleepiness,  sat  down  on  the  door-step,  went  to  sleep, 
wu  after  a  time  carried  home,  and  slept,  with  very  brief  inter- 
mptions,  for  four  years,  three  months,  atid  sixteen  days.  Onoc 
dnring  this  period  she  was  awake  eighteen  days,  sh^cping  natu- 
rally at  night,  And  seeming  like  h<>rself.  ller  uninterrupted  Klee[>s 
luted  from  forty-eight  hours  to  a  week ;  her  waking  periods  were 
St  first  only  ton  or  fifteen  minutes,  but  afterwards  several  hours. 
During  the  sleep  she  would  lie  quietly  upon  her  bock,  never 
altering  her  position,  with  her  hands  folded  over  her  alxlomen. 
The  skin  was  parobnieut-like  and  dry;  the  eyelids  were  ctosert, 
witJi  the  eyeballs,  when  exposed,  divet^nt;  the  face  was  deadly 

2« 


402 


DTAOXOSTIC  NEUROLOOY. 


pale,  except  the  lips,  which  were  red ;  the  pulae  was  slow  ind 
regular,  the  breathing  slow  and  verv  light;  the  injaensibility  of 
the  »kiu  was  complete.  She  waa  iiitiuh  eiaaeiated,  uud  tlie  tem- 
perature BecmB  to  have  been  subnormal.  There  was  habitual  stiff- 
nes-s  of  the  muscles,  whifli,  however,  coulH  !«  readilv  ovemome, 
aud  iu  the  ««rli«r  nioiilbs  of  ftleep  ^he  had  at  times  distinct  cati- 
leptio  syraptoDiB.     Ofteu  her  somnoleoce  went  off  gradaatlr. 

The  relntiou  of  hyKlerinal  sleep  to  the  condiiion  known  as 
hypnnliem  It  so  c\ase  that  it  seems  to  me  proper  at  this  plan 
to  m)iviider  briefly  the  subject  of  hypnotism.  To  duvuss  all  the 
phenomena  of  the  state  would  require  much  more  space  than  » 
permipsible.* 

Hifjinottxin, — Ry  causing  a  snsneptible  jieraon  to  fix  his  eyee 
steailily  upon  a  bright  object,  as  a  botton,  or  by  pressing  ibe 
eyelids  upon  the  eyes,  or  by  other  suitable  procedure,  the  r«i- 
ditiun  of  hypuuttsiu  is  produced.  Iu  its  nio«^t  typical  rona  il 
is  oompnsed  of  three  stagf^:  first,  catalei)sy;  scoond,  lelhar^; 
third,  artificltil  Romnambulisra. 

In  catalepsy  the  subject  nppcars  m  though  |>etrifipd  in  his  po^l 
tioD.  The  eyes  are  fixei)  widely  open,  with  dilated  pupils  andu'^ 
ineenuible  cornea.  AVilli  rare  exceptions,  the  general  aurfaceof 
Ihe  body  is  infusible  to  pain,  but  the  special  seuws  retain  their 
activity.  The  cxtrorniticH  are  snppli>,  but  when  Iwut  maintain  for 
a  great  length  of  time  any  {>08itiou  into  which  they  may  ban  I 
been  placed.  In  this  i^tate  (and  still  more  markedly  in  the  cdi- 
dition  of  lethargy)  paradoxuHtl  coniraetures  may  lie  pr«duc«l. 
They  are  developed  bv  so  flexing  or  bending  a  |Hirt  as  to  throv 
the  mtiscle  into  sudden  and  com[ilpte  I'elaxatinn,  when  it  imm^ 
diately  passes  into  a  condition  uf  severe  tonic  spasm.  The  con- 
tractures may  hI^o  be  tleveloped  by  striking  the  tendons,  or  evM 
by  rubbing  the  l>elly  of  the  muscle.  A  ])ecnltar  phenonienon 
which  oocurs  during  the  catalepsy  is  that  if  the  body  or  Iirab6.-ire 
put  into  a  position  expressing  some  emotion,  tlie  face  takes  upon 
it  an  expression  correi^poiiding  to  this  emotion,  and  the  whole 
individual  seems  overwhclmetl  by  emotional  excitcnipnt.  Thii') 
if  the  arms  are  thrust  forward  and  the  hands  raised  as  thougb 


*Por  d«ta)la  th«  t«fld«r  i*  nferrml  la   tlic  work  of  FnrdinMid  BoMJ. 
MaptjftUtttr  animnU,  Ptiria,  1880,  u  an  exoaltent  trMttlKQ  iipun  tb«  sabjcct. 


maoBUEiej  of  (XtsecioDSNEss. 


408 


1 


,        the 


I 

I 

I 

I 


pushing  away  or  shoving  sorofthing  out  of  sij^tit,  horror  and 
tear  gather  upon  the  muntcnnnre,  and  the  whole  btxty  wems 
to  bo  rwciiling  from  some  <ire«<l  ohj«ct ;  tf  the  person  be  pla«d 
in  the  attitude  uf  prayer,  tlie  expression  will  become  one  of  in- 
tense devotion;  if  tlie  posture  be  that  of  combat,  rage  will  be 
developed. 

During  the  lethargic  Atate  there  ii  complete  relaxation  of  the 
vhole  nuscular  si'stem :  the  bead  falU  upon  the  shoulders,  and 
the  limbs  are  absotntely  dacdd,  and  when  raiiied  drop  as  though 
deatl.  The  even  are  olo(>ecl,  and  frequently  botli  the  lids  and  tlie 
bells  tremble  constantly.  The  skin  in  insensible,  so  that  pinching, 
sticking  with  needles,  or  other  irritation  provokes  no  response. 

The  BOBinatnbuli«tic  condition  occurs  iu  two  rorms,^-oDe  with 
the  ^CB  closed  and  the  otlier  with  the  eyes  open.  The  appearance 
of  the  per«n  who  is  in  soniriambulii^m  with  doFcd  eyes  is  pre- 
:Iy  whnt  it  has  been  during  the  state  of  lethut^,  but  now 
the  word  of  command  the  i^omnambiilist  riAe:^,  marches,  and 
does  whatever  h«  is  commanded,  The  insensibility  of  the  skia 
remains,  but  the  special  !^>nses  are  awake,  and  even  muob  more 
acute  than  nornruil,  »o  that  the  subject  will  he  able  to  read  in  a 
darkened  room,  to  hpar  sounds  inaudible  to  others,  or  to  retvignize 
odors  not  perceptible  by  others.  There  is  aleo  in  some  cases  ex- 
altation of  Uiti  intellectual  faculty.  Thus,  a  young  man,  a  student 
of  mathematics,  during  an  hypnotic  state,  mlved  with  el^ance 
and  rapidity  problems  in  trigonometry  which  during  his  natural 
condition  he  had  ewayed  in  vain.  Ther<^  is  aliw  a  revi\-al  of  the 
DMmory  of  fiuTbt  apparently  long  since  forgotten,  and  even  nn  ex- 
prcHBion  of  remembrances  hitherto  unknown  to  the  consciousne^ 
of  the  imiivtdnni  when  nw»ke. 

The  phenomena  of  s<.'>mnnrnbulism  with  open  eyes  differ  from 
tliosc  of  somnambulism  with  closed  eyes  iu  that  instead  of  (he 
subject  being  aljsolutely  nntomaiic  he  is  full  of  an  unoi^nscioua 
activity,  and  when  left  to  himself  moves  restletiwly  hither  and 
thither;  at  times  he  offers  considerable  rewstance  to  the  will  and 
mand?  of  the  exfierimenler.  The  eyes  .ire  wide  ojwn,  with 
sight  fixed,  as  in  catalepsy,  upon  vucuitr.  or  there  may  be  m 
wild  eipreiision.  S[KMilmieou«>  hullucinations  apiKnr  frequently 
to  rise  within  the  brain  of  the  somnnmbnlist  and  to  find  expres- 
sion in  both  word  and  deed. 


404 


DUOKOBTIC  NECROLOGY. 


ily  a 

>bii[9 


Sl«ep  in  Iiuanity. 

Although  true  stupor  may  follow  upon  or  be  connected  wi 
pronounced  evklences  of  mental  sberrattoD,  yet  in  a  large  pi 
]>ortion  of  <iises  it  is  apparent  rntlicr  than  real.     If  an  i 
patient  lie  in  bed  absolutely  gtill   and   inert,  with   clasod  eyes, 
giving  no  rnsponse  to  the  loudest  quoAtiontng  and  making  only  a 
feeble  and  slow  resistance  to  personal  violence,^-or  if,  witli  h 
bent  forward,  joints  flexed,  aud   face  froxeu  into  on  immobi 
apiithy,  he  sit  motioalesa  in  his  chair, — he  seems  to  be  lost  in 
oonsciousnesf,  but  none  the  less  may  he  have  knowledge  of  his  sur- 
rouiidingrs  and  of  his  sorrows.     TSiis  lothar^-  may  be  the  direct 
result  of  au  iuleui*e  emotion  or  of  delu&iuu,  and  not  be  couddoosly 
assumed,  but  not  rarely  it  is  put  on  for  a  definite  end,  and  main- 
tainei)   with  a  tenacity  of   puriiosr  wludi   defies  detection  even 
during  the  intoxication  caused  by  ether  or  by  alcohol.     In  a  idi- 
jority  of  cas««,  however,  an  assumed  »tupor  «in  be  detected  by  llie 
use  of  iutoxicanta.     In  mauy  eaaee  it  is  im]K)!SJtble  to  penetrate  the 
veil  and  to  determine  why  the  intiane  person  keeps  up  for  months 
an  alwolute  silence  and  passivity ;  but  the  wcasional  revelation*      , 
made  by  patients  after  they  recover  their  reason  mIiow  that  a  de[i>fl 
sion  may  act  very  directly.     A  man  believes  that  he  has  received^ 
conirnaiidR  from  llie  Almighty  to  do  aK  lie  doeK,  htkI  battles  for  his 
eternal  salvation;   or  he  conceives  that  his  attendantM  are  con- 
spiring agninst  him,  and  will  do  him  great  evil  if  once  they  are 
assured  he  in  alive.    In  some  cases  the  lethargy  lb  the  result  of  an 
overwhelming  emotion  produced  by  the  delusion.   The  man  about       I 
to  be  devoured  by  foul  U-uHta  or  by  the  flames  of  hell  is  dutnb.^l 
through  fear^  or,  as  the  German  alienists  say,  is  tbunderstriKlt.  ^^ 
Occasionally  the  insane  83ee|»er  is  convinced  that  be  is  diad,  anJ 
by  this  delusion  his  will  is  so  far  paralyzed  that  it  is  unable  lo 
set,  and  the  man  really  cannot  move,  although  tlie  lower  nen-o- 
muscular  apparatus  is  intact. 

Toxeamlc  Sleep. — The  only  forms  of  toxtemic  sleep  which 
require  dlwcucMiiMi  are  tluwe  which  ariwe  in  chronic  Bright's  die- 
ea.'M*  and  in  diabeti'S  mellitits.     The  symptoms  of  unemia  haw 
already  been  snfliciontly  discussed,  and  it  only  remains  to  ooi 
sider  diabdir  coma, 

Coiua  occurs  during  the  course  of  diabetes  in  several  foi 


I 


DXBORD£US  OF  COKSdODSKESa. 


406 


h 


It  may  come  on  Iat«  In  tlic  liiscaiae  as  the  result  of  «i>condAr)-  or- 
ganic alterations  in  ibe  brain  itself.  In  another  claas  suddenly 
the  strength  gives  out,  the  |)ulse  betxmips  very  rapid  and  weak, 
the  extremiiiea  grow  cold,  and  in  a  very  few  minutes  or  hours  the 
patient  sinlis  into  a  syncopal  stupor,  which  end*  in  death.  The 
cause  of  these  tymjHonis  is  sudden  failure  of  a  heart  whoee  nins- 
de  has  degenerated.  Neither  of  these  two  classes  of  cases  are 
entitled  to  Iw  called  diabetio  coma.  True  diabetic  uunia  may 
ooeur  at  any  time  or  stage  of  the  disorder.  It  is  usually  pre- 
cedeil  by  a  tmin  of  nervous  symptoms,  which,  wllh  the  ooma,  are 
now  believed  to  be  due  to  the  preMciice  in  the  blood  of  a  aub- 
stanoe  produced  by  the  decomposition  of  the  sugar.  This  sub- 
starioe  i^  ttupiHWMl  by  some  authorities  to  be  aceto-aoetic  acid,  ami 
seems  to  be  at  least  an  acetone-producing  principle.  For  this 
t«f»oo  tlie  nanie  of  acfionamia  has  been  given  to  diabetic  coma. 
Tlie  peculiar  odor  of  acetone  can  in  most  cases  be  detected  iu  th« 
breath,  the  urine,  and  tlte  pcrepimtion,  whilst  usually  there  is 
sufHcieiit  w-etoue  in  the  urine  to  strike  a  Burgundy- red  color 
with  a  solution  of  chloride  of  iron. 

According  to  Prof.  Frerichs  (  Ueberden  Dudictea,  Berlin,  18S4), 
there  are  two  distinct  forms  of  iliabetic  coma.  In  the  one  variety, 
after  great  weakness,  gawlric  disturbance,  votnJting,  diarrhcea,  and 
perhaps  some  local  inHummation,  as  a  carbuncle  or  a  bronchitis, 
there  develop  he.idache,  restlessnew,  delirium,  exce^ive  anxiety, 
dyspncea,  with  very  deep  expiiutious  and  iuspiratiuuis  and  witli 
or  without  evident  cyanosis,  fall  of  temperature,  great  rapidity 
and  feebleness  of  the  pulse,  somnolence,  and  Bnally  coma,  which 
ends  ill  the  majority  of  cases  in  death  after  from  one  to  three 
daya.  In  the  other  form  of  diabetic  coma,  whilst  the  |)atient  is 
apparently  iu  good  iKxIily  couditiun  and  has  no  dyspntea,  head- 
ache, staggering  gait,  and  somnolence  suddcidy  come  on  and  eod 
in  a  coma,  which  invariably  proves  fatal  in  a  eliort  time. 

ORGANIC  STUPOR  AND  COMA. 

Organicdlseasesoftlic  brain  of  which  stupor  or  coma  isapromi- 
nent  oymptom  can  best  Iw  studio*!  for  the  pnrpoc-e  of  diagnosis  by 
dividing  them  into  ihuw  wliich  are  aocomjianietl  by  marked  head- 
acbt  and  those  in  which  headache  is  wanting.  These  grou])f;  I 
shall  respectively  note  as  Group  First  and  Group  Second, 


DIAGXOOTIC  NEUROLOOY. 


Gboup  FlItST.  Orgauic  brata-dUeuses  to  which  headache  tai 
istupor  are  prominent  Hymptomii  are  naturally  divided  into  two 
gets,  specific  and  noo-ajiecinc 

Non^pedjle  Stuporoue  Afedions, 

Brain-Tumor. — Stupor  is  liable  to  develop  st  any  time  during 
the  course  of  a  bniin-turnur,  although  it  is  in  no  eeosu  a  cbanie- 
terisiic  symptom  of  such  nfTcctton.  In  the  last  stages  of  brain- 
tumor,  when  the  surrounding  cerebral  substance  is  undergoing 
soAeniiig,  or  when  by  pressure  or  progressive  disease  the  ioipor- 
taut  vessels  ai-c  ioterfercd  wilb,  stupor  or  profound  coma  i»  very 
common.  The  rei-o^ition  of  such  a  coma  must  flepend  upon  the 
previous  study  of  the  case.  Of  different  import  is  the  stupor 
which  occasionally  develops  from  time  to  time  iu  the  earlier  stagei 
of  the  braiu-tumur,  and  is  not  dependent  u[)on  severe  strnctural 
lesions  of  other  |>ortion.s  of  the  l>rain  than  tlKkw  Iramedialelv 
implicated  by  the  growth,  but  to  a  general  cerebral  congffition. 
Such  stupor  may  or  may  not  be  aooompanled  by  convulsions. 
it  frequently  comes  ou  mpiclly,  and  may  in  the  course  of  a  feff 
hours  pasH  off,  or  may  remain  several  days  and  then  subside.  1 
liavc  seen  a  patieut  with  a  gliomatous  tumor  who  had  been  for 
several  days  absolutely  comatose,  passing  the  discharge*  involun* 
tarily,  and  thought  to  be  dying,  a  few  hours  later  walk  to  the 
clinic-room  Ju  a  distant  portion  of  the  hotjpital. 

Meningitis. — A  seiond  cause  of  organic  stupor  and  coma  ii 
infliimmation  of  the  meninges.  Acute  tncnlngiti.4  hnbitiially  ends 
in  eorua,  and  any  time  during  the  course  of  a  chronic  meuiugitts 
the  symptom  may  be  developed.  The  significance  of  coma  occur- 
ring iliiring  an  acute  or  even  a  chronic  meningitis  can  ;«aroely  he 
mistaken.  The  detailed  discussion  uf  the  symptoms  of  acute  and 
chronic  nietiingitis  will  be  entered  upon  in  the  next  chapter. 

Pachymeuinsritta  Hemorrhagica. — Pacliymcuiugitis  htetuor- 
rliogicit  is  a  ditiea&c  in  which  there  is  chronic  inflammation  uf 
tlie  dura  mater,  with  t}ie  formaiion  of  a  bloody  gmwtli  or  tumor, 
due  to  or  connected  with  repeated  hemorrhages  into  the  pnrt.  It 
is  esseotially  au  affection  of  old  age,  or  of  persons  who,  from 
syphilis,  scorbutus,  or  other  eoui^titutioaal  dyscrasia,  have  degen- 
eration of  the  vessels.  It  also  occurs  as  ii  secondarj*  affection  in  de- 
mentia psralyticn,  brain-atrophy,  hydrocephalus,  etc.     The  bead- 


I 

i 


DISORDERS  OP  COK8CI0USXE6S. 


407 


I 


* 


ach«  is  usually  severe  nod  throbbing,  in  most  cases  is  not  aoenrately 
localized,  and  ofleo  occurs  in  furioiu  paroxysms,  expecially  at  tbe 
time  when  fresh  hemorrhagts  lake  place.  The  motor  disturhouco 
nmrshow  ttwlf  in  pare^^is,  or  in  Imiilized  muscular  movelIlent■-^,  or 
in  general  epileptic  convulsions.  A  shifting  hcmiplt^a,  which  is 
DOW  on  the  one  side  and  now  on  the  other,  is  not  uncommon.  Mus- 
cular twitching  with  Hubjjequeiit  rigidity  may  aoporopaoy  or  follow 
the  shining  palsy,  and  permanent  hemiplegia  with  contracLious 
may  develop.  Conjugated  deviation  of  the  eyeballs  is  not  infre- 
quent, hut,  !U4  the  hsmatoma  Li  alma^t  invariably  on  the  vault 
of  the  cranium,  the  ocular  and  other  basal  nerves  are  nirely,  if 
ever,  involved.  If  facial  palciy  happen,  it  will  take  tlie  form  that 
is  chararteristio  of  central  brain -dtsnrrler.  Ps^'clilciil  disLurbanoo 
ifl  very  common,  and  vertigo  is  frequent.  The  pupils  may  be  con- 
tracted an<l  in!>enflib1e  to  light,  but  when  the  cerebral  compression 
is  marked  they  ililate.  During  conditions  of  cerebral  conipresaoo 
tlie  puliK*may  be  slow,  but  the  pui-'^e-rate  varies  almueit  indefinitely 
throughout  the  disorder.  Drowsincsti  witli  an  habitual  excca^  of 
fllwp  is  rarely  wanting  in  cases  whiuh  do  not  run  a  very  rapid 
oourae.  The  «tn[wir  may  lie  prolonged,  but  more  frequently  it 
comes  and  goes  m  the  cerebral  congestion  varies.  Profound  coma 
is  usually  developed  when  pressure  occurs  from  renewed  hemor- 
rhages, and  in  the  later  stages  of  the  disease  when  the  cerebral  sub- 
stanoe  is  undergoing  alterations  iu  the  neighborhood  of  the  lesion. 
In  a  large  pmi)ortion  of  cn«es  pachymeningitis  is  not  recog- 
a\z&.\  during  life,  and  tlte  diagnosis  may  be  inipuneible.  If  the 
patient  die  in  an  early  hemorrhage  the  symptoms  will  be  simply 
tbn«c  of  apoplexy  preceded  by  a  ronre  or  less  pronounced  head- 
ache. In  prolongo<l  cases  with  cImractciTstic  syniplonis  the  nature 
of  the  affection  should  be  made  out.  The  symptoms  may  resemble 
Terr  dosely  thoee  of  tubercular  nieningitia,  which  ts,  luwever, 
MB  aflection  of  children  :  if  the  patient  be  pa:^t  middle  life  and  be 
fi!«e  firom  tubercular  duteiue  in  oilier  |K>rtions  of  the  body,  the 
diagiioeis  of  pachymeningitis  h!emorrhI^{ica  would  l>e  justified,^-* 
diagnosia  which  would  be  greatly  strengthened  by  Jindiug  dt^^n- 
cntioo  of  the  vewicls  in  other  |iortions  of  the  body.  Choked 
diakf  In  one  or  lioth  eyes,  is  frequent,  and  the  coma  in  pachy- 
meningitis ocTflslonaily  has  rentisKions  and  exacerbatiaos  olo^ely 
rsembling  thoae  which  sometimes  occur  in  brain-tumur.    The 


T>IA0N08T[C  XEPROUXJY. 

afTcction  is  therefore  liable  to  be  confounded  with  braiD-tninor;] 
but  the  ag«  of  the  patieDt  antl  the  {>eculiar  drow^iueas  whidi 
ooture  between  the  cooiatose  conditiomi  usually  render  the  dtag- 
nasifl  posBihle.  Kurstner  hoH  culled  ottention  to  tlie  temperature 
of  tho  Iwly  as  a  means  of  diagnosing  bctwe«*n  pacliymeningitis 
haimorrhagica  and  a  cerebral  apoplejcy.  He  believes  that  in 
the  meningeal  hemorrhage  rise  of  temperature  ia  not  {jreceiled 
by  a  fall,  whilst  in  intra-cerebral  hemorrhage  such  fall  tisuallr, 
although  not  invariably,  occurs.  (^Arehiv  fur  Pttydiiatrif  uadlj 
NtritnkranUi(Uen^  1878,  Bd.  viii.  |>p.  1-31.) 

Spccijic  Stuporoiu  .'Iffediong. 

Syphilitic  Coma. — ^The  ordinary  l^ions  prodnocd  by  oerebml 
syphilis  are  meningitis,  localiiwd  or  diflused,  and  degeneration  of 
the  cerebral  vesaeU,     Either  of  these  changes  may  give  rise  lo 
tiomnolmce  or  to  profound  coma.     Such  tuma  li'ies  not,  how- 
ever, In  itM  syniploms  conform  to  a  regular  lv|)(>,  an  described 
Dr.  Julius  Althaus  {Mfdicat  XoM,  vol.  rlix.  p.  428),  but 
greatly  in  \tn  manifestations.     In  the  wardi^  of  the  PhiUdelphii 
and  University  IIotipilnlK  the  aQut^tJon  is  Mt  fretpient  tiiat,  aU 
though  at  least  sixt)*  per  cent,  of  the  cases  recover,  I  have  aeer» 
three  die  in  one  week ;  and  studies  made  cliiefly  in  tho.<»e  hospital 
lead  mo  to  divide  syphilitic  coma  for  the  purpose  of  dtscussic; 
into  several  varieties. 

The  first,  anil  least  cumnion  form  may  W  known  as  tnma 
droi/ant,  or  Jtdmlnating  coma.  The  i^yniploms  in  such  cases 
appear  to  develop  .•'u<lden!y  in  the  niitUt  of  good  health,  but  I 
lielieve  that  close  ejcaiainutiou  will  ."how  that  headache,  vertigo,  or 
sutue  other  indication  of  organic  brain-lf^lon  has  always  preceded 
the  violent  attack.  I  do  not  Ix'lieve  that  acute  syi>hilitic  menin- 
gitis or  an  acute  ooma  develops  an  a  primary  lesion  or  an  a  pri- 
mary symptom :  both  the  leaiou  and  the  syuiptum  are  preceded  by 
the  formatiun  of  the  gunitnatuus  tumor,  or  by  pronounced  d<^Q- 
enttioD  of  the  vessels.  It  it*  certain,  however^  that  the  structural 
dJHease  may  Ije  essentially  latent,  atid  the  attack  ap)RMr  to  come  ou 
abruptly  in  the  midal  of  health.  An  acute  fulminating  ttyphilitic 
coma  might  theoretically  depend  n|K>n  the  obliteration  of  the 
t«rebral  vissels  by  etnlwluii  or  thrombus.  In  such  cast;  the  symp- 
toms would  i>e  thoAc  of  embolism  or  thromboitia  from  other  tha 


DISORDEaa   OP   I.Y)NSCIOlIBNE8B. 


409 


I 


S|ieci6c  mawB.  The  altenitions  in  tlie  cerebral  vessels  pruduueiJ 
by  syphilis  arc  slowly  progressive,  and,  although  they  not  rarely 
end  in  cerebral  softening  «*irh  ib«  accompanying  stujKtr  and  coma, 
the  Bymptoni»  in  all  tli«  cases  which  I  have  seen  have  developed 
slowly;  the  blood-current  seems  to  be  gradually  sliut  oflf.  Fou- 
dnn'ant  or  frilminating  syphilitic  ooma  is  an  outcome  of  a  ganO'- 
niatou;*  inflamniaitoH  or  growth. 

The  stupor  may  or  may  not  be  accompanied  by  delirium  or  by 
convulsions.  A  man  about  thirty  years  of  age,  whom  I  saw  in 
consaltatioD,  thought  himself  in  }>crfcct  health,  but  became  very 
drowsy  about  the  middle  of  an  BHernoon,  and,  going  to  the  back 
of  bis  store,  fell  ajtlecp.  Being  found  in  tins  condition,  he  was 
aroused,  and  with  assistance  got  up-stairs  to  bed.  Veiy  shortly 
afterwanls  he  lieeame  comatose,  with  deliriouK  outcries  and  furious 
CQDvuUions.  In  a  case  reported  by  Dr.  J.  A.  Omicrod,  a  man  who 
had  l>een  in  gooil  henllh,  with  the  exception  of  heailache,  awoke 
one  morning  in  a  scmi-<]el{rious  condition,  and  for  three  days  slept 
at«adily,  arousing  only  for  mealii:  after  this  there  was  impairment 
of  memory  and  of  the  other  meulal  faculties,  but  there  were  no 
rnorf!  market]  sympioms. 

In  the  cases  reported  by  Dr.  Althaus  the  coma  developed  rap- 
idly and  quietly,  and  in  several  instances  during  sleep,  m  that,  al- 
tliough  to<.^l  or  general  couvulsive  symptoms  may  be  pruuounced 
in  fulminating  syphilitic  coma,  the  patient  may  be  completely  quiet 
Bod  relaxed.  Under  these  cireiimstanceB  the  ttyroptoms  are  simply 
those  of  profound  ooma.  There  ia  nothing  in  the  coma  itself 
which  will  eoable  us  to  distinguii^hed  its  specitic  source.  Hemi- 
plegia or  cviden(?es  of  liYcal  }ialsy  are  usually  wanting,  but  I 
have  no  doubt  that  it  is  i>ossibIe  for  them  to  be  present:  in 
ths  cose  which  I  have  juiit  mentioned,  after  recovcn'  of  con- 
sciotisiwse  partial  hemiplegia  was  very  noticeable.  The  condition 
of  the  puli«e  varies,  aa  it  does  in  coma  from  other  caus^B.  The 
rate  may  fall  far  belcjw  normal,  or  the  i)ulse  may  )>ccome  rapid 
and  fitful,  or  it  may  be  bard  and  wlr>':  it  may  be  large  with 
high  tension,  or  it  may  Ix*  large  and  soft.  The  cause  of  the 
coma  i4,  I  Ix'tieve,  couget^tiou  of  the  brain,  entirely  parallel  to 
that  which  occurs  iu  cases  of  Don-spcoi6o  cerebral  growtlis.  The 
Roogni^ion  of  tlie  fut^  that  tite  symptoms  are  not  pecidiar,  and 
are  due  to  a  sooonilary  oongcstion  of  the  brain,  is  very  important. 


DIAGXOSnC  NETHOWWY. 

becHUW  it  leafls  to  the  practli-al  coDclu^iou  tlmt  the  6r!!l  Irtaittueat 
of  such  a  case  miut  be  precisely  that  which  would  be  used  for  ilie 
relief  of  similar  Hymirtoms  due  to  nou-8|K*cific  bra  in- lesions.  In 
some  ca«€s  life  has  been  saved  only  by  free  venewction.  After 
the  acute  oymptoms  have  beea  nubdued,  very  active  specific  treat- 
ment should  \k  instituted. 

The  second  variety  of  syphilitic  *»ma  develoi*  gradually.  The 
patient  sibt  all  day  long  or  lies  in  bed  in  a  -ttatc  of  flemi-^tnpnr, 
indifferent  1o  everything,  but  capable  of  being  aroused,  ansivering 
quetttiotis  slowly,  imperfectly,  ainl  without  couiplaintt  but  in  au 
instant  dropping  off  again  into  hia  ({uictude.  In  other  cases  the 
sufferer  may  wtill  be  able  to  work,  but  often  falls  aeleep  while  al 
his  tasks,  and  especially  towards  evening  hatt  an  irresistible  desire 
to  slumber,  which  leads  him  (o  pass,  It  may  be,  half  of  bis  time 
in  sleep.  This  stale  of  [mrtial  sleep  may  precede  that  of  tin 
more  continuous  stupor,  or  may  pass  oCf  when  an  attack  uf  hemi- 
plegia seems  to  divert  the  symptoms.  The  mental  pheoomesa  ia 
the  more  aeverc  caics  of  *winnolency  arc  peculiar.  The  patient 
CAD  be  aroused, — iudeed,  in  many  iut>taDce«  he  exists  in  a  state  of 
torpor  rather  than  of  sleep;  wheu  sttrretl  up  he  thinks  with  ex- 
treme slownesH,  and  may  appear  to  have  a  form  of  aphasia;  yet 
at  intervals  he  may  be  endowed  with  a  peculiar  automatic  activity, 
e«[»ec[any  at  niglit.  Getting  out  of  be<l ;  wandering  aimlessly 
aud  »cemin)^ly  without  knowle<.lge  of  where  he  is,  and  nuablc  to 
find  hits  own  ImhI  ;  priHsing  his  excretions  in  a  comer  of  the  room 
or  in  other  similar  place,  not  because  ho  ia  nimble  to  control  hin 
bladder  and  bowels,  but  because  he  believes  that  he  is  in  a  propei* 
place  fur  such  acts, — he  seem»  a  rts<tle-i«  nocturnal  uulumaton 
rallier  than  a  man.  Apathy  and  indiflerence  are  die  charac- 
teristics of  the  somnolent,  state;  yet  the  ^Mitient  will  sometimes 
show  excessive  irritability  when  aroused,  and  will  at  other  periods 
complain  bitterly  of  palii  in  UU  head,  or  will  groan  as  tliough 
sulleriug  severely  in  the  midst  of  his  stu[K>r, — ut  a  time,  too,  when 
he  is  not  able  to  rcn^nizc  the  scat  of  the  pain.  I  have  seen  a 
man  with  a  vacant,  apatlietio  face,  ainiotrt  complete  aphasia,  per- 
sistent heaviness  and  stupor,  arouse  himself  when  the  stir  in  the 
ward  told  him  that  the  attending  physician  was  pre^rnt,  and  ooni4 
forward  in  a  dazed,  highly  puthetio  manner,  by  signs  and  broken 
utterancfcH  begging  for  something  to  relieve  his  head.     Heubuer 


k 


DISURDERS  OP  0058CI0C8XESS. 


411 


speaks  of  caeea  in  which  tJie  irritability  was  such  that  the  patieDt 
foof^ht  vigorottsly  when  aroused  :  this  I  have  not  seen. 

After  some  dajrs  of  eioeswive  somnolcnpft  and  progressive  deep- 
ening of  the  stupor,  or  aooietimes  more  rapidly,  ihe  victim  of 
cerebral  syphilis  may  pass  into  a  condition  of  profouud  ooma, 
out  of  which  ho  cannot  be  aroused,  and  during  which  his  fscccs 
and  urine  nrp  either  not  pa^eed  at  alt  or  are  voicied  iuvolunlarily. 
Thia  condition  of  coma  may  end  in  denth  ;  but  oven  when  the 
symptom  seems  raoet  aerious  the  patient  may  gradually  recover, 
slowly  emerging  from  ooma  into  stupor,  and  from  stupor  into 
wahefnlncsd  and  normal  life.  I  have  Mrvcrat  times  &ccn  excessive 
somnolence,  lasting  four  or  five  mouths,  ilnring  moHt  of  which 
lime  the  patient  was  aclually  comatc«e,  more  or  less  thoroughly 
recovereil  from.  In  wu««t  of  these  cases  hemianopsia,  or  motor 
palsy,  or  altered  mental  power,  baa  remained  to  show  that  the 
brain  had  been  iiermanenily  (InmagwI.  On  ihe  other  hand,  e%-en 
UQ  extreme  cases  the  recovery  may  be  complete. 

Syphilitic  stupor  ending  in  death  usually  puts  on  gymptonia 
exactly  n«en]blii,g  thuae  of  ad\'anced  braiii'fsofteniug,  to  which, 
indeed,  it  is  in  mofit  cases  due.  I  have  made  three  autopales  on 
snch  mses:  in  one  there  wa^  symmetrical  pnrnleut  breaking  down 
of  the  anterior  cerebral  lobea ;  tn  the  second,  softening  of  the  right 
frontal  and  temporal  lobes,  due  to  pressure  of  a  gummatous  tumor; 
in  the  third,  softening  and  breaking  down  of  the  brain  in  the 
region  supplied  by  the  middle  cerebral  artery,  probably  as  tho 
result  of  an  arrest  of  circnlation. 

■  Qboup  Second.  The  organic  brain-diseases  M'bich  produce 
stu{>nr  but  are  not  a;^>ciated  with  headache  are  not  very  numer- 
ous: prominent  among  them  is  dementia  paralytica,  in  which  dis- 
eaae,  however,  the  stopordoes  not  come  on  until  %-ery  late  in  tho 
affection.  In  all  forms  of  cerebral  softening  stupor  or  ooma  ts 
finally  developxl,  and  if  such  softening  be  due  t<i  dlMiasc  of  the 
blood -X'CseeU,  to  cerebral  sclerosis,  or  to  other  affection  whicli  does 
not  involve  the  brain -membranes  or  markedly  increase  the  blood- 
PRsrare  in  the  brain,  headache  is  tbtuully  wanting.  A  rare  but 
iniportaut  aOectiou,  of  w-hich  stupor  is  the  most  prominent  symp- 
tom, is  one  whkh  hai4  nut  been  heretofore  generally  recognized  as 
.distinct  disease,  although  cases  of  it  have  been  reported. 


413 


DTAONOenC  NEOBOLOOT. 


There  is  ao  much  uuity  of  structure  id  the  ganglionic  celk 
throaghout  the  nervous  system  that  it  can  hardly  be  otbenriae 
than  that  a  pathological  process  which  afTecte  one  set  of  these  celb 
sliall  find  lis.  laralle)  to  the  disease  of  otlier  oelln.  A  sderoaiB 
may  attack  any  portion  of  the  white  matter  of  the  nervooa  oen- 
tnw,  and  in  like  manner  I  believe  that  the  peni liar  degeneration 
which  occurs  iu  poliomyelitis  may  atutault  the  nervous  cells  of 
the  cerebrum.  Under  the  circa mstanoes,  loss  of  fuuctioo,  with 
or  without  evidences  of  ])niiuLry  irritation,  must  result.  For 
this  afl'ectioi]  the  name  of  Polioencfpliatitis  is  very  auitablc. 

In  some  cases  of  poliomyelitis  fever  and  other  evidences  of  ood- 
stitutioual  disturbances  are  pronounced  iu  the  1>egiuutn(;  of  the 
disease;  but  it  does  not  follow  from  this  that  tlie  chonj^  in 
oclls  are  due  to  aiuite  tiiflammation,  much  less  have  we  any  pr: 
that  the  slow  iilCerations  which  occur  in  the  subacute  and  chronio 
forms  of  the  so-called  poliomyelitis  are  inflammatory. 

It  is  probable  that  all  these  forms  of  poliomyelitis  are  repr^ 
sented  in  affections  of  the  cerebral  cortex ;  but  the  only  oases  o( 
which  I  have  knowltxlgc  iti  which  the  nature  of  the  disease  hu 
been  proved  by  post-mortem  examioation  represent  tbe  subactite 
forms  of  the  aOectiou.*  | 

The  [mUy  and  the  trophic  changes  of  poliomyelitis  are  evi- 
dences of  loss  of  functiouul  ]^>uwer.     Symptoms  due  to  the  irrita 


.ue 
re.1 


«  It  !•  ponibb  tb»t  Ills  cwwa  dwcribed  by  Dr.  AdoirStrilBip^l  (Ah 
Wiener  Med.  Zeitang,  1884,  29)  under  Uw  oamfl  of  encephalitu  of  cbfldliosd 
may  rcpmont  the  acute  form  of  pollomfftlitli;  bat  it«  In  do  cflM  vu  u 
fluiojiay  ma(l«,  and  ae  the  sjrmptomi  clo«ely  reseuMe  those  of  ordiDarr  infin- 
lilo  KpHNtic  piimlvsia,  thn  itmlter  in  op«n  U>  muvli  doubt,  oxpAcinlly  ■ioca  Th. 
Htrumpell  »tote«  tliat  bo  has  never  leen  tb«  alTection  in  lis  earlier  eUee«,  sod 
but  bad  tu  n^ly  upon  tb»  FtHtHiiKJii U  uf  purenu  for  lliv  dcMsriptioa*.  Accord- 
ing U)  ihfiBO  itutcmetiu,  the  lit^knem  ci>minen(?«a  with  fever,  Tomiting,  and 
CODTQliiAns,  nr,  in  «<>mc  mild  CMec,  with  a  Rhort  oonvuUlon  and  •light  fobfilft 
reaction.  Thii  lUgo  is  >aid  to  Uit  from  two  daya  tu  a  muntb,  during  wbicb 
tlma  the  parnnta  havo  ifOti>c043  parHly*!*  of  ono-half  of  tbe  body  or  aometiiiMa 
of  a  single  estremily.  Tbe  betniplsigia  Is  never  complete,  Ibe  p&ralybla  onea 
affecting  gruupo  uf  ehukcIik  und  conatitulifig  ii  muUi{iht  paUy.  There  an 
DO  trophic  ('liani;ea,  and  in  many  caM>a  facial  or  ocular  palsy  shows  tlial  the 
ni-r%'iiui  tyKtiMit  \*  aflfKtvd  vrry  high  tip.  Afirr  tho  ncute  stag?  had  paaaed, 
at  the  f<erJod  when  the  cues  were  seen  by  I>r.  StrOmpell,  there  were  marked 
contractu rj?,  witb  inoreaie  of  tbo  reflexes,  to  some  oaaee  there  was  athetMU. 
Epileptic  atucks  were  not  InlVsquent,  and  not  rarely  there  waa  marked  mental 
degoDorAiioD. 


d 


DISORDERS   OF   CONSCIOUSNESS. 


413 


tion  of  the  gauglionic  cells  seem  to  have  n<y  place  in  the  affection,, 
unless,  indeed,  the  convulsions  which  usher  iu  the  attack  be  looked* 

B  upon  as  of  such  character,  but  these  are  probably  cerebral,  aud 
sympathetic  local  »paHiiiA  do  not  occur,  w  should  be  expi-cted  if 
there  were  any  iiersistcnt  irritation  of  the  motor  ganglionic  cells. 

■  In  like  manner  the  symptoms  of  polioenoephnlitiji,  at  least  of  the 
subacute  cases,  are  the  uutconie  of  failure  of  function.  They  may 
be  >4ummed  up  as  failure  and  ])erver«ion  of  intellectioD,  pcrelstent 
stupor,  muscular  relaxation,  aoEeetheeia,  and,  in  cases  which  do 
not  recover,  death  in  a  stujiorons  dementia.  It  is  well  known 
that  in  |x>liomyelitis  partial  or  even  complete  recovery  .sometimes 
takes  place,  although  the  aymptomti  have  seemed  deitperate,  and 
H  is  probable  that  some  of  the  ca^cs  of  persiHtent  stupor  occurring 
among  the  insane,  followe*!  by  more  or  less  imperfect  recovery, 
are  instances  of  polioencephalitis. 

I  The  following  case  is  reported  hy  Br.  Legrande  du  Saiille  ((?a* 
rrtte  deg  HGpitaux,  1869,  xHI.  605),  I  conceive  it  to  be  a  cliar- 
acteristic  instance  of  subacute  polioencephalitis.  A  man,  aged 
thirty-two  yesira,  became  mclancliolic  during  June,186d.  On  the 
lOlh  of  September  he  went  into  a  profound  sleep.  The  eitremitiea 
were  rigid,  the  respiration  rapid,  the  pulse  aeventy-two,  and  geu- 
eral  sensibility  very  obtuse.  About  a  week  after  thi.s,  general 
niusinilar  relaxation  developed,  tlic  cutaueou.s  ana^the^ia  liecame 
complete, and  intestinal  inertia  very  pronounced.  The  respirations 
were  from  twenty-four  to  thirty-two  a  minute.     By  October  the 

ft  temperature  of  Uie  body  had  fallen  to  niuety-six  d^reee,  emacia- 
tion  had  become  extreme,  and  the  bowels  were  opened  only  once 
in  ten  or  twelve  davH.  On  tlie  4th  of  November,  after  a  blister 
to  the  head,  he  suddenly  cried  out,  "  My  God,  my  God,  have  pity 
on  me,  for  I  am  about  to  die !"  but  a  moment  afterwards  relapsed 
into  fttupor.  The  ])idse  during  Octol>er  was  forty-four  a  minute, 
but  Willi  his  gcncrul  condition  began  to  improve,  and  by  the  dose 
nf  yovcmber  the  pulse  was  nearly  natural  in  frequency  and  tlio 
lotetilinal  action  about  normal,  but  the  stupor  persisted.  The 
urine  was  normal,  except  tiiat  it  contained  some  excess  of  uric 
acid.  Inloxitsiion  wiih  aloohol,  ether,  and  hasheesh  failed  to 
elicit  any  sign  of  mental  life,  as  did  also  the  eflbrls  of  a  magnf- 
timir.  The  optic  papilla  was  very  pale,  and  opaque  from  serous 
trauMidalion.     The  man  died  of  pneumonia  in  the  latter  part  of 


114 


PIAOKOfmC   NRITROIiOOT. 


March.  A  Ihorongh  autopsj' showed  that  tlie  cerebral  gray  matter 
had  cliangeH  color  to  a  [lale  gray,  through  which  were  scntiered 
gbarply-definwl  Ulets  of  exce.'sivc  vascularity.  The  norve-celUof 
the  cerebral  convolulioos  bad  almost  completely  disappeared. 


A0Cn>ENT8   OP  SLEEP. 


I 


Under  the  head  of  accidents  of  sleep  I  propose  to  coosirler, 
briefly,  6r8t,  certain  curious  symptoms  which  have  do  connec- 
tion with  dreaming;  secondly,  certain  states  which  arc  cloeciy 
ooDuectcd  willi  ilreamiiig. 

In  the  first  division  of  the  present  subject  the  disturlnncesan 
chiefly  f«nsory.     The  most  im|>ortaiit  of  them  is  that  to  whicii  tlie 
name  of  satw-»fiovI:  has  heeu  given  by  Dr.  Mitchell.     It  Js  mtst 
frequent  in  hysterical  women,  but  docs  occur  in  men,  especially 
in  thi**  of  a  iieuriitln  tern peni men t  who  are  overworked.     It  is 
usually  felt  at  the  time  when  the  subject  ia  passing  from  waking 
to  sleep.     A  wnsation  like  an  aura  rises  from  the  feet,  or,  men 
rarely,  from  the  hands,  and  [Miases  upward  to  tlie  head,  where  it 
disappears  in  the  sense  of  a  blow  or  shock,  or  of  a  bursting  in  iht 
head :  not  rarely  at  the  time  of  the  explosion  the  patient  hears  a 
loud  noise,  or  sees  a  vivid  flasfi  of  light,  or  perceives  a  strong  odor. 
In  some  cases  two  or  even  more  of  these  sensory  manifestaliinf 
are  present  tcigether.     Tliere  is  no  loss  nf  oonsclousnesB,  and  soy 
motor  symptoms  which  may  occur  are  the  outcome  of  the  owr- 
powering  terror  which  is  felt  during  the  rrisis  and  is  sometiraa 
manifebted  by  a  shriek.     Occasionally  a  number  of  thecfe  sliock) 
follow  one  another  at  short  intervals.     The  paroxysms  may  occur 
during  the  daytinif.    These  atiackn  may  be  exi^saively  aonoyiog, 
but  they  have  no  serious  significance,  and  arc  to  be  looked  obM 
hysterical. 

A  sIee|>-«ymptom  which  Dr.  Mitchell  states  that  he  hsa 
in  Dudionuc's  disease  is  that  to  which  the  name  of  nigfU  paliifflt 
noriunuil  heniipUi/ia  has  l>een  given, — a  name  which  seems  to  toe 
improper  and  misleading,  as  the  symptom  is  not  connected  with 
loes  of  motor  [K>wer,  and,  in  my  experience  at  least,  is  never  of 
serious  )m[K>rt.  I  have  frequently  seen  it  in  hysterical  ur  neurotic 
women,  especially  at  the  time  of  the  menopause,  but  never  in  or- 
ganio  nervous  diocase.  It  consists  simply  of  a  feeling  of  numboea 
ID  oite  or  more  extremities  of  tlie  body  when  ttie  sleeper  awakafc 


i 

iworV 


DIHOHDBRS  OP  0ONSCIOUS>'BSS. 


415 


I 


The  most  common  seat  i«  one  arm;  but  the  s)-raptom  may  be 
homipI(^o,  nr  may  affect  the  wbole  body.  It  certainly  is  not  tlie 
result  of  lying  n]>nn  ihe  part,  nor  is  it  nny  indication  of  heart- 
dtBesne  or  of  orgaDic  nervuuH  ili»ea^.  It  appears  to  me  to  be 
Hmply  one  of  the  Dumerous  hysterical  i^mptoma  whose  exact 
nature  caanot  be  exptniiiet]. 

SamnanUmiigm. — Somuambutism  is  cle6ne«l  by  Dr.  H.  Barth 
(Du  Somrneii  nan-rutturfi,  Paris,  1880)  to  be  a  dream  with  exalta- 
tion of  the  memory  and  of  the  automatic  activity  of  the  nerve- 
oentroe,  combined  with  abvence  of  couscioueiiess  and  gpontaueouB 
will.  It  is  common  for  a  uieejier,  be  he  eillier  human  or  brute, 
M  give  evidenoe,  by  speech  or  by  movement,  of  the  dreams  that 
'■•n  cour&iug  through  \n»  brain.  Such  evidence  may  in  the  dog 
be  no  more  titan  a  bark,  or  an  impoteot  ruuuing  motion  of  Uie 
feet,  or  a  wagging  of  the  tail ;  whilst  in  the  man  restless  tofi(>iDg, 
movemetit-s  of  the  ttande,  or  miitierwl  words  may  lie  iJie  sole  indi- 
catioQ  of  what  is  going  on  within.  A  step  beyond  thi.%  and  the 
dreamer  acts  in  accord  with  the  drama  which  is  being  enacted  iu 
his  iiiu^oatioii.  Thus,  a  luau  strikes  hiii  wife  iu  the  I^ttef  that 
h«  U  wreittling  with  burglai^.  Sometimes  after  Bueh  agitated 
movements,  or  in  the  midst  of  an  apiKircnlly  profound  quiet  re* 
poae,  the  sleejier  Tisen  from  his  bed,  and,  unclothed,  or  aHer  first 
drwsing  himself,  [>as;r'es  altout  bis  room,  opens  his  door,  goes  out, 
or  does  other  actii  with  continuous;  rapidity  of  movement.  Every 
grade  between  the  slightest  dream-movcmt^nt  and  ihe  mn^t  active 
sleei>< walking  exuiis ;  but  whenever  a  dreamer  rises  from  his  couch 
he  may  he  i«aid  to  be  a  somnambulisl. 

If  the  ^^oraDambulist  l>e  approached,  bis  eyes  will  be  found  to 
be  closed,  or,  if  open,  with  the  rest  of  the  fiioe  they  are  impossible 
and  without  expression,  paying  no  attention  to  the  brightest  lights, 
and  appearing  to  have  no  power  of  sight  in  them :  yet  obstacles 
are  avoided,  narrow  places  passed  through,  feats  of  balancing  jter- 
form«d,  and  numerous  complicate*!  movements  made  so  perfectly 
that  tbe  by-slander  can  hnnlty  i>ersuade  himself  that  the  itleeper 
,j|.noc  awake.  When  seiznl  hold  of,  the  somnamhutist  usually 
'^4Mtsta  with  vigor.  Ijctt  to  himself,  after  wandering  for  a  greater 
or  leas  length  of  lime  he  returns  to  his  bed,  covers  himself  up, 
and  sinks  into  the  quiet  forgetfulncss  of  normal  sleep, 

In  tlie  milder  forms  of  somnambulism  it  is  sometimes  possible 


416 


DIAOSOfiTlC   NTPnm/MJT. 


to  turn  the  thoughts  of  the  sleeper  b^  spenking  to  him,  and  id 
obetlionne  to  a  Arm  coninmnd  he  will  return  to  his  bed  without 
awakeniDg.     Shaken  a  little  strongly,  or  aroaaed  with  a  dash  of' 
cold  water,  be  awakens  slowly,  and  in  a  little  lime  is  convcioosot 
his  eDviroumeiit. 

In  the  tiiure  severe  forms  of  Horn nambul ism  the  paroxysm  lasts 
for  a  oonRiderabIc  time,  and  during  its  continuance  acta  are  per- 
formed which  seem  impossible  to  an  unconscious  man.  TIiil*.  the 
somnambulist  will  actively  rehear«e  that  which  during  wakiog 
hours  oceupica  his  thoughts  and  his  acts.  A  parson  will  prepare 
his  sermone,  a  atiident  lahor  over  his  taaka,  an  artisan  toll  wiili 
his  hands.  Boui^arol  (Union  Mi-<L,  1861)  records  the  case  of  a 
sailor  who  would  r'\^  J'rom  his  hammock,  wander  about  the  vasel, 
cliinh  the  ma.'^ts,  and  high  above  the  sea  go  through  the  duties  of 
the  forctoimian.  Barth  recounts  the  caw  of  a  student  whom  hit 
comrade  saw  get  up  and  go  into  his  study  and  compose  a  piece  of 
Tjalin  verse,  but  who  on  tlie  morrow  was  ignorant  of  all  that  he 
had  douc,  and  reportcil  to  his  profussor  thai  through  lack  of  limi 
he  had  heeu  unable  to  perform  his  allotted  task.  Sometime 
the  Romnnmbtilist  will  reproduce  by  wool,  gesture,  or  act  sceDet* 
which  emotional  excitemcot  haa  impressed  upon  the  nenroua  o^ 
ganism.  Such  was  the  case  of  a  youug  girl,  cited  by  Barth,  who 
would  recount  with  detail  in  word  and  ac'tacrirainal  ttssaalt  from 
which  she  had  surtered. 

Even  in  the  mildest  formn  of  the  affection  a  mmnarobiiliAt  im^ 
be  leii  by  his  dreams  to  acts  of  violence,  and  in  llie  severer  parox- 
j'sraa  serious  injury  may  result.  ^M 

Barth  quotes  a  case  originally  recorded  by  Alfred  Maury,  io 
which  a  IiUftband  attempted  to  throw  his  wife  ont  of  the  window^ 
whilst  dreaming  that  his  house  was  on  fire.  M.  Fod6r€,  in  hi»^ 
treatise  on  medical  jurisprudence,  details  a  case  related  to  him  by 
a  prior,  who,  going  very  late  to  bed  one  night,  saw  one  of  the 
brethren  walk  in  his  sleep  up  the  entry,  open  the  door  of  his  (the 
prior's)  room,  and  pas's  in.  For  a  moment  the  somnambulist  stood, 
with  ojwu,  fixed  eyes,  and  an  expra^siou  of  determined  rage  Uj)0Q 
his  face,  and  then  miin-hLtl  to  the  beil  with  a  drawn  knife  in  one 
hand.  Pasiiing  his  unarmed  hand  over  the  bed,  he  seemed  to  feel 
the  presence  of  some  one  io  it,  and  then  struck  fiercely  with  the 
knife  three  times,  forcing  the  blade  through  the  bedclothes  deep. 


lie 


ep^ 


DISORDERH  OP  CONSCICIDRHEBB- 


417 


into  the  maitreKJ.  After  this,  with  an  air  aiid  ex|)rp<«ion  of 
great  aatisfflction  ou  liis  fnoc,  he  turned  and  went  back  to  his  own 
bed.  The  light  of  two  Iflmpa  shone  in  the  room,  and  apparently 
fell  directly  upon  the  eyes  of  the  soiiiuanibuliHt,  but  elicited  no 
TCifwnsc.  The  next  raoruing  the  prior  seat  for  the  brother,  who, 
on  l»eing  urgently  questioned,  eaid  that  he  had  had  a  frightful 
drtam  the  aiglit  before.  He  had  dreamt  that  the  prior  had 
killed  his  mother,  that  her  bloody  ghost  had  appeared  to  him 
demanding  vengtnnce,  and  that  under  ittt  direction  be,  in  a  (raD<4- 
port  of  fury,  had  forced  his  way  into  the  aiwrtmcnt  of  his  superior 
■nd  killed  him  with  a  poniard.  He  ended  his  aconimt  by  ex- 
pressing the  immense  relief  which  be  had  experienced  when  be 
awoke  and  found  that  all  was  but  a  dream. 

A  case  which  ended  more  tragically  was  tried  before  the  Eng- 
lish courts,  and  was  rcjiorted  by  Dr.  Yellowlees  in  the  Journal  of 
MaUalScUvce  forOrtolH?r,  1878.  The  history  was  that  the  family 
of  the  prisoner,  while  he  waa  still  a  mere  lad,  lived  alonfjside  nf  a 
mailing  torrent,  and  that  often  be  would  arise  tn  his  ^leep  and  go 
to  the  landing-plaix.',  and  eveu  into  the  water,  loudly  calliirg  his 
&vorite  sister  by  name,  feeling  out  with  hie  arms  as  if  rescuing 
her  from  drowning.  Sometimes  the  water  awoke  him,  and  some- 
timef«  it  did  not,  but  afler  his  efforts  he  would  go  quietly  to  bed. 
A»  his  life  went  on,  he  became  wore  and  more  liable  to  aeixures  of 
night- walking,  which  6nally  f<cttlcd  down  Into  a  common  type. 
During  hin  sleep  terror  would  ^etne  upon  him,  and  be  would  start 
oat  of  bed  to  escape  or  put  aside  the  impending  evil.  In  his 
dreams  the  house  would  be  on  6re,  the  walls  would  be  crushing 
htm,  or  his  child  would  be  falling  down  a  pit,  or  stilt  more  fre- 
qoently  a  wild  l^eai^t  hn<l  come  into  the  room  and  was  about  to 
daronr  him:  maring  franticfilly,  niul  in  an  ngony  of  fcttr,  he  wnuhl 
tear  his  wife  and  child  from  the  bed  and  fiercely  chase  tlie  wild 
boast  through  the  room,  throwing  the  furniture  about,  and  striking 
wildly  with  any  weapon  tltat  lie  iwnld  reach.  Ou  wverul  ocra- 
■iaiia  he  had  seized  a  companion  by  the  throat  and  strangled  him 
almost  to  death,  under  the  idea  that  he  was  struggling  ^vith  the 
wild  beast.  In  some  of  ibcMe  paroxyems  he  would  hear  and 
annrer  distinctly.  One  night  he  saw  a  Ui^  white  beast  fly  op 
through  the  floor  an<i  ptt»i  lu^'ards  the  bed  where  ihe  child  lay :  to 
save  it  be  gripped  it  by  the  breast,  and,  roaring  with  terror,  hurled 

27 


418 


DIAGNOSTIC  yEimOLOOY. 


\ 


it  againtit  the  wall  with  wioh  force  that  it  fell  dead.  That  the 
poruxysui  rcsembleil  an  attack  of  epileptic  deliriuiii  is  apparent; 
and  Dr.  Ecbeverria  {JfrnrwU  of  Menial  IXwue&i,  Januan-,  1879) 
attempts  to  prove  that  the  {utient  renlly  suflercd  from  noctumal 
epile])^.  The  fact,  however,  iliat  the  man  could  be  awtUEciKd 
during  the  paroxysms  indicates  ver^'  strongly  that  the  attack  was 
iiut  a  pure  Gpilriwy,  which  is  ooufirmed  iu  a  Diea§ure  by  the  total 
absenoe  of  epileptic  phenomena  duriug  the  daytime.  The  uri- 
nary incontiuence  which  Dr.  Echevorria  speaks  of  as  having  lieeo 
preseut  and  as  evidence  of  the  epileptir  character  wrs,  aci-oniing 
to  tlie  report  of  Dr.  Yellowlees,  essentially  difTenrnt  from  ihe 
iDOOiitiiicnce  of  nocturnal  epilepsy.  It  nccurreii  only  daring 
childhomi,  and  entirely  indejiendenlly  of  the  |>aruzy$iD,  and  was  j 
simply  the  iitcontinencc  of  a  feeble,  neurotic  child.*  I 

The  80-called  mght-ftrrca-*  of  childhood,  although  frequently 
spoken  of  as  a  disthict  aflection,  are,  in  truth,  only  a  form  of 
soninamhuli;!im,  or,  in  rare  coses,  epileptoid  ^izures.  Notbing 
is  mure  common  than  for  a  young  child  to  go  in  Uie  night  lo  itfi 
parents'  bed,  trembling  with  terror  or  weeping  bitterly,  with  the 
statement  that  It  has  had  a  bad  liream.  Such  a  di-eam  may  be  » 
vivid  as  completely  to  enchain  the  attention,  and  tf  at  the  hum 
time  tlierc  be  outward  manifestations  of  the  ovcr[)oweringaito> 
tions  from  whicli  the  rliild  is  suflcrlng,  a  |uiroxysni  of  nighl-tenw 
results.  With  screams  and  imploring  calls  upon  its  mother  for 
assJBtanoe  the  child  struggles  and  cannot  be  urou»etl  or  comforted, 
hut  at  last,  slowly  awakew,  or,  much  more  infrwiueiitly,  falls  ag&ia 
into  peaceful  slumbers.  Very  frequently,  even  during  the  psr- 
oxy^ni,  tbe  child  shows  terror  of  some  one  object :  a  cat,  a  dog,  a 
while  elephant,  a  muneter  of  some  kind,  is  imliuited  by  its  in- 
coherent cries.  In  a  large  majority  of  cases  night^terrore  are  Dot 
connected  with  any  organic  diacaae  of  Uie  brain  or  with  epile[iKy, 


*  Mi»d(«o-leg*11y  Lhii  ai>e  U  of  grcitt  inleroit.  Put  ua  trial  for  bii  lUis,  tha 
mtin  ploadfid,  "  I  ftiD  guilty  in  myaleop,  but  not  guilty  in  iny«eneM,"andil>« 
Jtiry  found  that  the  rimn  wab  iinooDiclmu  of  the  nntiire  of  the  act  whirh  M 
Ciinimitlfxl  tiy  reafton  nf  h  condition  eHftini;  from  (nmusRiliultiiiu,  and  th*ll>* 
will  not  n)fcp(in«ibl«.  Tlio  mm  cortaicily  was  Doliniutrie  in  ibv  ordinary  nMf 
of  the  word,  and  Just  lu  certainly  be  vrai  not  reaponiible.  Th«w  cmm  an  n 
flxcDplionnl  tbAt  1  bcliovo  no  country  hu  as  yot  a  lav  applicabte  lo  Hmhu 
Probably  the  best  that  n  court  could  do  would  be  lo  coiuidar  tba  allefM 
criminnl  m  bnving  br«n  temporarily  incane. 


DISORUKKS  OF  CX)K801OUSNB«. 


419 


I 


and  are  of  iio  more  gtfrioiis  import  thiiii  au  attack  of  somuam- 
bulisiD.  They  usually  depend  u|>od  some  pcrtphcrol  irritation: 
ei^)et:ially  are  tliey  conmionly  tlie  rtsuh  of  a  gaHtnt-intestinal  irri- 
tation from  aiidigestcd  food.  Hcooe  they  frequently  follow  heavy 
sappers,  or  overeating  of  some  kind  in  the  latter  part  of  tlie  day. 
Not  rarely  tliey  occur  during  active  dentition,  and  are  relieve<l  by 
cutting  of  the  yuins.  In  a  few  recorded  cases  the  cause  of  the 
mltacks  lias  been  intestinal  worms.  The  overpowering  emotion 
of  the  night-terror  is  sometimes  the  result  of  a  fright  during 
the  day,  as  in  the  case  reported  by  Meigs  and  Pepper,  in  which 
h  child,  who  had  been  bitten  by  a  parrot,  on  several  auooeesive 
Bights  sprang  up  out  of  a  sound  sleep  shrieking,  "  Take  the  parrot 
away !  take  tlie  [tarrot  away  1"  T  have  seen  in  adtilts  wminam- 
bulism  perfectly  porallel  to  this.  Thus,  after  a  house  was  robbed, 
a  woman  for  i^everal  nights  arose  and  walked  in  her  sleep,  trying 
to  etKvpe  from  bui^lars  aud  raise  an  alarm.  The  night'terror  is, 
I  think,  only  a  form  of  somnambalisui. 

Night-terrors  which  are  the  oiitoouie  of  serious  brain-<lisorder 
are  rare,  and  not  to  be  poMtively  distinguished  by  their  symptoms 
from  thu«e  of  less  serious  import.  They,  however,  frequently 
near  several  times  a  night,  and  continue  for  many  weeks  j  whilst 
the  niglit-ternir  of  irritation  usually  happens  only  once,  am]  ejc* 
tremeljr  rarely  more  tlian  twice,  in  a  single  night,  and  docs  not 
fiootinue  to  recur  for  weeks,  except  it  be  at  considerable  intervals. 
Moreover,  the  serious  uight-terror  is  almost  invariably  acuum- 
{joated  by  other  maDiftsstatiuiis  of  disorder  of  the  brain-action, 
wbioh  point  out  its  true  meaning.  Dr.  F.  Debocker  ( TMie,  Paris, 
1881)  has  reported  the  case  of  an  infant,  who  6nally  died  of 
tubercular  meningitis,  in  whom  the  earlier  symptoms  were  night- 
terrors,  which  were,  however,  usually  asMOciatetl  with  s|>ells  of 
ingfat  during  the  day,  and  with  distinct  evidences  of  hallncioa- 
tioD.  In  tlic  same  ihc-'ns  is  recorded  an  initanoe  in  which  the 
oooturual  terrors  <xx:urred  in  a  child  four  years  of  age  and  were 
■■oeiatcd  with  a  rapid  loss  of  power  which  ended  in  idiocy;  aud 
alioa  atae  m  which  the  outcome  was  epilepsy. 


I 


CHAPTER   XI. 

DISTURBANCES   OP   INTBLLBCTION. 

For  (lie  (mrpose  of  studyiog  tbe  symptDtns  of  tnenta]  disorder 
the  human  intellectual  facultii^  luuy  be  ^paralcil  into  the  will, 
the  intellectual  facultiot  proper,  such  as  reason,  imaginatioa,  eta, 
and  the  emotions,  such  as  fcnr,  anger,  etc 

Disorder  uf  one  menial  faculty  is  almost  invariably  acoooipa- 
nied  by  a  greater  or  less  dc^^ree  of  disturbance  of  the  other  mcntni 
faoutties,  but,  a  priori,  there  seeni8  tn  be  no  reason  why  one  fai-ultr 
of  the  mind  t^bouM  not  nuffer  alone,  and  ctuies  arc  said  to  occur 
in  praetiee  in  which  a  single  faculty  appears  to  be  under  the  io- 
flueiict^  of  disease  when  no  otlier  evidences  uf  meotal  disorder  caa 
be  detcc't-ed. 

The  human  will  acts  chiefly  upon  the  low*er  intellectual  and 
emotional  brain-fnnctions  as  a  repressive  force*  It  inbtbibt  or 
pub5  aside  thii^  thonglit  or  that  dI«(tmetion  nr  this  eniotiou,  ratJier 
than  brings  forward  anotlier  thought  or  emotion.  We  oannot 
will  ourAclven  inti)  a  pasAion,  though  we  can  by  a  direct  effort  of 
the  will  inhibit  or  repress  a  rising  anger.  If  we  dftsire  to  pro- 
duce a  fit  of  anger,  we  do  it  by  bringing  before  tlie  mind  tfaouglits 
which  aut  as  stiniiilanU  to  the  desired  emotion  :  the  almost  unuoo- 
scioua  rcoognition  of  this  fact  has  led  to  the  expression  "  work- 
ing one's  eelf  into  a  passion."  A::  h  nitualty  the  catm  in  diMrders 
of  inliibitory  iierve-fuuctiou,  affections  of  the  will  are  moet  plainly 
and  freqncntly  manifested  by  weakness  or  failure  of  power.  The 
exccK^ive  olk>[iiia<7  and  Hclf-a.sNtTtion  seen  in  ocrtain  forms  of 
insanity  indicate  a  condition  of  abnormut  exaltation  of  the  will. 
Generally,  however,  extravagances  of  thought  and  action  which 
appear  lo  point  to  au  cxce&sive  activity  of  the  will  are  really  due 
to  the  overpowering  action  of  some  emotion  or  some  idea  which  so 
dominates  the  wil!  as  to  govern  entirely  the  actions  of  the  indi- 
vidual. The  obstinacy  and  tf«tf-a&-'%rtiou  are  under  these  circum- 
stances realEy  the  outcomes  of  a  weakened  will  ratlier  tliaii  of  aa 
overpowering  eguieui, — the  person  being  obstinate  or  a^ressive 

LI d 


DISTrRBASCES  OF  ISTELLECTIOK. 


421 


I 


becanse  h\»  will  is  enKlaveil  by  a  lower  intellectiinl  nr  emotional 
nerve-centre.  Tim.*,  in  melancholia  inflexible  obstinacy  may  re- 
sult from  the  abeolulc  despotism  of  an  overwhelmiog  sorrow. 
In  li}'Sterta  the  will  is  prolKibly  always  ahtiormally  feeble,  but 
the  pcrsistcDoe  and  apparent  witfulnise  of  b}*Btcrical  subjects  are 
jMOverbial. 

Weakness  of  the  will  is  produced  by  various  organic  brain- 
dtseaseB,  which  lower  (be  nutritive  tone  of  the  cerebral  cortex. 
It  ifl  caused  very  frequently  by  chronic  iioisornngs,  lieing  one  of 
the  most  pronounced  symptoms  of  alcoholism  and  of  opiumism. 
Under  these  circumstances  the  subject  may  fAiow  an  extraordi- 
Dar>'  persistency  wlien  dominated  by  bie  apjwtite,  and  yet  is  i-eally 
moBt  infirm  of  purjMJsc.  entirely  unable  to  decide  upon  a  course  of 
action  in  regarti  to  oniinary  matters,  or  to  carry  out  Uh  det^ifiion 
when  reached.  He  is  liable  to  he  inordinately  influenced  by  his 
awociates  and  by  his  environ?*,  cannot  resist  entreaty  and  Ii'ni[>- 
tatioD.and  w  becomeb  mure  and  more  the  )«|K>rt  of  bia  d«eirt«  and 
of  external  influences. 

Acute  illness,  starvation,  hardships,  a^,  chronic  diseweByUy 
influence  which  lowers  the  nutrition  of  the  higher  nervfr-oeDtna, 
may  produce  M-eukneas  of  the  will.  So  varied  are  the  caoaes 
which  may  produce  the  so-called  alniKa,  or  abnormal  weakness  of 
the  will,  that  it  h&s  no  further  diagnostic  im|)ort  than  to  show  a 
serious  functional  or  structural  alteration  of  the  cerebral  cortex. 

Exaggeration  of  the  will-power  is  known  as  hifperhufui,  and 
ffbowB  itaelf  in  aome  forms  of  mania  and  of  cerebral  cortical 
excitement. 

Tlie  emotional  nature  may  be  by  disea<ie  depressed,  exidtwl,  or 
perverted  j  the  alteration  often  affects  persistently  a  single  eiuotion 
or  a  single  class  of  emotions,  or  it  may  attack  guccc^ively,  at 
■borter  or  longer  intervals,  emotions  ibat  are  antagonistio.  Thus, 
a  sulject  may  be  in  a  continnul  Mate  of  joy  or  of  emotional  de- 
prewion,  or  be  may  rapidly  or  slowly  pass  from  one  8tale  of  emo- 
tional excitement  to  another,  now  carried  away  by  anger,  now 
proBtrated  by  fear,  now  soaring  with  joy,  now  overwhelmed  by 
adnesB. 

lo  advanced  Atagca  of  cerebral  diAcaite  a  condition  of  true  eino- 
Uooal  enfeeblement  or  lethargy  may  be  preaent,  so  that  external 
drcumstaoces  which   nalunilly  affect  most  vividly  Lliis  or  tliat 


422 


DJAONOenC  NEUBOLOOY. 


emotion  fail  to  produce  any  respuose.      This  mental  oondiUon ' 
ought  logically  tu  be  known  as  emott<Hial  dcprcsBion.     It  ia  to  be 
olparly  distinguished  from  excitement  orovernttivity  of  the  depres- 
eive  emotions,  sucb  a«  Mrrow  and  their  coogcnent.     Viewerl  in  this 
way,  tbe  melancholic  person  is  not  la  a  oooditioD  of  emotional  de->^| 
prcffaiou,  but  in  one  of  emotional  f^xcitt^mfnt, — i.e.,  of  excitf^taent 
of  the  deprestfiive  emotions.     Melancholia  is,  it  k  true,  frequently^ 
aasocintcd  with  dcprewtion  of  the  nervnuA  s)'?tera,  but  thifi  »  notH 
fllvrays  the  ca**,  and  tbe  victim  of  melancholia  agitata  may  be  in 
a  condition  of  general  ner\'ous  en'thmm  as  prononnccd  as  that 
which  afipcfs  the  maniac  with  wtldly-ex[)ani)ive  dclusioii6.     On 
the  other  hand,  high  hopes  nnd  abandant  joy  are  in  advaoeedj 
genera!  paralysi*  closely  linked  with  the  mo«t  profound  evideooes 
of   failing  nerve-power.      If  melaiiuhulia    ii  to  bv  cDUMdered  aj 
state  of  lowered  emotional  activity,  whilst  joy  and  auger  are  the] 
oiitronira  of  emotional   excitement,  it  logically   follows  that  the 
antagonistic  emotions  are  different  manifestations  of  one  eerebnd 
function,  joy  being  the  result  of  excessive  stimulation,  sorrow 
excessive  depression,  of  the  laime  brain-eclls, — »  conclusion  which 
1  think  few  persons  would  be  rtady  to  accept  as  correct. 

The  relations  between  the  diverse  emotions  of  whieh  I  have  jtist 
8]>oken  are  of  some  iraporfanoe  m  explaining  tlie  fact  that  in  rsri- 
ous  mental  affections  mania  and  melancholia,  or  opposite  emotional 
States,  may  follow  eavli  other,  and  even  apjxar  to  be  prrxlutvd 
by  the  same  brain-lesion.  Thus,  in  paretic  dementia  the  perstst- 
eiit  liypcrfpmirt  of  the  brsin-oortex  may  cause  throughout  tbe  atlark 
iDteuMi  s.Hdness,  ur  «u  eiuutioual  deprew^ion  may  r>iiddcnly  replace 
the  expansive  happiness  usual  to  the  aOeotion.  To  aoroant  for 
sneh  a  change  it  is  only  necessary  to  suppose  that  tJiere  is  a  shift- 
ing of  the  hyperemia  and  the  excitement  from  one  portion  of  iJm 
braia  to  another. 

The  intellectual  functions  ])roper  may  suffer  from  actual  ex- 
altation, giving  rise  to  increase  of  |»)wer;  from  an  cxaltatioa 
which  is  tio  unbalanced  as  to  produce  a  derangement  of  aetiuD; 
from  a  real  depression  or  loss  of  power. 

AbsoiiUe  increnHc  of  mnxial  potcer  ie  a  rare  condition,  and  is 
never  present  in  any  advanced  stage  of  disease.  It  does,  how- 
ever, sometimcft  ooour.  The  suhjccE  of  a  pronounced  mental  exal- 
tation has  a  passion  for  intellectual  labor,  accompanied  by  a  oorre- 


PlbTDItBANCCS  or  lyXELLECTION. 


423 


spondiog  power  of  aooompliglinient.  It  ia  no  longer  an  effort  to 
fix  the  Bltenlion  n{M)ii  an  intricate  subject  for  successive  hours. 
The  feiiKe  of  fatigue  in  loKt,  nrid  the  brain  worka  un  without  pain, 
the  quality  as  well  a.»  the  quantity  uf  the  result  being  beyond  ibat 
which  the  indiviihinl  in  Wxa  normal  condition  mn  proHnoe.  Thi<) 
state  of  mental  ■.•xbilaratlon  Kometimes  conies  cm  during  pro- 
tracted mental  labor.  it  is  probai)ly  always  associated  with 
bypeneniia  of  the  brain-cortex,  and  is  usually  uixtjmpatiied  by 
pronounced  insomnia.  It  is  a  verv  diingerotis  condition,  and 
should  he  the  signal  for  immciliate  cefwatioii  of  nientnl  effort  and 
for  meilical  treatment.  It  is  sometimes  develojief]  without  obvious 
cause  as  a  prodrome  of  severe  mental  diRca>ie.  Thus,  I  bnve  seen 
it  precede  a  fatal  outbreak  of  acute  phrenitis,  and  it  may  usher 
ID  paretic  dementia. 

If  one  or  more  of  the  mental  functions  are  excited  entirely  be- 
yond the  control  uf  the  will,  and  judgment  becomes  iniiioesible,  a 
mental  coudilion  ts  produced  which  in  its  most  severe  at^ute  form 
is  soroetimen  spoken  of  as  delirium,  and  in  its  milder  or  more 
dironio  forms  as  insanity. 

Failure  of  the  mmttU  powers  is  a  very  ooramon  result  of  func- 
tional and  organic  brain -iliaoiise.  When  complete  it  constitntcs  the 
condilinn  known  as  ilementia. 

It  U  often  of  vital  tmportanoc  to  recognize  the  dawnings  of 
mental  fnihire.  The  failure  usually  manifests  itself  first  in  loss 
of  aiemurv-.  Thi;;  lia-^  already  been  sufficiently  diseut-seil  (see 
page  369).  Next  to  memory  in  the  order  of  impticution,  and 
sometimes  even  preceding  tt,  in  the  power  of  fixing  the  attention, 
Tlie  min<l  of  man  naturally  grander*  from  subject  to  subject.  A 
oontiuuous  thoughtful  application  depends  upon  the  exertion  of 
the  inbibitive  ]H)wer  of  tlie  will  in  repreasing  distracting  thoughts 
nod  shutting  out  new  jwrceptions.  The  power  of  persistent  at- 
UDtiOD  to  one  «nbject  is  to  a  great  extent  ao(|uired  by  training.  Its 
caMTose  is  a  lai^  feature  in  all  severe  intellectual  work.  Couim^- 
quenlty,  when  the  brain  is  cxhaustnl  not  only  do  the  reasoning 
faculties  laUir  with  difficulty,  but  incrca^etl  effort  is  required  from 
the  weakened  will  to  maintain  the  neoe.<<sary  fixity  of  attention. 
Mental  toil  becomes,  therefore,  most  irksome,  as  is  reougnizeil 
by  the  common  expression  of  sufferov  that  "work  is  becoming 
more  and  more  of  an  effort."     Failure  uf  memory  and  failure  of* 


124  DIAGNOSTIC  KEUBOLOGT. 

tb«  power  of  fixing  the  attention  have  no  particular  dia^ostic 
irnfMjrt.  Wbeu  they  wexist  aud  are  aasocialwl  witli  au/  other 
evidences  of  mental  dcmngetueut,  they  indicate  a  serious  diseue 
of  the  brain  itself.  The  loss  of  the  power  of  fixing  the  attention, 
however,  u-hcu  il  exists  alone,  usually  depends  upon  simple  oei«< 
bral  asthenia, — a  cwiditiou  ia  which  there  may  also  be  some  iaes  _ 
uf  memory.  I 

A  symptom  which  may  depend  opon  eitlicr  mental  exdtement 
or  loss  of  mentui  power  is  tnmkcratce.  An  iniwherence  due  to  a 
heightened  but  irr^ular  cerebral  activity  requite  from  tim  ex- 
oewive  rapidity  of  the  intellectual  acts,  as  well  as  frooi  their  dia* 
conueiHed  acque[ic«t4.  Before  one  idea  in  fully  iTau^late^l  inlo 
wordd,  another  rushes  iuto  expression,  and  a  hopeless  eoufusionof 
talk  results.  The  ideas  tumble  out  as  it  were  over  oae  another. 
Incoherence  from  laok  of  mental  [lower,  on  the  other  baud,  arises 
either  from  the  inability  to  complete  the  mental  act  or  hotn  the  lack 
of  tlie  power  of  translating  it  into  suitable  words.  In  typical  uses 
there  is  little  difficulty  in  dUtinguUbiug  bciwecn  the^  varieties, 
which  it  is  allowable  to  call  re8i>ectively  cuAivt  and  pnmve  iooo- 
herenue.  The  rapid  utterances  of  the  niving  maniac  usually  shov 
moutplaiuly  that  his  mind  is  pouring  out  broken  hinL^of  an  infinite 
series  of  jostling  ideas;  whilst  the  slow,  confusml,  diaoonDect«d, 
hesitaliug  words  of  the  dement  no  lees  unmistakably  portray  hia 
inability  fully  to  conceive  an  idea  aud  embody  it  in  words.  There 
are,  however,  cases  of  diseiise  iti  which  menial  excllement  ooexiats 
witli  failing  power,  and  in  which,  therefore,  the  incoherence  i 
mixed  type. 

Human  character  is  the  reKult  of  the  established  balance 
twoen  llio  will,  ilie  iutellcclual  attributes,  and  the  emotional  fta«x» 
of  the  individual.  When  any  of  the  ooiTclatcd  factors  are 
altereil  there  must  beacorrcflgMndingohange  in  character.  Char- 
acter is,  therefore,  always  seriously  implicated  in  tueiital  affections. 
Not  rarely  clmnges  in  the  intellectual  or  emotional  nature  so  sub- 
tile or  hidden  as  not  to  be  readily  perceived  r(^i^te^  themselvefl 
with  astounding  distinctness  on  the  dlal-ptate  of  cimracter.  Heooe 
alterations  of  character  are  of  the  weightiest  diagau6tic  import. 
They  may  be  tlie  flrst  evidences  of  a  developing  pure  insanity, 
but  when  sudden  and  severe  they  usually  point  towanis  demenUa 
paralytica.     A  primary  sudden  criminal  outbreak  in  dementia^ 

b^ J 


< 


exuts 
e  to^ 


DISTURBANCES  OF   INTEIJ.ECriON. 


425 


» 


paralytica  is  geo»ally  ecxual  in  its  direction.  Thus,  in  a  case  now 
under  my  ran-  the  firet  niurked  disorderly  aotinn  n'as  an  attempt 
til  rape  a  servant-girl.  Ai>er  this  it  was  discovered  thnt  very 
largo  and  foolish  purrhaseis  had  Iteoti  mnde  as  the  beginning  of  a 
graml  business  scheme  entirely  foreign  to  the  daily  oocupatton  of 
the  mau.  An  estimable  citizca  goes  to  a  distant  city  luid  attempts 
lo  turn  a  hotel  into  a  biiwdy-housu.  Auotlu-r,  wliili-t  wtill  per- 
forming acceptably  the  duties  of  an  important  public  otHcc,  tries 
to  Beduoe,  and,  this  failing,  to  rape,  his  own  daughter. 

In  dementia  paralytica,  as  in  the  pure  iiuanltie^  the  moral 
degradation  may,  however,  run  in  other  than  sexual  channels. 
The  teniiierace  man  suddenly  becomes  addictetl  to  drink;  the 
honest  mnn  all  at  onoe  appropriates  large  sums  of  money,  which, 
it  may  be,  he  spemls  in  licentious  revels;  he  who  has  always 
b«en  exoepLiouully  gelf-cou trolled  becomes  violently  j^msstonate ; 
the  amiable,  loving  husband  and  father  changes  into  a  household 
demoo.  Oareful  examination  under  lUe^  cireuuLStanoc^  will  usu- 
ally detect  other  symptoms  of  paretic  dementia.  The  evidences 
to  be  searched  for  arc  failuro  of  memory,  deterioration  of  mental 
facultioa,  inetinalities  of  the  pupil,  perceptible  loist  of  physical 
eodurancc  or  of  the  jmwcr  of  doing  line,  complex  pliybicnl  acts, 
habitual  emotional  stales  uf //tm-flrc,  and  a  tendency  to  exiiansive 
deJuaiona,  as  shown  in  the  subject's  estimate  of  bia  owu  powers, 
bttsiQees  prospects,  or  schemes,  and  of  the  value  of  his  poeeeseious 
or  Burroundings.  AV'henever  any  of  these  things  can  be  found,  it 
is  the  physician's  duty  to  give  warning  to  the  friends  of  the  pa- 
tieot,  and,  with  their  asaent,  to  act.  There  are  certain  specific 
symptoms  ivhoee  relation  to  cerebral  diseases  is  so  close  and  so 
important  that  they  demand  very  careful  consideration.  These 
symptouia  are  naturally  dividetl  into  two  ^^elu:  tirst,  those  which 
indicate  disorder  of  the  perceptive  faculties ;  secondly,  thooe  which 
are  oounected  chieily  with  the  intellectual  and  emotional  spheres. 
Uad«rtlie  first  head  I  shall  consider  Hallucinations  and  Illusions; 
nixler  the  second  bead,  Delusions,  Imperative  Conceptions,  Mor- 
bid Impulses,  and  Morbid  Desires. 

An  Hallucination  is  the  |MToeption  by  any  of  the  senses  of  an 
object  which  has  no  existence.  It  is  the  conscious  reoognilion 
uf  a  seosation  of  oight,  hearing,  feeling,  taste,  or  smell  which 

not  due   to   any  impulse   received   by  tlie   jKrcepttve  appa- 


426 


DtAONoenc  wEVBOwwy. 


ratus  from  without,  but  anaea  withiu  the  peroeptive  apptraioa 
it^lf:  in  other  «-or(l<;,  an  halludnatiim  i»  a  siilijet-tive  wnsstioD 
which  a£»uiu<»  ttie  tl«tioitc  attrihutue  of  au  ubjei-tive  sensotioa. 
It  is  commonly  simple, — i.e.,  coDnwted  with  a  siugioscnac  Thia, 
the  viition  i^  iiKunlly  Ae«n,  not  seen  and  felt.  The  false  voice  U 
beard,  the  mysterious  presence  i»  felt,  but  the  pre2<«iK'e  and  the 
voice  usually  do  not  tMjexist.  Iii  tlie  order  of  tlieir  fmjaeucy 
of  implimtion  the  senfies  may  be  enumeraled  as  follows :  sight, 
hearing,  touch,  smell,  taste.  Tlie  luirticiilar  characters  of  the 
|icrccivwl  object  van*  imlefinitclv,  ami  involve  the  whole  r«nge 
of  peroeptiotM.  Even-  variety  of  color  and  form,  of  sound  soil 
otlor,  of  feeling  and  taste,  may  be  perceived.  , 

In  same  oases,  sw  in  mirage,  »/alae  ptrrtqitlon  may  amount  al- 
most to  an  hallucination ;  that  is,  an  impulse  from  without  may 
give  rifw  to  jiuch  a  dUtorted  misleading  conscious  perception  that 
the  person  rually  soca  or  feels  or  hears  that  which  has  do  exist- 
ence. A  distorted  sensation,  or,  in  other  words,  the  perccptioD  of 
an  objeiTt  in  characters  which  it  dncH  not  {weBCSS,  h  frequently 
spoken  of  as  an  Ulunion.  In  natnre  there  is  no  sharp  line  be- 
tween illusions  and  slight  distortions  of  the  perception  of  objects, 
or  between  illnsions  and  imllucinalionA.  .\n  halhicination  may 
be  caused  bv  an  external  stimulus  so  s!iL;hl  that  it  cannot  be  His* 
covere<l,  hut  it  may  arise  entirely  from  witliin  the  nervous  system. 

An  hallucination  has  no  definite  diagnostic  import.  It  msy 
come  from  exhaustion  of  the  nervous  system,  especially  whiin 
thtire  is  at  the  same  time  mi  intense  desire.  Thus,  llie  wife,  worn 
out  with  long  watching  and  gn'ef,  sees  in  obcflienoe  to  her  yearn- 
ings the  living  form  of  her  dead  husband.  The  monk,  uhaustdl 
by  long  prawr  and  fa.'^ting,  if  consumed  by  ardent  devotion,  is 
visitcfl  by  saints  or  angels,  or,  if  ho  bo  tormonted  by  i^uppreaaed 
sexual  desires,  is  haunted  by  troops  of  tempting  deviU  or  Tolup- 
tuoii.1  sirens.  Tlie  person  peri>ihing  with  thirst  sees  or  hears  cool 
springs,  babbling  brooks,  or  plusiliing  fuuutaius;  gorgeous  feaats 
float  before  the  virion  of  the  starving,  and  the  shipwrecked  raari' 
ner  is  lautali/ed  by  n>«ntng  barks. 

Hallucinations  may  bo  the  result  of  the  immediate  action  of  s 
poison,  as  in  the  beatific  visions  of  the  hasheesh-cater,  or  may 
be  the  outcome  of  the  peculiar  nervous  state  which  follows  the 
abuse  of  narootic  stimuli,  as  in  delirium  tremens.    ConditionB  of 


DISTUUBANCK   OP   INTKLLBCTION. 


4'27 


I 
I 


the  nervous  centres  ot  present  inexplinible  may  oill  hallucina- 
tSoTU)  into  being,  as  in  hysteria.  More  rarely  the  hallucination 
is  the  rwult  of  an  organic  braiii-<)iaeaM,  wht^n  it»  nature  is  almost 
invariably  pointed  out  by  (>oexiiJting  BvinplomB,  such  aa  epileptic 
paroxysms  or  local  palsy.  The  structurtil  alteration  in  ttuoh  cases 
is  commonly  in  the  iKrve-tra<:t  e8]>ccially  connected  with  the 
affboted  sense. 

An  hallucination  does  not  depend  upon  or  prove  the  existence  of 
intellectual  uuNJUiidness.  Ic  is,  however,  very  apt  to  be  aisocialed 
with  such  unsoundness,  because  the  o(indition  of  the  5en.sory  bniin- 
tnct  which  produees  it  is  apt  to  accompany  a  similar  condition 
of  the  higher  or  intellectual  centres.  Moreover,  it  often  affords  us 
a  meaoH  of  testing  the  condition  of  the  brain-centrtsi.  If  the 
jmlgment  fails  to  correct  the  (csliniony  of  the  dihordcreil  senac  by 
that  derived  from  other  senses,  the  sniiject  is  of  unsound  mind. 
Mrlien,  for  example,  the  individual  believes  that  the  vi>tiou  that 
he  sees  or  the  voice  that  he  hears  really  exists,  then  is  his  judg- 
ment dethroned.  It  will  be  readily  seen  tliat  in  such  ii  cose  it  in 
not  the  swing  of  the  vision,  but  the  lose  of  the  power  of  weigh- 
ing evidence,  that  is  the  proof  of  the  intcllcctunl  d<^radation. 
As  will  become  very  apparent  during  the  discussion  of  delusions, 
the  halluciualiun,  in  the  case  jtiat  imagined,  huii  given  rise  to  a 
delusion. 

The  wor<l  drliiairm  may  lie  defined  to  be  a  false  belief,  hut  as  it 
is  uwd  by  alienbiis  the  term  means  something  more  than  this.  By 
Spitzka  the  insane  delusion  is  said  to  be  "a  faulty  belief  out  of 
which  the  subject  caunot  be  reasoned  by  adequate  methods  for  the 
time  being/'  The  objection  to  this  definition  is  that  there  are 
many  faulty  or  fal«?  beliefs  held  by  perfectlv  sane  persons  out  of 
which  such  person^  canuol  be  r«i»oncd,  but  which  are  not  inEanc 
delusions.  Tlius,  either  tlie  Chrii^tian  or  the  Mussulman,  under 
such  definition,  is  the  victim  of  on  iusane  delusion.  To  meet  lliu 
neeesitiiies  of  the  case  the  definition  should  be  modified  no  as  to 
read,  "A  faulty  belief  conc^ing  a  subject  capable  of  phy^cal 
demoiwtration,  out  of  which  the  person  cannot  be  reasoned  by 
•deqnate  methiKls  for  the  time  Iteing." 

The  pamllclism  between  n  delusion  and  an  hallucination  is  very 
elote.  A  delusion  m  a  falw  belief.  An  hallucination  is  a  false 
peroepUoD.    The  delusion  l>ecomes  an  insane  one  only  when  the 


false  belief  cannot  be  dissipated  b}' absolute  proof  of  its  inoorreolr 
nem.  The  hnllunnation  bcoomca  bd  imianc  one  only  when  the 
false  peroeptioD  catiQot  be  corrected  by  the  judgment  through  tha 
other  sensee.  lu  either  oise  the  essenoe  of  the  insane  mental  state 
is  loan  of  power  to  receive  and  weigh  adequate  evidence. 

Thus,  John  Smith  hears  voices  where  there  are  none;  he  is 
insane  only  wlien  h«  Ja  unable  to  correct  the  evideuoe  received 
through  the  M:nso  of  hearing  by  that  received  tiiroagh  the  seiiMB 
of  gigbt  and  feeling.  If  he  persistently  believer  that  persons  sftesk 
to  him,  although  he  cannot  see  or  touch  them,  his  jad^^ent  is  in 
abeyance.  On  the  other  hand,  John  Jones  believes  that  a  certain 
UixQ  existK  upon  a  certain  field  where  there  is  uo  barn.  Under 
tlicsc  circumstances  he  has  a  delusion,  a  belief  which  lias  grown 
up  in  bia  mind  from  some  cau.se  unknown.  Now,  if,  when  taken 
to  the  field,  he  is  incapable  of  receiving  the  evidence  of  hU  senses 
and  persists  m  his  belief  that  the  barn  is  there,  he  is  insane;  but 
if  he  receives  the  evidence  uf  his  senseti  and  i>erceives  that  the 
barn  di>t«  not  exiat,  he  in  not  insane.  In  case  of  insane  ballnciaa' 
tions  or  delusions,  the  truth  or  falsity  of  the  vision  or  of  the  belief 
IB  not  essential.  The  essential  thing  is  the  condition  of  tbe  mind 
of  the  individual, — a  condition  whicli  prevents  it  from  rooetvlag 
evidence.  Hence  au  insane  belief  may  be  true  although  insanely 
held. 

In  the  supposititious  case  given  above,  assuredly  tbe  mentiil 
state  of  the  individual  is  in  no  wise  dependent  upon  the  absence 
of  tlie  Wm,  althuugb  aucIi  aliseiice  renders  a  test  of  llie  saljeot's 
mental  condition  possible.  The  distlnBtioo  just  drawn  may  seem 
unimportant  and  so  trite  an  to  be  unworttiy  of  discussion,  hut 
the  failure  to  uudenitand  it  has  been  one  cause,  in  my  experience, 
of  the  inability  on  tlie  part  of  learned  lawyers  to  comprehend  the 
subject  of  insanity. 

Not  long  ago,  after  due  process  of  law,  on  insane  man  by  the 
name  of  Taylor  was  hung  in  Philadelphia  for  Uie  unprovoked 
munler  of  a  prison  warden.  It  wa«  iu  evidence  that  the  man 
believed  that  all  the  attendants  of  the  prison  were  Cathnlios  and 
were  "down  on"  him  because  he  wa**  a  Proteshint,  and  were  de- 
stroying him.  The  pi-oswuling  attorney  asked,  "Stippoaing  it  were 
proved  that  the  prison  attendants  were  Catholics,  would  it  not 
liave  to  be  acknowledged  that  the  man's  Iwlief  was  correct,  and 


L 


DISTTRBAXCK}  OP  ISTF.LLECTION. 


429 


I 


that  he  was  not  insane?"  Apparently  neither  lawyer  nor  judge 
coald  be  made  to  undenitand  that  the  falsity  or  the  truth  of  the 
prisoner's  belief  in  the  Catholicieni  of  the  atteodanta  bad  little 
to  do  with  the  question  of  his  insanity.  It  wat;  proveil  that  he 
bad  other  dclasionft  of  pcrsoeutiou,  and  hie  having  adopted  a 
belief  in  regard  to  the  Catholicism  of  his  atiendants  which  was  in 
accord  with  such  delusions,  without  any  evidence  of  their  alleged 
Catholicisui,  and  having  reasoned  insanely  upon  the  subject  and 
act«]  in  a<Tonlani'c  with  (Mnohi^ions  bh  readied,  sliuwe<I  that  his 
■ctiou  rested  upon  mental  unsoundness.  Surely  the  "ftecaiiae  / 
am  a  ProUMant,  therefore  they  were  destroying  me,"  ought  to 
have  made  the  mental  oondition  of  the  prisoner  clear.  lo  the 
language  of  Spitzka,  "  Rejieatedly  docs  it  occur  iu  the  alienist's 
experience  that  the  facts  of  a  case  and  the  delusion  happen  to 
correspond."  This  is  well  illnstrated  in  a  case  reported  by  him. 
Ad  artist's  model  asserted  that  he  was  the  5ne^t-buiH  man  in 
the  United  States.  He  really  had  a  raagiii6oent  Sgure,  but  his 
auudunoement  was,  notwithstanding,  that  of  a  paretic  dement, 
for  inquir}'  elicited  the  statement  that  the  "girls  looked  at  him 
becan-<«e  he  had  a  [lecutiar  exprc'^sion  in  his  eyes  which  tliey 
fancied,"  aud  he  revealed  other  unmistakable  evidence  of  geueral 
paralysis. 

An  insane  belief  or  delusion  may  rest  upon  on  hallucination, 
may  be  built  upon  a  foundation  of  disordered  sensation,  may 
apriog  from  the  most  trivial  circumstance,  or  may,  so  far  as  can 
be  judged,  be  self-eugeudered  in  the  mind.  Thus,  tlie  voice  that 
is  heiLrd  as  an  hallucination  gives  rise  to  the  delusion  of  an  ovcr- 
prcBent  persecutor ;  a  persistent  distress  in  the  abdomen,  to  a  delu- 
sion of  pregnancy,  or  that  the  bowels  are  dropping  out,  etc.  The 
following  cu^  frotu  my  note-book  illustrates  very  forcibly  the 
carious  way  in  which  a  delusion  develops  in  the  mind  without  the 
■lightest  fmindntion  in  verity.  A  man  af^r  a  malarial  fever  be- 
gao  to  have  suspicions  in  regard  to  the  chastity  of  his  wife.  For 
■  time  he  kept  thise  to  himself,  but  finally  be  accused  her  of  infi- 
delity. AOer  tliii4  had  oontiuued  for  some  wf^eks  he  presentetl 
himself  with  his  wife  at  my  clinic,  saying  to  me,  "  1  think 
my  wife  goes  with  other  men.  She  thinks  I  am  craey.  I  am 
UDcertain  whether  she  or  I  am  right."  On  being  questioned,  he 
stated  that  he  first  noticed  her  hxiking  behind  her,  as  though  she 


DIAOKOCTtC  VEVROLOar. 


^ 


1 


were  looking  for  some  ooe,  when  tb«y  n-alked  together ;  that  b« 
afterwards  saw  a  hanil kerchief  lying  uo  the  bureau  in  her  roam, 
just  aa  she  would  have  left  it  if  ahe  liad  been  flirting  with  eumo 
one  out  of  the  window,  and  tJiat  when  he  saw  a  chair  by  the  win- 
dow of  her  room  and  a  man  at  the  corner  of  the  street  he  wu 
C(mviiia?il  that  his  &u8]))cioiia  wore  mirrect ;  iu  tlti«  he  was  cor- 
robornted  by  finding  three  dollars  in  a  truuli,  which  he  bcUeved 
biH  wife  had  reoei^-e*!  "  for  evil  oonrses,"  although  she  had  declared 
that  he  himself  had  given  it  to  her.  He  furtlier  stated  thai  be 
watclied  her  eyes.  Id  a  very  e^er,  tremuloua  maoDer  he  said* 
"I  got  a  lamp,  and  when  I  found  her  eyes  were  dark  beneath  I 
told  her  there  was  aomotliing  wrong  with  her,  and  then  she  began 
to  (hink  there  wn»  M)niethitig  wrong  with  me.  T  lirmly  believed 
■lie  was  going  with  other  men."  The  man  had  aa  inherited 
tendeney  towards  insanity,  and  hod  lost  much  sleep.  When  his 
whole  case  was  thoroughly  explained  to  him,  he  f^d  that  he  "now 
undcretood  it,  and  was  glad  to  hear  it,  and  that  it  gave  him  power  fl 
to  brace  hiniwlf  against  the  notion,"  ending  with  the  assertion  that 
be  believed  that  "  be  had  a  good  woman."  In  reply  to  a  question, 
he  said,  "  I  do  not  tliink  there  is  danger  of  ray  hurting  my  wife, 
but  these  things  come  on  me  so  that  I  cannot  control  mvself  at 
times,  and  I  am  willing  to  go  to  an  allium  if  it  if  thought  to  he 
right." 

The  relation  between  the  emotional  »tate  of  an  insane  man  atid 
his  delnsions  is  vpry  clase.  Expansive  or  happy  delu!y<ius  ac- 
company euiulional  exaltation,  while  horrible  or  sorrowful  delu- 
sions ^o  hand  iu  hand  with  dcpres^'ive  emotions.  Thus,  the  md- 
aucholic  worann  is  oppressed  with  the  belief  that  she  ts  hojielceHly 
damned,  that  her  husband  is  unfaithful,  or  that  she  is  pregnant 
with  devils;  whilst  the  maniac,  overflowing  with  animal  spirits, 
is  a  prophet  sent  of  God,  is  owner  of  uovouuted  milliooaf  or 
mayhap  is  about  to  become  the  mother  of  the  Messiali.  The 
emotional  state  and  the  delusions  ixmstautly  react,  upon  one 
another.  Some  alienists  believe  that  the  character  of  the  delu- 
sion is  directly  dependent  U[>o[i  the  dominant  emotiiHi;  but  it 
seems  to  me  more  probable  thut  the  characters  of  the  emotions 
and  of  the  delusions  ore  the  result  of  a  common  cause,  rather 
than  tliat  either  governs  the  other. 

The  nature  of  delusioas  varies  so  indefinitely  as  to  render  toy 


DiaroRiiAKCEH  OP  iprrEJ-LBcrroN. 


431 


I 


■tt«apt  at  ■  thorough  clas^incation  futile.  There  arc,  however, 
oertaiD  claaet^  of  ilelusinn^  which  nre  so  frequently  mel  tritli  and 
ea  charaotemtic  as  to  require  especial  stmly.  The  most  intportnnt 
of  the^  arc — t.  Expansive  Dehisions.     2.  Hvpochondri;ioal  De- 

3.  Delusioiu*  of  PenwcutioD, 

rice  Delugtong  usually  ooncorn  the  personnlity  of  the 
tndividiial  who  had  them,  either  m  to  his  prowesH^  his  mental 
or  physical  attainnienU,  his  posscaaioDR,  or  his  future  praspertfl. 
The  patient  l)«ist*»  that  he  is  the  strongest  man  in  the  world, 
averts  (hat  his  mental  powerit  are  ininiense,  or  that  he  is  a  king 
or  other  uotability,  or  more  commonly  talks  of  his  millioiLs  of 
jBoney,  his  gold-mines,  his  farms  of  unlimited  extent,  his  vast 
lies  fall  of  nnnumlwred  horses  of  the  ehoicc«t  breiMlti,  ]m  far- 
reaching  and  gigantic  business  schemes,  etc  This  eoudltiou  con- 
itituteR  the  detire  de  i/randeur,  and,  whilst  tn  the  majority  of 
CBBCB  it  depends  njiou  the  exlstenoc  of  general  pamlysiK,  it  may  be 
present  in  many  forms  of  mental  disease.  I  have  seen  it  very 
pronounced  in  cerebral  syphilis,  and  have  tviitcbed  thi-  millions  of 
dollars  poooeoocd  h\  the  subject  aliriuk  to  thousands,  and  the  tJiou- 
flantla  to  haodreils,  as  the  bnun>lesions  grew  leas  under  the  atl- 
ministraiion  of  mercury.  Then  even  the  hutidreil.s  illsapfwared, 
and  his  own  poverty  was  ooDfcsscd ;  but  the  assertion  still  re- 
mained that  "  his  uncle  was  worth  a  million,"  uulil  at  last  this  too 
\*aiii»hed  in  the  recugaitiou  of  the  desolate  truth. 

Jl^pocfiondriaeai  Dthinons  relate  to  diseaa;  of  the  person  of 
the  |Niiient,  and  are  usually,  but  not  uhvayH,  aftuxtiated  with  a 
(lepreasive  emotional  state.  They  sometimes  rest  upon  a  aub- 
Htltttum  of  ill  feeling,  or  even  of  actual  ili^casc,  io  the  part  ulli^od 
be  liopeleesly  aflecteil.  They  an.*  often  obvi(ni>-ly  absurd,  as 
that  the  l(^  are  made  of  glass.  Of  all  forms  of  delusion  thu 
iis  the  one  in  which  the  gradations  l^etwecn  the  sane  and  the  in- 
sane belief  are  most  subtile.  Ever>'  step  can  be  found  between 
the  slighteot  exaggeration  of  symptoms  and  the  hypochondriac 
foundation  less  belief.  Unlets  a  hy|)ochondriacat  deluHiou  \s  upon 
it8  iaoe  alisunl,  the  physician  must  be  very  careful  in  basing  upon 
it  an  opinion  that  the  subject  of  it  is  irresponsible,  since  many 
iovalids  are  hypoiJiondriaos  and  have  exaggerated  beliefs  border- 
ing c!(»«ly  upon  delusions,  but  are,  nevertheless,  of  sufficiently 
coun^iUQd  for  the  |>erformaace  of  the  ordinary  duties  uf  life. 


432 


ETAGSOenC  KCtJBOLOOT. 


DdttMonM  of  Ptr»eaition  arc  common  in  melancholia,  bat  are 
not  alva}v  associateH  with  s  |>rouuuiiued  dcjin»si%'e  erootHml 
<!OD()itt(Hi.  Ttiey  oru  alwa^  the  souroe  of  great  aanoyaoce  and 
diBtrcfw  to  the  sntgect,  and  are  uftually  a<tsocialed  with  halliiciDa- 
tioQ»,  which  I  think  are  most  apt  to  be  connecte<I  with  the  aeow 
of  hearing.  Very  cotntnooly  olwceDe,  reproachful,  or  threaten- 
iog  voiocfl  are  heard  at  all  times  and  in  all  phu<uti.  Usually  tlie 
delusion  of  pei'sccution  does  not  attach  itself  in  the  mind  of  its 
victim  to  one  person,  hnt  to  clatsci  of  people  or  to  unseen  spirits. 
Sometimes,  however,  the  delusion  does  affix  itaelf  to  one  individ- 
ual, as  in  a  recent  oaae  iu  which  a  woman  travelled  across  the 
oontioent  of  America  to  kill  a  rU>f:tor  who  .she  believed  was 
placing  a  spell  upon  her.  Of  all  the  quiet  elates  of  the  ioMM, 
those  who  have  dehinionii  of  persecution  are  the  most  dangerooa. 
They  are  impelled  bv  motives  of  revenge  and  of  fear  to  kill  those 
who  are  penrecnting  tliem.  This  \s  especially  the  case  when  the 
de]u>;Ion  attachpK  itself  to  one  individual ;  but  eveo  voioes  in  the 
■tr  niny  lead  to  sudden  violent  assaults  upon  by-standcrs  who  vn 
for  the  moment  thought  to  be  the  source  of  the  wordjs.  More- 
over, the  lunatic  may  at  any  time  fix  in  hi»  miud  upon  any 
acquaintance  or  notable  person  as  the  origin  of  bis  pcreecntion 
and  make  his  plans  in  accordance. 

A.  very  important  division  of  delusions  is  into  systematiBetl 
and  unsyBtcmatizeil.  A  FyHtanatlzed  delwnon  is  one  oonccmiog 
whicli  the  subject  reosous,  and  which  he  defends  more  or  lesB 
logically.  Any  character  of  delusion  may  be  sy^tematieed.  If  a 
lanatic  assorts  that  lie  is  worth  a  million  of  dollars  and  simply 
sticks  to  his  belief  when  it  is  denied,  he  has  an  un.<)'st«natixed 
delusion  of  grandeur;  hut  if  he  should  attempt  lo  defend  hts 
delusion  by  describing  how  he  had  Inherited  his  wealth  or  bow  he 
had  acquired  it  through  inve!itment»  or  business  venturva,  hiit  de- 
lusion would  be  systematized.  Again,  a  person  sufiering  from 
melancholia  believes  that  his  soul  is  lost.  It)  when  opposed,  lie 
simply  reavowfl  his  belief  and  assigns  no  reasons  for  it,  his  de- 
lusion is  unsy^temntiMd  ;  but  if  he  says  he  is  lost  because  he  his 
coramitted  the  nn|)ardoDable  sin,  quotes  Scripture  to  show  that 
such  a  sin  wan-ants  his  dtnim,  and  |H;rlia|)R  tells  why  and  when  he 
sinned,  his  dolnsion  is  pystcmatized. 

Great  diagnostic  value  has  been  attached  by  some  recent  wHten 


* 


I>I8TtrRBiLKCE8  OF   INTELLBCTIOS. 


433 


the  distinction  l)Gtween  tt>'<itcroat)«!d  and  ui)s>'stemfltizcd  delu- 
sions, and  much  has  been  }>redictited  upon  it  in  the  classlBcatiou 
of  insaniliefl.  According  to  my  ex{)erieuce,  howuver,  in  nature 
every  pjnidation  is  to  Ik;  found  iMstwecn  the  most  thorouf^lily  sys- 
tematiwd  dchision  and  that  which  is  must  completely  isolated. 
I  have  seen  various  cuses  in  which  it  was  doubtful  whether  the 
doluRiou  shfxild  lie  classed  as  systiimatizcd  or  iinsysteiiiatiMHl ;  and, 
whilst  I  acknowledge  that  in  typical  partial  insanities  the  delu- 
sions are  syfttemHtiTcI  :tnd  in  typi(»l  ^noral  inAanitlos  they  are 
un»y«itematized,  I  aia  of  the  opinion  that  in  thi^  character,  as  in 
others,  the  two  groups  of  general  and  partial  icsauittes  pais  in 
nature  Int^nsibly  into  each  other. 

There  are  certain  conceptions  or  general  ifleas  which  may  arise 
in  the  brain  of  a  person,  and  to  a  greater  or  less  degree  dominate 
his  actions,  altJiough  the  reaaou  may  not  be  unscltled.aud  the  fal- 
si^' of  the  conception  may  be  recogniited  by  the  individual  whom 
it  contrtils.  Sucli  a  pht^iiomenon  U  known  aa  an  fwfnT<ttirr  Om- 
ofj^tm,  and  differs  from  a  delusion  in  that  its  falsity  is  recognized, 
although  the  individual  la  powerless  to  withstand  its  influence. 
Closely  allieil  to  the  imperative  conception  is  the  Morbid  Impitlac 
Some  alienists,  indeed,  teach  that  the  im|)erative  oonoeptioo  gives 
ri^  to  the  morbid  impnlse.  In  certain  casra  thU  nndnnbtedly 
bapjiens,  aa  when  the  imperative  uonception  of  personal  deSIemeut 
gives  origin  to  the  impulse  of  escaping  from  that  which  defiles; 
but  a  morbid  impulse  may  arise  without  any  <lit>coveruble  tm])er- 
ativc  concejition.  Thus,  1  long  lind  under  my  care  a  man  >n 
whose  family  insanity  was  distinctly  hereditary,  but  in  whom  the 
only  Hymptom  that  I  could  tiud  was  an  impulse  to  assault  by- 
standers,— an  impulse  apparently  born  of  no  reason,  although  felt 
with  8uc;h  nrgeiiry  as  i'>  t\ll  the  patient  wilh  a  terror  of  himself. 
Oncc^  upon  returning  home,  I  found  this  man  sitting  iu  my  office 
terribly  excited,  and  greeting  me  wilh,  "Doctor,  doctor,  I  nearly 
did  it!  1  nearly  did  it!"  It  upiKarL-il  that  he  had  spent  forty- 
eight  hours  without  intermission  iu  a  vortex  of  ]>olittraU  excite* 
ment,  and  suddenly  the  impulse  to  kill  had  come  on  him  with 
fiuch  power  that  only  by  flifeing  to  my  olBce  was  be  able  to  save 
himself.  The  impulse  to  throw  one's  self  from  a  precipice,  uaused 
by  standing  on  its  brink,  is  a  familiar  instance  of  a  mild  morbid 

ipulse  without  an  apparent  foundation  of  an  imperative  oon- 

■28 


ccption  ;  whilst  the  reasonless  dread  which  many  perBOTM 
of  a  smalce,  toad,  cockroach,  or  other  harmlesn  creature  probably 
depends  upou  an  iaciplent  imperutive  i.Y>nceptiou  of  personal 
dcti  lenient, 

TIiG  act  which  results  from  a  morbid  itnpi]1<t^  i.q  siimedma 
spoken  of  as  an  ImpenUive  Act.  -Vn  imperative  coac«pt)on  B 
viewed  br  some  alienists  as  an  "undeveloped  deluiaion."  It  is, 
lioiraver,  not  a  proof  of  general  menuil  unsoundness,  but  id 
some  cases  finally  the  ronton  of  the  patient  fail^  tn  rero^nin 
the  untruthfulness  of  the  irapcrative  conception,  which  conosp- 
tion  thereby  becomes  converted  into  a  delusion,  preciaely  aa  an 
hallucination  may  give  rliH>  to  a  delusion. 

A  ver}'  im[K)rliiDt  and  oomnion  imperative  mnceptton  is  a  moi^ 
bid  fear.  This  may  take  almost  any  form,  and  may  be  simpk 
an  ex^;gera(ion  of  a  normal  fcclinf;  or  may  arise  tie  novo.  Thu.*, 
in  aome  persons  the  fear  of  a  tJiunder-«torni  i&  m  violent  as  to 
destroy  fur  the  time  twing  alt  ratiunullty;  in  others  the  natunl 
dislike  of  filtJi  is  inrrtiascd  nntll  it  dominates  every  action  of  life. 
On  the  other  hand,  the  liornir  of  walking  in  an  open  plaee,  which 
is  sometimes  t«o  overwhelm  lug,  iteeui!?  scarcely  to  be  based  upon 
any  natural  feeling.  To  many  of  these  morbid  fcurs  names  hare 
been  given  by  systematic  writers.  The  fears,  however,  vary  bo  in 
their  detail  that  it  i<t  not  pftsaible  to  exprcM  them  accurately  and 
fully  by  any  syetcin  of  nomenclature.  A  few  of  tiiese  naraa 
may  be  cited,  za  representing  the  more  characteristio  forms  of 
morbid  fear.  The  following  list,  taken  from  Dr.  Beard,  ponnje 
vcrv  well  the  absnrdities  of  nomeudaturc : 

Astraphobin,  fear  of  lightning.  ToiM)phobia,  fear  of  ploceii— 
a  geaerlc  term,  with  these  subdivisions :  Agoraphobia,  fvax  of  open 
places;  Claui^troplmbiu,  fear  of  narrow,  clofwd  pl&ocs.  Anihro- 
phobia,  fear  of  man, — a  generic  term,  including  fear  of  sode^. 
Gyniephobia,  fear  of  woman.  Monophobia,  fear  of  being  alone: 
Patltophobt.1,  fear  of  di^rease, — imually  called  hypoohondriasis. 
Pantaphobia,  fear  of  everything.  Phobophobia,  {liax  of  being 
afraid.     Mysophobia,  fear  of  contamination. 

As  illustrating  imperative  conoeptinns,  a  few  cases  from  my 
own  e]t|)crience  may  be  cited.  A  very  strong  shoemaker,  past 
middle  life,  was  oppressed  with  the  idea  llint  ho  could  not  walk 
unlcas  he  liad  nome  covering  over  hia  head.     On  a  stormy  day 


OterrDBBANOES  OF    INTELLKOriON. 


480 


le  natural  cloud-canopy  sufficed^  and  on  a  clear  day  aa  umbrella 

irried  over  lii.t  head  gave  a  measure  of  rcller,  &o  that  he  w&s 

'able  to  conintond  \m  mnvemeuifl.     He  con\ti  wnlk  in  a  thick 

wood,  but,  as  bo  himself  said,  if  ten  feet  of  clear  sky  luterveii«d 

HweeD  the  wood  and  a  ^^pring  he  would  die  of  thirst  before  lie 

luld  cross  over.     So  oihc-T  syniptom  of  physical  or  mental  ail- 

lent  could  be  detected. 

A  lad}'  had  a  dread  of  personal  dciilcment :  hundreds  of  timea 

lily  she  washed  her  hands,  without  avnil ;  bank-notes  fresh  from 

!ie  press  were  the  only  money  she  would  use ;  a  door-knob  alia 

rould  never  touch,  but  would  remain  in  tlie  room  uulil  some  one 

)pened  the  door;  in  putting  on  her  clothes  only  the  inside  of  each 

r^iece  was  touched  by  her  fingers,  and  this  as  daintily  as  jxissible. 

Without  entering  into  further  detaila,  sufiice  it  to  state  that  her 

fhole  life  was  arranged  in  order  to  avoid  as  raucli  as  poftriible 

'^contact  with  any  pi'rum  or  thing.     On  my  asking  her  to  shake 

hands  her  embarrassment  was  ejrtreme:  though  naturally  polite, 

^Blnd  feeling  under  some  obligation  to  me,  she  was  nevertheless 

^^pifinly  dominated  by  her  imperative  cuuceptiun.     FinaHy  she 

^Hud,  "  Dear  doctor,  don't  ask  me :  you  know  you  touch  so  many 

people." 

^K    A  gentleman  entirely  rational,  able  to  manage   his  business 

^nfiairs  well  and  to  converse  ou  all  subjects',  was  completely  ruled 

^■by  imperative  eonoe]>tiunH  and  morbid  impulse.'^,  the  connection 

'     and  the  independence  of  which  are  well  illustrated  by  his  case. 

Thus,  for  many  years  he  had  an  impulse  continually  to  rub  his 

arms  against  his  sides,  and  this  he  did  iuce?«sautty  until  coat  after 

coat  was  rubbed  iuto  holes.      No  morbid  eoneepiiou  could  be 

found  underlying  tlii>i  or  some  of  the  other  im|)ulse9  which  he 

^had.      Nevertheless,  he  did    have  imperative  conccptlonii  with 

^■(Hitgrowing   secondan.-    impulses.      For    many   months   h«   was 

^^  markedly  my-sophobic.     Then  he  had  the  uoiiception  that  he  must 

I       lay  things  down  straiglit  and  could  not  do  it.     Most  of  his  waking 

^uioments  were  at  this  time  spent  in  putting  down  and  arranging. 

^^Vhen  he  placed  a  book  on  the  table,  over  and  over  and  over 

again  he  would  lift  it  up,  straigbtea  it,  pick  it  up  aud  re-lay  it,  etc. 

OAeii  at  night  he  wouk)  be  two  or  three  hours  getting  away  from 

lis  coat,  which  he  was  perpetually  arranging  upon  the  chair  on 

[which  he  had  laid  it.     There  was  no  delusion,  and  on  my  asking 


436 


DTAONOeTlC  NEtmOLOOY. 


the  man  why  he  yielded  to  the  impulse,  he  said,  "  I  can 

for  B  while,  but  aJYer  a  time  the  same  overpowering flenasUoD  totom 

as  when  I  hold  my  breath,  nnd  I  mosi  do  it.     I  fanve  fbnnd  that 

if  I  say  very  fjiel^  '  It  is  straight^  it  U  slraigbt,'  over  and  over 

again,  at  the  same  time  erackiiig  my  fingets  briskly  by  sliabiag 

tny  hand,  the  impulse  onen  suddenly  vanishes,  with  immediate 

relief." 

The  relation  of  imperative  conceptions  and  morbid  impu1*eA  to 
ioHuiity  is  a  matter  of  great  tlieoretical  and  practiool  intaroL 
They  are  undoubtedly  freci^ueiit  in  the  JOztane,  and  UKtially  careful 
examination  of  u  case  in  which  tliey  are  present  will  revetU  dU- 
(iiict  symptoms  of  alienation.      They  may,  however,  exist  in 
pertionti  whoetu  iuteltecLual  actions  are  in  oiher  reapectd  entirely 
normal,  and  in   whom  tlic  judgment  Is  not  dominated    by  Uw     , 
conception  which  may  influence  the  actions  against  the  judgmeo^^B 
To  himself  the  sane  subject  of  an  imperative  conception  aeena^l 
posse^sctl  by  a  demon  wlioni  he  ranst  obey. 

The  relation  of  morbid  couoepUomi  and  impulaaa  to  legal 
reaimnaibllily  for  acts  committed  involves  questions  of  gnat 
practical  difficulty.  The  victim  of  the  morbid  impulse  cannot 
properly  urge  such  impulsea  as  excuses  unless  the  deed  in  quo- 
tiou  114  immediately  produced  by  them.  When  the  act  ia  cocd- 
mitted  because  tlie  actor  is  foroe<l  to  do  it  by  a  morbid  impulse, 
the  actor  U,  of  course,  morally  blameless ;  but  who  onn  tell  whether 
the  impulse  wm  resisted  to  the  utiermottt?  Moreover,  the  needs 
of  society,  aud  the  ease  with  which  sucli  impulses  could  bealU^ 
or  oountcrtelted,  very  ]>roperly  give  us  pause  in  attempting  by  tlwin 
to  excuse  a  criminal  act  The  olearei^t  poaBible  proof  should  be  re- 
quired that  the  impidse  was  really  morbid  and  irresUtible. 

KaineK  have  bei.-o  given  to  various  morbid  impulsee.  lu  moat 
coses  these  names  are  misleading  in  their  etymology  and  primaiy 
meaning.  They  iiMially  end  in  "mania;"  but  ihe  morbid  im|iul«e 
is  not  a  mania,  but  a  symptom  which  may  either  coexist  with  ma- 
niacal nianifoitations  or  be  isolated.  Thus,  pyromania  is  a  morbid 
impulse  to  set  lire  to  buildings;  ktepfomania,  a  morbid  impulse  tu 
steal ;  homiadal  mania,  a  morbid  impulse  to  bill ;  suicidai  tnania, 
a  morbid  impulse  to  commit  suicide,  etc.  Unfortunately,  the 
nomenclature  is  made  tttill  more  complicated  by  the  fact  that 
often    when  the  morbid  impulse  exists  iu  an  insanity  the  oanu 


DiarURBAXCES   OF   INTELLECTION. 


437 


lenally  applied  to  the  impulw  is  given  to  the  whole  attack. 
i'haH,  a  melnnoholia  with  nn  impulse  to  net  lire  to  houses  would 
called  pyromania.  Not  rarely,  indeed,  there  is  not  even  the 
[cu.se  of  the  c.\i«Lcncc  of  a  morbid  impulse  for  the  name  given 

the  disease.  Thus,  the  man  who,  not  believing  in  a  future 
existenop,  commita  suicide  l)ccanse  Itc  is  sufTtTin}::  from  the  un- 
ntti^rable  misery  of  metaticholia,  i?  logical  and  roAsonable  In  his 
suicide,  and  does  not  kill  hiiiwelf  through  any  morbid — f.f.,  un- 
reasoning— impulse.  Stiioidal  and  homicidal  maniacs  are  simply 
Iierwtu.i  who  have  a  tendency  to  kill  themselves  or  others. 

Morbid  de»ire*  are  exaggcrntions  or  perverBioos  of  natural  ap- 
petites, and  are  chiefly  seen  in  regard  to  hunger  and  the  sexual 
pas!>ion.  Mei-e  depravity  and  wickedness  may  convert  man  into 
a  monster:  neither  cannibalism  nor  the  lowest  sexual  degradation 
ifl  necessarily  the  offspring  of  disease.  Nevertheless,  disease  may 
affect  the  appetite  for  food  or  for  sexual  congrcaa  ae  it  does  other 
foDctions  of  tlie  nervous  system. 

In  mania,  in  paretic  dementia,  in  hysteria,  indeed,  in  almost 
B^ibnn  of  insanity  with  excitenicut  and  exaltation,  the  sexual 
may  become  an  all-devouring,  insatiable  hist.  In  the 
female  this  condition  is  known  b»  ixymphoumnta ;  in  the  male, 
as  saitfriasi^.  The  victim  of  it  talks  incessantly  and  indecently 
about  sexual  ouugrc^,  makes  furious  luve  lo  all  persons  of  the 
opposite  Bex,  exposes  the  jwrson,  etc.  JCi-ofomania  ia  a  very  fre- 
quent condition,  in  which  there  is  the  ap[»earancc  but  not  the  reality 
of  sexual  excitement.  The  sulyect  of  it  conceives  a  strong  attach- 
ment for  some  jwrson  of  the  opposite  sex  whom  perlia|»s  he  or 
ahe  has  never  seen,  and  lives  in  a  ]>crpetual  worship.  SometJmea 
the  object  ia  in  public  life,  and  ia  followed  from  place  to  place 
with  a  jwrtiiiacity  and  publicity  which  may  amount  to  actual 
persecution.  Even  if  opiKirtiuiity  offer,  the  erotomaniac  makes  no 
effort  at  coliabitation.  Satyriasis  leads  to  sexual  ex<5CMS  and  to 
rape.  Erotomania  is  a  ptatonic  affection,  which  involves  the 
higher  oonoeptivc  sphere  rather  than  the  lower  nerve-centres,  and 
leads  to  sexual  abstinence. 

The  individual  Hyniptoma  or  manifestations  of  disordered  men- 
tal Bodon  having  been  sufficiently  di.>)cu!4sed,  the  con.<(l deration  of 
tlie  so-called  mental  diseases  is  in  order.  Before,  however,  enter- 
ing upon  the  subject  of  insanity  it  is  necessary  to  discuss  the  pro- 


i 


DIAONOenc  NEDROLOOy. 

found  active  dtm^rder  of  intolloction  cnDntxrted  with  consdialioiBl 
affections  to  which  the  name  delirium  is  given. 

By  the  term  delirium  h  meant  an  acute  mental  oondition  in 
which  there  is  inccesant,  uinrc  or  lets  locohercnt  talk,  which  it 
not  directly  inspired  by  surrounding  objects, — tJie  sufferer  being 
BO  occupied  with  hi.t  own  mental  nono^ptions  that  he  ifl  not  entirely 
ooniacious  of  his  situation:  indeed,  in  most  cases  there  U  net 
a  true  oonscioiUDCss.  Deliriuni  may  be  either  low  in  type,  or 
wild  and  furious.  It  is  produced  by  a  large  numl>er  of  diseuM 
which  are  not  immediately  connected  with  the  nervous  systen: 
ander  these  circumHtances  the  cause  of  the  mental  aberration  is  to 
be  made  out  by  diagnwiug  the  disease  whtdi  produces  it.  It  h 
a  general  law,  with  few  exceptions,  that  a  delirium  which  b  lav 
and  muttering,  if  acute,  and  not  preceiled  by  protracted  evideaon 
of  cerebral  disease,  is  due  to  some  aflection  not  immediately  ooft- 
nccted  with  the  brain.  Violent  acnte  delirium  is  often  the  resoh 
of  brain 'disease,  but  may  be  scotndary.  In  pneumonia  ovcurriag 
ia  persons  exhausted  by  diasipatJon  a  wild  delirium  may  be  tbe 
mo«t  prominent  Kymploni,  and  give  rise  to  the  faUo  diagnosis  of 
plirenitis.  In  every  case  of  sudden  severe  delirium  the  lunp 
tboald  be  carefully  examined,  when  the  physical  signs  may  de- 
monstrate a  pneumonia,  aliliough  there  may  be  neither  cough, 
pulmonic  distrces,  nor  apparent  disturbance  of  the  respimtiuos. 

A  mdden  severe  deliriuni  may  mark  also  the  onset  of  an  acute 
general  disease,  such  as  malarial  fever,  scarlet  fever,  etc  Usually 
iu  such  a  case  the  delirium  itself  is  tow  and  muttering;  but,  even 
if  it  be  fierce,  the  pulse  is  weak  and  fi«ble,  the  countenance  is  de- 
pressed, and  a  general  expression  of  vital  failure  exists,  which  to 
the  experienced  eye  at  once  indicates  tlie  presence  of  a  depressing 
poison  iu  tlie  blood.  , 

m 

Before  entering  njion  the  discussion  of  the  classifications  oii 
insanity,  (lie  question  how  much  of  abnormal  mental  a<rtion  b 
compatible  with  sanity  seems  naturally  to  present  itself.  Its 
answer  involveM  the  definition  of  llie  words  sanity  and  insanity, 
and,  like  these  definitions,  probably  will  always  be  unsatisfactory. 
Insanity  is  not  a  definite  disease,  but  an  abnormal  stale,  vatring 
indefinitely  in  its  intensity, — sepurated  by  no  tangible  line  from 
sanity, — arising  from  a  number  of  diverse  diseases,  and  termi- 


i 


DtBTtTltBASCES  OF  nPTELLECTION. 


439 


Dating  in  mwt  varioiiH  way<).  It  i«  a  mental  weakness;  and  it 
would  Ix*  as  absurd  to  ask  for  a  detiuile  Hue-  M^paraliiig  ilie  phys- 
ically weak  from  the  physically  stroog  as  to  usk  i'ur  udc  separating 
the  menially  weak  from  the  mentally  strong. 

For  his  owD  purposes  of  science,  or  even  of  treatment,  th« 
physician  Dt:ed8  do  deiiuition  of  insanity,  but  the  relatiuns  of  man 
to  man  are  »o  aliorcd  by  insanity  that  the  law  niubt  take  )Hur- 
tieular  notice  of  the  subject  of  iniianity.  Even,  however,  for  the 
purpoHCft  of  the  law  insanity  itt  not  a  fixed  term,  beuiiise  it  is  a 
well-assured  axiom  tliat  a  man  may  be  legally  mne — f'.if.,  respoii- 
^ibIe — for  one  claw  of  acta,  aad  insane — i.e.,  irresiwnsible — for 
another  clats  of  aete. 

As  already  contended,  there  can  be  no  scienti^c  definition  of 
insanity  except  that  it  is  a  Mate  of  mental  aberration.  Sucli  a 
defiuiliou  doe»  not  meet  the  needs  of  the  court-room,  wliiuh  de- 
mand an  arbitrary  although  shit'ting  line  between  the  sane  and 
the  insane.  The  term  insanity  oa  used  by  jiid^cs  and  lawyers  is 
le^l  rather  than  scientilic,  and  the  law  ought  oleurly  to  define 
the  word.  It  does,  however,  no  snch  thing.  It  does  not  frame 
an  authoritative  definition  of  iii8uniry,  but  tlirongh  the  mouths  of 
lis  exponents  puts  forth  an  abutidanee  of  contradiction. 

Probably  as  good  »i  definition  of  insanity  aa  the  expert  can 
frame  to  meet  tlie  clamor  of  lawyers  is,  that  insanity  is  a  con- 
dition of  mental  aberration  sufficiently  intense  to  overthrow  the 
nornial  relations  of  the  individual  to  Ins  own  thoughts  and  acts, 
80  that  he  is  no  longer  abk'  to  rontret  them  through  the  will. 
The  difficulty  of  applying  this  definition  to  the  individual  case 
consists  in  the  fact  that  ihL-  will  dues  not  all  at  onoe  loM  its  grasp 
on  the  lower  facu]lie:>,  but  ttiat  Little  by  little  these  slip  from 
nndcr  ita  control.  Of  degrees  of  responsibility  none  but  the  All- 
knowing  can  judge,  and  to  say  with  assuretl  correctness  just  when 
the  lost  control  lin.-t  been  lo^t  is  not  given  to  niortaU.  In  a  court 
of  justice  it  becuines  the  expert  to  state  as  nearly  as  may  be  the 
exact  mental  condition  of  the  prisoner,  leaving  to  Uie  judge  the 
decision  as  to  the  legal  responsibility  of  the  prisoner, — t.e,,  the 
relation  of  his  mental  condition  to  the  law  of  the  oommoowealth 


1  simply     I 


illogical  to  consider  ditFerent  forms  of  it  as  distinct  diseaBOi:  tin 
beRt  that  rain  he  ilnnc  is  to  dtfivribc  the  dtaeaaes  of  the  bnain  tai 
the  iuaaniiies  which  acoompuur  them  so  far  tis  wc  know  ad 
diMttses,  and,  when  our  knowledge  of  diaeasefl  fuls,  to  describt 
forms  of  iuftanity  not  a»  diseases  but  an  »ym[it4)m-gn)ii|ie. 

The  purposes  of  diaooBStOD  neoeHeitatc  the  naming  of  tfaae 
symptom-groupA,  for  it  becomes  esnential  to  have  tafaort  tenu 
which  fthall  convey  a  whole  group  of  symptoma  at  onoe  to  tiit 
mind.  Naming  m'mptom>groups  naturally  leads  to  the  deloaoa 
that  Utene  groujHi  are  diseases:  lieuce  inelaDdiolia,  mauia,  etr., 
are  oonHtnntly  written  about  B3  though  they  were  terms  of  equiv- 
alent force  to  typhoid  fever  or  scarlaUoa,  whereas  they  are  simply 
of  the  itame  rank  as  diarrlKSa  or  paralysis. 

This  b  showD  by  the  followiuj^  facts : 

Ifit.  Siniilar  mehtal  Bvmptoma  may  be  produced  by 
organic  braiu-<li9casc»;  or,  as  Di:  Charles  F.  Folsom  says  ^j4i 
tean  Syxlem  of  PraHical  Medit^ne^  vol.  v.  p,  202),  **  tumor*,  new 
growtlifl  of  all  kinds,  exostw^es,  spicules  or  ]>ortiuD)i  of  depresnd 
bone,  embolisms,  hemorrhages,  wounds,  injuri«>,  cyaticcrci,  nuy 
give  rise  to  any  of  the  symptoms  of  the  various  psycho-neurosei 
and  cerebro-psycboses," 

2d.  Almost  any  form  of  insanity  may  cxiitt  without  demonstn^ 
ble  orgatiici  leHion.  This  is  sliown  by  the  well-known  fact  that  in 
a  large  number  of  autopsies  n[ton  the  in-tanc  skilled  observcn 
have  failwl  to  detect  alteration  of  brain-«tructure. 

3(1.  Antagonistic  forms  of  insanity  may  be  produced  by  lesions 
which  are,  so  far  as  we  can  perceive,  identical :  as  is  witnesasd 
by  the  circumstance  that  in  paretic  dementia  the  usual  expansive 
delusions  may  l>c  rcplaivd  b}'  a  profound  nielnncholy.  Furtber, 
lesions  usually  aocom|)auied  by  insanity  may  exist  without  mental 
diKonlvr.  Dr.  FoUom  says,  "  Indeed,  nearly  ever)'  palholog^l 
coiicliiion  of  the  lirain  known  in  inmnity — in  kind,  if  not  In  ex- 
tent and  degree — may  be  found  in  diseased  or  injured  brains 
wh«r(^  there  lia!>  been  no  mental  disease  in  consequence." 

4lh.  The  form  of  the  insanity  may  change  in  the  individual 
without  appreciable  cause  and  without  conceivable  cliange  of  dis- 
ease. 

6t)i.  Almost  every  grade  of  case  exists  in  nature,  onittng  by 
an  unbroken  scries  die  various  insane-symptom  groufis.     ThuS| 


DIBTURBANCX8  OF  I>'TEU.ECTION.  441 

tif  the  two  moet  aotagonUtic  forms  of  acut«  inaanity,  aoDte 
tnauia  and  acute  melanofaolio,  Buckiiill  and  Tuke  s^y  (Phila. 
edition,  lS74f  p.  427),  "  Between  acute  mania  and  acute  melan- 
cholia no  dutinct  line  of  demarcation  t»Ti  l>e  drawn.  The 
domains  of  the  two  diseases  overlap  so  much  that,  in  prnctioc, 
cues  not  iufreqtieiitly  present  themselves  wliich  may  with  equal 
propriety  be  roferred  to  one  or  the  other." 

The  nonsiderations  which  have  been  brought  forward  show 
that  the  various  forms  of  insanity  are  not  entitled  to  be  con- 
sidered as  distinct  diseasefi,  and  that  at  present  we  cannot  connect 
cerebral  lesion  ami  mciiUil  sympl-oms  in  their  causal  relations. 
More  than  this,  the  rapid  retxjveriuB  which  80inetimet>  ucvur  in 
apparently  hopel«B  cases  of  inamity  show  that  the  symptoms 
cannot  depend  upon  alterations  of  the  brain-substance  suflSdently 

■gross  to  be  detected  by  our  present  methods. 
I  shall  narrnte,  an  showing  this,  a  single  case,  that  of  a  lady 
'      with  whom   1  was  thrown    in  almost  daily  crjntacl  for   many 
years.     At  about  the  age  of  foriy-fivo  she  was  taken  with  re- 
ligioos   melancholia  of   the   most    pronoun<*d   character,  which 
was  accompanied  by  agitation,  and  sometimes  by  frenzy.     This 
^■persisted  for  fifteen  years.    There  had  l^en  in  all  this  time  not 
^■the  slightest  wavering  of  the  mind  of  the  woman  in  regard  to 
Hher  future  life.    She  firmly  believed  that  her  soul  was  irretriev- 
ably lost.     At  tlie  same  time  her  general  emotional  nature  liod 
undergone  a  retrograde  change:  she  had  beofjme  exceedingly  jeal- 
oas  of  attentions  [laid  to  other  persons,  and   had  lost  many  of 
the  peculiar  traits  of  rofinoment  which  had  been  heresi^ecialchamo- 
teristic.     After  being  in  an  asylum  fur  some  time,  she  recovered 
H  JDtellcctual  power  sufficient  to  enable  her  to  take  charge  oomioalty 
of  her  husband's  houi^e,  wliich  was  reallv  managed  by  her  at- 

Itendant,  but  tliere  was  nn  wavering  in  her  delusion,  nor  even  any 
temporary  abatement  of  her  misery. 
One  night  the  attendant  noticed  this  lady  on  her  knees  at 
the  Ijed.side.  This  was  the  6r^t  time  in  fifteen  years  that  she 
bad  l»een  known  to  kneel  in  prayer.  The  nurse,  Iwing  a  vise 
woman,  did  not  disturb  her,  and  there  she  remainc<i  all  night. 
In  the  morning  she  joined  the  family,  and  said  that  slie  had 
found  Chriist,  and  that  she  was  perfectly  well  and  happy.  Her 
old   disposition    had    returned,  and   her   peculiar  jealous  senai- 


442 


DIAGNOSTIC  NEtJEOLOOY. 


tiveness  bad  dlsuppoared.  The  woman  wliu  had  beeu  barni)  h 
fifteen  years  had  emerjied  in  one  night  without  oven  the  grave- 
clothoi  ubuuc  her.  TIiIh  ooaUnutMl  for  one  week.  ThpntheuJd^ 
cload  came  oo  her,  and  Tor  days  she  was  in  the  old  oonditMa^^f 
but  suddenly  the  sunlight  again  broke  through  the  ctoadB,  aoil 
ebe  raniained  well  for  three  or  four  d:iy»,  to  relniMw,  and  after 
some  hours  again  to  regain  her  sanity.  These  attacks  ooDtiQiud 
to  recnr  at  gradually  lengthening  intervals.  Finally  $h«  bd 
been  perfectly  sane  for  several  consecutive  mouths,  when  soddenlf 
she  wiis  seized  with  a  tieroufi  diarrhtsa,  causeless  a»  far  as  codd 
be  a>KX3rtaincd,  and  hopeless  as  far  as  relief  by  remedies  was  ooa- 
oemed.  In  forty-eight  hours  she  was  dead.  I  beliere  that  tif 
cauAe  of  that  deatl)  vr»A  (he  same  obscure  something  whicli  luiil 
BO  potently  afK.'cted  for  years  the  emotional  life:  that  vrhich  for 
BO  many  years  had  dominated  the  nerve-ecnires  of  higher  life 
attacked  and  |iaralyzed  the  lower  ucotre;)  of  animal  Hfejand 
came  speedily. 

Wc  can  scarcely  conceive  the  n.iture  of  a  lesion  which,  after 
having  held  for  HAeeu  yearo  the  uurvo-ceulres  in  an  iron  grip, 
suddenly  let  go  its  hold.     For  its  demutiBtration  the  microsonpe 
is  useless.     Our  be<^t  instruments  flhow  ui  in  human  spermatozoa 
nothing  but  irregular,  transparent  specks  of  protoplasm,  not  to 
be  distinguished  one  from  the  other.    Yet  the  records  of  post  geu- 
erations  are  written  in  the  little  formless  particles,  io  whicli  also 
are  enfolded  the  potentialities  of  future auooessioiis  of  men.   Stnio^H 
ture  and   function  seem  m  widely  independent  tliat  it  is  alnu^H 
ho}>el€88  to  expect  that  we  shall  ever  nnderstand  the  infinitely 
delicate  changes  which  take  place  in  the  oooiplex  protoplasm  uf 
the  brain,  and  U)  bo  able  Ut  say  why  waves  of  emotional 
mental  pnmlysis  sweep  over  the  individual.     1  believe  that 
changes  are  physical,  but  I  ali^)  l^elieve  that  it  will  never  be  witl 
liumau  )>ower  to  recognize  their  nature.     The  aiicrudcupe 
ooars^  blundering  tool,  powerless  to  reveal  the  ultimate  ohaugis 
of  nervous  protoplasm  gone  mad.  ^M 

Almost  every  systematic  writer  upon  the  s«bje<4  has  his  oi^ffl 
private  classitication  of  insanity, — a  fact  which  is  strong  evident*  ' 
that  no  claHHifictttioii  as  yet  made,  or  as  yet  possible  to  be  made,  is 
Hcientificatly  accurate.      Much  of  the  confusion  arises  out  of  the 
false  view  that  the  so-called  distinct  insanities  are  distinct  di( 


m  ul 

i 


t  diseas^^ 


DISTURBANCES  OF   IKTEIXECTION. 


443 


llf  it  were  once  generally  acknowledged  that  almost  all  of  thene 
furias  of  insanity  in  nature  uliiule  into  one  another,  and  that  tlie 
separations  are  arbitraryt  simply  made  for  convenience  of  study 
,  and  discue^on,  the  simplest  arrangement  would  become  popniar 
H  becaus«  the  most  convenient.  The  following  arraiigecnent  is  more 
simple  than  novel,  and  better  adapted  to  the  need  of  the  practical 
alienist  and  student  than  to  that  of  the  theorizer. 

■  Group  I. — Complicating  insanities,  in  which  there  arc  distinct 
physical  Hvmptoms  of  di«>ase  of  the  brain,  the  cerebral  disorder 

•  not  being  due  to  an  acquired  or  inherited  constitutional  diatbesU. 
Group  jr. — ConBtilutional  insanitiesj  in  which  the  cerebral  dis- 
order 13  due  to  an  acquired  or  inherited  oonBtitutional  vice,  in- 
cluding in  the  latter  term  diatlteiii^,  constitutional  dJBcasos,  and 
subacute  and  chronic  poisonings  involving  wide-spread  areas  of 
the  body. 
m  Granp  III. — Pure  intyinltic8,  in  which  the  mental  disorder  is 
HDOt  accompanied  by  essential  symptoms  of  organic  bratn-diseatie 

■  or  dependent  upon  a  diathesis. 

Almost  any  form  of  organic  brain-diisease,  such  as  abrioeas  or 
tumor,  may  be  aceomiiaiiiwl  by  mental  di«order.  If  the  gross 
lesion  be  fijcal,  it  gives  rise  to  focal  symptoms,  by  which  its  exist- 
ence is  betrayeil.  In  other  %vords,  the  charaeter  of  a  fiHwl  hsion 
_  in  complicating  insanities  is  to  be  made  out  by  a  study  of  the 
f  purely  physical  sym|jtom9,  it  being  borne  in  mind  that  pro- 
found mental  aberration  of  a  ehrouio  type,  and  net  accompanied 
by  RtuiKir,  i[ulit3ites  a  wide-spread  cortical  lesion  rather  than  a 
focal  ilisease.  The  cortical  lesion  may,  however,  be  secondary  to 
'a  focal  diseajw. 

The  only  wide-eprea*!  brain-<liseBftes  which  produce  Complicating 
^Insanities  arc  Meningitis,  acute  and  chronic,  and  Perieuvephulitis, 
I  acute  and  chronie. 

Memngitia. — Acute  meningitis  is  very  rare  in  the  adult,  but 
may  be  the  result  of  a  sunstroke  or  of  a  traumatism.  It  is  usu- 
ally secondaiy  to  a  chronic  meningitis,  a  brain-abt»ces»,  or  otlier 
organic  cerebral  affections.  If,  us  is  very  rarely  the  case,  the 
chronic  disease  has  ticcn  obscured  ami  perhaps  altogether  over- 


COMPLICATING  INSANITIES. 


444 


DIAGX06TIC  MEOBOLOOY. 


looked,  a  secondary  meoiDgitui  may  appear  to  be  a  primuj  afleo* 
tioD.  This  1  have  «si>e(-iiit]y  sl<«q  in  ecreliral  syphilbir  wbeu  the 
original  gumawtoiis  tumor  ha^  probably  bccu  very  limited  in 
its  extent.  It  U  probable  that  an  acute  tueningilts  may  be  pro 
dtictxl  directly  by  septic  polsooing. 

The  8ym])tonia  of  aii  acute  meniugitifl  are  furious  delirium, 
with  wild  outcHcB,  great  restlessness,  perpetual  6ghtiug,  and  oftea 
coavuLiionfl,  the  attack  Iieing  preceded  by  ao  agonizing  hea<1achc, 
which  ])ereit>taaa  loug  as  con«ctousneaa  is  retained.  There  is  always 
ID  the  bc^iDoing  pronounced  fever  and  excitemeut  of  the  circu- 
lation, which  is  revealeil  by  a  rapid,  bounding  pulse,  or  by  ooe 
which  ia  amall  and  very  hard, — i,e.,  the  "corded  pulse."  The 
disease  ia  often  ushered  in  by  a  rigor,  vomiting  i:^  frequent,  and 
violent  epileptiform  oouvuUious  may  mark  the  abrupt  ooset.  Xbe 
bc&dachc  and  mental  excitement  are  intensified  by  bright  lights 
ur  loud  souniU.  The  n)nvulsiuiis  may  be  partial,  and  lu  mild 
cues  the  motor  disturbanoc  may  be  manifested  by  persistent 
iitDOacular  rigidity,  which,  when  the  base  of  the  brain  is  chiefly 
[mffeuled,  ia  moMt  marked  in  the  neck.  The  stage  of  excitement 
"Iflflts  from  a  few  hours  to  several  days,  and  is  followed  by  one  of 
paralysis  and  depression,  in  whidi  there  is  stupor  deepening  tato 
coma,  a  slow,  intermittent  pulse,  or  other  evidence  of  failing  cir- 
culation, and  finally  death  amidst  wild  couvulsious,  or,  it  may  be, 
in  profound  muscular  relaxation. 


The  meningitis  of  which  I  have  so  far  been  speaking  is  the 
Asthenic  disease  as  it  cecum  during  adult  life.  To  childhood  to-l 
ilummation  of  the  brain-mem brancs  ta  comparatively  frequent, 
but  in  the  great  majority  of  cases  it  is  due  t<>  the  preaeooe  of 
tuberclcii  in  the  pia  mater.  In  the  child  aufiering  from  meniih- 
gitis  delirium  is  usually  not  so  marked  a  symptom  as  is  stupor 
or  coma.  This  ia  owing  partly  to  the  inipresHible  nature  of  the 
cerebral  cells  during  early  life,  which  leads  them  to  be  over- 
whelmed by  an  irritation  which  would  in  tlie  adult  produce  only 
an  active  delirium,  and  partly  to  the  tendency  to  the  outpouring 
of  Keroufl  exudation  into  tlie  cerebiura  Iwing  mucli  greater  in  youth 
than  in  age. 

For  the  purpose  of  diagnosis  it  is  Iwtter  to  study  first  the  oom- 
moueet  form  of  meuingitis  in  childhood,— 1.«.,  tubercular  meiuD-. 


DTfiTUUBAKCES  OP   INTEIJ.ECTJON. 


445 


g^tis.     Before  doing  so,  tiie  tubercular  affection  as  it  ooours  in 
mlnlto  requires  Aome  lunsiderntion, 

Except  in  very  rare  caaes,  tubfrcul-ar  meningitis  in  tbe  adult  is 
secomlury,  developed  as  the  result  of  a  tubereuliir  infection  pro- 
duced by  tubercular  ur  caseous  degeneration  of  tlie  lung  or  other 
distant  organ,  or  coming  on  dnriiig  convalescence  from  typhoid 
fever  or  other  acnto  .systwmic  afFfction.  It  may  develop  middenly 
with  violent  ]>»ychical  dlaturbances,  which  may  ooDtinue  for  a 
few  hours  or  days  and  then  be  lost  in  coma.  Tbe  first  marketl 
symptom  may  be  furiouK  nimiiiu»l  oiilbreiiktt,  hapiKuiug  only  at 
night,  the  patient  during  the  day  being  entirely  rational  and  free 
from  any  pronounced  symptoms  of  cerebral  disease. 

Oocasioaally  tlie  tubercular  deposit  is  !H>  localized  that  the 
earlier  symptoms  are  those  of  a  focal  lesion.  Thus,  cas<»  have 
been  recorde<l  in  which  an  aphasia  was  the  fii-Ht  evidence  of  the 
disease;  and  a  local  spasm,  or  even  local  paralysis,  or  a  sudden 
JaclcMniaii  epileptic  attack,  may  usher  in  the  disease.     In  typical 

B  cases  tho  attack  begins  with  u  headache,  which  may  be  verj'-  severe, 
and  may  be  a«companic<l  by  marked  anxiety,  depression  of  spiriut, 
and  often  pfiyohtcal  symptoms  rwiembling  those  of  insanity,  snch  as 

B  hallucinatiotis,  melauchotia,  or  a  mild  mania.  The  motor  symp- 
toms usually  follow  rapidly  upon  the  other  evidences  of  cerebral 
disturbances.  General  or  lueal  eonvulsions  are  rare,  but  various 
forms  of  paralysis  are  frequent ;  the  palsy  may  affect  one  arm  or 
one  1^,  or  take  the  form  of  a  hemiplegia;  under  these  oircum- 
Btances  it  U  rarely,  if  ever,  complete.  Pta«i»,  strabismus,  dilata- 
tion or  contraction  of  the  pupil,  facial  palsy,  or  other  losses  of 

H  power  about  the  face  are  very  frequent,  on  account  of  the  tendency 
of  the  tubercular  eiudation  to  mass  itself  about  the  ba.se  of  the 
brain,  Fever  is  usually  a  pronounced  symptom,  and  may  be 
irregular  or  may  have  a  diurnal  rhythm  similar  to  that  of  typhoid 
fever.  The  abdomen  is  usually  retracted,  and  constipation  pro- 
nounced. Vomiting  is  often,  but  not  invariably,  present.  If 
there  be  local  disease  of  the  alimentary  canal,  severe  diarrhoea 
may  entirely  mask  the  other  abdominal  symptoms,    \yhonever 

^  in  a  case  of  phthisis,  ur  during  the  ounvalesoeuce  from  an  acute 

^  fxmstiiutional  disorder,  symptoms  of  irregular  cerebral  diitturlv 
anoe  develop,  the  physician  should  always  suspect  the  cccurreDce 
of  a  tubercular  meningitis.     The  symptoms  of  the  disorder  vary 


446 


DIAGNOSTIC   NEDKOLOOy. 


greatly,  and  tite  diagnoeis  is  ju9t!6e(l  whenever  in  tbe  preseooe 
of  the  eliciting  cause  organic  braiu-diaease  is  indicated  br  the  oo- 
cnrrcncc  of  headache,  marlcod  peychical  distnrbancc,  or  local  paUv, 
provided  no  otlier  explanation  of  the  svmptonu  can  be  made  cni. 
The  symptomH  ijf  a  typical  case  of  tubercular  meningitis  oocor- 
ring  in  childhood  may  well  be  arranged  in  three  stages  bet^idea  tbe 
prodrornic  [leriod.  It  must  be  Ixirue  in  mind  tJiat  this  division  is 
Brhitrnry,  and  that  the  stagea  insensibly  pass  into  one  anodier  in 
any  individual  case;  al-w  that  in  some  cases  one  or  more  of  the« 
staged  ore  abeent,  and  that  in  other  instances  the  symptoms  are  so 
mixed  together  that  none  of  the  stages  can  be  clearly  made  out. 
The  first  period  ia  prodrnnitc.  Tlie  child's  health  be^ns  to  ftil 
mysta*iously ;  its  dii^position  alters  so  that  it  becomes  peevlsli  and 
eapecially  irritable;  it-i  itleep  at  night  19  broken,  sometimes  deliri- 
ous, eometiuies  interrupted  by  nigbt-terrora ;  the  ap{)etite  fails,  the 
bowels  are  constipated,  and  vomiting  may  occur:  at  tbe  same  time 
there  is  a  fe\'erishnes»  rather  tlian  a  distinct  fever.  This  prodro- 
mic  condition  losta  for  about  a  week,  when  tbe  child  enters  tbe  fir»t 
,  *tage  of  the  develo{K<l  affection.  The  symptocus  of  tlm  »<tage  ate 
as  follows :  headache,  wlilcli  may  not  be  severe,  but  wliioh  is  com- 
monly by  older  children  bitterly  complained  of,  or  in  young  chil- 
dren is  manifested  by  a  peculiar  plaintive  cry,  occurring  at  irregular 
inte^^'a]s,  and  otten  breaking  out  in  the  midist  of  a  restless  night- 
slumber,  although  rarely  heard  after  the  coma  has  been  fully 
develo[>ed,  and  bo  chamcteriKtic  as  to  be  known  as  the  hydro- 
etpkalic  ory ;  vomiting,  which  may  occur  only  at  long  intervals, 
or  may  he  incessant  and  associated  with  nausea,  and  which  is  very 
frequently  produced  by  changes  of  position ;  cvnstipatiou,  with 
retraction  of  the  belly, — a  symptom  which,  however,  mar  be 
entirely  mashed  if  there  be  tubercular  or  other  irritation  of  the 
intestines  or  their  glands;  a  condition  of  the  pulse  which  is  not 
in  acoord  with  the  extent  of  the  fever,  aud  may  be  diiitincdy 
slow  and  even  somewhat  irn^^ular;  spasmodic  oontmction  of  che 
muscles  of  the  nccU,  causing  some  retraction  of  the  occipnt  and  a 
perceptible  stiffness  of  the  neck  when  the  head  is  raised  from  tbe 
pillows;  fever,  wliich  has  nothing  characteristic  about  it,  but  ia 
rarely  severe.  General  or  local  nonvnlsioiu;  may  occur,  and  the 
pupil  may  lie  implicated.  When,  however,  pupillary  symptoms 
beoome  marked,  and  the  evidences  of  paralysis  appear  about  the 


* 

^ 

i 


I 


eye  and  face,  (he  child  may  be  consklfrred  to  have  entered  into  the 
second  stngf^  of  the  disorder. 

Stupor,  coma,  and  raiiscuUr  relaxation  are  the  most  pronounced 
synptoius  of  the  eew^nd  stage.  The  pnpili;  are  dilated  or  con- 
tracted, siupEifth  in  their  movements,  or  altoj^tber  filed  ;  Ptrabis- 
nane,  distortion  of  the  face,  faihire  of  the  power  of  artirnlation, 
or  other  evidences  of  loss  of  power  in  (he  muwles  about  the 
head,  mav  show  that  one  or  more  of  the  nerves  at  the  base  of  the 
brain  nrc  miObrinfi:  from  the  pressure  of  the  exudation.  Head- 
ache, vomiting,  and  conBti[>atinn  may  continue.  The  pnlsc  in  iisn- 
aJly  alow  and  intermittent  or  otherwise  irregular.  Various  con- 
trartures  may  be  present;  convulsions  or  convulsive  movements 
of  the  extremities  are  frequent;  tlie  rigidity  of  the  neck  persists; 
and  the  hvdroocphalic  cry  indicates  that  In  the  midst  of  the 
stupor  the  little  patient  is  still  sensible  of  his  sufl^rings.  As 
this  stage  progresses,  the  stupor  deepens,  until  the  child  no 
longer  exerts  any  control  over  the  bladder  or  rectum  Hnd  cannot 
be  aronseil.  Gradually  as  the  coma  becomes  more  pronounced 
the  final  iiaralysis  is  reachefl,  and  often  tlie  rigidity  of  the  neck 
and  the  retraction  of  the  belly  disappear  amidst  the  universal 
muscular  resolution.  The  pulse  becomes  rapid,  feeble,  and  irreg- 
ular; the  temjwrntiire  may  become  subnormal,  or  it  may  rise 
very  high,  or  it  may  twc  and  fall  without  regularity  or  order 
until  at  last  death  ends  all. 

The  ^mptoms  of  the  prodromiv  stage  of  tubercular  meningitis 
are  sufficient  to  excite  suspicion,  but  rarely  do  they  warrant  a 
positive  diagnosis.  If  the  case  has  developed  in  an  ordinary 
manner,  and  especially  if  there  is  in  the  medical  history  of  the 
child's  family  a  distinct  tubercular  taint,  the  character  of  the  dis- 
ease is  usually  apparent  by  the  time  the  first  stage  of  the  disorder 
is  fairly  entered  into. 

In  irregular  cases  the  diagnosis  is  not  so  easy.  The  prodromic 
stage  may  l>e  slight,  and  there  seems  indeed  to  be  a  form  of  the 
disease  in  which  the  attack  is  said  to  be  ushered  in  by  convul- 
sions. There  is  said  to  o^uur  in  young  children  an  idiopathic 
meningitis  or  leptomeningitis,  the  diagnosis  between  which  and 
tubercular  meningitis  may  be  attended  with  much  difficulty.  The 
idiopathic  affection  more  frequently  than  tlie  tubercular  disorder 
iMgins  abruptly  with  furious  oouvulslona,  but  for  several  days 


448 


DIAGNOSTIC  XEDBOLOOY. 


before  this  outbreak  there  may  be  headache,  restlessness,  «leeptea&- 
neae,  or  delirium  at  night,  change  iu  thu  disiKMfitioD,  vomitiiig, 
ooDStipatioD,  contracted  pupils,  with  excoi^ive  seusittvctieas  to  light 
and  sound,  or  otiicr  hypencctthesia,  vertigo,  and  other  symptoms 
cloeely  resembling  tho«e  of  the  prodromic  period  of  the  taberculnr 
diaease. 

Duriog  the  oonvulsious  of  idiopatliio  menin^tis  the  child  is 
eDtirely  unconticious :  epasm  of  the  glottis,  as  indicated  by  long- 
dntwn,  crowing  inspiration  and  impeded  expiration,  is  not  rar 
Either   through  it  or  through   cramp-arreot  of  tlie    respintiud 
oyanotiis  may  be  induced  and  death  occur  during  the  first  series  of] 
couvalBions.     Pamxyi^ms  of  oonvulHiona  may  succeed  ooc  anothf 
at  abort  intervals  for  many  houra,  or  may  subside,  when  stuj 
or  ooma,  ocular  and  facial  paralyus,  loss  of  sight  and  hearit 
and  progreasively  inoreasiug  muscular  relaxatioo,  with  or  wiihout 
contractures,  indicate  the  constant  I  y-iuneBsiug  pressure  from  ex-^ 
udation  int«i  the  memhrtines  and  ventriclpfl  of  tlie  brain. 

Since  tubercular  meningitis  almost  of  necessity  ends  in  death,! 
whilst  ID  non-tubercular  meningitis  the  child  has  a  cliauoe  of  re- 
covery, great  interest  attaolioi  tu  the  diagntuitj  between  the  two 
affections.  Unfortunately,  tbero  are  no  symptoms  which  are  pa- 
thognomonic of  either  disease.  The  eiriatenoc  of  a  known  heredi- 
tary taint  renders  the  diagnosis  of  tubercular  meniDgiti:^  probable; 
its  abwmoe  favors  the  hope  tliat  the  attack  is  not  tubercular, 
prolonged  prodromic  period  indicates  a  tubercular  affection ;  and] 
yet  I  have  seen  three  cohcs  iu  which  tlie  •lymptonis  »ecnie<.l 
warrant  the  diagnosis  of  a  hopeless  tubercular  meuingitlttg,  but  ii 
which  the  ]>atients  recovered. 

In  one  of  these  cases  the  father  wag  a  very  dii«i|iated  man,  anc 
Buflicient  ground  was  ailbrded  to  warrant  tlie  suspicion  that  tlu 
meningitis  was  due  to  inherited  syphilid.  The  second  case  oocun 
in  an  orphan  fourteen  years  of  age,  of  no  kuowu  family  history, 
but  did  not  prenent  any  other  syniptonm  of  syphilid  tliun  those  of 
a  slow,  progressive  basilar  meningitis.  Recovery  under  the  use 
of  iodide  of  potassium  was,  however,  complete. 

In  the  third  ca»e,  occurring  in  a  child  whose  joints  and  n\»^ 
indicated  a  rucbttic  tendency,  syphilitic  taint  was  absolutely  denied 
by  boLli  parents.    There  was,  however,  a  history  of  podsible  trau- 
matiam,  and  the  symptoms  were  chiefly  furious  repented  convul- 


DISTURBANCES   OF    WTEIXECTIOS. 


449 


sioos,  with  some  rigidity  of  the  base  of  the  neck,  rapid  loss  of 
flesh,  nod  headache.  Recovery  took  place  under  pro[Kr  hygieiiio 
mcasiirfs  and  the  use  of  io<Iidc,  pliriitphntni,  etc.,  the  iiKlidc  of 
potAssiutu  s€iemii)g  to  achieve  most  of  tho  result. 

Cerebro-«pinal  nieningitis  attat-kiug  a  yoting  child  may  produce 
syoiptoiua  whicli  are  not  to  be  di^liigiiishcd  from  those  attributed 
tua  fultuiaatiiig  idiupnthic  meDingitis,and  it  is  probable  thatcai<c8 
.tiippoGcd  to  have  been  idiopathic  have  really  been  iiistanccit  of 
the  epidemic  disease.  Moreover,  pneumooia  ruar  produce  sytnp- 
toius  closely  resembling  those  of  a  true  meutngitis :  even  in  the 
adult  the  cerebral  symploius  of  a  pneumonia  iuay  completely 
mask  the  pulmonic  disturbance,  and  Cirisollc,  as  quoted  by  Prof. 
T^KimiA,  flflirma  that  the  usual  physical  signs  may  be  altogether 
waotiog.  I  have  seen  a  number  of  casus  iu  which  the  sole 
distinct  symptomatic  evidence  of  pneumonia  wns  acoeleratton  of 
tlie  bn-atliing,  not it!i'al>Ie  only  when  rarefully  looked  for,  and  in 
which  no  crepitant  rftle  could  be  heard  at  any  time  during  the 
•diseaae.  Absence  of  veiicular  murmur  or  presence  of  bronchial 
breathing,  however,  usually  betrays  the  ]>uliuonic  lesion.  Possibly 
bronchial  brt^thing  may  in  some  cases  be  wanting,  and  even  a 
iran<imitted  vesicnlnr  murmur  be  heard;  but  I  can  scarcely  con- 
ceive that  percuss ioii-dulness  can  be  absetil  in  the  pneumonic  con- 
solidatioo  of  the  adult.  In  young  children  I  have  seen  headache, 
strabismus,  cunvulsiou:!,  intense  [jcreistent  rigidity  of  the  ueck, 
irith  fever  and  a  slight  occasional  barking  cough,  followed  by 
death  on  the  sixth  day,  and  at  the  poist-mnrtem  have  found  (exten- 
sive pneumonia,  with  simple  hypcraamia  of  the  brain-membranes 
and  an  excess  of  serous  fluid  iu  the  brain,  the  microscope  showing 
that  there  bad  licen  no  nut-wandering  of  blmxlHXtrpuRcleR  and  no 
purulent  or  fibrinous  exudaliou.  In  this  case  the  only  physical 
sign  that  could  be  detailed  was  a  relative  dulness  over  the  affected 
lung.  The  percuissiou-note  was  dUtinet  and  clear,  but  not  ({uite  so 
dear  as  over  the  opposite  lung.  In  such  a  case  as  this  tlie  lung- 
aObction  might  very  atsily  Im  overlooked.  The  intensity  of  the 
I  fever  is,  however,  much  greater  than  in  either  meningitis  or  oere- 
bro-epinal  meningitis,  and  is  especially  out  of  proportion  to  the 
severity  of  the  meningeal  sympLoniB;  tJie  breathing  is  also  ex- 
cessively accelcrateil.  Meoiugitis,  genemlly  of  the  vault,  is  a  not 
very  infrequent  complication  of  pneumouia,  hut  there  is  no  way  of 


DIAGN08TIO  NRUROIXJOY. 


diBlinguiahing  between  mei]in(;iti&  aotl  tucningcal  irriUitioo  in  th« 
pneiimoniH  of  cliildliood.  Tho  practical  point*)  are  that  in  ik&e 
cAseA  tlie  pueuraonia  ia  the  primary  affet^tion,  to  which  the  treat- 
mcDt  u  lo  be  cspcciully  (liret-lcd,  and  that,  n-hcncver  symplowa 
of  fiihiiiiiating  iiu'itiiigitiK  ap]Hsir  in  cliiUlreii  nr  very  old  [wople, 
tlio  liingtt  slioulil  be  carefully  examined,  csjKciulIy  in  tlicir  apical 
lobes,  which  are  usually,  but  not  always,  the  part  afiFeoled  tn  the 
soHjalled  cerebral  pneiitnoiiia. 

Aoute    Periencephalitis, — Acute     Peripheral     Bnccphaliti 
Fhrciiilis,  Mauia  Gravis,  Typhomania,  Acute  Delirium,  Deliriu 
GravR,  Bcll'ji  DitKosc  (Luther  BotI). — This  affection  Kometim 
follows  intense  emotional  excitement,  sometimes  appears  as 
result  of  a.  prolotig^d  ntraiu  upon  lite  nervous  system,  such 
oociire  during  a  business  cnsis,  and  sometimes  develops  without 
apparent  cause.     It  is  more  frequent  in  femalen  than  in  males, 
and  eii[iecial]y  oocur<i  in  cases  of  sc<diiccfl  prejj^ant  women. 

The  symptoms  may  come  on  with  extreme  saddeaneas,  or 
may  be  preceiled  by  protlromic  evidences  of  cerebral  diiAturlwoce. 
These  prmlromes  in  rare  cases  take  the  form  of  increase  of  men-^J 
tal  power,  in  others  of  brief  noctLirnal  attacks  of  wandering  dfe^H 
lirioos  restlessness;  or  there  may  be  short  iieriods  of  impaired 
coueoiousueas,  es{>ecially  upon  waking  in  the  mornlDg,  or,  as  io 
one  of  my  cases,  even  an  epileptifurm  convulsion.  Tbe  fully- 
developcil  disonler  naturally  divides  itself  into  two  stages, — Bret, 
that  of  acute  nuiniacal  delirium,  and,  seoond,  that  of  apathy  and 
collapse,  with  coma.  The  delirium  is  always  of  an  excited  type^ 
acouiiijiaiited  by  violent  incoherent  speech,  and  usually  by  a  fury 
of  fighting  and  of  destmclivenesR. 

Halluoinationa  and  half-formed  dclosiona  ore  present,  and  ofteo^^ 
bear  a  close  relation  to  the  cause  of  the  attack.     The  abandonej^l 
mistress  will  in  her  raviuga  recount  her  past  shame  and  present " 
agony.   The  business-man  will  be  ]>erpetuuUy  occupied  with  an  in- 
coherent jumble  of  business  transactions.    Almost  invariably  along 
with  the  delirium  ihorc  is  great  physical  rcstlcsanesa,  which  grows 
more  intense  until  it  causes  tlte  [Kitient  to  leap  from  his  bed  and  to 
attempt  to  run  away.     Very  commonly  violent  assaults  are  made 
upon  the  altcndanCs.     Convulsions  are  not  common.     In  many 
cases  llie  delirium  is  at  first  not  continuous,  occurring  only  at 
night,  or  is  at  least  interrupted  by  brief  intervals  of  comparative 


DISTUKBANCEH  OF    INTEIXBCTIOS. 


451 


rationnlily  {luring  the  daytime.  Finally,  however,  there  is  per- 
riateot  intense  mania.  In  one  of  my  own  cases  the  patient,  during 
the  <!ay,  UM  his  wife  that  she  must  protect  herself  from  him,— 
that  he  luvet]  her  iiiORt  fiKidly,  but  that  he  was  going  into  a  con- 
dition of  insanity,  in  whieh  he  would  certainly  kill  her.  From 
thin  time  until  his  death  he  wai  fiirioiwly  maniacal  (hiring;  the 
night,  althougl)  for  several  days  he  would  recogiilxe  hi.^  friends 
during  the  daytime,  and  for  a  moment  or  two  talk  rationally. 
There  is  usually  alutolntB  insomiua.  The  imlwe  is  rapid,  and  even 
if  iu  the  beginning  it  possesses  a  show  of  force,  it  is  really  soft 
and  compressible.  There  is  no  desire  for  food,  and  generally  nn 
absolute  refusal  to  take  it  There  is  ailno  distinct  fever,  the  tem- 
perature rising  sometimes  to  106"^  F.  According  to  my  obser- 
vation, the  temperature  varies  with  a  storiny  irregularity  which 
ia  almost  characteristic,  rising  and  falling  many  degrees  many 
times  during  the  tweniy-four  honrs.  Its  variations  are  con- 
nected witli  the  mental  and  physical  excitement  of  the  palieul, — 
maniacal  outbursts  producing  an  immediate  rise  of  the  tempera- 
ture. The  pupils  may  be  coutraeted,  dilated,  or  normal.  In  the 
course  of  a  few  hours  to  several  days  the  second  stage  of  the  dis- 
order develops.  Tliere  is  now  quiet,  with  coma  or  else  mutter- 
ing  delirious  unconsciousueijs,  failing  pulse,  cool  skin,  and  general 
evidences  of  collapse.  In  the  early  part  of  this  stage,  when 
aroused  the  patient  nmy  r<Mpon<l  incoherently,  or  perha|«  ^ve 
some  slight  evidences  of  comprehfjidlng  what  is  said  to  him, 
but  rapidly  i>ink!i  lower  and  lower  until  he  dies  from  exhaustion. 
Early  in  the  dij^onler  the  skin  beeomcri  very  harsh,  and  finally  cya- 
notic; in  the  later  stoge-s  irregular  desquamation,  or  even  ulcei^ 
ation,  may  occur.  In  a  ca.'te  quoted  by  Spit/ka  the  ana»thesia  was 
so  complete  that  the  patient  gnawed  oS'  a  portion  of  one  of  his 
fingere.  Pemphigiisi-like  vesicle!!,  phlegmons,  gangrenous  patches 
of  skin,  or  gangrenous  extrpmitios,  not  raircly  appear,  hnl  are  fre- 
quently absent,  and  arc  not  characteristic.  Complete  recovery 
never  takes  place,  although  it  is  affirmed  that  in  rare  cases  the 
patient  is  restored  to  a  fair  degreo  uf  physical  health  with  only  a 
slight  mental  defect.  Usually  the  end  is  death;  sometimes  per- 
manent complete  dementia  and  more  or  less  wide-spread  paralysis 
rttult.  After  death  evidences  of  peripheral  encephalitis  are  to 
be  found. 


452 


DiAoyosnc  kedbologt. 


Tilts  disease  U  very  closely  related  to  acute  mania:  indeed, 
unless  it  be  by  the  presemv  of  marked  fc-ver,  aud  by  the  intendiw 
of  the  sympton»8f  i  do  not  8ce  how  the  aScctioD  is  lo  I«  Heparated 
from  acute  tnaoia.  If  it  be  correct,  as  is  aswrted  by  Harnmood 
{IVealisf:  on  /n«tnrty,  p.  546),  that  the  temiK-rattire  is  never  e!e- 
vat(*<1  in  acute  mania,  then  it  is  possible  to  Uiagno^  between  acute 
mania  and  penphernl  eur«plialitis.  Folfom,  however,  affirms  litat 
in  actite  mania  the  skin  is  hot;  and  at  pre^nt  we  are  not  able  to 
state  ]H>3itive1y  that  attacks  of  acnte  mani»  are  other  than  coses 
of  peripheral  enceplialitis  of  a  mild  tyjw.  (See  Acute  Mania,  p. 
471.) 

General  Paralysifl  of  the  Insane — Paretic  Dementia,  Perien- 
oephaiiti«,  General  Paralysis  of  the  Iiiwiiie,  Paresl^i — is  a  diseaiie  in 
which  tlie  lesion  is  a  pnigreiiHive  inflammatory-  alteration  of  the 
brain -oiirtcx,  which  registers  itself  syoiptomatically  in  the  motor, 
sensory,  and  mental  spheres  of  airtion. 

Caaes  of  paretic  dementia  are  di^nsiblc,  so  far  aa  their  mental 
symptoms  are  concerned,  into  four  varieties ;  bnt  it  must  he  reraem- 
bcml  tliat  this  diviiiiun  i^  an  arbitrary  one,  mid  that  whtUt  abuo- 
dant  cases  exist  in  nature  crirresponding  aoeuratcly  to  one  or  oihvr 
of  the  classes,  yet  every  grade  of  case  exists  between  the  clasaeSj 
and  the  inarch  of  the  mental  malady  sometimes  is  so  irregular 
thiit  in  one  portion  of  its  course  the  individual  case  miglit  be 
BBstgned  correctly  to  one  variety  of  the  disease,  but  at  another 
time  would  bf-long  to  another  variety. 

In  the  (irst  form  nf  parrtio  dementia  are  includeil  those  oases  in 
which  progressive  failure  of  power  constitutes  almost  the  whole 
mental  distnrbanoe,  the  mental  faculties  consentaneously  growing 
lese  and  leai  until  the  [jalicnt  becumeH  cliildi!'!),  and  at  Iohl  oom- 
pletcly  demented,  without  emotional  disturbance  or  delusions 
having  been  pre-sent.  (It  is  these  cases  esitecially  that  are  popu- 
larly !«poken  of  as  s^ofletiing  of  the  brain.) 

The  seeoud  variety  of  paretic  dementia  is  tliat  in  which  dela- 
BJons  of  grandeur  or  ex[xiiisive  delirium  are  ]>resent.  The  rbaracter 
of  thc«  delusions  has  already  l;ecH  suffieiently  pointed  out.  (Sec 
page  431.)  It  is  essential  to  rcmctnber  that  these  deliisU-us  may 
exist  ill  80  mild  a  degree  that  they  may  be  very  reailily  over- 
looked. Further,  in  many  cases  they  ar*;  replaced  by  a  bien-Hrt 
which  may  be  looked  upon  as  a  condition  of  nndeveloi>ed  dela- 


PISTUABANCE8  OF  lNTEL,LECTION. 


453 


» 


* 


I 


fe 


L 


TliDK,  the  man  sunk  in  tlie  deepest  poverty  wilt  be  exoee- 
Mveiy  happy  and  jolly,  miafortuiiw  having  no  jiower  to  depress 
him,  although  lie  malcts  no  osscTtion  of  the  pos.se3^ion  of  great 
power  or  wealth.  lit  all  rases  r>f  the  present  variety  of  general 
paralysis  (here  is  progressive  meulal  failure,  ami  it  i(t,  therefure, 
evident  Ihat  the  casein  in  which  a  simple  bien-Hre  exlais  may  be 
looked  ujwii  as  midway  hetwecii  the  lir»i  and  the  trecond  variety 
of  the  disease. 

Maniacal  outbursts  may  ooriir  in  any  variety  of  general  paraly- 
sis, but  they  are  more  coniioou  aud  more  freijueiil  when  there  are 
deluKtons  of  grandeur. 

The  third  form  of  geuerat  paralysis  U  that  in  which  there  is 
emotional  depression,  and  even  pronounced  melancholia,  with  de- 
pressive delusions.  Not  mrely  the  depressive  delusion  relates  to 
the  periiOD  of  the  patient,  who  believes  himwif  ill,  deformed,  ur 
wanting  in  some  nieinl;er  or  function,  lu  this  way  arises  tlie  so- 
called  liypochondriaail  variety  of  general  pandvHis. 

The  fourth  form  of  general  paralysis  is  that  described  bv  Dr. 
Fabre,  in  which  exeiicment  and  deprt^^aion  alternate  so  a^  to  make 
a  periodic  or  circular  insanity.  The  existenec  of  tliia  variety  hits 
been  conlirmed  by  Dr.  W.  Julius  Miokic  [Oeneral  ParalynU^ 
London,  1880),  who  further  sayj^  that  when  there  are  only  two 
phases  these  succeed  each  other  suddenly,  but  that  in  some  cases 
there  are  three  periods, — (I)  excitement,  (2)  calm,  (3)  depression, 
— in  this  differing,  therefnm,  from  iRin-puralytli;  circular  intmnity, 
in  which  the  usual  onler  is  (1)  excitement,  (2)  depression,  (3) 
quietude  or  lucidity. 

The  pliyitical  eyniptoms  of  paretic  dementia  are  chietly  von- 
with  the  motor  functioUj  although  late  in  the  disorder  sen- 
n  iaalso  inip:iii-e^l,  and  may  be  almost  alwljithed.  KxccfM  in 
regard  to  the  epileptic  attacks  (see  page  1 16),  the  motor  sympioras 
are  always  pandytic,  and  are  especially  eharafteri»cd  by  their  iu- 
completeneiss  antl  by  their  conuectiou  with  tremors  and  lo*»i  of 
control  over  muscular  movements.  In  the  earliest  stages  of  the 
disorder  the  loss  of  control  ovpr  complicated  muscular  movements 
id  first  raanifesle<l  in  the  hands,  and  may  he  very  pron(iuncx:d  at  a 
time  when  the  general  muscular  power  ia  but  little  weakened. 
Thuti,  a  man  may  be  able  to  lift  many  pounds,  although  he  can- 
not write  his  own  name.     The  acute  development  of  such  a  loss 


464 


DtAGXOSriC  NEUROLOGY. 


of  mu^nlar  contnd  ocfiirring  in  a  rann  of  middle  a^,  witVon 
obvious  cause,  is  a  ^ertouH  symptom,  and  probably,  iu  the  majority 
of  cases,  is  prodromic  of  general  paralysin.     It  is  especially  to  be 
oolioed  very  mrly  in  enpravcrs  and  otiier  persons  wliose  daily 
vixtation  requires  great  tocbnicnl  skill. 

A  varviiig  inequality  of  the  puptis  may  ofXMir  very  early,  al- 
thongli  more  constant  in  the  later  stages  of  tlie  dUcxse.  It  may 
l)C  associated  with  exeessive  dilatation  or  contraciion.  When  there 
is  no  focal  brain-lettion,  and  no  disease  of  the  neck  or  of  the  cer- 
vical Bpiiial  cord,  this  symptom  is  almost  path<^nomonie. 

Tile  departure  of  the  speech  from  the  norm  in  general  paraly- 
sis Ls  partially  of  mental  and  partially  of  physitml  origin.  Asa 
consequence  of  the  loss  by  the  lips  and  tongue  of  their  delicacy 
of  movement,  there  is  a  diffioulty  of  pronunciatirm,  whlt^h  ia  es- 
pecially manifested  with  lingual  and  labial  con^onautii  aud  ru  the 
eyilables  of  long  words.  This  causes  a  peculiar  stuttering  or 
hesitation,  with  some  thickness  of  speceb  and  un  oocasioual  cltsioa 
of  syllables,  so  that  the  speech  somewhat  resembles  that  of  intoxi-  j 
cation.  In  advan^-ed  i^tages  of  the  disease  the  uncertainty  of  the  ' 
movements  of  the  Ii|)6  and  tongue  is  plainly  visible  to  the  eye,  ^H 
and  is  associated  with  tremor,  or,  more  correctly,  with  tremulous-  ^^ 
ne!v<;.  In  general  paralysis  the  mind  thinlcR  slowly  and  imper^ 
fectly :  it  fails  not  only  in  the  formation  of  ideas,  bnt  also  in  the 
quick  association  of  these  ideas  with  suitable  words.  There  w, 
consequently,  slowness  of,  well  as  lio^itation  of  apeccli.  In  soma 
cases  the  mental  actions  seem  1o  be  performed  in  a  ^h^'thrainll 
manner,  giving  rbw?  to  a  peculiar  utterance  which  somewhat  re-  ^M 
semblee  that  used  by  the  scliool-boy  in  scanning  Latin  {xiclry,  ^4 
and  hence  often  spoken  of  as  the  "scanning  &f>eech."  There 
is  al^o  in  many  cases  a  uao  of  improper  words.  Not  rarely  the 
paralytic  talker  drops  a  word  from  his  sentence  or  repeats  a 
word ;  mayhap  he  elides  or  repeats  a  whole  clause.  Movement  . 
of  the  jaws  similar  to  mastication  may  take  place,  and  even  causa  ^| 
grin<ltng  of  the  teeth  or  champing  of  the  jaws.  ^^ 

Tlio  Inev  of  adniitiuss  an<l  exac-titnde  of  movement  may  first 
ap|)ear  in  the  hands.  The  handwriting  becomes  shaky  aud  irreg- 
ular, and  the  letters  are  111  formed,  even  widely  se|»anited  from 
one  another,  sometimes  resembling  bientglypli.s  rather  than  mem- 
bers of  the  Roman  alphabet.     Very  frequently  the  finely-graded 


DtSTURBAXCCS  OF  ISTELLECTIOX. 


strokee  of  fnrrccC  writio^  ^mppMr  in  a  comman,  thick,  unocrtain 
line.  The  wriling  not  nnly  shows  tlie  physical  dc^uUliou,  httt 
has  the  same  menial  chanictcristiat  as  the  speech.  'I'he  ideu  are 
often  inoongruoiis  and  devoid  of  proper  ai^snciation,  and  the  words 
incorrectly  used.  Letters  are  dnip]w<l  out,  syllables  omitted  or 
repealwl,  and  wonU  or  even  clauses  elided  or  interjecte<). 

The  gait  may  be  early  aflected.  It  be«>mes  awkwiird  ami  uu- 
t?ertaiD,  the  steps  may  be  long  and  ^dightly  irn^uUr,  ami  the 
patient's  lack  of  oontnil  over  his  inoveraeots  comes  out  sharply 
when  be  attempts  suddenly  to  turn  or  to  alter  his  |Kwitiou.  As 
the  disease  progreegcs,  the  ^1  beuomes  slow,  heavy,  and  unsteady, 
whilsl  the  wiiic-ly-scpii rated  ffet  readily  trip  over  an  ine(\iiality  or 
linexpecMd  obstacle.  In  the  :Klvance<l  stages  the  posture  of  the 
patient  resembles  tliat  of  old  age,  the  body  being  beut  awkwardly 
forward  or  to  one  side.  With  diniculty  he  walks  with  a  slow, 
unsafe, swerving  gait;  in  the  most  advaiiccti  stages  tottering  for- 
ward, aided  by  an  arm  or  some  support,  and  day  by  day  losing 
control  over  bis  limb^i,  until  he  becomes  l)edrid(lcn. 

The  symptoms  of  general  paresis  may  l)e  summoil  up  to  bo — 
chauge  of  e.hanu;ter;  pnigrtssive  mentHl  deterioration,  with  delu- 
sions of  grandeur,  emotional  exaltation,  or  emotional  dvproasion; 
oocnsional  manisnal  mitbreaks  and  epileptic  attacks;  prcgrcssivo 
physi<-al  deterioration,  as  shown  by  irregulority  of  the  pnpils,  dis- 
order of  speech,  loss  of  eoolrol  over  the  movements  of  the  hnitds 
and  legs:  all  symptom)^  fninlly  being  swallowed  up  iu  a  complete 
p«raty!?iH  of  intellection  and  of  vuluntjiry  motion.  When  tho 
disease  is  fully  formed  there  can  bo  no  difficulty  in  rociignixing 
it.  In  the  earlier  stage?,  however,  the  diagnosis  may  1k'  almost  us 
difficult  as  it  is  important.  Iu  making  it,  the  age  of  the  |>4ilit-iit 
and  the  presence  in  the  history  of  tlic  ordinary  causes  of  gvneral 
paralvjits  nhould  have  great  weight. 

In  civil  life  the  aficction  is  most  frequent  between  forty  and 
fifty  yearfl  of  age,  although  it  not  rarely  iwcurs  as  wirly  on  thirty 
years,  and  more  freijueutly  as  lut«  us  the  firty-fiflh  yttir.  In 
sailors  and  soldiers  Mickle  noted  that  the  aven^  ogu  was  alsiut 
thirty-three.  The  causes  of  the  ufTt^tinn  ap{icur  to  b<.'  bahilual 
emotional  and,  to  a  less  extent,  purely  intellectual  over-eJcdte- 
meut;  excessive  use  of  alcohol ;  sexual  eioesMS,  espoctally  when 
combined  with  syphilis  j  and,  much  more  rarely,  sunstroke  and 


456 


DIA0NO9T1O  NEUROLOGY. 


Other  tranmatwiiw.  Wlipiiever  any  of  ihe  earlier  symptoms 
]i«ar  in  a  man  of  miildlc  age  wlinsc  life-hlstory  presents  the  ca.iaei 
of  the  ilisease,  general  jiaralysis  should  be  coiwitlered  Immiomt, 
aw.\,  \vhili<t  it  may  nut  be  proper  to  give  a  poaiUve  opinion,  it  ts 
usually  right  to  take  measures  of  rcstraii)t.  The  earliost  important 
symptoms  are  an  api>arently  ntuselcKi  change  of  character,  epj- 
kptic  attacks  which  cannot  be  otherwise  explained,  and  dtstinct 
mental  symptoms  t^ucli  as  have  been  described.  When  the  diag- 
umtn  nata  lielwceii  frencml  ]Hiresis  and  some  other  form  of  miiii 
insanity,  the  condition  of  the  memory  should  be  cnrcfully  atudiad. 
Under  these  riiviimBtnnces  distinct  failure  of  memorj'  [joints  veiy 
strongly  towards  general  paresis.  A  rnoug  the  phpical  symptoms 
the  niorit  important  are  iueqimllty  of  the  pupils,  aud  loss  of  power 
of  exwriiiiug  fine  movements,  sucb  as  those  of  writing,  of  buttoning 
or  Qtibuttoning  the  clothes,  of  dancing,  etc.  These  physical  symp- 
toms usually  come  on  early ;  aome  of  them  may  even  precede  dis* 
turbanoe  of  iutcllectiou.  On  tlie  other  hand,  I  have  seen  the 
physical  health  greatly  improve  and  the  muscular  power  increase 
in  the  earlier  stages  of  the  disorder, — at  a  tioK-,  too,  when  the 
intellectual  symptoms  wore  very  pronounced. 

Cerebral  Scleroeis. — Sclerotic  affections  of  the  brain  more 
ii>>ually  take  the  form  of  a  niulliplc  ijckn>NiK  ihan  lliat  of  a  wide- 
spread cortical  change.  In  multiple  sclerosis  the  only  mental  ^r- 
ration  that  is  common  is  a  progressive  hws  of  power,  especially 
markei),  at  least  in  the  earlier  stages  of  ihe  disease,  in  regard  to 
the  memory  of  roeeat  events.  If  oonsidetablc  cortical  regions  be 
.involved,  complete  dementia  may  result  even  in  a  disseminated 
•clerosis.  In  terminal  dementia  it  is  not  uncommon  for  sclerotic 
changes  to  be  detected  at  the  autogisy,  and  it  Is  probable  that 
various  cases  supposed  to  be  iuslanccb  of  pure  insanities  are  really 
examples  of  the  earlier  stages  of  a  cerebral  sclerosis.  At  preeent, 
however,  wc  are  not  able  to  connect  mental  abemition  with  incip- 
ient sclerotic  disease  of  the  brain-cortex,  or  in  any  way  to  diag- 
.  aose  the  existence  of  the  latter,  nnleis  it  manifests  itself  also  by 
^physical  (tymploms.  For  further  remarks  upon  this  subject,  see 
Syphilitic  Insanity,  p.  464. 


4 
4 


DXSTTRBAKCBS  OF  rXTELI-ECTION. 


DIATHETIC  INSANITIES. 

The  diathetic  insaoitics  arc  not  distinct  forms  of  disease,  but 
groups  of  symptoms  of  various  and  varying  character,  which  are 
tbe  outcome  of  conatitutional  vice  or  dieeatse.  Thu«,  tliere  is  noth- 
ing io  the  symptoms  of  a  gouty  insanity  which  would  eaable  us 
to  diagnuee  the  nature  of  the  case.  Tho  oiuim  of  the  mental 
aberration  in  such  a  caso  can  be  reoogiiized  only  by  recognizing 
the  presence  of  lithffiraia.  The  importance  of  distingnishing  an 
iDKanity  of  the  present  clatta  lies  in  the  fact  that  relief  is  to  be 
obtained  not  by  treating  the  insanity,  but  by  treating  the  dificaeeil 
HOonditinn  which  is  the  canse  of  thu-  menial  diKonler. 
V     The  most  important  of  the  diathetic  inaanitiea  are  ibc  Gouty, 

the  Epileptic,  the  Hysterical,  and  the  Toxremic. 

K     Cktuty  Insanity. — It  is  well  known  that  gouty  paroxysms  are 

^Kfrcqucntly  accimipanied  and  preceded  by  pc<>u]iar  nervous  irrita- 

Hbility.    At  such  limes  there  is  a  depression  of  spirits,  with  an  irri- 

"tability  so  great  tliat  it  can  scflrecly  be  controlled  by  the  jwitient. 

In  «ome  caises  these  symptoms  become  so  intensified  as  almost  to 

amount  Ui  insanity;  mureover,  hallucination}',  delusions,  loss  of 

mental  power, — indeed,  almost  every  coneetvnble  manifestation  of 

mental  disorder, — mny  be  directly  or  indirectly  caused  by  gout. 

Carrol  in  1859  said,  "Gouty  mania  is  occasional  I  y  seen  ;"  and  in 

1875,  Dr.  P.  Berthier  (Des  iV^rrowa  diathfsifpics,  Paris)  publi(?hed 

a  iwllectioti  of  forty-six  rases  of  nervous  disease  attributable  to 

gout;  one  of  hallucinations;  one  of  migraine;  four  of  tetanus; 

^ptHree  of  chorea;  one  of  hypochondria;  seven  of  epilepsy;  one  of 

^paralysis;  and  twenty-six  of  mental  affections,  including  in  these 

dementia,  melancholia  with  stupor,  mania.     Although  in  some  of 

tliCBO  eases  the  evidence  is  not  at  ail  positive  that  gout  was  tlie 

materia  morbi,  yet  in  others  the  relation  wema  to  have  [teen  clearly 

^made  out. 

H     In  his  paper  read  before  the  International  Congress  at  Loudon, 
BI88I  (iii.  640),  Dr.  Kaynor  supported  the  following  conclusions: 
H     1.  Pri)tr!ic1e<I  gouty  toxtemin,  when  not  very  intense,  usually 
^besults  ill  sensory  hallucinations  or  melaucliulia. 
^P    2.  Sudden  and  intense  toxicmia  results  in  mania  or  epilcj)sy. 
3.  Intense  and  prutnicted  to.\femia  usually  results  in  general 
,  paralysis. 


4«8 


DUONOSnc  SErKOLOOV. 


4.  If  there  Iw  a  tendency  to  vaacalar  de^etiemtion  from  plum- 
bism,  alcoholism,  etc.,  varying  degrees  of  dementia  are  produced. 

lu  the  discussion  vphich  followed  the  reeling  of  Dr.  Raynur's 
piiper,  Dre.  Savage  and  Crichton  Browne,  of  London,  l><)Ui  ex- 
pressed (he  belief  that  gout  dors  cause  insanity,  the  latter,  how- 
ever, qualifying  bv  the  stati'-ment,  "  only  where  there  is  hereditary 
prcdispowtiou  to  insanity."* 

The  conclusions  of  Dr.  Kaynor  are  borne  out  by  a  oaae  of 
ray  own.  A  lutly  at  regular  iutervals  of  four  years  had  bad  a 
number  of  attacks  of  severe  gout  Bssodated  with  great  depreasioii 
of  fipirit^  at  timed  amounting  almmt  to  prnnonncc^l  mcUncIioIia. 
Finally,  at  the  cud  of  four  years  of  health,  tiie  patient  vna 
seized  with  symptoms  of  acute  dementia  or  stuivorous  melancholia, 
associated  with  markeil  tctiderncAs  of  the  nerve-trunks,  and,  lu 
certain  portions  of  the  botly,  violent  neuralgia,  and  a  urine  tliat 
was  loaded  with  uric  acid  and  uratea.  Death  occurred  after  tome 
weeks  from  cedcmaof  the  lungs.  At  the  autopsy  there  was  foaoil 
gouty  kidney  and  a  remarkably  pronounced  atheromatous  degen- 
eration nf  the  cerebral  ves-^els,  the  himiria  of  Kome  <>f  the  basilar 
arteries  of  the  brain  being  almost  obliterated. 

Epileptic  Insanitr. — In  considering  the  relations  of  cpilefwy 
to  mental  uberratiuii  it  is  necessary  to  dis^-uss  Heparately  the 
mental  symptoms  which  may  oocur  in  or  replace  n  single  par- 
oxysm, and  tliofw  which  are  the  result  of  a  long  sucoesoion  of 
paroxysma.  The  parox^'smal  mental  symptoms  may  be  considered 
amler  the  heading  of  Epileptic  Automatism  and  Epileptic  Maaia. 
In  a  very  large  proportion  of  cases  the  epiltjptic  paroxysm  a 
followed  by  profound  sleep,  from  which  the  patient  wakes  in  a 
more  or  hfs  dn)!i>d  condition,  which  may  continue  for  some  mo- 
meuts.  In  many  cases  the  palieut  may,  after  the  epileptic  por- 
oij-sra,  appear  to  be  conscious  and  yet  not  really  be  himself,  as  k 
shown  by  bin  Hiibjw«.]iient!y  l>eiiig  unable  to  rememl>er  anything 
that  has  hnp(>encd  shortly  after  the  convubiioo.  In  some  comb 
dirtinct  hystcntfll  maiufefltitions  aocoinpaoy  tbis  |>ost-epilepdc 
condition,  aud  even  hysterical  coDVulsioua  may  occur. 


*  Kurther  proof  of  the  coniiEwIion  liclween  gout  and  iBiaaltf  m»j  h«  found 
in  the  Paris  Thuis  of  M.  Bellikrd  (188S,  No.  ^»»),  in  which  are  d«Uit«d  nri- 

Otl>  CUM. 


bai 


DISTl'RBANCFS   OV    INTELI-EfTTION. 


459 


The  so-called  automatic  actions  of  epilqisy  are  prolmbly  in  tlie 
nmjority  of  cases  ]>ost-paroxysmal,  anti  cx*ar  during  the  jwriod 
which  lias  just  been  s[K>ken  of.  Tn  iheir  siniplcst  form  these 
acttdUB  (xinsist  in  the  doing  of  eonietlitng  whirh  is  usually  iitcon- 
gruoQs.  According  to  Gnwcrs,  a  very  eoniraon  |>crfornmnce  is 
that  of  undressing.  In  otiier  cases  the  patient  habitually  lays 
hold  of  all  (tmall  objeute  near  him  and  4ecreU»i  them  about  his 
posoD.  Iq  a  case  related  by  Gowere,  the  patient  wa^  accustomed 
to  cut  bread,  butter  it,  and  eat  it  as  fast  as  possible.  Sumetirues 
the  actiona  are  very  complex.     (lowers  relates  the  cose  of  a  car- 

linan  who,  for  an  hour  af^er  his  fit,  would  drive  through  the  most 
crowded  streels  of  Loudon  without  aoci<lent. 

Sometinifs  the  Hubject  nf  epilejttic  automatism  will  get  up  after 
the  convulsion  and  continue  with  whatever  w*ork  was  in  hand 
when  the  attack  developed,  although,  in  fact,  ]>erfectly  uncon- 
scious^. Thug,  a  woman  under  luy  own  care  has  been  attacked 
witli  the  convulsion  as  she  was  netting  the  lable  for  a  meal :  get- 
ting op  in  two  or  three  miimles,  tthe  would  continue  to  dish  up 
the  dinner,  arrange  the  ptutes,  etc.,  in  an  apparently  natural  way, 
but  would  after  a  time  suddenly  wake  up  and  have  no  knowl- 
edge of  what  »hc  had  done.  Other  cases  of  epileptic  automa- 
tism have  already  been  cited  (see  {rage  107),  and  siillicient  ex- 
amples giveu  to  show  that  the  at;Ls  may  apparently  be  pur- 
nve  or  purposeless,  and  most  simple  or  most  complex,  and 
that  often  it  is  very  dilTicult  to  [jenjuade  by-utanders  that  the 
patient  is  not  in  a  contUtion  of  true  c-ousciousue^.  lu  many 
cases  of  epileptic  automatism  du  display  of  emotion  is  made; 
sometimes,  however,  the  patient  is  Iiilarious,  and  even  aggressively 
affectionate,  aud  still   more  frequently  rage  or  violent  emotions 

i&re  manifested.  It  is  through  cases  in  which  violent  iiassion 
itself  that  epileptic  automatism  passes  into  the  scMiailled 
epileptic  luauia, — which,  indeed,  may  Im  very  logically  considered 
as  a  form  of  the  automalisira  as.-4ociated  with  excited  emotions. 

I  Epileptic  automatism  is  more  apt  to  follow  paroxysms  of  petit 
raal  than  the  nmjor  convulsions.  Nut  nirely  tht!  vertiginous  aud 
convulsive  symptoms  arc  so  slight  that  they  are  discovi-nible  only 
by  the  most  cnreful  observation ;  and  it  is  probable  that  in  some 
cases  the  automatic  actions  are  the  sole  outcome  of  the  epileptic 
disehai^,  all  the  other  stages  of  tlic  paroxysm  being  wanting.     1 


460 


IC  inEUROI-OOY. 


have  oertainly  seen  the  attack  of  epileptic  ntitomatisni  precede 
the  general  coiivulsiou. 

The  actiotis  of  epileptic  automattsm,  m  already  slated,  may  eo 
closely  re^mblc  those  of  the  normal  state  as  to  make  the  recog- 
nitiuii  of  tiiuir  true  nature  somewhat  difficult.  The  cliaraeterirtic 
feature  is,  however,  that  the  |jatit;nl  docs  not  after  hia  recovery 
rememlwr  anytbiog  of  the  occiirrencee  which  have  taken  place 
duriu);  the  Htitumiuio  Htat^.  The  jieriod  is  an  absolute  blank 
with  him.  It  is  hanlly  necessary  to  point  out  the  cli»se  rela- 
tions which  exist  between  the  epileptic  aucomatJAm  and  the  so- 
called  double  coiiscioutfuees.  The  fiict  that  in  typical  double 
cottsciousncie  the  subject  shows  vivtd  revolleL'tion  of  ocournaioeA 
daring  previuua  jiaroxysms  of  the  same  ty|>e  afTords  some  dis- 
tinction ;  but  in  nature  cases  appear  to  grade  into  one  another, 
the  cQiiuectiog  remembrances  being  sometimes  very  slight  and 
sometimes  verj'  vivid. 

in  epileptic  mania^  so  called,  there  is  violent  exciteme&t  and 
deliniiiii,  which  may  take  Uie  fonn  nf  an  acute  mania  or  of  an 
agitat«d  melancholy :  in  either  case  the  inoohereoce  is  usually  lea 
than  iu  the  corresponding  noD-epJtcptlcatfectiou.  Not  rarely  after 
a  primary  iieriml  of  violent  disitonnecled  spi-ecJi  the  |iatient  is 
seized  with  an  ambitious  or  mystic  delirium,  or  sometimes  a  delir- 
jam  of  persecution,  or,  more  rarely,  with  an  erotomania,  in  which 
sentence  uHer  sentence  flows  out  with  extraortlinary  volubility. 
The  attack  usually  comes  on  8uddeDly,Bnd  is  always  accompanied 
by  Imlluciiiatiuus,  which  Hometimes  develop  bnmjticly,  or,  mure 
rarely,  in  the  course  of  a  few  minutes.  The  hnllucinatiuns  affect 
all  the  senses  and  give  rise  to  delusions  which  conform  with  the 
type  of  the  emotional  disturlmuce.  The  delirium  may  last  for  a 
few  moments  to  several  days.  It  Is  especially  characterized  by 
the  tMideticy  to  nets  of  extreme  violeoue, — U)  suicide  tti  tJie  mel- 
ancholic form  and  to  homicide  in  the  maniacal  variety. 

In  epileptic  fury  the  subject  has  no  control  over  his  actions, 
and  when  munler  and  other  crimes  are  committed  it  is  important 
that  the  medical  jurist  recognize  the  true  nature  of  the  attack. 
When  the  mania  is  of  mild  type  the  danger  of  overlooking  ita 
character  is  greatest.  The  diagnosis  is  to  be  made  by  obtain- 
ing the  bistor}*  of  previous  attacks  of  epilepsy,  by  the  brutality 
and  causeleesneBs  of  tiie  crime,  an<t  especially  by  the  fact  that  the 


* 


DISTURBANCES  OF   INTELI.ECTION.  4(tl 

patient  has  do  memory  of  occurrences  which  took  plaoD  during 
the  mania.  In  a  certain  proportion  of  the  cases  the  attacks  of 
epileptic  mania  are  repeated  in  exact  counterfeit  one  of  the  other. 
The  maniacal  ombreak,  may,  however,  not  recur  for  a  great 
length  of  time.  T]ie  difliriilties  of  the  expert  are  IncreaMsl  by 
the  fact  that  the  6rst  paroxysm  of  an  epilepsy  may  take  tlic  form 
«f  a  furious  ontbrenk  of  epileptic  mania.  Under  these  circura- 
stanoes  it  may  be  eatKntial  that  the  patient  be  kept  fur  a  length 
of  time  under  fiurvetllance,  since,  ailhough  the  circumstances  of 
.the  paroxysm  may  (<atisfy  the  mind  of  the  metlical  expert,  they 

If  fail  to  carry  conviction  to  judge  and  jury.  K^quirol  states 
that  the  homicidal  mania  of  epile{>sy  is  never  radically  cured^ 
and  that  its  subject  i^  atnnys  liable  to  a  frefili  outbreak.  Whether 
this  be  ahsolutt'ly  true  or  not,  it  is  certain  that  the  recurrence  in 
anfficienttr  babittial  to  demand  the  perpetual  surveillance  of  the 
epileptic  eriininaL* 

Epilepsy  frequently  leads  to  mental  degradation,  which  loayend 
io  complete  dementia.  More  rarely  a  permanent  insanity  deveiops 
in  the  epileptic,  although  it  is  doubtful  whether  the  convnl- 
eions  in  these  cases  are  not  the  direct  onlcome  of  the  original 
neurotic  vice,  rather  than  the  cause  of  the  insanity.  The  type 
of  such  insanity  is  said  to  be  usually  melancholic,  with  delusions 
of  pen«ecution  and  suicidal  impulses.  The  chaRurteristic  mental 
state  of  ehrcfnic  epilepsy  is  progressively  lowered!  mental  [rawer, 
with  a  peculiar  irritability  and  brutal  selfishness,  and  outbreaks  of 
furious  anger  on  the  slighte-'tt  provocation.  Even  while  the  men- 
tal imwers  arc  still  active,  epileptics  very  frec|uently  are  peculiarly 
irritable  and  revengeful.  After  a  paroxysm  these  tendencies  are 
increftftwi.  The  tendency  of  epilepsy  to  cause  dementia  is  usually 
iu  direct  relation  to  the  earlines^  of  the  age  at  which  it  first  »]>■ 
pears,  as  is  stiuwn  in  the  following  analyciis  of  fourteen  hundred 
and  fifty  cases  collected  by  (Jowers  : 

As*  ef  rint  H«iitel  D«hat 

App*u«ac*.  ilaT*)i:qi«d. 

Coder  10  years » 66  per  c«aL 

Betw<wn  lOand  59jMni 88    "     ** 

"        aOmdaOywn 9    '*     "    . 

Over  SOjrevt ^ «    "     " 

*  For  Airtber  details  u|>od  thii  eulyect  oonaalt  U.  T.  MAgnan,  L'fyitepine, 
PxrU,  1882. 


462 


DIAONOBTIC   NBUEEOI^DQY. 


Hysterical  Insanity. — Severe  bysteria  is  amially  acoompoQied 
by  a  peculiar  meDtal  organ!  eat  ion,  vih'irh  may  amount  to  a  distiDi^t 
and  chanK^emiiR  ]wy'^)i<^iB-  In  its  aggravated  form  this  psy- 
cbosia  ought  to  be  txNtsidereU  as  bcloDgiogto  theiiortial  insanities, 
and  ought  to  acquit  its  victim  of  legal  re8|M>n»ibility  and  to  afibnl 
sufficient  grounds  for  restraint  The  pcuulinr  (.-haract eristics  of 
tbis  hysterical  temperament  have  l)een  so  vividly  set  forth  in  a 
few  senteuoes  by  Dr.  Folsora  that  we  quote  his  words : 

"  It  is  characterized  by  extreme  and  rapid  mobility  of  the  mental 
symptoms, — amnesia,  exhilaration,  iiielaucliolir  depre»siati,  theat- 
rical display,  suspicion,  distrust,  prejudice,  a  curious  combination 
of  truth  and  more  or  lesi^  uncoa»cious  deception,  with  periodi  of 
mental  clearue»  and  sound  judgment  which  are  oflcn  of  greater 
degree  than  is  common  in  their  families;  sleepleaanea^,  distressing 
and  grotesque  hallucinations  of  sight,  distoruon  and  |>ervernoa  of 
facts  mther  than  definite  delusions,  visions,  hypontsthesias,  anas- 
the^ias,  pan«stliesia8,  exceeding  sensitiveness  to  light,  touch,  and 
sound,  morbid  attachments,  fanciful  beliefs,  an  uubtalthy  imagi- 
nation, abortive  or  sensational  suicidal  mnucenvrcii,  occasional  out- 
bursts of  violence,  a  curious  combination  of  nnspeakable  wretched- 
□ees  alternating  with  joy,  generosity  and  selfish uess,— of  giHs 
and  graces  ou  the  one  liaud  and  exactions  on  the  other.  The 
mental  instability  is  liki!  a  vane  veerwl  by  every  ze|)hyr.  The 
moAt  trifling  causes  start  a  mental  whirlwind.  There  is  no  dis- 
ease giving  rise  to  more  genuine  suffering  or  appealing  more 
strongly  for  symiKithy.  Yet  when  lhi»  is  freely  given  it  does 
iiarm.  One  such  person  in  the  house  wears  out  and  outlives  one 
after  another  every  healthy  member  of  the  family  who  is  unwisely 
allowed  to  devote  herself  with  conscientious  real  to  the  invalid." 

During  the  paroxysm  of  major  hysteria  there  is  a  period  of 
delirium  which  may  simulate  acute  mania,  uud  I  luive  seen 
recurring  attacks  of  hysterical  cpilqiay  replaced  by  u  furious  out- 
break of  acute  mania,  lacking  in  none  of  the  symptoms  charac- 
teristic of  that  disease.  It  seems  to  mc  that  in  such  a  case  the 
maniacal  explosion  must  be  looked  upon  as  the  direct  outcome 
of  the  hysterical  neurmis,  and  that  therelore  the  exiftcnce  of  an 
hystericul  acute  mania  not  in  itself  distinguishable  from  ordinary 
acule  mania  must  be  acknowledged.  In  most  cases  in  which  sucJi 
maniacal  symptoms  exist  the  neurosis  is  so  thoroughly  engrafted 


OttrrURBANCKS  OF    IHTKULEUriON. 


Upou  the  coDstituttoii  Uiat  pvrmaueiit  recovery  is  not  posciible, 
the  patient  during  life  snSering  from  various  forme  of  hysterical 
atlark,  »ml  b«ing  alwaytt  |)os.si~^<^e(l  i>f  the  [H^fiultaritiei)  wliiolt  hove 
alrcadj  boen  spoken  of  as  cbaracleristic  of  the  hy«tertcal  tem- 

i^perameat.  Hysterical  symptoms  may  occur  duriDg  almost  any 
form  of  in^iiiity,  hut  do  not  wan-ant  our  lookiug  upon  etich  a 
melanttholia  or  mania,  or  whatever  form  the  ailectioii  may  lake, 
as  hyflteriral,  scarcely  more  than  we  should  l>e  warninted  in  con- 
sidering pneumonia  when  a^sociat^d  with  hysterical  iaymptotn»  aa 
hysterical.  At  the  same  time,  the  relation  of  the  hysterical  tem< 
peranient  to  monomanias  and  to  general  insanities  is  diAtini;!,  and, 
according  to  my  helief,  it  is  entirely  possible  for  any  form  of 
inflaoity  to  be  simulated  by  Jtyinptoma  which  have  their  origin  in 
the  original  faulty  organization  that  is  the  basis  of  chronic  hys- 
teria :  moreover,  such  faulty  nerve-orgHuization  is  closely  allied  to 
the  jieeuliar  neurotic  temperament  which  itt  the  ba>us  of  much 
insanity. 

I  Syphilitic  Insanity. — Insanity  of  any  type  may  occur  with- 
out deiiuite  organic  bmiu-iltsease  in  a  pcr»ou  w)io  has  t^yphilis. 
In  such  a  case  the  syphilU,  by  causing  mental  distress  or  general 

\  &ihire  of  health,  may  be  a  potent  factor  in  the  production  of  the 
mental  disease;  but  there  is  at  present  no  reason  for  believing  that 
syphilis  can  directly  produce  insanity  without  a  demonstrable 
bruin-lesion.  By  interfering  with  tlie  circulation  of  the  brain- 
cortex,  or  by  propagation  of  the  indanimation  to  the  cortex,  gum- 
matous meningitis  may  profoundly  iiiAuenr'e  the  bmrn-functions, 
and  experience  has  sltown  that  the  aberrations  produoed  by  them 
organic  changes  may  simulate  almost  any  form  of  insanity.  Such 
insanity  offers  no  charanteristio  Rymptotn»,  and  really  l)elongD  to  the 
eomplicating  insanities.     The  significance  of  the  mental  distarb- 

L-Aoce  is  to  be  made  out  by  recognizing  the  physical  symptoms  of 
the  urgunic  lesion.  Violent  headache,  epileptic  attuckij,  o<:ular  or 
other  forms  of  local  paUies,  tocail  spasnKs,  liK-alized  neuralgic  pains, 
or  other  evidenccA  of  generalized  or  localized  gummatons  inflam- 
mation, almost  invariably  enable  lis  to  make  out  at  once  the  nature 
of  the  disease.  Syphilis  may,  however,  produce  a  wide-spremi 
structural  disease  of  tlie  brain-cortex  without  implication  of  the 
membranes  or  of  the  Imsnl  nerves,  and  the  connection  between 
the  consequent  mental  derangement  and  the  syphilitic  infection 


464 

may  be  v^ry  'liRIcult  to  trace.  Thei-e  may  b«  no  symptoms  uf  a 
focal  (lUeuee  of  tim  braio,  and,  iuUeed,  no  (tislJDct  proof  of  the 
existcnoG  of  gross  orgaoic  lesion. 

SfMnetimes  the  ins^inity  in  manincal ;  now  it  takes  the  form  of 
religious  raelanclioly,  again  it  resembles  confusional  mania,  nipitJiy 
passing  into  deaientia.  There  is  eerlaioly  a  form  of  sc;lenisis  uf 
tliQ  cerebral  convolutions  wiiich  has  a  more  or  Ices  direct  oonoov 
tion  with  syphilis,  in  which  the  symptoms  Hnritig  life  a r«  those 
of  a  chronic  infinity  with  a  gradual  deterioration  of  the  mental 
powers,  ending  in  complete  dementia.  In  one  caw  in  which  I 
had  the  opportunity  to  follow  the  symplnraa  for  a  long  time 
during  life,  and  to  confirm  the  diagnosis  by  a  post-mortem  exam- 
ination, there  was  no  headache,  hut  for  many  months  a  ]>eculiar 
mental  condition  marked  by  great  restlcssuesg,  with  a  perpetual 
deHire  to  be  u|}on  the  go,  with  excessive  volubilit)'  and  a  curious 
loes  of  the  power  of  judging  of  the  relative  in>|K)rtance  of  ihingA, 
so  that  the  man  would  talk  for  hours  about  a  triBing  incident 
and  have  no  intcrcft  in  events  of  the  utmost  imporlanoe.  To 
llie  course  of  time  wild  maniacal  symptoms  were  added,  and  the 
cose  parsed  into  an  npimrenlly  ordinary  dementia. 

Although  medical  records  prove  that  a  patient  whone  ftyroptoms 
are  apparently  those  of  a  pnre  insanity  may  have  a  dyphilitic 
brain-disease  which  will  yield  to  treatment,  such  cases  are  «x- 
traordinarily  rare.  In  an  experieucG  covering  several  hundred 
cases  of  brain-syphiliu  I  have  never  seen  one.  I  have  seen  a 
number  of  attacks  of  an  apparent  pure  initanity  in  persons  who 
have  had  syphilis,  but  have  never  been  fortunate  euough  to  get 
good  from  antisyphititio  remedies.  It  is  otherwise  with  caees 
whtMe  symptoms  n?Hcmh]e  tho»o  of  general  pamly-siifof  the  insane. 
I  think  we  must  recognize  as  established  the  opinion  of  Voisin,* 
that  there  ts  a  syphilitic  p^riencophflHtis  which  presents  svmptonis 
closely  resembtiug  those  of  general  |)araly8i8.  Such  cases  ore 
examples  of  the  pucudo-parutysie  ginirale  of  Fournier.f  The 
question  r»  to  Uic  diagnosis  of  tlicae  caspa  from  the  true  innnrahle 
paresis  is  very  important,  and  has  been  considered  at  greut  length 
by   Voisin^  Foutnter,§  and  Mickle.|)     The  points  which  have 


* faralyiMgtniraUdet AUtnh,\Vl9.  ^ LaSifphili»dit0irceaM,7a.m,  1979. 
X  Loo.  ciU  i  Loo.  «1U  M  Brk.  and  For.  MtiL-Chu:  H«e.,  IBTT. 


DISTURBAHOEK  OF    l.vrKI.LKCTION. 


46fi 


been  relied  upon  as  diagnostic  of*  eyphlittic  pseudo'geueral  paral- 
j^is  are — the  aocurrence  uf  headache,  worse  at  night  &tid  present 
amoi)^  the  prodromes;  an  early  [lereistent  insomnia  or  somnoloooe; 
early  epileptiform  attacks ;  the  exaltation  being  less  marked,  less 
persistent-,  and  perhaps  lew  associated  \rith  general  maniacal  rest- 
Icsancs8  and  cxeiloment ;  the  articulation  being  paralytic  rather 
than  paretic;  rhe  absence  of  trcmn loudness,  especially  nf  the  upper 
lip  (Fonrnicr);  and  the  effect  of  antispeclflc  remedies. 

"When  tlie  conditions  in  any  case  correspond  with  the  characters 
just  paragraphed,  or  when  any  of  the  dUtiDguishiog  cbaracteris- 
ticB  of  bruin-eyphilis,  as  previously  given,  are  present,  Llie  prob- 
ability is  that  the  disorder  is  specific  and  remediable.  Bat  the 
absence  of  these  marks  of  .specific  di.seai»e  is  not  proof  that  the 
patient  is  uut  suCfering  from  syphilis.  Headache  may  be  absent 
in  cerebral  sj'philis,  na  also  may  insomnia  and  somnolence.  Epi- 
leptiform attacks  are  not  always  present  in  the  jiscndo- paralysis, 
and  may  be  present  iu  the  gcuuiiie  aftcction;  megalomania  may 
be  very  pronounced  in  specific  insanity.  A  case  with  ver)*  pro- 
nounced delirium  of  grandeur,  In  which  the  autopsy  revealed 
unqupHtionabiy  specific  brain -lesions,  may  be  found  in  Chauvet's 
Thegi»^  p.  31.  I  have  aeen  symptoms  of  general  paralysis  occur- 
ring in  pentons  with  a  sjwcific  history  in  which  of  (hew:  so-called 
diagnostic  diflcrcnces  the  therapeutic  test  was  the  only  one  that 
revealed  the  true  nature  of  the  disorder.  In  these  ca.ses  a  pri- 
mary, immaliatc  diagnosis  wus  simply  impossible. 

In  coiiclasion,  I  may  state  that  it  must  l)e  considered  as  at 
present  proved  that  syphilis  may  produce  a  disorder  whom:  symp- 
toms and  lesions  do  nut  differ  from  those  of  general  paralysis; 
that  true  general  paralysis  is  very  frequent  in  the  syphilitic;  that 
tlie  only  constant  ditTcreiu-e  between  the  two  diseases  iii  a^  to  cura- 
bility ;  that  the  curable  sclerosis  may  change  into  or  be  followed 
by  t))c  incurable  form  of  the  {lisease.  As  a  careful  untisypliilitic 
treatment  can  do  no  harm,  iu  any  doubtful  ease  of  iusunity  it 
•honid  be  eflsaycd. 

Aloobolic  Mental  Disorders. — Mental  dielnrbances  produced 
by  abuse  of  alcoliol  may  be  divided  into  the  subacute  aud  chronic 
forms,  to  which   the  names  Delirium    Tremens  and  Alcoholic 

Ilnsunity  may  he  assigned. 
IJdirium   Treniaia. — Delirium  tremens  is  a  peculiar  series  of 
80 


• 


I 


466 


DlAOKOenC  NEtmouxiY. 


acute  symptoms  wliicli  are  produced  by  excessive  driaking 
af^'tiou  13  eflpecialty  npt  to  devcloj)  u|toii  tlie  suililcn  cc^eatiun  io 
the  tii*e  of  the  stimulants,  but  may  come  oo  duriuf;  tlie  debauch. 
In  their  mildest  furm  the  nymplum:^  constitute  that  condttioa 
known  by  old  druiikunis  as  "  tin;  hurmrs,"  in  which  tht*  Bleep  ji 
difihirbnl,  the  hand  trcmulou.'t,  the  mind  weak  and  confused,  tm^ 
the  patient  troubled  with  frightful  imaginings,  vague  alart: 
und  an  apparently  causele-^B  dvpreiwion  of  HpiritH.  "When  the  at- 
tack is  mure  !«uvcre,  Imllurinatituis  of  siglit,  of  hearing,  and,  more 
rarely,  of  toueli,  occur.  The-'^:  liallueinMtiun.s  always  have  in  them 
an  elcnieut  of  terror  or  of  horror.  Dia^stin^  objects,  auch  u 
snakes,  toads,  rats,  and  mice,  and  (-imilar  unclean  creatures,  crawl 
over  the  bed  or  ttie  person.  Voices  predicting  evil,  or  bringing 
muuffi^-s  of  remorse,  or  uttering  threats  of  punishment,  are  heard. 
The  iKtticnt  may  Heeni  violent,  and  nuiy  even  attack  biu  attendant^ 
but  the  violence  ia  (hat  of  terror,  and  not  of  l^^rc^ioD.  The 
attack  is  an  attempt  at  defence.  There  is  great  ineomoia,  and 
usually  when  the  patient  can  be  made  to  Kteep  the  mind  is  clear 
afier  the  awakening.  Thiri  is  not,  however,  invariably  the  ua§e: 
I  have  seen  delirium  tremens  gradually  pass  through  suocesBiii 
days  of  wakefulne^  and  nights  of  $lee|>ing  into  a  chronic  raanitl 
nut  reailily  to  Iw  dir'tinguUhetl  from  that  arising  from  other  causes* 
In  tlic  earlier  attacks  of  dcltriuni  tremens  occurring  in  very  robust 
people,  whi-n  all  the  mu(«ns  mcnibrancii  are  irritated,  and  when 
probably  there  is  direct  irrit:ition  of  the  brain  and  its  menir 
there  may  be  a  slight  febrile  reaction  and  even  a  strong  and  excite 
pulse;  but  the  dtr^enHi^  is  typically  afllienic,  with  loss  of  mu^ular 
power,  trcmulousness,  and  rapid  feeble  pulse,  and  when  death 
occurs  it  is  from  exhaustion.  Cardiac  failure  is  in  such  cases 
always  to  be  guarded  against. 

SoMietinics  the    patient    sufiering    from  delirium   tremens 
sufficient  nitionaliiy  to  recei\*e  his  physician  with  a  tiiiicl,  gcnll 
courtesy,  and  to  answer  questions  without  irritation.     It  will  be 
noted,  however,  that  he  is  eviitenlly  preoccnpirtl,  and  tJiat  t* 
bioiially  he  luriu  his  head  or  caMts  furtive  glances  from  one  [>ai 
of  the  apartment  to  the  other;  and  a  little  finesse  will  reveal  tl 
fact  that  during  ihc  whole  time  he  li  seeing  visions  or  hearii 
nmuds,  or  is  at  leaitt  laboring  under  a  profound  apprehension 
attack. 


dii^Dosi^  of  delirium  trcmcDH  is  usually  easy,  even  when 
the  liiritory  of  the  case  is  not  clwir.  The  peculiar  terror  uuder- 
lyiug  all  the  deliu^ious,  hatluoiiiatioiis,  aud  utteuipb  at  viuleucc 
ia  characteristic,  a'*  is  also  the  treinulousneas  of  the  Imnds  when 
extended.  When  pneumonia  occurs  during  a  period  of  delirium 
tremens  the  type  of  the  delirium  raay  change,  tremon*  may  be 
lost,  aud  the  paLieut  may  becuuie  so  violently  aggressive  as  iu  lead 
to  a  mibinken  diagiMisiH. 

Aleofioti/;  JtuKinity. — The  prolonged  use  of  alcohol  may  lead 
to  a  grailiuil  functionnl  and  finally  structtirjil  alteration  of  the 
nervous  system.  Under  the  continuona  in6uenoe  of  tlie  narootio 
the  hrain  performs  its  functions  ylowty  and  imperfectly  and  the 
mental  movemenis  liticdme  sUiggisti  and  weak ;  the  memory  is 
greatly  impaired;  the  power  of  fixing  the  attention  steadily  di- 
minislies,  but  the  intellectual  weakness  is  esiwcially  showu  by  the 
Ivsseuing  of  the  power  uf  the  will,  so  that  uot  ouly  is  the  judg- 
mcot  uncertain  but  its  dictates  are  aot  carried  out.  There  in 
also  a  dit^tinct  tendency  to  etnutioiial  depression,  am)  often  n  pcca- 
liar  BUspiciousnoss,  which  is  the  ground-work  for  delusions.  A 
step  further,  aud  halluciaatious  hauut  the  victim.  The  route  to 
infinity  aud  trresftunsihility  from  tliiB  condition  ij>  ahurl.  Out  of 
such  B  state  is  easily  developed  the  most  characteristic  and  fre- 
quent form  of  alcoholic  insanity, — uamely,  that  with  depressive 
delusions.  In  some  cuses  this  variety  of  alcoholic  insanity  ap- 
pears suddenly  with  symptoms  for  a  time  not  to  be  distinguished 
from  delirium  tremens.  Iiideeil,  I  tln'cik  it  perfectly  correct  bo 
ny  that  a  patient  may  pa^  from  delirium  tremens  into  ahH)liolic 
inwoity. 

It  is  affirmed  tliat  headache  and  other  symptoms  of  sudden  con- 
goition  of  tliG  brain  occasionally  usher  in  the  attack  of  alcoholic 
insBoity.  When  the  symptom!^  are  active,  liallucinuiiuiis"'  are  very 
numerous,  constantly  changing,  and  nlmost  always  are  such  as  to 
iuapii-e  terror  or  disgust.  In  a  very  short  time  they  are  accom- 
panied by  delusions  uf  |H;rsecutiou :  voices  of  reprouuli,  threutea- 
iDg,  or  remorse,  mocking  faces,  unclean  beasts,  tormenting  devils^ 


P  *  Spilxkn  niTS  tbvy  *ro  uaually  of  vtkion  ;  Dr.  F.  Lantx  {Dt  I' AUttJkotitme) 
m;»  that  ibey  ar«  iluust  exclusively  of  liwriog ;  mjr  «xp«ri»ace  ia  Ibtt  both 
fafiDt  of  hHllucinition  aro  frcquout. 


46S 


oiAONoenc  mbubolooy. 


— tbese  and  atmilnr  visions  drive  the  victims  into  prnfound  mclan- 
chuly,  and  iinally  mny  lead  to  suicide  or  murder.  A<xx>rdii^  to 
Spitska,  tlie  delusions  of  chronic  lUeoholiara  almost  alwajs  relat« 
lo  the  sexual  ot^aos,  to  the  sexual  relations,  or  to  poisouiug.  Uu- 
derlying  this  variety  of  aluohuliu  mania  is  frequently  an  intense 
fear,  which  may  lead  to  violcooc,  as  when  a  man  kills  hi^t  wife 
because  he  fears  that  fUie  will  poison  him.  Not  uncommonly  the 
depressive  sexual  delusion  teuds  to  an  outburst  of  uucontrolUble 
jealousy  and  r^e^so  that  ^rife-niarder  from  motives  of  jealousy 
is  not  a  rare  result  of  alcohuliu  mania.  There  is  in  some  of  tbem 
cases  a  very  marked  relation  Iwtwcen  the  presence  of  alcohol  in 
the  blood  and  the  insane  outburst.  The  drunkard  may  be,  when 
not  under  the  intlueuce  uf  the  poison,  fairly  ratiuoal,  but  is  ODn- 
verted  by  alcohol  into  a  wild  beast,  aUlmugh  he  has  few  or  ncme 
of  the  ordinary  symptoms  of  intoxication.  The  man  may  walk 
straight^  and  talk  rationally  on  general  subjects,  but  be  profoundly 
under  the  influeuce  of  a  depressive  or  penweutive  delusion  wliicli 
ditnppears  when  tlie  blood  in  free  from  aloohol.  Thus,  in  the  case 
of  a  man  recently  tried  at  Elkton,  Maryland,  for  the  morder  of 
his  brother-in-law  and  child,  it  was  proved  that  when  the  priaooer 
had  ab^taioed  for  two  or  three  weeks  from  liquor  he  was  kind  to 
hiH  family,  and  attaclicd  to  his  wife,  in  whom  he  also  had  com- 
plete confidence:  so  soon  as  he  began  to  drink  again  be  would 
become  possessed  with  the  idea  that  "she  was  no  better  than  a 
common  wliore,"  aud  on  several  occasions  he  had  attempted  to 
murder  her.  The  immeiiiate  recovery  of  the  man  during  absti- 
nence removed  bis  case  from  being  fairly  considered  as  one  uf 
insanity ;  but,  although  a  few  moments  before  the  murder  the 
man  had  been  talking  rationally,  the  court  came  to  the  conclusion 
that  he  ivas  in  a  state  of  temporar}-  iusanity  from  the  iuflueuoe 
of  alcohol, — that  is,  in  the  condition  of  legal  drunkcnneas, — aud 
that  the  degree  of  his  crime  was  therefore  matiHlaugliior:  h  being 
the  theory  of  the  law  that  a  sudden  murder  committed  during 
iotoxit'ation  is  not  committed  with  that  malice  prei)etise  which  is 
necessary  to  constitute  a  murder  in  the  Oret  degree.  The  prisoner 
bad  been  drinking  heavily  for  twenty-four  hours:  he  first  shot 
his  brother-in-law  in  front  of  his  house,  then  went  in  and  called 
his  two  little  cfiildreu  to  himself,  and  blew  out  tlie  brains  of  his 
oldest  son  whilst  the  child  was  on  his  knees  praying  for  mercy. 


I 


The  second  boo,  seizing  hold  of  bis  father's  pantaloons,  pleaded 
for  his  life,  bat,  seeing  that  his  father  contiiiueil  to  load  his  gun, 
ran  for  the  front  door;  as  ho  suddenly  stopped  to  open  it,  the 
father  fired,  the  shot  tearing  away  the  brim  of  the  boy's  hat. 

Tbe  relation  between  depressive  alcoholic  ioi^nity  and  mania 
B  potu  is,  as  has  been  already  stated,  very  close.  Insomnia,  emo- 
tional excitement,  especially  c>onneot<Hl  with  fear,  hallucinations, 

,nd  dehwions,  arc  oommon  to  each;  but  the  tremors  are  more 
marke«l  in  delirium  tremens,  and  when  nn  attack  of  alcoholic  in- 
sanity is  acute  and  tremors  are  prououneed,  it  may  I>e  considered 
to  be  mania  a  potn. 

Dr.  F.  J^nlz  (he.  eit.,  page  491)  calls  attention  to  a  form  of 

Icoholic  insanity  with  exijan-sive  dehisiions.  and  halhu-inatioiu  of 
sight  and  hearing  which,  very  strangely,  in  most  instances  relate 
to  God  and  a  fnture  slate.  Visions  of  supernatural  beings,  and 
especially  of  the  I>city  bathed  in  an  aurpole  of  light,  perpetnally 
haunt  the  patient;  the  ministrations  of  angels  seem  to  bring  relief, 
or  mayhap  the  voice  of  God  himself  is  he-ard  in  command  or  in* 
8t  ruction. 

It  would  appear  that  two  forms  of  alcoliolio  insanity  must  be 
reoogniEed, — one  a  lypcmanin,  or  melancholia  with  delusions  of 
persecution  ;  the  other  a  megaloninnia,  with  a  strong  tendenc}'  to 
xdigiutu)  baUucioatioDs. 


PrRE  INSANITIES. 

In  the  present  group  are  included  those  insanities  in  which 
there  are  no  other  evidences  of  brain-disease.  The  group  incl  udes, 
in  other  words,  all  cases  of  or<linary  insanity,  so  called,  in  which 
there  are  no  jdiysical  symptoms,  and  in  which  we  still  have  no 
knowledge  of  the  disease  which  produces  the  insanity. 
I  For  the  purposes  of  clluieal  study,  mental  derangements  of  this 
cloj*  are  conveniently  divided  into  sub-groups,  which  in  default 
of  better  names  may  be  known  as  Oimpletc  and  Inoomplete 
Insanities. 

Compfiif  Iniianiim  are  those  in  which  the  disorder  U  wide-spread, 
volving  all  tbe  faculties  of  the  mind.     The  delusions  in  them 
are  usually  unsystemiitised. 

Ineomptd«   Insanities  are   tlioac   in   which    the  whole   mental 
mechanism  is  not  involved,  although  the  mental  anomalies  m&y 


Insai 
^Butvol 


470 


rtAOKfWnC  ITEUROIOOT. 


be  00  pronounced  a.s  lo  dominnte  the  thinking  as  well  as  the  life 
of  the  iuJividual.     The  delusions  are  usually  systc  mat  iced.* 


COMPLETE  INSANITIES. 


J 


Inaaaitics  of  tliiH  group  may  be  divided  for  clinical  study  info 
those  ill  which  tlie  attacks  are  single  iu  the  iodivitluat,  or,  if 
rocurront,  have  no  definite  time-relntioD»  witli  one  another,  and 
those  in  which  the  periods  of  mental  aberration  recar  repeatedl^^ 
at  more  or  less  regular  intervala.    The  terms  Non-Periodic  l4^| 
Bunitie»  and  Periodic  Insanities  may  be  employed  to  daaigoate    ' 
these  gronpt;  of  cawfl. 

The  distinction  between  these  groups  is  important,  becaoae  non-     j 
periodic  insanities  are  nttt  necessarily  (he  oiitoome  of  an  original 
vice  of  constitution,  and  are  ofleu  recovered  from ;  whiUt  periodic     ! 
insanities  arc  the  expression  of  an  original  imperfect  organizatioD 
or  development  in  the  brain  of  the  patient,  who  rarely,  if  ever, 
gets  completely  well. 

OOUPI.ETE  NON-PERIODIC  INBANITY. 

lusanities  of  this  group  may,  in  order  to  fadlitate  di»:u 
be  iiiiefully  divided  iiiio  three  groiii»s,  on  the  baws  of  tlie  emo-" 
tional  conditions.     The  division  is  given  below. 

It  must  Ik  remembered  that  this  classification  is  not  oEfered 
'separating  divcri^e  ditfean^a,  but  as  afiurding  au  easy  means  of 
sgniziog  clinical  symptomatio  groups  reprcseotiag  a&ectioD& 
of  whose  |talhology  we  have  no  distinct  knowledge. 


*  In  MpArftlini;  thete  twogrotipt  Ideflir«tor6-«ver  ray  b«li«f  tbal  thedftui* 
flailSui)  i*  i>ru4iticjil  nttlivr  Iban  >ci«ntiflc,  nnd  UikL  tliirre  kra  grsOkUoni  bt- 
twopn  iho  moat  si>v«ra  complete  Intaoilie*  and  th«  moct  partial  form  of  iIm 
disorder,  w  tb«l  vm  ntkjr,  at  timni,  Im  at  a  lot*  to  koow  in  wfatofa  clan  u 
indiridtul  case  of  ininniij  b«)angi.  There  is,  hovever,  untall;  no  difflmlt; 
in  krmngtiig  ihe  cmm.  A  vcrj  important  diSeroiico  which  ha*  been  dwotl 
u[uiD  by  recent  aliunUu  u  dittin|{uiii)ting  cauw  of  the  two  danei  U  in  tb« 
all«i;cd  fuel  lliat  in  complete  icBanities  Uie  delusions  nre  nlwayt  anijnlaisa- 
tiied,  and  in  tbn  lDcompIet<>  they  are  lyaumatized.  I  hava  already  aute4 
(h'o  pac^B  432)  that  the  dblinclion  bdtwMD  syalemaliMd  and  unayatmiatiaed 
deltuion*  in,  iti  my  opinion,  to  soma  oxtent  an  arbitrttry  on«,  and  tbkt  in 
nature  every  )>radatioQ  between  tla«  thoroughly  syitenuitised  attd  the  un«y*- 
(anatlxed  clflluiiuii  may  b«  mat  with. 


1 


DISTUBBAKCES  OF   INTELI.ECmOII. 


471 


MuMMoi  Alb. 


BtstlalJona 


DfpnMrioD. 


ApftUijfroDi  l«aior 
•r  varialila. 


fhrm  q/' IwmKDf. 


Ihak 


lAnM. 


HiiDtal  Dolo- 
rlonitloiM, 


InlMcDIly. 


PriMMT  I>«aiMtk. 


Tmntnal  DanMUtlft. 


DamefOMaU.  \  Bcbwkmatk 

FtlBtatr    0*11- 

turirqiltl     1n> 

Bivparaai   la- 
•ulir. 


HtMalluMlOlll. 


I 


Mania. 

Mania  is  a  mental  condition  in  which  there  is  un  emotional 
exaltation,  accompanied  by  illuiuonfi,  halliicinalion);,  delusions, 
great  mental  and  pLvdical  excitemoiit,  and  a  complete  loss  of  tlie 
inhibitory  power  of  the  will :  in  acute  cases,  and  frequently  in 
the  chronic  fornis  of  the  disease,  Lhcra  h  a  marked  ilcetruetivetiees 
and  a  tondKnty  to  violence. 

Aonte  Mania.— Acute  nmnia  isswmetimea  developed  with  great 
suddenness ;  more  often  it  is  preceded  by  a  prodromic  stage  of 
emotional  dejirtssion.  The  depressive  stage  may  Inst  from  a  few 
days  to  three  ninnths.  There  in  often  a  sense  of  lasflitude,  with 
inability  or  disinclination  to  work,  a  lack  of  the  usual  power  of 
fixing  the  attention,  depr«a«iion  of  spirits,  and  a  feeling  of  unrest 
which  causes  the  subject  to  worry  perpetually  about  himself;  the 
bowels  are  costive,  the  appetite  is  [Mior,  and  dys[iepl.it)  syniptoma 
are  often  troublesome.  Tiie  resemblance  of  this  condition  to  a 
mild  melancholy  is  so  close  that  It  i»  frequently  spoken  of  as  the 
melauchuliu  »tage  of  lULinia.  Uetually,  after  a  time,  the  sul)}ect 
gradually  returns  to  his  noi-mat  slate,  except  perhaps  that  his 
peroeptions  are  abnormally  ()uick,  and  ihat  he  la  abnormally 
happy  or  even  gay.  Kapidly  now  the  emotional  excitement  rises, 
delusions  and  Inillnrinations  ap|M>ar,  and  the  maniacal  stage  is 
reached.  When  the  affection  is  at  its  height  its  victim  raves 
ittoeBsandy,  shouting  out  a  perjictnal  stream  of  incx>)iurent  tlirejit- 
enings,  rovilingB,  ol>«!pnilies,  and  hlanphemies.  With  n  pro- 
digious and  untiring  strength  he  mshcfl  about  his  a)>artment, 
struggled  with  his  attendant-s  or  liitt  mechuolcal  restraints,  tears 
into  slireds  whatever  clothing  he  caa  lay  his  hands  upon,  destroys 


473 


DlAOKOenc  NEtTROLOGY. 


about  bim  that  »  breakable,  smcani  his  cxcreoient  over  his 
DD  aod  surroundiugs,  aud  so  passes  whole  ilays  ani]  nighbt  in 
anoeasing  fury.  KveD  if  for  brief  intcT>iils  «1eep  comes^  H  ts 
fillfNl  willi  (IrKimR,  nnd  is  hrokc-n  and  6lfiil.  The  balludnatiotu 
and  nnjiysteinatizcd  dchiaions  are  constantly  changing.  There  is 
usually  great  eexual  excitemeut,  as  «howD  by  satyriasis  or  nympli- 
■oniaiiia.  There  is  ofteu  a  iuarkc<l  blunting  of  !ieQ.sation,  so  that 
the  Diaaiac!  does  not  feel  tliu  wutmds  he  inflicts  upuii  bimself  in 
hi»  blind  fnry. 

In  vcn.'  many  cases  of  acute  mania  the  symptoms  are  milder, 
but  of  similar  character  to  those  juet  detailed.  Restless,  1  ioentioite, 
blai'plicmoiis,  iucuhereiil,  nlieccuc,  the  maniac  looks  the  fury  of 
tlie  previous  picture;  or,  occupied  by  his  own  hallucinattons  and 
delusions,  he  may  be  rapt  in  n  delirium  of  enjoyment.  In  a 
stilt  milder  form,  acute  mania  shows  itself  in  incoherence,  ir- 
rationality, restleseneffl,  evidences  of  Iml I U(;i nations  and  delutttous 
with  marked  intHininia,  Hnd  total  loss  of  modesty  aud  of  oare  for 
or  notice  of  the  usual  relations  of  life. 

In  the  mildest  possible  form  of  the  disease — Ut/fxtmanui — the 
hallucijiations  may  be  n-anting,  and  the  mania  reveal  itself  ooly 
in  a  change  of  ehnractcr,  a  peculiar  egotistic  hiiarily,  perpetual 
eitravagnncea,  ivfitlesRneM,  increa.««d  sexujil  appetite  with  lessened 
control  of  the  wilI-|>ower,  leading  to  great  sexual  excesses,  and  a 
tendency  to  brutal  violence.  The  diagnosis  in  these  coses  is  often 
very  difficult,  and  can  Ije  made  only  by  noticing  the  ivniplcte 
alteration  in  the  life,  disposition,  und  mental,  moral,  and  physical 
habits  of  the  individual.  Indeed,  I  believe  that  the  maniacal 
state  grades  iuHcuMibly  by  rare  cases  into  (he  normal  condition, 
and  that  there  are  states  in  which  the  will  still  exerts  its  oontrol, 
but  the  mental  and  moral  attributes  are  so  altered  that  tlie  man 
i«  not  his  natural  self.  Every  one  has  his  houi-s  and  s^mictima 
days  of  exaltation,  and  exactly  when  or  how  far  the  mood  triumphs 
over  the  individual  who  shall  nay  ? 

In  most  ca^s  of  acute  mania  periods  of  exoitemcnt  alternate 
with  |>erioi1s  of  comjMiratlve  calm.  The  usual  duration  of  the 
disease  is  from  three  to  six  raootltx,  altliough  recovery  may 
occur  in  a  few  days  or  be  postponed  for  over  a  year.  Death 
may  take  place  from  cxlmustioa ;  or  the  mental  al>erration  may 
pass  into  (Tronic  mania,  or  into  a  condition  of  slight  mental 


I 

I 
I 

I 


p 


K 


p 


imimirtneiit.    Complete  recovery  occurs  in  about  seventy  per  ceot. 
of  tlie  cases. 

Under  the  uuoie  o? transitory  fremy  is  described  asymptomatic 
affection  which  in  the  early  houre  of  the  attack  might  easily  be 
confounded  with  acute  mania,  imd  vhicb  in  some  cases  may  really 
be  an  incipient  peripheral  cerebritis.  It  is  defined  by  Spileka 
as  a  coodittoD  of  impairet]  conHciousiietts  characterized  by  either 
an  i[iteii&e  maniacal  fury  or  a  eoDfused  hallucinatory  deHriuoi, 
whose  duration  does  not  exceed  the  period  of  a  day  or  two.     It 

ill  be  {leen  at  once  from  this  definition  that  the  only  distinction 
which  separates  tliis  alleged  disease  from  acute  mania  on  the  one 
hand  and  acute  cerebritis  on  the  other  is  the  rapid  recovery. 
The  symptoms  also  do  not  differ  fW>m  those  of  an  epileptic 
frenzy.  The  attack,  however,  differs  from  ordinary  epileptic 
mania  in  occurring  only  once  in  the  life  of  the  individual.  I  do 
not  think  that  transitory  frenzy  should  be  considered  as  a  distinct 
adectioD,  but  only  as  an  attack  of  acute  violent  mania,  ])nM]uc<ed 
by  unknown  and  pnibahly  varying  ratises.  It  would  be,  to  my 
mind,  just  as  rational  to  erect  into  distinct  disca»c8  the  occ^asional 
epileptiform  convulsions  which  occur  without  our  being  able  to 
discover  their  cause,  as  to  consider  transitory  frenzy  »  distinct 
atfectiun. 

I  Chronic  Mania  may  develop  as  the  result  of  an  acute  mania, 
or  may  come  gradually  without  a  preceding  sta^e  of  violence. 
Jt  is  a  condition  of  general  mental  aberration  characterized  by 
the  presence  of  varying  or  non -systematized  delusions,  and  by  a 
condition  of  exalted  emotional  excitement.  In  most  cases  the 
ihrontc  maniac,  although  more  or  less  disturbed  intellectually  all 
:be  tiuie,  suifers  from  irregular  exacerbations,  in  which  the  oott- 
ditiou  of  excitement  may  berime  extreme  and  the  i^ymptoms  rise 
In  severity  until  thry  resemhle  those  of  an  original  acute  mania. 
During  these  paroxysms,  and  often  indeed  in  the  intermissions, 

lere  are  incoherence  of  speech,  lack  of  power  of  association  of 

eas,  delusions,  oflen  iiK-reaw-d  activily  of  the  perceptive  facul- 
les  with  Imliucinations,  and  mental  and  physical  excitement. 
The  symptoms  of  chronic  mania  are  similar  to  those  of  acut« 
mania,  but  are  less  severe  iu  ly{)e.     They  are  also  modified  by 

e  prt^nssive  failure  in  the  intellectual  power  as  the  patienta 


474        ^^^      Duososno  keukoixjgy. 

drift  towards  dcraentia.  The  hallut^tnalinoB  and  drltiitioas  arc  od- 
fixed,  constantly  chunging,  arc  nut  sy^stfinatizcd,  usually  are  con* 
formed  to  ihe  emotional  cicitcmrut  of  tlie  patient,  or,  if  they 
bHouUI  take  for  the  moment  a  depressive  or  disagreeable  forin,  do 
Dut  aflTnrt  llie  niuod  of  the  individual.  They  may  be  eoucemlng 
any  coooeivabic  person,  thin^,  or  place,  or  may  lake  forms  not 
reached  by  the  most  vivid  imagination  in  !te  sane  moments.  The 
moral  wnw  is  completely  alteneil  or  nbolished  :  those  to  whom  the 
individual  had  previously  been  nLtacliixl  btvome  objuete  ot  hate; 
modesty  there  ia  none,  the  patient  revelling  in  obscene  npeecli  and 
immodest  g«itnre«,  and  often  suffering  from  seximl  fury.  Like 
acute  mania,  chronic  mania  varies  greatly  in  its  inteosity :  indc«<l, 
the  mild  form  of  mania  knonrn  as  hypomnnia  y  es\Mxiti\\y  apt  to 
pursue  a  slow  course.  Chronic  mania  not  rarely  (dianges  into 
chrttnic  melancholia;  whether  primary  or  secondary,  it  is  of  long 
duration.  Occasionally  recovered  from,  it  usually  Icrminatcsja 
from  two  to  five  yean  in  dementia. 

Mffancholia. 

The  connection  between  the  depressive  emotions  and  the  bealtb 
of  the  abdominal  organs  is  too  well  recognized  to  need  commeat. 
There  is  a  condition  in  which  oxalate  of  calcium  is  found  in  ibi; 
arinc,  associated  with  a  great  deal  of  emotional  depression,  some 
mental  sluggishness,  and  a  certain  amount  of  bodily  wealcnefe, 
and  occasionally,  although  not  always,  dyspeptic  symptoms.  This 
condition,  which  is  known  as  oxaluria,  is  largely  relieved  and  fn.-- 
queiitly  cured  by  the  free  administration  of  nitro-muriatio  acid, 
with  an  ocoasionfll  purgative,  especially  if  tliese  remedies  be  aided 
by  fre«  czerciee  and  abstineuve  from  the  use  of  sugar.  TImm 
ca.%8  of  oxaturia  might  be  considered  a  mild  form  of  melan- 
cholia, but,  according  to  the  studies  of  Dr.  G.  D.  Stahlcy  (JHfiUcal 
Netrs,  June  5,  1886),  oxaluria  oot^rs  proportionally  as  frequently 
in  other  ca-tes  of  tn.4aaily  as  it  doca  in  melancholia,  and  in  melan- 
cholia it  may  at  times  be  present  and  at  times  absent  withoui 
change  in  the  menml  condition.  It  would  appear^  therefore,  that 
there  is  no  direct  relationship  between  seven  cbbbb  of  melancholia 
and  oxaluria. 

In  fully-formed  melancholia  the  basal  condition  is  a  profound 
emotional  dcprcHsiou. .  In  a  proportion  of  coses  of  eo*called  mel- 


Jl 


OISTURBAKCEH   OF  INTELLECTION. 


476 


anchol!a  there  is  not  a  complete  intellectual  Insautty,  bnt  merely 
an  emoiionul  depre^ion.  Tlie  patient  failti  to  be  interested  lu 
the  life  around  liim,  not  because  he  is  incapable  of  understand- 
ing the  problcmfi  of  life,  bat  because  nothing  but  himself  is  of 
interest  to  him  or  occupies  his  thoughts.  In  the  lighter  degrees 
of  the  affection  the  patient  will  simply  say  that  he  is  horribly 
depr(>»^e<l  and  cares  for  nuUiing.  He  sila  all  day  in  a  cliair, 
qniel,  perhaps  with  the  hand«  folded,  soemingly  thinking  of 
nothing,  with  an  expression  of  perfect  indifference  and  apathy 
on  his  t-DunteRanr--e.  There  in  no  interest  in  busine^t,  because  the 
interest  is  all  the  time  centred  in  himself.  There  is  no  interest 
in  wiffl  nnti  family,  not  because  the  relations  are  not  retiogni?,u(l, 
bat  because  the  man  is  absorbed  in  nursing  the  phantom  spirit 
which  oppresses  him. 

When  the  symptoms  are  more  active  and  tievere,  instead  of 
simple  apathy,  there  is  wringing  of  the  hands  and  perpetual 
moaning  and  lamentation,  not  for  any  definite  reanrju  that  the 
patient  can  assign,  but  simply  because  of  the  depression  of  spirits. 
Under  these  circumstances  it  will  be  found  that  all  his  thoughts 
are  tinctured  with  liiis  emotional  tlepre^tHiou.  If  Lite  man  ia  a 
bnsiaess-man,  he  sees  nothing  but  ruin  before  him.  If  he  has  a 
conscience  which  is  nni  void  of  offence,  the  memory  of  hU  past 
misdeeds,  like  a  Nemesiei,  forever  haunts  bim.  If  his  children 
are  ill,  tbey  are  going  to  be  swept  away  by  death.  The  whole 
liu)daea|)e  is  covered  with  n  black  cloud,  which  throws  cverj'ttiing 
into  the  darkest  shadow.  JsY-vertheless,  there  may  be  e\'en  yet  tio 
intellectual  delusions.  When  the  patient  is  aroused  he  talka  well 
and  reasons  well.  If  yuu  can  get  him  to  forget  hliuaelf  for  a 
moment,  his  intellectual  actions  sre  perfect  AAer  a  time  delu- 
sions make  llieir  appearance.  They  arc  in  typical  cases  always 
nnsjrstematieed.  They  usually  develop  gradually,  and  not  rarely 
are  the  outcome  of  some  real  feeling  which  the  patient  ha^.  They 
may  exist  willi  or  without  halluulrmtio»s.  Both  hallucinalious 
and  delusions  alnrays  take  the  depressive  type.  Hall uciuat ions 
of  hearing  arc  the  mait  frequent.  The  patient  hears  voices,  but 
they  are  evil  voices.  Those  who  have  committed  murder  have 
sometimes  asserted  that  they  had  two  voices  in  them,  one  cry- 
ing, '*  Kill !  kill !"  the  other  voice  trying  to  restrain  them.  Men 
have  held  their  hands  in  the  fire  until  they  n-ere  burnt  black, 


476 


DIAGNOSTIC    SEtmoriOOY. 


beeaiue  thev  have  hpard  I'oices  telling;  them  that  it  won  better 
enter  into  the  next  world  maimed  than  to  go  with  a  whole 
guilty  of  blood  or  other  ofieuce. 

Sometimes  hnliucinntions  of  sight  occur;  but  these  are 
conimon  than  halhioi nations  of  hearing.  Troops  of  npirlts  from 
the  other  world  pass  before  the  ]>a(ieDt,  bat  it  is  never  angeb 
or  spirits  from  heaven,  hut  always  sights  of  ewrow  and  of  woe. 

Delusions  of  touch  are  rare,  aud  deltuioos  of  fimell  are  still 
more  uncommon.  I  do  not  recall  a  case  in  which  I  have  Been 
a  patient  with  detusiouK  of  tunell.  They,  however,  are  occasion- 
ally present.  The  melancholic  never  sraoll  pleasant  odors.  It 
ia  always  sulphurous  vaimra  or  horridly  fetid  exbalatioas  that 
oppresB  thoDi. 

There  are  certain  varieties  of  melancholia  which  n«ed  hricf 
mention.  When  there  are  no  rlelu-sion^  the  cases  are  eometimeB 
spoken  of  aa  Simple  MeiancJioliOy  us  Melaticholia  without  Delirium, 
or  as  I lypo-melanchoiia.  In  this  form  of  melancholia,  although 
the  riiiml  of  the  patient  may  l>e  clear,  suicidal  and  homicidal 
impulses  are  very  frequent. 

Mtlanchotia  Agitata  is  that  variety  in  which  there  is  great  ex- 
citement, the  [latient  being  continually  on  the  move,  ruling  up 
and  down,  lamenting  loudly,  wringing  the  hands,  tearing  the  hair, 
destroying  his  clothes,  etc.  The  agitation  may  rise  to  the  pcwnt 
I  of  complete  frenzy.  The  melancholic  frenzy  difiers  from  that  of 
'  mania  in  being  founded  upou  a  slate  of  intense  terror  and  fear. 
The  patient  assaullfi  by-slandurfi  asa  matter  of  self-defence  against 
their  supposed  machinations  or  attacks.  Homicide,  suicide,  and 
self-miitilation  are  very  frequent  during  the  outbreak  of  melau* 
cholic  frenzy. 

Mehncholia  AttonHa,  or  Melancholy  vrilh  Stupor,  is  the  variety 
in  which  all  the  physiral  as  well  as  the  luenial  powers  of  the 
patient  are  overwhelmed  by  the  emotional  depression:  he  is,  aa 
it  were,  paralyzed  and  dumb  under  the  power  of  his  fear.  Lying 
io  be<l  with  the  eyes  open,  or  more  rarely  dosed,  asking  for  uo 
food,  giving  uo  heed  to  any  personal  desires,  but  living  in  a  oou- 
tinuous  state  of  absolute  wantlessneas,  he  exists  as  an  automaton. 
Tf  taken  up  aud  dressed,  he  remains  sitting  iu  the  same  iadiSereat 
hopele^  passivity. 

The  physical  condition  in  acute  melancholia  is  always  that  of 


4 


DISTtmBANCKS  OF  INTEI-LECTIOX, 


477 


depression;  the  bowels  are  usually  constipated,  the  breath  U  foul, 
the  tongue  heavily  coated,  the  surface  of  the  borly  oool,  the  pulse 
feeble,  slow,  or  eometimeis  rapid,  uiid  the  akiu  liandi.  lu  the 
acute  oasee  there  is  oftcu  rapid  eniaciatiou. 

In  certain  forms  of  cerebral  syphilis  with  stupor  the  symptoms 
may  for  a  time  re!«eml>Ie  thuee  of  uiclancholiii  attouila;  but  the 
diagnosis  can  usually  be  made  out  by  the  history  of  coutiauuus 
hcadai-be,  or  tlie  presence  of  some  evidence  of  a  focaU  lessioii. 

Mtlancholia  may  eud  in  deutli,  recovery,  or  terminal  demeotia, 
or  may  be<x>me  essentially  chronic.  It  ia  very  unusual  for  it  to 
last  less  than  three  months,  and  I  have  known  it  to  last  unchanged 
for  many  yeaiB,  and  then  the  patient  rapidly  recover.  From  fifty 
to  sixty  per  cent,  of  the  cases  r«»iver.  Of  all  tho  varieties  of 
melancholy,  melancholia  attonita  is  most  apt  to  end  in  dementia. 

Katatonia. — A  few  years  since,  I>r.  Kahlbaum,  of  Gorlitz, 
tteparated  from  melancholia,  under  the  name  of  Kutuiwtia,  a  claiiS 
of  cases  which  are  now  believed  by  many  alienists  to  be  distinct. 
The  disease  is  defined  by  Spitxka  as  fullows: 

"  Katatonia  is  a  form  of  insanity  characterized  by  a  pathetical 
emotional  state  and  verbigeratiouj  ootDi>Lued  with  a  condition  of 
xaotor  teusion. 

"The  illness  begins  with  an  initial  stage,  resembling  that  of 
an  ordinary  melancholia.  This  ts  followed  by  a  period  in  wbicli 
th«  patient  presents  an  almost  cyclical  allerualion  of  atony,  ex> 
citemcDt  of  a  peculiar  type,  confusion  and  depre^ion,  which  finally 
merges  into  a  state  of  mental  weakness  appmac^hitig,  if  not  reatib- 
ing,  the  degree  of  a  terminal  dementia.  Any  single  one  of  these 
enumerated  phases  may  be  absent. 

"  The  excited  stage  presents  symptoms  of  a  kind  different  from 
those  of  ordinary  melancholia,  and  constitutes  a  oouuectiug  liuU, 
as  it  were,  between  the  symptoms  of  an  agitated  melanchoHao 
and  those  of  a  lunatic  with  6xed  delusions.  Some  of  the  patients 
present  exaggeraled,  otiiers  dimioislietl,  self-esteem,  and  not  rarely 
does  the  developing  delirium  assume  an  expansive  tinge.  But 
all  kfllatonii^  exhibit  a  peculiar  pailio^i,  cither  in  the  ilircctios  of 
declamatory  gestures  and  iheatriral  behavior,  or  of  an  ecstatic 
religious  exaltation.  Frequently  Ihe  patients  wander  about,  imi- 
tating great  actors  or  prcachcn!,  and  often  express  a  desire  and 
take  steps  to  become  such  preachers  and  actors." 


478 


The  lifillucinationR  of  katatonia  are  always  depreffiive  and 
acoonipauied  by  a  melancliolic  depresslou  of  spirits,  wbich  ia 
8flid,  however,  Dever  t<>  be  ro  painful  as  in  melancholia.  Seven 
rKX*ipital  headache  ami  calalcptoid  attacks  are  asserted  to  be  char- 

^acteristic.  The  cataleptokl  condition  is  typical  and  extreme,  the 
itient  remaining  for  long  j^eriods  corpee-Iike  and  immobile.  I 
have  eecii  two  oases  wliiuli  [lerhaps  ought  to  be  classed  as  kata- 
tonta.  Whilst  under  uliservatiou  there  vas  no  headache  and  Qo 
peri<^*d  of  cxciteracDt;  but  the  cataleptnid  condition  was  very 
marked.  For  hours  the  patient  would  remain  standing  or  sitting, 
^rfectly  immobile   in  whatever  position   he   might   be   placed. 

rCerlain  forms  of  melancholia  atlonita  rcseniblc  katalonic  insanity, 
and  I  do  not  uee  how  the  diagnosis  could  be  niiide  between  melan- 
cholia Atlonita  and  a  kaiatonia  from  which  the  stage  of  exdt9-| 
ment  wa»  wanting.  Masturbation  is  alleged  to  be  very  frequent 
in  kutalouia,  and  wus  markedly  present  in  one  of  my  cases.  It 
IS,  however,  very  common  in  all  cluesea  of  mental  woakm^s  ap- 
proaching dementia. 


Mental  Dderiomtiom. 

In  its  fullest  development  dementia  is  that  condititxi  in  whreh 
all  the  higher  cerebral  functions  are  abolished,  so  that  neither 
thought  nor  emotion  remains,  and  the  individual,  reduced  to  an  an- 
tomaton,  simply  cats  when  fed,  and  brcatliea  when  air  is  preeenled 
to  him.     The  animal  fuuctious  go  on  uncontrolled  by  the  will,        . 
the  bladder  and  rectum  arc  evacuated  when  full,  or  if,  ss  is  ofkeo  ^H 
the  caw,  the  general  nervous  power  is  reduced  to  a  minimum,  ^^ 
tlie  urine  and  fteceis  dribble  over  when  tlieir  natural  receptacles 
are  full, — the  pcrpettial  dropping  of  urine  indicating  a  diE^tended 
bladder,  and  a  constant  jmssing  of  small  quantities  of  focoea  a 
diittcndcd  rwtum. 

The  approach  to  dcuieutia  is  usually  gradual,  and  deatlt  often 
ocLMin!  before  the  lowest  degradation  is  reached,  so  that  ia  the 
majority  of  oatics  more  or  less  mental  activity  exists.  The  emo- 
tions are  apt  to  survive  the  intellectual  faculties,  and,  unchecked 
\>y  the  will,  whoiw  power  is  gone,  may  even  be  unduly  activsL 
Irritable,  brutal,  more  unreasoning  and  hence  mure  unreasonable 
than  a  brute,  the  dement  may  be  a  most  daugerous  lunatio. 


mSTURBANCES   OP   INTELLECTION. 


4Td 


rarely,  hovever,  gentle,  easily  led,  be<au»e  without  oapabilily  of 
intellectual  persistence,  he  li  vca  a  childish  existence. 

In  alMolule  deiueutia  there  are  no  grades^,  but  the  gradual  courses 
of  nature  and  the  necessities  of  dUmfviion  have  mused  the  t4^>rm 
to  he  widened  in  its  use,  until  now  it  is  employed  to  signify 
dimply  any  mentfil  defect  which  is  so  serious  as  to  ]ianklyze  the 
thinking  ability  of  the  individual. 

I  A  dementia  which  has  been  congenital  or  haH  developed  in 
infancy  is  usually  upoken  of  iw  imfirciliti/  or  idiocy.  It  if  peiior- 
llly  due  to  orifrinal  lack  of  brain -ilevelopmout,  and  is,  therefore, 
Scarcely  tbe  r«sult  of  disease,  and  I  shall  say  no  more  about  it  in 
this  bouk. 

Demcntiafi  due  to  mental  disease  are  either  primary  or  ter- 
minal: a  primary  dementia  is  one  thai  has  devcto[)ed  without 
obvious  previous  mental  disease;  a  terminal  or  eonsccutivc  de- 
mentia is  one  that  folto^-i^  an  attack  of  insanity. 

Primary  Dementia. — Primary  dementia  ia  a  condition  grad- 
ually, nipidly,  or  suddenly  developed,  in  which  there  ia  suajien- 
gion  or  great  impairment  of  the  menial  pt)WerH  without  distinct 
emotional  disturbanees.  There  are  include*!  under  it  cases  which 
differ  greatly  in  the  cause  of  the  dementia,  as  well  as  in  the  degree 
tC  the  mental  impairment  and  in  the  iiltiniiitc  results. 

For  our  ]>re3cnt  jiurposca  these  various  cases  of  primary  de- 
leutJa  are  divisible  into  those  in  which  the  dementia  is  connected 
obvious  organic   brain-dibcase, — i.e.,   Organic   Dementias; 
in  which  it  is  connected  witli  general  developmental  changes 
if  the  body,  such  as  puberty  and  old  age, — i.e.,  Developmental 
Dementia*;;  and  those  which  do  not  belong  to  cither  of  iheee  two 
^■classes, — i.e.,  Miscellaneous  Demeutia*. 

^P  Ortranic  Dementiaa. — In  dementia  of  this  class  the  memwy 
HlnioHt  invariably  suffers  earlier  and  more  severely  than  the  other 
mental  faculties.  There  is,  liowcver,  nothing  in  the  dementia 
it^lf  suflieiently  characteristic  to  enable  us  to  recognize  its  eti* 
ology.  The  diagnosis  ts  to  be  made  out  by  nutiug  the  various 
symptoms,  other  than  mental,  which  itidicate  organic  brain-diseuse. 
When  there  is  severe  headache,  an  organic  dementia  is  usually  the 
B  result  of  chronic  meningitis,  brata-tumor  or  abscess,  or  brain- 
syphilis;  when  headache  is  not  prevent,  Uie  disease  la  ordinarily 
general  |iaralysis  or  its  .syphilitic  counterfeit. 


4S0 


I>IAOM0BTIC  NEUBOLOOY. 


DeTelopmental  Dementias. — In  tlii.';  rla^f?  T  propose  tooon- 
sider  two  mental  deteriorations, — Senile  Dementia,  and  Hebe- 
phrenia, which  respectively  are  associated  with  old  ag«  aad 
puberty. 

In  Botne  caaes  of  old  age  the  mental  faculties  nre  prenerved 
almost  intact  amidst  the  geneml  physical  wreck,  but  more  fre- 
quently the  intellectual  powers  undergo  delerioratioo,  which  mar 
even  exceed  in  extent  that  of  the  muscular  strength.  To  Uiis  cod- 
ditioii  the  tmmcof>Smt£e2>em«n/tn  is  commonly  given.  The  roeoiol 
enfeeblemcnt  ia  sometimes  aocx>mpanicd  by  emotional  dl<4tarbanoM 
which  wamint  our  speaking  of  the  patient  a^  suflenDg-  from  9eniU 
meiancMia  or  wnile  mania,  a&  tlie  case  may  be.  Delusions  are 
very  frequenUy  present,  even  when  the  emotional  diBturbance  b 
not  marked.  TlieKC  delusions  may  take  the  ambitious  form,  hut 
uanally  are  depressive.  According  to  Spitzka,  they  are  almost 
always  unsystematized,  but  I  have  certainly  seen  them  very  thor- 
oughly systematized.  Frequently  some  maater-pasBion  of  tbe  indi- 
vidual seems  in  old  age  to  increoBc  rather  than  lofie  in  force,  until 
at  last  it  dominates  the  whole  Hiaracter,  a  result  which  is  greatlr 
facilitate<l  by  the  gradual  weakening  of  the  will.  Not  rarely  a 
moral  change  occurs :  he  who  has  been  during  life  cliaste  and  re- 
fineil  becomes  cuar»e  and  tiltliy  in  langua^  as  in  pereon.  A  pecu- 
liar sexual  cxcitemcut  is  on  oocaBions  present,  giving  rise  lo  "eeoile 
satyriasis,"  which  may  lead  toindecenta«snult8, but  more  frequently 
is  manifested  in  tbe  contraction  of  absurd  or  incongruous  marriages. 
Dtilitsionsof  persecution  arc  very  frequent,  and  tliesubjeia  may  live 
in  |ierpetunt  fear.  Senile  dementia  develops  gradually,  and  a 
recognition  of  its  earlier  stages  is  frequently  a  matter  of  tbe  great- 
est im[)ortance  when  there  is  no  emotional  disturbance.  Tbe  fir^t 
symptoms  of  important  change  are  usually  a  loas  of  memory  for 
recent  evetitH,  wirb  ii  loss  of  power  of  peroeiving  the  relative  im- 
portance of  tilings  and  afliiirs.  So  long  as  tbe  memory  is  fairly 
preserved  and  sufficient  intelloctual  balance  exists  for  the  pmper 
weighing  of  events,  the  raedietd  expert  should  be  very  slow  in 
deciding  that  the  aged  person  is  legally  incompetent  unless  dis- 
tinct delusions  exist.  It  must,  however,  be  borne  in  mind  that 
the  weakening  of  lite  will  and  the  perversion  or  increase  of  bocdq 
of  the  emotions  render  the  aged  especially  liablo  to  be  improperly 
controlled  by  designing  persuns. 


DISTTmBANCra  OP  raTEixEcnow. 


MAephrmia,  or  Insanity  of  /^ufiesoniM,  in  defined  by  Spitzkai 
chancteriaed  *'by  m«nti1  enfeeblement  ntarkcd  by  a  silly  dl«[ 
aitioii,  followiug  a  prcliuiiuary  pvriod  of  dcpresaiou,  which  has 
the  some  tinge  as,  without  the  depth  ol',  that  charaderizing  that 
of  melanrholia,  and  which  ooincides  with  or  follows  the  period 
Lof  puberty." 

B     This  form  of  iiitellectual  aberration  might  very  well  be  classed 
as  a  variety  of  inelaiuiliolia,  but  I  have  preferred  to  put  it  in  this 
place  becouae  In  the  coses  that    I    have  seen  tlie  emotional  atate 
htm  hcen  one  of  indifference  and  apathy  rather  than  of  acute  de- 
pression. 
H      The  peychoeis  may  develop  gradually  or  slowly.     There  is  a 
Hcondition  of  restlcRsneas  and  disinrltnation  to  mental  labor,  oom- 
Hbiued  with  a  line  of  conduct  beat  described  as  silly.     There  ia 
r  usually  a  distinct  alteration  of  character.    Rapid  emotional  changes 
^  rejerabling  those  which  are  so  fi-ec|ueut  in  hysterica]  subjecle  some- 
B  times  take  place.      Faying  no  attention  to  buaincas,  abandoning 
lucrative  inireuits,  or  wandering  from  poHilion  to  jmeition,  with  a 
constantly-increasing  egotiitin  and  even  a  peculiar  sentimentality, 
the  subject  of  hebephrenia  slowly  loses  mental  power.     Even  at 
this  stage  sudden  furious  maniacal  outbreak**  oucur,  and  when  the 
I088  of  mental  power  becomes  extreme  these  outbreaks  arc  more 
frequent.     Hebephrenia  in  the  majority  of  ca.%s,  if  not  in  all, 
Bnwts  upon  a  foundation  of  originally  faulty  nervous  organization, 
and  is,  therefore,  a  protracted  psychosis,  which  is  rarely,  if  ever, 
completely  recovered  frntn.     It  may  pans  mpidty  into  a  terminal 
dementia,  or  the  patient  may  long  remain  in  a  oindition  of  marked 
mental  eufeeblemenl.     A  few  cases  occur  in  which  permanent  im- 

•  provement  hufi  followed  treatment.    Iti  a  large  proportion  of  cases 
hebephrenia  Is  connected  with  excessive  masturbation :  henoc  by 
some  writers  the  insanity  is  spoken  of  &s  the  Ituanity  of  MaMur- 
_^  baiifm. 

f      MisoeUaneous  Dementia. — In  tht8  division  are  include\l  three 
cliLsses  of  ca-'«es, — Dementia  of  Shock,  Confusiooal  Insanity,  and 
.Stn]K»rouH  Insanity. 

Demetiiia  of  Ckrthml  Shock. — There  are  varions  recorded  caaes 
in  which  a  sudden  emotional  excitement  has  produced  complete 
Io»;  of  the  intellectual  faculties:  h&  in  a  case  recorded  by  Buck- 
tiill  and  Tuke,  in  which  a  young  lady  of  refmement  and  edu- 

81 


482 


blAGKOSTlO  ITKUROLOOT. 


KOfS 


cation  wai}  assaiiUed  and  raped  by  a  baod  of  mffiam  and 
at  once  a  specchlesG  idiot  for  life.  In  a  secund  case  a  yoa 
having  by  mistaku  fatally  }H>tsoned  bcr  futher,  from  the  Ctme 
of  bis  death  "  was  lost  to  all  knowledge  or  notice  of  persons  aod 
occurrences  around :  food  she  never  took  except  wben  it  wss 
placed  upon  her  tongue :  tlic  only  sound  wbicb  iscafiud  her  lipi 
waa  a  faint  yes  or  no." 

Prinuirt/  Con/usionat  Inatmity  is  a  form  of  mental  abemii 
in  which  tberr  is  contusion  of  ideas  and  marked  incoherence 
speech  without  decided  eniotiooal  disturbance.  Tbia  condittoD 
may  develop  acutely  as  tbe  result  of  an  eamtional  sboek,  or  uf  a 
cerebral  overstrain,  or  of  an  exiiausting  disease,  and  mar  be 
looked  upon  as  a  milder  form  of  dementift  of  cerebral  Ahock.  It 
seemtt  to  be  a  simple  condition  of  inlelleolual  exbaudtion.  It  mav 
develop  ioiwediately  after  (he  biraia,  or  there  may  be  a  few  da\> 
of  incubation,  ilalluci nations  and  delusions  unt^table  and  cveu 
contradictory  in  r-hanicter  are  frequent.  The  memory  may  be 
affcL-ted  so  that  the  patient  docs  not  recognize  old  acquaintance;!  or 
tuniiliar  places.  Delusions  of  identity  are  stated  by  Spitzka  to 
be  very  freqneuL  According  to  the  same  authority,  the  speech 
aSbrds  the  most  characteristic  symptom,  the  itcntencce  bang  left 
incomplete  becau.se  the  subject  is  unable  to  follow  an  idea  V*  its 
oonipletion.  Thus,  »  patient  said  to  Dr.  Spitxka,  "  I  am  I — I 
don't  know  that — \ — is  dead — funerals  are — how  do  you  tlo — 
met  you  in  Boston  BtamiL-r — ibis  is  London — l^ondon — I  am  sure 
of  it — Boe!  I  have  not  forgotten  everything — there  are  not  w 
many  now," 

StuporoM  TrutoHitj/f  Acuie  or  Primary  Deaumtia  of  tunny  £ 
lish  writent,  Prinuunf  Ourabie  DemeiUia  of  some  German  writen^ 
18  an  affection  which  usually  comes  on  in  young  adults,  and  which 
so  closely  simulates  melancholia  attonita  in  its  symptoms  tliat  it 
is  scarcely  to  be  distinguished  from  it.  There  is,  however,  no 
distinct  emotional  disturbance ;  but  if  the  a|)atfiy  be  extreme  it 
may  he  impo^itile  to  dclerntine  the  exi^^tence  or  nonnsxisietioe 
of  depressive  emotions,  and  1  believe  that  tlie  two  mental  statcB 
grade  into  each  other.  The  symptonts  may  come  on  gradually  or 
suddeidy.  At  the  height  of  the  attack  tbe  patient  is  innuobile, 
insensitive,  absolutely  apnthetic,  silting  or  lying  as  placed,  with 
no  wants  and  apparently  no  perception  uf  surrounding  objects. 


:  00 

enM 
..■I.      I 


[n  some  cases  this  cotKlition  becomes  ao  extreme  that  even  tlie  re- 
I«x«s  are  afTcc-tvd,  and  iii  fecOing  the  patient  it  is  n«xtseaiy  to  pat 
lie  food  well  buck  into  the  pharynx.  The  same  lack  of  energy 
is  shown  in  all  the  invohiiilftry  miiecles :  the  heart's  action  h  slow 
and  feeble ;  the  bowels  are  obstinately  constipated  ;  the  extremi- 

Ilies  are  cold,  ami  the  feet  cedematous,  as  the  result  of  vaso-motor 
we:iknesB.     The  urine  is  rich  in  phosphates,  imd  the  physiological 
diMhai^^  of  the  skin  and  uterus  ore  Hupprcsscd.     I  have  !%en 
syraptoms  exactly  resembling  those  of  stiiporoiia  insanity  as  laid 
down  in  the  booki*  produced  by  gouty  atheroma  of  the  cerebral 
vessels  (sec  page  4o8),  and  sioiilar  cases   have  liccn  described 
by  Voisin.      In  dementia  depending  upon  disease  of  the  cere- 
bral vcsscla  Tccovcry  rarely,  if  ever,  occurs.     Stuporous  insanity 
has  been  produced  by  euiotional  shock,  exoe^wive  overwork,  aud 
various  causes  of  exliaudtiuu,  such  as  Ktarvutiuo,  profuse  hemor- 
rhage, or  exhausting  diseliarges.     It  is  also  not  rarely  closely  r«ii- 
I      nected  with  excessive  raasturliation.     It  seems  to  me,  therefore, 
^Btfaat  we  can  scaroely  consider  it  to  be  other  than  an  intense  d^ree 
~  of  the  ao-calletl  primary  confiisioiial  iuaauity.     The  prognosis  is 
statc<.l  to  be  highly  fuvunibic,  ninety  i>er  cenl.  of  the  patients 
recovering  in  a  period  of  time  which  varies  from  three  weeks  to 
three  or  four  months.    The  prognosis  is  less  favorable  wlieu  there 
^vit  exoenive  masturbation. 

^P  Terminal  Detaentia. — Almost  any  form  of  active  insanity  nuiy 
be  followed  by  a  stage  in  which  the  mind  is  so  far  lost  that  even 
the  distinctive  charactcriaties  of  the  original  inaaaity  have  more  or 
less  completely  disappeared.     This  state  is  the  so-called  secondary 

Per  terminal  dementia.  The  compleleuesfi  of  the  mental  ruin  varies : 
in  some  cases,  apathetic,  mindless,  without  thought  or  emotion,  the 
'  individual  lives  on,  a  mute,  almttit  motionless,  vegetating  uutom- 
^fe^tOD ;  in  other  instancca,  restless^  full  of  obtrusive  or  deatruotive 
^■BCtivity,  noisy,  witli  incoherent  talk,  tlie  dement,  although  over- 
ly" flowing  with  auimal  spirits,  aod  perhaps,  also,  jxissebeet]  by  a 
peculiar  aggressive  egotism,  is  useless  for  any  purpose, — mayhap 
^ft  U  almost  nnoontrollabte  and  excceilingly  troublesome.  Sometimes 
1^^  the  mental  condition  is  simply  that  of  weak-mindedness,  and  (he 
harmless  imbecile  seems  like  aa  overgrown  child.  Not  rarely  a 
little  iulelleclual  power  remains;  and  if  with  this  there  be  docility, 
,tbe  dement  may  be  usefully  employed  about  a  farm,  in  the  wards 


484 


DCAQKOSTIC  NECROLOGY. 


of  a  bo8|>ital,  or  in  other  situations  in  which  he  can  be  carcfalljr 
watched  over  and  conatantly  directed  and  taken  care  of. 

PERIODIC  iySANITI£8. 

Periodic  insanities  are  naturally  divided  into  those  in  which  the 
nttaokB  take  the  form  of  mania;  those  io  which  they  are  ttivIaD- 
choiic;  and  those  iu  which  mania  and  melancholia  altcroale  in 
regular  oyclee.  These  forms  are  respectively  known  as  PeriudJc 
Mania,  Periodic  Melancholia,  aiid  Circular  Tnsanity. 

The  attacks  of  PeriotUc  ifatua  often  begin  abru|rtly,  but  may 
be  preceded  by  prodromes,  such  as  emotional  depression,  v«t^, 
neuralgia,  etc.  During  the  active  stage  there  are  I lallnci nations, 
delusions,  violent  oxcitemcDt,  furious  outbursts  of  anger,  and  a 
pronounced  tendency  to  ini[>uUive  actions,  such  as  caoseloM  «- 
saults,  iudeoeut  exposure  of  i>ensor>,  attempts  to  rape,  etc. :  in  a 
word,  the  symptoms  of  the  active  stage  do  not  differ  from  those 
of  onlinary  anite  mania. 

The  attacks  of  Periodic  Melancholia  are  similar  to  those  of 
ordinary  melancholia,  with  a  pronounced  teiKleuoy  to  impulsive 
acts,  es{M!ci»!ly  to  euioide. 

In  dradar  Inaanii^t  or  Cffeb)thj/mia,  the  cycles  vary  iu  length 
from  a  few  days  to  many  months  :  as  a  general  rule,  the  more 
violent  the  symplonis  the  shorter  is  the  time  required  to  complete 
a  cycle.  The  arrangement  of  the  oyole  varies  in  different  indi- 
viduals, but  it;  co]i.sta[it  iu  ilie  name  case.  In  this  way  a  melan- 
cholia may  be  followed  by  a  mania,  and  this  by  a  lucid  interval, 
or  the  mania  may  first  appear,  or  the  lucid  interval  may  folloir 
the  melancholia.  The  passage  fn>m  one  mental  condition  to 
another  may  lie  abrupt,  but  more  commonly  it  is  gradual.  The 
mania  may  be  violent,  resembling  in  all  'us  symptoms  an  attack 
of  ordinary  acute  mania.  It  may  be  mild,  or  it  may  even  simply 
amount  to  a  contlitlon  of  mental  exaltation,  in  which  the  i>ub- 
ject  is  dominated  by  all  sorts  <ir  immoral  impuLseti  and  tendencies, 
which  lead  to  a  line  of  conduct  that  haa  been  aptly  spoken  of  as 
inaanity  of  action.  Tn  like  manner  the  melancholia  varies  in 
intensity  from  the  must  profound,  hopeless,  despairing  apathy  to 
a  alight  depression  of  spirits.  &i>nietimi«  the  lucid  interval  is 
wanting,  and  mania  fallows  melancholia  and  melandiolia  follows 
mania  in  perpetually-recurring  alternation.     These  cases  constitute 


DlffTUXtBAKOCS  OF  INTELLECTIOS. 


485 


the  /o/i<  ctrcu/oire  of  Falret.  There  are  c-erlaiu  cases  id  which 
the  sy[uptoin!>  of  a  irirciilar  insanity  are  so  »li);;ht  that  tho  patient 
does  not  at  any  tinip.tc  the  eye  of  the  ordinary  olwerver,  overste|) 
the  bounds  of  rauity.  Such  individuals  are  avoided  by  tlieir 
friende  as  moody  and  unreofiooable:  to-day  sanguine,  talkative, 
energetic,  and  extravagant,  to-morrow  they  are  tacittini,  apathetic, 
or  full  of  vain  regrets  for  acts  that  they  have  done  or  enterprises 
that  they  have  entered  upon  while  in  the  condition  of  exaltation. 

In  moat  cases  of  pcrimlic  insiuiity  llie  patient  during  the  lucid 
iuten-al  will  reveal  to  the  csperienoed  observer  evidences  of  ab- 
normal mental  action.  Sexual  perversion,  morbid  fearH  and  morbid 
impulsed,  excessive  excitability,  moral  degradation,  sexual  erceisaca, 
Iwsof  self-oontrol,  inonlinate  development  of  avarice,  jealousy,  or ' 
other  passion, — thetw  are  among  the  most  couimuu  luanifestattona 
of  cerebral  aberration  during  tl)C  lucid  periods  of  periodic  insanity. 
According  to  Spttzka,  kleptomania  is  commonly  a  symptom  of  the 
lucid  intervals  of  a  periodic  insanity. 

Periodic  insanity  rests  upon  an  original  faulty  organization  of 
the  nervous  syMem,  and  i»  generally  liopeless.  In  Uiesc  respects 
it  is  closely  related  to  the  partial  insanities.  When  the  lucid  in- 
tervals are  long  and  with  marked  mental  irrcguhirities,  the  disorder 
might  well  be  classified  as  a  i>arlial  insanity  with  regular  exacer- 
bations. 

1NCOMPI.ETK  INSASITY. 
Partial  Insanity,  Reasoning  Mania,  Mania  teithotd  Delirium, 
Monomania,  Mania  of  Charrwter. — These  terms  have  been  em- 
ployed by  \'arious  writers  to  designate  a  large  class  of  chronic 
insanities  in  which  the  insane  condition  is  limiteil,  ut  least  in  its 
marked  niiinifirstations,  to  certain  [jurtions  of  the  bra  in- functions. 
The  best  scientific  definition  of  monomania  thnt  I  know  of  is  that 

I  given  by  Spitzka.  He  says,  "  Monomania  is  a  chronic  form  of 
insanity,  based  ou  an  acquired  or  trauamitteil  neuro-degenerative 
taint,  and  manifesting  itself  in  anomalies  of  the  eonceptioiial 
Bphere, — t.c.,  the  sphere  of  tlioiight, — which,  while  it  does  not  de- 
stroy entirely  the  mental  mechanism,  dominates  it."  This  defini- 
tion is,  1  think,  scarcely  wide  enough.  I  believe  that  the  term 
monomania  should  include  tiot  only  those  cases  in  which  the  intel- 
lectual or  conceptional  sphere  is  involve<l,  but  also  those  iii  which 

,the  emotional  condition  is  affected.     Avarice,  envy,  vanity,  and 


488 


DIAONOOTIC   SRUBOIJOaV. 


Other  passions  are  an  much  cerebral  functioos  as  is  tlie 
power  iteclf.  Tliere  are  cnM?i4  in  which  ih&ie  emotione  hcooraem' 
magnilictl  in  their  power  that  they  dominate  the  whole  tDdlvidoal. 
As  8D  ejcaniple  may  be  taken  the  miser,  in  whom  avarice  haa 
grown  until  it  has  cDttrcly  subjugated  the  ego,  so  (hat  ilie  maa 
perishes  of  hnuger,  gloating  upon  the  useless  gold  which  he 
clatches  in  his  hand. 

The  cases  of  partial  insanity  naturallj  group  iheinaolvcft  itito' 
two  clashes:  in  the  fir^t  of  the?¥  are  comprbicd  those  eases  in 
which  the  dclumons  are  distinct  and  ap^iurcnt ;  in  the  second  are 
included  casoi^  in  which  the  delusions  arc  altogether  wanlJog  or 
are  ver)*  ol»cure,  the  infinity  being  conflned  chie6y  or  altogether 
to  the  eniotioDal  and  moral  sphere.  The  seooud  of  these  gnjup* 
constitutes  the  mania  of  character  of  Pinel. 

The  following  quotation  from  Morel  (quoted  by  Hammond,] 
TreaiiM  on  Insanity,  p,  .165)  jiortrays  very  well  subjects  of  t\ 
mania  of  chai-acter,  or  moral  InMiiity  : 

"Surne  have  great  pndeand  ambition,  aud  consider  themselves' 
as  being  destined  to  the  performanoe  of  acts  of  momeotons  im- 
portance. No  consw^uenoe,  howevp-r  absurd,  to  which  their  in- 
sanity leads  them,  shakes  their  coofiJenoe  in  theiiiwlves.  Oth« 
are  impelled  by  Iwid  tendencies  to  the  perj>etration  of  the  most 
extravagant  or  nionettrous  8ct&  They  rebel  against  all  family 
or  Bocial  obligations  and  duties,  and  arc  constantly  considering 
themselves  the  victims  of  misundcratanding  or  injustice.  For  the 
persecution  of  which  they  imagine  themselves  the  subjects  the) 
seek  to  avenge  themselves  on  their  relations,  their  friends,  and 
the  world  at  lai^e  by  making  a  iMinidi-  of  their  immoral  con- 
duct, thinking  to  compromise  the  interests  of  those  who  ought 
to  be  dear  to  them  by  the  shameful  exhibition  of  Uieir  depravity! 
They  go  into  the  streets  and  other  public  places  in  a  filthy  iui( 
ragged  condition.  They  Let  their  liair  grow,  and  endeavor  to 
attract  attention  by  all  kinds  of  ridiculous  and  improper  ads. 
Others  apply  their  brilliant  intellectual  faculties,  notwithstanding 
they  are  marketl  by  an  irregularity  and  incoherence  of  action, 
the  production  of  literary  works  of  which  the  extent  and  tl 
plan  esceed  the  limit  that  it  is  possible  for  himmn  po\ter  to  reac 
These  works  are  often  in  their  teachings  contrary  to  public  mor 
ity  and  feeliug.    They  are  dreamers,  Utopians,  false  guides,  win 


D1STUBBANCE8  OF  CSTEIXECTIOK. 


487 


d  in  the  results  of  their  intelligence 

ame- 


saoie  eccentricity,  the  game 


I 


L 


in  their  mental  oonceptionj^ 
and  imagination  exhibit  tl 
Iwanctti,  as  ID  tlieir  actN." 

In  all  cases  of  mania  of  character  there  is  a  menial  inability  to 
weigh  evidence  that  conflicts  with  the  dictates  of  the  roling  pas- 
sion, which  almcitt  amounts  to  an  intellectual  Jniqinity.  Tn  the 
great  majority  of  cases  sooner  or  later  delusions  will  appear, 
altliough  careful  uearcli  may  be  required  to  detect  them.  As  an 
example  of  such  a  case  ihe  following  history  is  in  point  Several 
years  ago  I  was  railed  to  n  palatial  mansion,  and  was  met  iu  a 
boudoir  by  a  handsome  young  woman,  perfectly  Udy-ltice  and 
self-restrained  in  her  manner.  She  said  to  me,  "Doctor,  1  have 
sent  fur  yon  uniler  very  painful  cinnimstances,  because  I  feel  that 
I  roust  confide  in  some  one."  She  then  went  on  to  say  that  she 
had  syphilis,  that  this  bad  been  given  to  her  by  her  husband, 
and  that  sbe  had  had  a  child  born  iu  a  certain  watering-place, 
which  had  died  of  heretlitary  syphilis.  She  further  told  me  in 
detail  of  having  personally  detected  her  hu.><hand'H  infidelities.  I 
examined  the  woman  thoroughly,  but  could  not  find  the  alighteat 
evidence  of  specific  disea^iie.  T  finally  wrote  to  the  physician  who 
had  attended  the  woman  at  tlie  birth  of  the  child.  He  at  once 
rcplic<I  that  the  child  was  well  formed  and  perfect,  and  that  it  Imd 
died  of  an  ordinary  acut<>  infantile  disease.  I  then  a<^snred  the 
woman  that  she  had  not  bad  syphilis.  She  expressed  bemelf  as 
much  relieved,  but  was  unrelenting  towards  her  husband,  who  she 
said  kept  »  niiBtrcss,  and  frequently  annoyed  her  by  (x>mmuni- 
<nting  with  said  mistress  at  places  of  amusement  to  which  he  bad 
taken  herself,  and  by  having  said  mistre^  to  drive  immediately 
behind  Ibem  iu  the  Park.  She  had  detectives  employed  to  watdi 
her  hu.sband,  and  bad  a  well-kuowu  lawyer  engaged  to  super- 
intend tlie  detectives.  At  first  I  entirely  believed  the  woman's 
story ;  but  after  some  weeks  I  began  to  suspect  that  there  wag 
somelbing  wrong  with  her  brain,  and  to  watch  her. 

To  make  a  long  story  short,  my  patient  watched  her  husband 
more  ami  more  closely,  at  an  expense  of  hundreds  of  dollars,  and 
at  last  one  night  at  a  theatre  poinlal  out  as  his  paramour  a 
lady  who  was  well  known  ntid  entirely  beyond  suspicion.  The 
whole  of  her  story  was  nndonbtcdly  invented,  altliough  she  her- 
self believed  it,  and  for  a  time  even  misled  me  into  crediting  it. 


488 


ifOCTIC  NEimOLOOT. 


Her  Itu-shatid,  howpver,  bclicvod  ihat  she  was  full  of  the  devil  aai) 
wtuittxl  to  tortiient  bin),  tind  never  could  be  ]>erKuade«l  that  the 
was  insaue.  She  was  all  the  time  acting  itgsiiist  Iter  uwn  iotere&t. 
Her  husband  was  a  man  of  ^rcnt  wealth  and  natural  kindiinfs&, 
dotiiiglv  fond  of  her,  and  would  have  granted  her  utmost  wuh  if 
she  had  acted  In  a  decent  manner  towunU  him. 

Her  intellectual  powers,  except  ia  regard  to  her  busbaiid's  io- 
fidelities,  were  perfLft.  She  mingleil  in  «H-iety,  reasoned  well, 
and  did  everything  well,  but  she  had  this  delnsiou.  I  found  ia 
this  case,  as  is  found  in  most  cases  of  monomania,  that  clear  badt 
to  childhood  there  had  been  evidenoett  of  wraelhing  not  qaile 
ri^lit  with  the  ecrebral  functions.  The  woman  liad  always  been 
extremely  vain,  wildly  Ambitious  to  shtue  in  fashtounble  sode^, 
and  excessively  egotistical, — cliaracteriatics  which  frequently  pre* 
cede  the  evidences  of  mouomania,  as  was  well  exemplified  in  the 
history  of  Guiteuii. 

Although  lO-iquirol  ufwd  the  term  monomania  as  belonging  to 
those  ca^^  in  which  there  is  an  excess  of  animal  upiritH  ami  of 
the  emotionii,  such  as  ambition  and  anger,  which  arc  related  to 
ag^resaivcncfu^  and  }>owcr,  there  cau  be  no  doubt  that  tbciv  are 
two  distinrt  classes  of  nionomniiiacai  per5f>n8, — tliosTe  iu  wliom 
there  is  a  condition  of  emotional  exaltation,  and  those  in  whom 
there  is  a  condition  of  emotional  depression,  corresjionding  lo 
the  mania  and  melancholia  of  general  insanity. 

The  delusions  of  immnmniiia,  like  the  delusions  of  geuend  in- 
sanity, conform  in  type  to  the  emotional  state,  and  often  grow  out 
of  something  having  a  real  existence.  A  raelaneliolic  or  hypo- 
chondriacal manoniuniac  may  have  some  bad  feeling,  which  is  in- 
creased  ia  his  mind  until  it  dominates  his  whole  lite:  thus,  a  dys- 
peptic aymptoni  leads  him  to  the  belief  that  ho  has  no  stomach. 
These  esses  are  to  be  distinguished  from  the  cases  of  hypochon- 
driacal melancholia  by  the  fact  tb-it  the  delusion  is  "syMematiied," 
■^Ia,  it  is  one  about  which  the  patieut  reasons,  and  which  he 
defends;  but,  as  has  already  been  stated,  the  systematized  delusion 
grades  into  the  unsyKteniatized,  and  hence  cases  of  monomania 
grade  Into  cases  of  chronic  mania  or  chronic  melancholia. 

On  the  other  hand,  the  line  between  moDomaniacal  insanity  and 
sanity  is  an  entirely  arbitrary  one,  and  cannot  be  fixed  by  any 
Unite  power.     As  is  well  known,  the  cbildreu  of  insane  peraons 


J 


DISTCKBAKCES  OF  ISTEIXECnOJr. 


I 


P 


ore  very  apt  to  be  more  or  less  diScrent  from  ordinary  Imman 
beings.  Although  ihev  perform  all  the  dutie*  of  life,  their  men- 
tal or  oormul  ur^iuiizatioQ  seetux  to  be  luckiog  in  someibiug,  or 
to  have  suBered  somo  twi^l.  Perverse,  drifting  alraoet  of  neces- 
sity into  criminal  acts,  eccentric,  such  unfortunates  are  a  long 
series  of  human  atoma  whose  faulty  brain-organ izntion  separatee 
them  from  their  more  fortucate  fellowe.  When  this  separation  is 
sufficiently  wide,  when  tlie  mental  organization  is  so  bad  that 
ever}*  one  can  perceive  that  the  man  is  the  victim  of  his  own  im- 
perfectly-developed brain,  he  is  said  to  be  inaane.  But  «'hen  the 
aafortuoate  individual  ia  a  little  more  like  tlie  oormal  human 
being,  he  is  looked  upon  simply  as  ecoentrie,  perverse,  or  wicked, 
and,  unloved  and  nnpitied,  drifts  llirough  life  sonietimos  to  pov- 
erty, somolimea  to  the  hospital,  sometimes  to  the  jail,  and,  it  may 
be>  to  the  hangman's  scaffold.  Sanity,  insanity,  criminality,  power 
over  self,  free  will,  mental  attributes,  theee  aud  similar  terms  are 
household  words  with  all  of  u»,  but  no  man  knows  whence  they 
oome,  or  what  they  are,  or  how  far  the  individual  is  master  of 
himself  or  is  driven  by  the  hand  of  fate,  as  represented  in  the 
physical  conformation  of  the  nerve-cells  and  fibres  of  his  brain. 

As  has  »lrea<ly  been  insisted  uimn,  insanity  is  not  a  disease  or 
a  distinct  entity.  Necessity  for  an  arbitrary  line  between  sanity 
and  insanity  is  not  of  Acienlilic  but  of  legal  origin,  and  when  the 
medical  expert  affirms  tliat  he  is  unable  to  measui-e  out  accurately 
the  exact  degree  of  human  responsibility  he  simply  acknowledges 
that  he  himself  is  a  finite  being,  and  tliat  the  problems  of  life 
baffic  his  utmost  thought.  It  has  been  reserved  for  judges  upon 
the  l>encb  and  lawyers  at  the  bar  to  arrogate  to  tbemselvet  the 
attribute  of  iuiiuity,  whilst  minister^  uf  the  goa[>el  hut  too  often 
teach  that  the  la.st  and  highest  revehition  of  a  merciful  God  is 
that  this  pour,  broken  humanity,  helplms  fio  often  iu  the  iron  grip 
of  its  own  pervere^e  nature,  shall  be  punished  by  6ames  eternal. 

The  difficulty  of  drawing  a  line  tietween  .<^nity  ami  insanity  is 
well  illustrated  by  religious  mouomauiaus.  Are  tliose  who  believe 
Uiat  Uiey  habiuially  hold  conimuuion  with  spirits,  the  dupes  of 
modern  spiritualism,  to  be  considered  insane?  Is  the  woman 
who  18  convinced  that  Providence  has  as  the  result  of  her  prayers 
put  back  the  ordinary  course  of  nature  and  relieved  her  of  an  in- 
curable affection,  sane  or  insane?     In  matters  of  religious  belief, 


490 


DrAONOETIC   NEUBOIOQY. 


every  man  who  holds  strongly  to  a  certain  faitli  might  cooAKkr 
every  pemon  who  believes  in  a  different  faith  to  be  insaiic  Pro- 
found belief  in  the  daily  presence  of  spirits  and  in  tlie  ntmost 
vagaries  of  modern  spiritualism  ma^  coexist  with  grent  scientific 
or  buHineea  acttmen. 

Although  it  seems  impoeaible  to  iiz  a  line  which  shall  (>eparate 
a  aanc  from  an  insane  religious  trust  or  belief,  it  can  hardly  be 
doubted  that  many  of  the  devotees  of  spiritualism  most  be  oon- 
Bidered  as  acrow  the  line.  To  illustrate  how  closely  moaomaoU 
is  related  to  sauity,  and  how  difficult  it  liomctimGs  is  to  draw 
the  line,  I  may  cite  the  cane  of  a  e)ii|)ertar  officer  of  the  United 
States  army,  now  dead,  who  was,  at  the  time  I  speak  of,  stationed 
at  one  of  the  froatier  poets  of  the  oountr>',  and  was  |>erforming, 
vitb  aatiKfacttoii  to  all,  the  duties  appertaining  to  his  rank.  One 
day  he  said  to  a  friend,  "  My  life  in  this  fronUer  post,  from  its 
monotony,  would  be  absolutely  insupportable  if  it  were  not  for 
my  doily  mail  which  I  get  from  my  dead  friends.  I  had  a  letter 
from  your  brother  last  week,  and  every  morning  I  live  in  ex}»ec- 
tation  of  receiving  a  letter  from  some  deceased  friend  or  relative." 
Ue  was  asked  how  tlie  letters  came,  and  it  was  teamed  that  they 
■were  received  through  a  certain  living  medinm  in  the  castem  part 
of  the  United  States.  This  woman,  no  doubt  receiving  a  stipend 
from  the  officer,  would  almost  daily  write  him  a  letter,  which  was 
reoeived  by  him  with  absolute  credence  as  comiag  through  her 
from  the  spirit-world.  On  another  occasion  he  said,  "  There  is 
one  thing  that  gives  me  great  comfort,  and  that  is  that  I  am  a 
descendant  of  the  Virgin  Mary."  Some  one  intimating  a  doubt 
of  that  genealogy,  he  continued,  "  I  know  that  I  am  a  desoend- 
aut  of  the  Virgin  Mary,  because  I  had  a  letter  from  her,  and  she 
lays  SO;  and  she  certainly  otight  to  know."  C^ui  wc  hesitate  in 
deciding  that  here  was  a  delusion  which  was  thoroughly  system- 
atized and  logically  defended  by  its  holder?  The  Brat  premise, 
that  he  received  letters  from  the  spirits,  was  false,  but  his  rcasoa- 
ing  based  upon  it  was  sound. 

Not  only  is  it  difficult  to  draw  the  line  between  sanity  and 
insanity,  but  there  is  a  close  relation  between  partial  insanity 
and  high  inlelleotual  power,  especially  with  reference  to  genius 
or  the  power  of  original  tliought.  There  can  be  no  doubt  that 
0  proportion  of  those  who  are  considered  as  the  most  pronounced 


DISTOUBAVCBS  OF  IKTELI.SCTIOIT. 


491 


» 
» 


I 


ejcampleg  of  genius  are  men  whose  intellects  are  on  tlie  border 
of  insanity.  To  siy  tliut  un  individual  is  a  genluii  usually  means 
tiiat  lie  1)08  a  »:rtaiii  runccion  of  the  mind  exalted  high  above 
the  other  rnnctiong.  A  man  whose  imagination  is  developed 
out  of  proportion  to  his  reasoning  facultiei  la  apt  to  be  a  poet 
or  a  novelist,  and  produces  works  which  may  live  through  cen- 
tnries.  Such  a  mai]  is  above  his  fellows,  not  by  virtue  of  great 
brain-power,  hut  bceanse  his  brain  takes  a  peculiar  limited  direc- 
tion. A  genius  ie  recognized  as  a  mau  not  practical.  By  a  man 
not  practical  is  meant  one  lacking  in  common  Ben^e;  and  common 
sense  is,  after  alt,  neither  more  nor  leua  than  the  term  used  tu  ex* 
press  good  judgment  in  the  ordinary  matters  of  life.  A  man  who 
has  great  imagination  usually  lacks  r^^asoning  power,  and  is  not 
praotical,  because  of  his  great  imagiuatlou.  One  of  the  best  ex- 
amples of  the  relation  between  extraordinary  imngioalive  power 
and  monomania  is  John  Bunyan,  the  author  of  "  The  Pilgrim's 
Pn^^ress,"  which,  according  to  any  standard  that  we  have  a  right 
to  set  up,  is  one  of  the  five  or  six  greatest  books  in  the  English 
language.  It  is  certainly  more  rcail  tliau  any  othur  book  with 
the  exception  of  the  Bible.  No  one  wlio  reads  the  history  of 
Bunyan's  life  can  doubt  for  a  moment  that  he  for  a  long  time 
suffered  from  monomauia  with  depressing  delusions,  and  bis 
immortal  dream  may  have  been  to  him,  at  least  at  times,  much 
more  than  a  dream. 

Space  is  wanting  to  do  more  than  call  attention  to  the  over- 
weening egotlftm  of  Byron  and  to  the  agonies  of  mental  depresnion 
which  overshadowed  the  life  of  Cowper;  but  I  cannot  forbear 
citing  at  greater  length  the  case  of  Victor  Hugo  as  illustrating 
the  close  relationi^hlp  between  insanity  and  genius.  HU  uncle 
died  insane ;  his  brother,  Charles  Hugo,  in  his  late  boyhood  gave 
promise  of  remarkable  talent  for  literature,  but  before  twenty  he 
became  insane,  and  linally  he  passed  into  a  conditiou  of  complete 
dementia.  One  of  the  daughters  of  Victor  Hugo  is  now  and  has 
been  for  many  years  living  in  an  insane  asylum.  According  to 
the  London  Medical  7\Ws,  there  are  in  many  of  Hugo's  6aest 
productions  numerous  passages  which  could  have  been  conceived 
unly  by  a  diseiif^d  iinaginatiou,  and  whicli  are  indelibly  stamped 
with  madness.  A  remarkable  fact  in  the  menial  history  of  the 
great  French  poet  is  that  along  with  his  extraordinary  imagina- 


4 


492  SIAONOSTIO  NSUBOLOGY. 

tion  there  was  a  shrewdness  almoet  as  great  No  banker  could 
have  more  carefully  managed  his  fortune ;  no  politician  could  have 
more  tenderly  nursed  his  popularity.  He  who  had  amassed  over 
a  million  of  dollars  died  the  idol  of  a  communistic  democracy ;  he 
who  bad  played  at  fast  and  loose  with  all  political  parties  was 
buried  amidst  a  tumult  of  universal  sorrow. 

The  pn^nosis  in  monomania  is  exceedingly  unfavorable.  This 
is  because  the  condition  is  so  oflen  the  result  of  a  faulty  formation 
of  some  part  of  the  brain.  There  is  a  peculiarity  of  the  cerebral 
organization  which  shows  itself  from  the  very  first.  Only  a  small 
proportion  of  cases  recover  entirely. 


INDEX. 


A. 

Abdomiaal  reflex,  181. 
AMowtii  nerra,  86. 

pAraljiit  of,  328. 
AbnormBlitiea  of  the  optio  dUk,  831. 
Abrupt  oerebrftt  hemiplagia,  3S, 

pftr&p1«g;i&,  49. 
AbnUa,  deflnitioD  of,  421. 
Aeoidents  of  Ble«p,  414. 
Aoetonnmia,  tee  Toxnmio  Sleep. 
Aaata  eentrkl  mjolitiR,  &3. 

delirium,  *ee  Aoate  Perienoephalitli. 

m»nia,  471. 

perieaoepb otitis,  450. 

p«riph«rttJ  enoephalitio,  •»  Perlen- 
o^haliiia. 
,£atheciometer,  253. 
AffeetioDf,  o  on -sped  Bo  Btaporoni,  4D0, 

■pecifio  alnporoDS,  408. 
Afriwn  sleeping  diseaM,  Me  Nelavui. 
Agrammatiama,  362. 
Alutapbuia,  «ee  Agrammatinua. 
Aleoholio  epiiepsj,  117. 

beadaofae,  304. 

inaanit;,  467. 

mental  diiorders,  465. 

paraljBis,  27. 

epinal  paralyais,  60. 
Amauroait,  345. 
Amblyopia,  organio,  346, 

toiieinio,  34fl. 
Amneaia,  360. 
Amnesio  apbaaia,  861. 
Amyotropbio  lateral  loleroiit,  67. 
Anemia,  ipinal,  62. 
AnKmio  headache,  308. 

spbBcelua,  tfe  Rajoand's  DiMaae. 
AntBttheaia,  bladder,  256. 

cmanMoB,  256. 

doloroaa,  56. 

gontj,  26T. 

hyUerioal,  257. 

diagDOBia  of,  263. 

of  tbroat,  25A. 

organic,  265. 

general,  266. 
looal,  274. 

psjchio,  2S4, 

reoUl,  255. 

vaginal,  258. 

viaceral,  255. 
Anatomy  of  tbe  cortex,  60. 

of  the  optio  tract,  344. 

of  the  fpinal  oord,  46. 


Animal  ohoraa,  154. 
Ankle-olonoi,  162. 

effeot  of  diiease  on,  IBS. 
Anterior  orural  nerre,  93. 

spinal  artery,  temporarj  arrest  of  idr- 
oulatlon  in,  30. 

tboracio  Dervet,  91, 
Aphnmio,  definition  of,  869, 
Aphasia,  359. 

amnesia,  381. 

ataxio,  360. 

fa  national,  363. 

hemiplegia  with,  39. 

leeioDB  of,  364. 
Aphonia,  defloition  of,  859, 
Apoplexy,  3B3. 

oongestire,  383. 

spinal,  49. 
Argyll-RobertBOD  pnpil,  837,  389. 
Araenioal  poisoning,  242. 
Artery,  anterior  spinal,  temporary  arreat 
of  eiroulalion  in,  80. 

basilar,    arrest    of     oiroalatlon     in 
branobea  of,  30. 

posterior    cerebellar,  temporar;    ar- 
rest of  oironlation  in,  30. 

vertebral,  embolui  in,  31, 
thrombns  in,  31, 
Arthropathies,  bamiplegio,  227. 

ipinal,  228. 
Asoending  paralysis,  28,  49,  51, 

lesions  of,  53. 
Assooiated  paralysis  of  tbe  eye,  329. 
Assumed  paralysis,  25. 
Ataxio  apnasia,  360. 

gait,  196. 
Athetosis,  162. 
Atrophy  by  propagation,  61. 

joint,  82. 

looal,  81. 

of  the  optio  papilla,  385. 

progressive  mnsonlar,  83. 

reflex,  81. 
Aural  vertigo,  209. 
Automatic  coDSoiouiness,  100. 

movements,  OT,  175. 
Automatism,  psyohioal,  177, 


B. 

Basilar  artery,  arrest  of  eiroulation  In 

branches  of,  30. 
Bell's  disease,  ttt  Acute  Perienoapbalitla. 
paralysis,  67. 

408 


494 


IKDEZ, 


Blftddor  Min>th«aUs  2S0. 

BlephftroipMin,  137. 

Bnin,  orgkoio  disemM  of  tlie,  112. 

tnmor,  406. 
Bnut,  hjitsriokl,  S82. 
Bulbar  general  panilyrii,  30. 

hemianvithNia,  268. 

paraljrii,  inflammfttorj,  31. 
Bentatiou  in,  31. 


C. 

Caffeinio  headache,  305. 

Cardiao  and  pulmoaio  beadaobe,  806. 

criai*,  300. 

epilepi]',  111. 

Tertigo,  204. 
Cata1epi7,  394. 
Oeatnl  myelitii,  aoute,  &S. 
Bubauiite,  64. 

nerTODi      diseaiM,    trophic      bone- 
ebaDgee  in,  226. 
Cerebellar  Sections,  198, 

diariBe,  gait  in,  198. 

UtDbation,  198. 
Cerebral  oootraoturea,  167. 

oortei,  motor  flbree  of,  37. 

geaeral  paralysis,  20. 

bemianffiBlhesia,  270. 

hemiplegia,  35. 
abrupt,  36. 

hemorrhage,  ooDTiiIeionB  ftom,  116, 

monoplegia,  72. 
abrupt,  72. 
.prugresaife,  72. 

raultipio  p&raljaiB,  75. 

■oleroiis,  456. 

Bhook,  dementia  of,  481. 
Cerebro -spinal  meniogitii,  440, 

Bclcronie,  multiple,  144. 
Cervitral  poch.TmfiiingitU,  63. 
Chin-jerk,  are  Jaw-Jerk. 
Choked  disk,  331. 
Chorea,  146. 

electric,  150. 

genernl,  148. 

hysterical,  159. 

in  iotorniLt  inflammation!,  IGB. 

majiir,  97,  175. 

□tiCure  and  UmitBtionB  of,  151. 

of  pregDBDcj,  158. 

of  Btump,  164. 

paralytic,  160. 

post- hem Iplogic,  IBl, 

p08t-pH.rnljrtic,  1R1. 

pre-hemiplogic,  ISO. 

reflei.  152. 
Cborean,  local,  100. 
Choreic  movement,  07. 
Chronic  mnnia,  473. 

myelitis,  65. 

paraplegia,  65. 

peripheral  paralysis,  83. 
Circular  insanity,  484. 
Clot,  diagnoiis  of  position  of,  37. 


Colnmni  of  Ooll,  47. 

of  Tnrok,  47. 
Coma,  deflnition  of,  370. 

fondroyant,  408. 

■Tphilitie,  408. 
Complete  iasanitiM,  470. 

non-p«riodic  intanity,  470. 
Complicating  insanities,  443, 
Congeetive  apoplexj,  S83. 

headache,  308. 
Conjngattd  dariation  of  head  and  vjti, 

329. 
Conseioasnen,  antomatie,  100. 

ditorden  of,  367,  377. 

double,  371. 

■nddeo  low  of,  3T9. 
Contraction  of  the  field  of  Tiilon,  353. 
Contractures,  166. 

cerebral,  167. 

hyilerical,  109. 

in  infantile  paralfiis,  168. 

of  neuritis,  169. 
Conrnlsion,  epileptiform,  97. 

hjsteroidal,  oharncteristiot  of,  lOS. 
Conmlsioni,  06,  97. 

from  oe  re  bral  hemorrhage^  115. 

bysteroidal,  100,  120. 

in  fever,  117. 

of  childhood,  109. 

temperature  aa  an  ^d  to  diacnocttin, 
121. 

tetania,  102,  122. 

urMmio,  118. 
Co-ordination,  oaases  of  loai  of,  196. 

disturbance  of,  194. 

loss  of,  as  a  complicating  sjmptom, 
198. 
Corpus    striatum    general   paralysis,    ttt 
Lenticular  Qenaral  Paralyiti, 
lesion  of,  38. 
Correlated  disorder!  of  memorj  and  oon- 

sciou^neBB,  369. 
Cortex,  anatomy  of  the,  69. 
Cortical  spasms,  134. 
Cough,  nervous,  130. 
Cranial  reflex,  182. 
Cremaster  reflex,  181. 
CroMed  oculo-motor  pally,  41. 

pnralygiii,  40. 

pyramidal  tracts,  47. 
Crutch-palsy,  73. 
Cutaneous  anteBthesia,  256. 
Cyclothymia,  tee  Circular  Insanity. 


Dead  finger,  tee  Raynaud's  Dilease. 
DeoobiCuB,  213. 
Deep  reflexes,  182. 
Delirium.  4.38. 

grave,  lee  Acute  Periencephalitis. 

ofgraodeur,  leeExpaniire  Delnaions, 

tremens,  465. 
Delusion,  427. 

aystematiied,  432. 


IND3BZ. 


496 


Dvlniiona,  exp4DdTe,  431. 

h/pocboDdriaoftI,  431. 

of  penecDtiao,  432. 
DameDtJa  of  cerebral  ahook,  481. 

miHellaneoui,  481. 

pkmlytioa,  itnpor  in,  411. 

primary,  478. 

lenile,  tet  DeT«Iopiaental  Dementiu. 

terminal,  483. 
Dementias,  developmental,  480. 

orgaDic,  479. 
DetirM,  morbid,  437. 
Dorelopmental  dementiaa,  4B0. 
Diabetio  aoma,  404. 

bcBdoche,  305. 
Diathetic  in-ianitiet,  457. 
Dipbtberitio  paraiyiis,  7B. 
Diplopia,  321. 
Direct  cerebral  traota,  47. 

pyramidal  tracts,  47. 
Disease,  definition  of,  17. 
Disk,  abnarmalitics  of,  331. 
Disorders  of  cousciousnaH,  377. 

of  memory  and  oonioiounieBS,  357. 

of  sight,  344. 

of  sleep  oonneoted  vitb  aant«  feTors, 
390. 
Distarbancea  of  eqnilibratioD,  194. 

of  intellection,  420. 

of  the  special  senses,  317. 

of  vision,  341, 
Donble  comcionsDeM,  371. 

personality,  371. 
Dynamometer,  24. 


B. 

Embolism  and  hemorrhage,  dlagnoda  be- 
tween, 36, 
Smbolus  in  vertebral  artery,  31. 
EpigRstrio  reflex,  161. 
Epilepsy,  103. 

alcoholic,  117. 

aura  !□,  103, 

oardiao.  111. 

eonruliive  stages  of,  105. 

diagnoaiB  between  Idlopatbio  and  or- 
ganic, 114. 

idiopathic,  103. 

Jaekfonian,  96,  112. 

organic,  112. 

pleuritic,  110- 

relations   between  the  conralsion  of 
childbood  and,  109. 

spinal,  76. 
Epileptic  iDB&nity,  458, 

mania,  460. 

sleep,  396. 

vertigo,  204. 
Epileptiform  eonvulsion,  97. 
from  toxemia,  117. 
in  general  paralysis,  116. 
Equilibration,  diitnrbancee  of,  194. 
Erector- spinal  reflex,  181. 
Erotomania,  437, 


Erytbromyalgia,  *««  Raynaud'!  Dlaaaw, 

Essential  vertigo,  212. 
Exaltation  of  memory,  368. 
Exhaustion,  beadaohe  of,  308. 
Expansive  delusions,  431. 
External  popliteal  nerve,  94. 
Extremities,  pains  in  the,  289. 
E;e,  associated  paralysis  of,  329. 

movements  of  the,  318. 
Eye-strain,  headaches  of,  306. 


r. 

Faoe-pains,  312. 

Facial  hemiatrophy,  progressive,  249. 

nerve,  87. 

spasm,  136. 

paralysis,  39,  40. 
Failure  of  memory,  369. 
Fever,  convaliioDs  in,  117. 
Field  of  vision,  342. 

contraction  of  the,  368. 
Fifth  nerve,  SO. 
Fixed  pains,  290. 
Fourth  nerve,  86. 

Fnlmt Dating  ooma,  tee  Coma  Fondroyant. 
Fanctional  aphasia,  363. 

paralysia,  24. 

paraplegia,  42. 


6. 

Qait,  aUxie,  196. 

in  cerebellar  disease,  198. 
Qastrio  headache,  305. 

vertigo,  207. 
General  anfcstbesia,  organic,  SS6. 

oborea,  148. 

paralysis,  26, 197. 

epileptiform  oonvuliioni  in,  110. 
lenticular,  32. 
of  the  insane,  452. 
OeniUI  crises,  298. 

hyperesthesia,  282. 
Qirdle-pain,  295, 

sensation,  05. 
aiohua  hytteriooa,  100,  120. 
OlosBO-labial  paralysis,  247. 
Qtosso-pharyngeil  nerve,  89. 
Gluteal  reflex,  181. 
Qoll,  columns  of,  47. 
Oouty  anrosthcsia,  267. 

insanity,  457. 


H. 

Habit  chorea,  166. 
Hnmatomyelitis,  49. 
Hal  la  oi  nation,  425. 
Headache,  301. 

alcoholic,  304. 

annmic,  306. 

caffeinia,  305. 


496 


INDEX. 


Bwdkobe,  otrdiM  *nd  pulmonle,  SOS. 

wngMtive,  308. 

diabetic,  SO  6, 

gMtrio,  305. 

h^iterioBl,  308. 

lithnmio,  803. 

mdkrial,  303. 

nawl,  307. 

n«TTODi,  307. 

of  exbauition,  SOS. 

rheamktie,  303. 

BjmpBthetio,  300. 

toxemia,  303. 

arnmto,  304. 
Headoobu  of  ejo-itnin,  30t. 
Houl-pAina,  301. 
Hearing,  317. 
Heat-exbkQBtion,  3SD. 
BebepfarflDift,  481. 
Hemiknefltbeiia,  but  bar,  1S8. 

oeTebnl,  370. 

from  diseue  of  pons,  288. 

from  Imiod  of  p«dniiole,  300. 

hjaUricml,  Z5S. 

InvolTing  ipeoial  nnaas,  271. 

organic,  ZB7. 

ipinal,  2A7. 

without  inTolTem«Dtoftp«eta]iaiMa, 
267. 
Heminnopeia,  348. 
Hemiataxia,  162, 
Bern  ion  ia,  348. 
Hemiplegia,  32. 

cerebral,  36. 

diagnoBia  between  true  and  fklse,  34. 

disorder  of  sensalion  in,  3S. 

from  lexinn  in  pons,  39. 

hjEterioal,  34. 

progrcMive,  from  lesion  of  pooa,  42. 

apinnl,  35. 

with  aphaiis,  39. 
ITemiplegin  arthropathies,  227. 
Hemorrhage  and  embolism,  diagnosis  b»- 
tween,  .tO. 

cerebral,  convnlsions  from,  116. 

with  spinal  membranes,  49. 
Herpetic  pain,  294. 
Hydrocephalic  cry,  446. 
Hydrophobia,  spurious,  120. 
Hjperfesthosia,  281. 

genital,  282. 

hysterical,  282, 

organic,  285, 

spinal,  234. 
Hypcrbulia,  (leGnition  of,  421. 
nypoobnndriacal  delasions,  431. 
Hypnotism,  4U2. 

HjpO'melaDcbolia,  ttt    Simple    Melan- 
cholia. 
Hysteria,  122. 

minor,  120, 
Hysterical  anwsthesia,  257. 
diagnosis  of,  262. 

breast,  282, 

chorea,  150, 

contractures,  16tf. 


Byatarioal  ganaral  pvaljiia,  37. 

headaohe,  308. 

hemianasthesia,  250. 

hemiplegia,  34. 

hyperastbeaia,  382, 

insanity,  463. 

joints,  283. 

monoplegia,  07. 

paralysis,  26. 

paraplegia,  44. 

sleep,  401. 

spasms,  134. 

Tcrtigo,  205. 
Hjsteroidal  oonTDtaion,  100. 

oharacterittiM  of,  102. 

oonTulrions,  120. 


I. 


Idiopatbio  epilepsy,  103. 

poliomyelltu,  238. 
Ilio-ojpogastrlo  nerve,  03. 
Ilio-ingninal  nerve,  93. 
Imperative  act,  definition  of,  433. 

oonoeption,  deBnition  of,  433. 
Incomplete  insanity,  485. 
Infantile  paralysis,  oontraotorea  lo^  108. 

spastic,  75. 
Inferior  ginteal  nerre,  S4. 
Inflammations,  internal,  ohorea  in,  100. 
Inflammatory  bulbar  paiaJysii,  31. 

spasms,  134. 
Insane,  general  paralyris  of  the,  463. 
Insanities,  complete,  470, 

complicating,  443. 

diathetic,  457. 

periodic,  464, 

pure,  460. 
Insanity,  alcobolio,  407. 

circular,  494. 

complete  non-periodie,  470. 

deflnitioD  of,  439. 

epileptic,  458. 

gouty,  457, 

hysterical.  462. 

incomplete,  485. 

of  masturbation,  see  Hebephrttnta- 

of  pubescence,  see  Hebephrenia. 

primary  confiuional,  482. 

sleep  in,  404. 

sypbititic,  403. 
Insomnia,  389. 

Intellection,  disturbanoe*  of,  420. 
Intercostal  nerves,  03. 
InlermitteDt  paralysis,  27. 
Internal  popliteal  nerve,  95. 

J. 

Jacksonian  epilepsy,  S6,  112. 
Jaw-jerk,   183. 
Joint  atrapbies,  82. 
Joints,  hysterical,  283. 

trophic  obangee  in,  237. 
Jnmpers,  tee  Hiryaohlt. 


^           njDEx!                                    4Wf       ^H 

^           iT 

nembrajiea.  fplnal,  facBtorrhftS'  Into,  40.              ^^H 

Heuwrjr.  iliuird«r«  of,  3i7.                                      ^^H 

F          Kktktonta,  47T. 

axaltatioD  at.  itb.                                           ^^M 

L           Kkptnint>ni>,4.1(t, 

fulnre  of,  369.                                                  ^^H 

^H    ED•^-j(I^k,  ItiS. 

Muarkl.  BA8.                                                      ^^H 
HfBMra'*  diMUa,  ««■  Atirat  T*rtigO.                    ^^| 

^^H          aonilMMjr  of,  It)T. 

^^1         JImum  wbtvh  tnorwue,  Itl. 

Htolugaal  Tlclditj,  1M.                                          ^H 
Meuiaitlla,  4M,  4(3.                                               ^^1 

^^1          iUmmm  nbioh  IwMo,  18T. 

ocrobro.tpiiial,  44fl.                                                ^^H 

Uiopsibie,  dta|[nu«i>  of,  448.                           ^^H 

^P 

taMraalar,  44S.                                                ^^H 

diaKnwU  of,  448,                                      ^^^^ 

'         Ludrr'ipwdTrii.^f.AL 

Kjrmulonit  of,  440.                                     ^^^^ 

MmioOS. 

BffoUl  (l«tiiri«nitiona.  4T8.                              ^^^H 

l«i7iiKW'  oriiM.  n>. 

diiordora,  al^aobolio,  409.                           ^^^^^M 

LftrraclnBiia  nrliluliii,  181. 

MMallotbarap?.  34,  2I>9.                                 ^^^H 

^_    Lauh,  Ht  Hlryaebll. 

HffTiJol),                                                           ^^^H 

^K   UMnl  Micnwit,  SI.  171. 

Minor  bTiUrU,  120,                                         ^^^H 

^y                 uo^otrotkhia,  ST. 
l.ciul-p«iaoiiin(,  243. 

Hli7a«bi(,                                                          ^^^H 

UiwellanMUR  deiucoti*,  481.                          ^^^^H 

I^ntioali^r  gmetti  fwrftlyaia,  ^2. 

Hobilo  pains,  SSO.                                            ^^^^H 

Lciioo*  or  •phui*,  Sfll. 
LHhkr»,  XS3. 
UUtMnIo  hsulMbn,  ADS. 

MonnanM'tlhMia,  orjanio,  SIS.                        ^^^^^| 

Honnniania,  485,                                                     ^^^^^| 

Uuiiii|>l»,c>a,                                                              ^^^^^1 
abrupt  iivrnbml.  T2.                                            ^^^^| 

hatmi  ghor«u,  IHO. 

pcnlyii*.  SS. 

cvrvliTal,  72.                                                            ^^^| 

•paan*,  I8!t. 

dciuble.  64.                                                               ^^H 

■jneope,  >rr  R»;akiid'i  DiieM*. 

from  iujut^  or  dlixaio  of  i>a(TM,  7t,              ^^^| 

1 Loooootor  «UKi».,  IPS. 

tr^m  pi«*ar«  on  narrv,  TS.                             ^^H 

^^L                  Idu  of  iMth  Id,  af  Tropbia  Bon*- 

hjctarioal,  C7.                                                  ^^H 

^^^                    pain-erianla,  19S. 
r          LojopW^i.  340. 

irrofaUrit;  of  inpliokdon  of  DUelai           ^^H 
U,6S.                                                          ^H 

ytriphatnl,  T3,                                                ^^H 

b           Loac  thuT«eio  nerre,  il«. 

pivgnnlva  eertbtsi,  Ti.                              ^^^^^ 

^K   LoM  of  nannnal  jdeatitj,  ^71. 

^^^^H 

■ 

rarittkiuf,  6S.                                         ^^^^H 

■ 

Uorbid  AfuAm,  437.                                         ^^^H 

H 

ImpnlM,  dcGoiUoD  of,  433.                       ^^^^H 

V 

■loep,  3V0.                                                   ^^^H 

'          Uid*r  rvDsl  MnipttgU,  44. 
MaUri*]  bwHlnoho,  .10.1. 

Uotw  os^Umcnta,  Sit.                                         ^^^H 

HavtmeaU  of  th*  «jn,  318.                                ^^H 

Hklignanl  niulliple  ntuHtJa,  it. 

roUtorj,  3DU.                                                    ^^H 

Unnis. -171. 

UnJlipIo  Mr«liro-«piiikl  attlcroda,  1 14.                   ^^^| 

^^^                     BlTUlc,  471. 

neuiitis,  li!>,  197.                                              ^^M 

^^L           ahrusic,  473. 

iliagniiila  of,  &8.                                            ^^^^ 

^^H           epilcptio,  460. 

muligaanl,  ilk.                                              ^^^M 

^^^^^H  vravia,  •«  Aabt«  PaiiiBotplwlltJ*. 
^^^■f  hnmlokUl,  43C. 

puraljiia,                                                                 ^^^H 

^^^^^■of  ebanoUr,  4M. 

oorobral,  75.                                                   ^^^H 

^^^■iwrlodli?. 

paraplngia  from,  4fl,                                    ^^^^ 

^^^^B  taMUDlog.  4U. 

porlpbnral,  TS.                                                ^^H 

^^^"  Mkldftl,  4SS. 

tlmnlHting  g«o«nl  panlyila,  St.            ^^M 

^H           wUlMut  ddiriam.  iSli. 

•yphllUlo,  7i.                                          ^H 

^F    MHtarbaliuD,    innnit;     of,   k«    B»b«- 

(ptnal  totoro*!*,  S7,  14&.                                  ^^H 

pbronU. 

iltudf,  tterno'inattoiil,  SV.                                    ^^H 

UsdUti  narva,  (II, 

trap«tlui,  89,                                                     ^^H 

^    HeUji«boUa,47S. 

MukIm  of  orgBDJo  life.fpuna  ot,  188.                 ^^H 
tropbis  iMiona  of,  3w.                                 ^^H 

^H          Driuu,  47'''. 

^K          attonlta.  47^ 

TCi1ai[C»)7  ipum*  of,  131.                                ^^H 

^H          iwriixllc,  <lli. 

Muoular  atropby,  prO|{r«MiTe.  213.                        ^^H 

^^H          isnilB.  »r<  DeTcIi>p menial  Dcittaiitlw. 

drgenrniti'Dii,  iliMaaei    whiob    o^um*            ^^^| 

^^H           ainiplc,  470. 

^^M 

^^P            without  d«l!riiitn,  im  Simpl-a  Ifelan* 

Mnsoiito'i^alaneatii  nortB,  VI.                                    ^^^M 

^^               cbolia. 

Miuculo.aplral  ncrre,  91.                                           ^^^^ 

U«1annh<ily  iritli  atvpor,  •"'  Molaoeholia 

Mjclitia,  acuta  eeatral,  H.                                        ^^^M 

1              AtinniUi. 

obronlo,  a.                                                            ^^^U 

^b 

^H 

IKDKI. 


ICytlttia.  nbrMsU  oantnit,  H. 
trniirma,  B*. 


offaeu  »f  hjrtMri* 


K. 


If  M»l  kewlMsha,  SOT. 

Narre,  •bdvoeu,  H. 
KnlKMir  cruU,  VS. 
ritaraki  poiillta*!,  M. 

belal,  97. 

artb,  M. 

Ibiirtb,  M. 
uiv-bjpofutn*,  93. 

lUv-iiriiBiti,  as. 

InTvrior  |lnU»I,  M. 


lalmwl  poplitc*),  SS. 
lone  thDmeto,  09. 
moJiKB,  VI. 


,11. 


monopUKl*  froca  praMura 

■mianlo-cotknaoui,  VI. 

■mwnlo-spLrml.  SI. 

obtiimtor,  OS. 

iMrODMl,     ite     Bstunal      Poplitttftl 

potUrior  tibUl,  V5. 
mUUc  9i. 
(lith,  Bll. 

>|iUwl  SMMWOry,  AS. 

■nbMkpular.  Vl. 

tnjMrfor  glat«»l,  M. 

triK'Biiniw,  M. 

trocblMir,  S(. 

ninttr,  VI. 
X«frM,  *Bt«Hgr  lbi>r««ie,  VI. 

laterwfUl,  V3. 

noBopIegU  ttwm  lnjBr7«r  diMUeof, 
7S. 

■ptaal,  »3. 

aapr»-*OBBalBr,  VV. 
NtrroM  oon^fa,  ISO. 

h«>duh«,  IDT. 

•7»lein,  (rtiphlo  obBBgM  in.  9M. 

WMhOM*.  18. 

HavTslglk  of  trlgorain*!  narva^  S13. 
NMir&lgla  tanipBranaal,  }B7. 
KaanialheiiU,  1ft. 

■■•untlKim  in.  30. 
K*bHiU,  o-ontrBolurH  of,  ICO. 

miillii.lo,  iS,  1(17. 

iBailjptuit,  SA. 

optle,  331. 

NBdtioiu  of  d*c«a»Mti«B  In,  AO, 

trifBiDinal,  111. 
NsBroflM,  oeaupulon,  ISSi 
NigM-pitUj,414. 
NIlht-tMTArii,  .118. 
No«(uriial  h»nlpl«{ik,  414. 


Von.p«)Brul  i>kr>pl«glk,  il. 

yjtupbacnsnui,  437. 


O. 

ObtonUor  nwrt.  VS. 
OMBpBllon  neuroMB.  Hi. 
OealBT  r«niKo.  lOM. 
Oasla.BKitor  pMnlyita,  85,  ZXIU 
CRaoplkBsc*!  'pMrn,  138, 
OplittaBl»Apl«ci»  wunu,  SSS, 

InitrBi.  3S;. 
0|>lio  ncBrUif.  Ml. 

(ikpilla.  klrapbjr  «f.  fllA. 

IracC  anuuBr  o<,  314. 
Or;g»Bic  aiabljopia.  MA. 

■n)P*tbwiB,  ?0&. 

d«cntnttM,  47V. 

diiaua  of  Ikn  bnun,  III. 

•pll«p«j.  III. 

EanarBl  aB»f  ibwU,  3U. 
MDtMiMutbotia,  387. 

vitboui   lB*«lvMB«at  of  rpwUI 
wiMM,  3<7. 
hjp*rHith<*l»,  S4S, 
law)  BawiihMu,  STt. 
nawNUWilbaalB,  371. 
pkinlrals,  28. 
panuMibBriB,  373. 

pBMpl«CU.  10. 

atBpor  BM  eoiBBi  M&. 
Tarligo,  303. 


P. 

PiBbTBiaBlnKilit,  oarvinal,  03. 

bwiBiMTba(ie*t  4tiA. 
PB]D,388. 

erifw.  3V5. 

Bx»d.3«ff. 

rir4la. »». 


J 


Id  tMi 


sxttvaUtlaa,  til. 

a»Mia.  no. 

of  narUbrBl  Mtli^  CM. 

r«flp(.  3H8. 

trunkal,  its. 
PBlnfnl  panplrgia.  10. 
Pditt.  hM,  SI3. 

uT  obroalo  Sbrotu  (nflaiamBUast  3V4. 

r«llii,  3B3. 

rfaeu>i»li«v  £94. 

tuiwinie,  394. 
Palmii  roaex,  ISl. 
I*krtDiCboaia.  ZAS. 

maJfiT  rnniil,  44. 

ni>n-pilnfiil,  SI. 

organ  la.  40. 

pBinrul,  SO. 

•uba«ute,  BD, 
PiiralyMB.  (ana  ml,  31. 
r-nilrai*.  3.1. 

aglUn*.  HI. 

aJc'jbolio,  27. 


^                                     niDRx!                                    499      ^M 

PaTkljili,  alcohoHi)  iplii*],  06. 
1                     BMWDdiDg,  2i,  4»,  51. 

P«Hpb«r«l  Irritmtion*,  1A7.                                     ^^^| 

moBopl^lm,  TS.                                           ^^^^^^| 

^^L           awiunad.  25. 

iiiulllple  pkfaljrlt,  TO.                             ^^^^^| 

^K       Baii'f,  sr. 

nortoiH      ditMUM,     Iroplilc     boBt^^^^^H 

^^^^H    fcnlbftt  |>ti*rs1,  SO, 

ebiDmln.325.                                ^^^^^| 
pMnljiTf,  ebrOBic,                                ^^^^^| 

^^^H   «M«fcrm]  Biiiltlplci, 

^^^^F  «bnml4  p«Tl|ib«ntl,  83. 

toitrraic.                                        ^^^^^1 

^H             MMMd,  <». 

TMtlpi,  3(IS.                                           ^^^^H 

^^1                   Moto  motor,  41. 

Pcrfonftl  Idrntiiy.  low  oi;  271,                  ^^^^1 

^H            JMeetion  of,  3S. 

PtrMDkHljr,  doobi*,  311,                             ^^^^^M 

^H          diphtborilie,  TV. 

Prilt  ma),                                                      ^^^H 

^H         fMiki.  :ig,  10. 

Pbantotii  tninor,  ISO.                                   ^^^^^H 

^^1            fann*  of,  Trora  diwaae  of  pon^  n9. 

^^^^H 

^H             funrtlniia],  SI. 

l>I»i>Ur  rcB«3.                                                    ^^^^1 

^^1             gtnorkl,  lur. 

PovuDiooia  (eicinbliii'K  maoiniptu^  449.      ^^^^^| 

^H                      ccr«l>Tal.  SB. 

('Dlii>ce«pb>li(ii,  411.                                             ^^^^ 

^^1                      cfiilcplirorin  oonmUiotu  in,  IIB. 

PolloED^clitU,  Sa.                                          ^^^^H 

^^M                     of  tlic  icuno,  4A3. 

tdlopBtblc,  3SS.                                         ^^^^H 

^H             nlono-Ubinl,  IfJT. 

Pod*.  M)ffith*iia  lo  iMim  of,  41,              ^^^^^| 

^H             bytfvrioBi,  35. 

fortn«  af  u«r«i);fti  trom   rfliooto  *fi^^^^^| 

^H                     fMiMuT,  !7, 

^H 

^^1             tnfsntilo  iiNuUe,  SO. 

betnUotMllmw  frou  4iM«M  fit,  2H,           ^^M 

^^M             i  n  flam  III  xvry  balb«r,  .11, 

liceDiplt|[io  frvm  iMioo  in,  30.                     ^^H 

^H            iateniilit«iit,  17, 

pamlTfif,  2V.                                                 ^^H 

^B            L«ndr7't.  i«.  51. 

pr«KTM*i*e    bouiiplccift   (Vvn   loioa         ^^M 

^^1            knlteutkr  ftDerftl,  31, 

^H 

^M           locRl,  85, 

tumi>r  of,  30.                                             ^^1 

^H            uuIlifU.  74. 

PofkliMi  of  olol,  diaKDDAlt  of,  37,                        ^^M 

^H                    fiaraplaK'o  from,  48. 

PoaUrior    Mrobullftr    art  trj,    toBtponry         ^^H 

aiTMt  of  aircaUtioa  In,  M,                      ^^H 

^^H            oealo-mclor,  ti6,  3:13. 

tibial  n«'^v^  U&,                                             ^^M 

^^^            of  ftbtluot^BR  ncrvo,  32A. 

Poll  hviuinlofio  oboroa,  151.                      ^^^^^M 

^H            «f  trooblear  norv,  3Z5. 

Prc'hcmipleina  ohoraa,  100.                           ^^^^^H 

^^^             OTgnnio,  28. 

Primnrj  coDfuiional  Inikfii^,  482,             ^^^^^H 
ourabli  dnDaaUa,  «»  StDporotu   In-         ^^H 

^^P             perip'bffnil  mulliplo,  19. 

^H            p«n>,  !S- 

(anlljr.                                                                ^^^| 

^^B             fiiatujd'h^pnrlroplilc,  !'4. 

domonlla,  479.                                                     ^^H 

^H             i-tltx. 

PfopowW*  fa«tal  h«inlatra;jb7,  249.                ^^^| 

^^^^^    •nnmry,  252. 

CDBseular  ntropbj,  6S,  242,                    ^^^^^H 

^^^^K    •]M«tio  iDfaiitllo,  75. 

PnMojwlEin,  '^15.                                          ^^^^^H 

^^^^B   vpMlU.  le«io>»  (if,  1i. 

Piemlo-soacral  paral/d*,  4(4,                   ^^^^^^| 

^^^^^^     *j>|)l>ilitr.?  tuultiiiio,  75. 
^^M             t«iii»ui«  i^nonvl,  38. 

bjponropbio  panLljtii,  SI.                      ^^^^^| 
pmlyti*,  •'(  Lonlicular  GntonU  Pa-        ~^^H 

^H                       p«rif  heml,  ^2. 

nir*i>,                                  ^^^H 

l*ftral]rtiOG)Kir«K,  leO, 

Poirobto  tBBfVhoiiih  3fl4.                           ^^^^H 

P)u«iiMth«ilk,  argule,  372, 

PnvblMlautomatlnn,  177.                         ^^^^H 

Pmitt,  SU.                                                  ^^^M 

PkTKphMla,  3«3. 

MUOB  of,  10  ii|:lic  3:iv.                           ^H 

PkraplRgi*.  -12. 

disoiao*  in  whiab  dorangcd,  340.                   ^^H 

^m            tktrvpt,  49. 

movoracnU  of  aooeoiicodalioii,  SS9.            ^^H 

^H             obmnio,  95, 

nijFdnuU  of,  330.                                    ^^^^H 

^H            from  iiiultipio  f*r»iym4,  48. 

^^^^^M 

^H             fiiDi-tiulikl,  42. 

Pur«  inMiiili**,  4KB.                                    ^^^^^M 

^V            tijutericsil,  44. 

Pjrrauidal  Irairb,  47.                                       ^^^^H 

H      Pnrcii*,  4(>2. 

P.fTamauia,  436.                                           ^^^^^^| 

^1       Pdrollc  <l«iii(inli>,  452. 

^^^^^^1 

^H       Piirk)iiM)n'«iti*nLii7,  141. 

^^^^^^H 

^           209. 

Pc4DniiiUr  iract,  :^S. 

^^^1 

Ranwiid'i  dlHuo,  217,                            ^^^^H 

PirfomtJDK  utoor,  315. 

lUMdoB  «r  d*cw«»Uoii,  23i.                 ^^^^H 
Kauontsg  muU,  4t&.                          ^^^^H 

Porioncspbalitlf,  453. 

Mute,  450, 

^m       P«rioilic  intknities,  4H4, 

ipsro.  IZO,                                       ^^^^H 

^B              Dunin,  4SI. 

Reflex  cbor«a,  153,                                      ^^^^^H 

^H             ■elnDiAb-aliB,  4M. 

^^^^H 

H             500                                                    INDEX.             ^^^^^^^^^^^H 

^^^K        RaflaK  pain*,  S43. 

8|iMiB«,  hyitoriMi,  1>4.           ^^^^^^^| 

^^^1              pkralfam,  14, 

tnflaiDMiatdr;,  134.                    ^^^^H 

^^^^H               ipuoii. 

lowl,  138.                                   ^^^H 

^^^^B             IngtDthftl  iiirT*  pain,  111. 

niMlUliBK.                                 ^^^H 

«Mophac«a),  1S9.  ^^^H| 
of  iba  muMlM  ot  orpuie  1U«,  tW.     ^ 

^            lt«4ex«a,  190. 

^ft                     dMp,  181. 

«f  valuntorr  iDMeieii,  131. 

^^^^a              aflbela  of  mtt^Bj  mi,  \V7. 
^^^B           sMun  or,  in. 

rwtal.  ISO.                                      ^U 

nd«s.  134.                                      ^M 

^^^F            M|>nrSoi*l,  ISO. 

rhTtkniflkl,  ICO.  ^M 
■plnal  awMMrj,  ISH.                        ^H 

^H              Rlicumatio  D«MlMho,  803. 

ureLhnI,  I».                                           ^M 

^1                      iwliu,  294. 

SpBflii-  iDfantila  par«l>ii*,  3V,  7S.            ^^| 

^M              Rlt]rihiBl<nlB|iuiDa,  159. 

paraljriU.  luion*  of,  TS.                        ^^| 

^H                RoMnlkkl's  teat,  St. 

ttpDCial  mumh,  dirturbance*  ot,  S17.          ^H 

^H              Rotfttarf  moveaoaCa,  SIM. 

bwiiiiiDvilliMta  involrift^  271- 

v«rti|;o  trata,  SUB.                                   . 

RparatataiTlMu,  IS.                                   ^H 

Spinal  aopawMry  Mrri^  BS.                      ^^| 

^^v 

•mm,  138.  ^^ 
mmta,  SI,  *3,  *««  abo  Spina]  Hj- 

^L^        SalyrlMU,  487, 
^^^H       Swpqiu-  rafl«x.  I8t. 

Mrmlhwtii. 

^^^P      SolMlo  Barv*.  04. 

artbropailiiM,  238.                            ^^M 

^^^^>       BeI*rQf!>.  Ma^vtnphU  laUnl,  tl. 

aMiOeial,Z^                             ^H 

^V                     eanbral,  1^0 . 

wrd,  aDatofuyoT,  4S.                         ^H 

^M                      laUral.  AT,  ITI. 

laurai  oolamna  of,  47.      ^^^^H 

^H                      niuliiplcMTebro-fplnal,  144, 

motor  Obm  of.  37.            ^^^^H 

«pllfpf7,  78.                              ^^^^H 

^1              SuUa  tUBori.  140. 

hamlaDnetliMU,  247.               ^^^^H 

^1                    4«iDtBtU,    rw    DsrahipmaaUl    D»> 

h«nilple(ia,  U.                       ^^^^H 

^1                        iD»artu. 

bjrpenrttbesia,  SM.                  fj^^^H 

^B                       niAUnahotik,  are  IHTBlopnealkl  D»- 

irritation,   •'■'  Bpjaal   Aiuemla,  m4 

^H                           iDantisB. 

.Spinal  llj-ponnitli«rik 

^^^^_        SaQMLion  in  bulbar  paraJialf,  31. 
^^^K              humIh  of  twClog,  XU. 

DMmhianaa,  hiuBorrbai^  IdIa,  49.      ^^J 

■ikaBliiglll*,ehrDalo,  100.                   ^^^ 

^^^V       EbiuB-*hook,  414. 

narva*.  81.                                                ^^M 

^^^^        SaiiM  uf  auiall,  ^{57. 

pa)ral]r«ia,  alrobolin,  Ad.                        ^^M 

^1                       of  uuln,  nib. 

ael*rvt<«,  inulllpt*,  07,  114,              ^^t 

^H                Sonatbilitj',  asallatiuni  of.  3SI. 

Starno-inaitoH  iii«m1«,  89.              ^^^^^| 

^H               BvoMvy  aphiaia,  (cr  Wcfd-Blin4iM««. 

SlrabtiKua.                                       ^^^^H 

^B                      p«r«l7*i«,  ii3. 

diplopia  hnm,  31l.                   ^^^^H 

^H                      palbwKTt,  dMeripll«o  of,  !B^, 

Stupor,  dadnlUoti  of,  S78,                                 ' 

H              Siflit,  3I& 

SUipOTViu  aSitcUoa*,  kcO<«jlMlfls,  40«. 

^1                    dftordan  of,  344. 

tpfBlOo.  4tfS.  ^^ 
InMoltj,  403.                                     ^H 

^H              BLntita  mtliiDcboUa,  4Tft. 
^H              Sixu  Bflr*B,  9ft. 

St,  Vllua'a  daDM,  148.                       ^^^^M 

H             Skin  dl»u««B.  m. 

Subomte  c«nuiU  mjtUlii,  SL         ^^^^H 

^H              Skin  pupijiar;  r«ne>,  3M. 
^1               SiMp,  abnormal,  SVI. 

iDnltlpItt  nenritia,  &S.                ^^^^H 

paranUgia,  60.                            ^^^^H 

BnbaoapuW  n«nr<^  BO.                              ^^M 

^M                      aosidrataor.  IM. 

^^^^              daftDilion  «f,  ST8. 

Sadden  low  ot  etwudou— Mi^  STft.  .^^^^M 

^^^^^             diiordrr*  of,   uunnaetsd   with    moaim 

Suniirahn.  ft^O.                                  ^^^^H 

^^^H                 rcTcr*. 

l^tiparflclal  rcBexea,  ISOi.                   ^^^^^H 

^^^H 

r^D)i*rl<ir  glulaal  narr*.  It.                 ^^^^^| 

^^^^H 

Su  [un-Koapular  narraa,  H,               ^^^^^^ 

^^^^H               il>  diaunlvn  Bod  acoidBnu,  389. 

tijrmpiitbBtis  hcAdaoba^  SIHk             ^^^^^B 

^^^H 

Sypbt11tiiii>oiitia,40S.                        ^^^H 

^^^^H               tuswniio,  404. 

iiiHUihj,                                      ^^^^H 

^^^K  inaii,  ••DM  o(,  an. 

iDultlpU  panlyrii,  '9.               ^^^^H 

^^^^^^  l^iutiiodle  Ubsi,  AS. 

^^^^H 

^V             SptfiDi,  SO. 

^^H 

^^                     appBnQll^6uiMl«M,  183. 

^^^^^H 

^^^^             BorllcAl,  134. 

TalMt,  upanBOdlO,  W.                  ^^^^^H 

^^^^P           fMikI  nerro,  138. 

H&M  ot,  IM.                     ^^^^^H 

^^m  .i 

Tem^ormucnt,  iieonljtie,  ^7. 
TamiDftl  Jntumtik,  48:3. 

Trnnlial  pAlna,  393.                                            ^^H 

Tabwrealax  maoingilia.  443.                           ^^^^^H 

Tating  tUun,  idsIIkhI  uf,  St\. 

diagooaU  of,  448.                      ^^^^H 

TetauicKoiTnliioiii,  ini,  lit. 

ajinptotoa  uf,                               ^^^^^^| 

^m       T>l»noi-l  affucLioiui,  diSarttatlal  diuoaili 

Tumor  of  paoM,  30.                                    ^^^^^^| 

B                 135. 

Tnrok,  oolumDi  of,  47.                               ^^^^^| 

^r      Ttoniu,  123. 

TrUny,  IJt. 

TTpbomult.  »«*  AoKte!  Pvifln<wpb*Utli.        ^^M 

Tbalkmut  optidt  IuIob  of,  SS. 

^^H 

ThoraM  forn,  nt  Biiutrab. 

^^^1 

TfcDBMn'l  dlMM«^  IT!. 

^1 

T^Kl,  fta»ithe>]«  of,  SU. 

^^H 

Tbrombu*  in  verUbrM  krUrv.  31, 

UIdm  n^rre,  93.                                                   ^^| 

Tie,  MS. 

UiiMikMion«n«H  from  indireot  «WUM,  3W.       ^^H 

Tie-do u Ian r«ax,  ISS,  Sit. 

from  inlornal  dUoMM,  3W.                         ^^H 

'HtiibkUiMi,  IM, 

from  irriUU**  noIfOBI^  tSA,                         ^^H 
from  opium,  384.                                 ^^^^^H 

MMlMllar.  les. 

dlanMtle  i»)ue  of.  IW. 
ToviiDoiria,  Mil  Wry-^nik. 

from  urnmift,  88d.                             ^^^^^^| 

^^^^H 

Toxwnic  Bojbljoni&,  340. 
naaral  panl^ida,  28. 

^^^^^H 

Uroiiiiia  ooDiraliiiiiia,  119.                             ^^^^^^^| 

hcadBobe,                                            ^^^^^| 

F^iM,  194. 

UrMbr*)  tpuni,  129.                                 ^^^^^H 

If                  poripbanl  pKr*l;>i*,  U. 

^^^^^1 

H               (iMp,  4lM. 

^^^^^^^1 

■                 vorUga,  >ll. 

^^H 

^        TokIq  nmlinpltgtft,  7*. 

^^^^^^^1 

tr^non,  ltd. 

rkglnal  unAktalft.  t:>*.                          ^^^H 

1            Tlwrt,  ilireet  o«re1init,  34. 

V«nobnU  wriM.  psln  of,  204,                   ^^^^H 

^^                r^dUDOular,  39. 

Vtn\glnw  »Utu*,  201.                                           ■ 

^H       Tracts,  orMiwl  |iymmidftl,  IT. 

V«rtiK«.  3D0. 

^K             dlr«et  e«rcbnl,  47. 

annil,  309. 

^H                     |)7miiiid«l,4}. 

oftrdbLc,  31)4, 

^F             ftjmntd*!,  4T. 

MUfM  of,  303. 

TntnoA,  SOJ, 

•pilaoUc^SM. 

Trkiuitor;  TreiM/,  473. 

«MmUftl,  211. 

^H       TnuvoTM  ta/cliiia.  SO. 

tnto  Ibe  ■pecikl  hdm*,  Sfl8.               ^^^^S 
SjBlrrionI,  3U&.                                         ^^^^H 

^H                     owl/  du^oaia  of,  BV. 

^H      Tnpetiiia  miucle,  tftl. 

^B      Tremor,  07. 

aAlcire  of,  202,                                                          ■ 

^1        Ttcinon,  140. 

neutkathaaic,  20&. 

^1                MDila,  140. 

ocular.  :u?. 

^1                toil<^  140. 

orgnn'tc,  203. 

^H      Trigaintnal  n«rr«,  DtnralgUi  •T,  Sll. 
^H                        rnflax  pain  of,  313. 

peripliara!,  300. 

loxivmie,  311. 

^H              nauritif,  314. 

Vl»o»ral  aniMlkaaiB,  356, 

^B      Trtgemlou  DerT»,64. 

Tifkia,  aootraocloi)  of  tlio  6vlJ  oC  35S> 

^m      Trlioinf  nHn&torum,  I2S. 

dlatnibanow  of,  341. 

^1      TnHhIcKr  Dsrv*.  8C. 

l«ldor,  343. 

^H                        pnralrn*  at,  33i. 

■Mlbod  of  l«ftiiic,  Ul. 

^1      TropbU  boDC'cbanjcat,  333. 

Vtmlllnc,  l». 

^H                     toM  »f  Uatb  froED,  33S. 

^H             BhkiiMi  in  tba  balr  kqiI  ti>il«,  S38. 
^H                    bi  jolnti,  237. 

W. 

^H                    Id  tbe  ■wvMii  (yaUn,  330. 

^K^     iMioiif.  313. 

Wakafnlnan,  ftbnormBl,  tSt. 

^^^^^          ftmM  dMlraetlT*,  SI3. 

Word-blindnH«,  301. 

^^^^H          lUitMMmpMkM  b;  w1d«-«)>rt»d 

Wofd-auafluM,  a«t. 

^^^^F                 daalruatiOB  of  tUM*,  331. 

Word  memorj,  StU. 

^^F                        of  uiuicln*,  Z3S. 

WriUr**  arunp,  IS,  ISt. 
Wrj-AMk,  140. 

^K^     akln-obangva,  Z31. 

^^^^^^B 

MMJ>. 

IMPORTANT   MEDICAL  WORKS 

BY  H.  C.  WOOD,  M.D.,  LL.D. 


Treatise  on  Therapeutics. 

OomprlMlDit  W*t«rla  H«dlaa  and  Toxlaolnsj,  with  Sapvolal  Rerer«Doe  to 
thv  Aspllutloa  Of  tbe  PbraiDloslCBl  Action  of  Drnra  to  CUUoal  Hed- 
l«lne.  Br  a.  O.  WOOD.  M.U..  L.L.U.  Sixth  Edition,  Hoviaed,  with 
Important  Addlttonti,  and  Adapted  to  the  New  Fharinaoopaeia.  Oq« 
volam*.  Ito.  Extrft  ClDlb.  SB.OO.  JLlbrvr  8b«»p.«S.flO.  BalfHuHla, 
•7.00. 

"  AhoKdlliOTi  IbUwotk  •lanJdv  tbatf  k*tb«  (•nlr  i:i>nitilctD  [rrnllBXiii  tkB|ilir(i>il'if<Ml  u-'llsn 
at  droA  IB  lb*  Knjiltsfa  t«i^<UiC>,  bd4  na  itniloni  af  •rl*utlh«  tl>M»r*iit>n  (bMiid  1i«  wtUivnt  It." 
-I— £■  AneUVoMr. 

"TaMMIjat  Itanwl  ■oirii*  damiindi  a  ariAil  pftunl  aS  »itj  p«l*-  Ilitioalil  bda  ib« 
Hbnrr  oftitrj  meitmimta.  W«  ebMrfullf  noucnsMDii  It  Id  Ih*  imrfaaalaD."— OiK^wiaU  fiT—ff 
■ad  rllirfr. 

"Il  1*  aiinf^MMrf  Iv  wy  Iv  *D*«tii']*nl  of  in«I'Ha  nnUca  <liat  IIid  »ort  at  PrarMMrWcoil  li 
B  MariiUril.  anit  lliitt,  aa  aa  >i(aaltlui)  nf  il'i*  |i]i^ari>lii(lnl  arlicin  uf  ^Itiii*  and  lla  B|i>lliadaD  V> 
ctlBtcal  tnadlcli>a,lt  <■  niwiirpaMfd.  Tlia  ntccKwar  tba  work  li  vull  B>trii«d,  aod  raflacli  CTodil 
ii|Kin  lla  atuilji  lua  and  ■nami'liahMl  anlliut," — Mno  Toit  U1ll^rat  BrrarJ. 

"Till*  ■auidaM  vork  arlll  ratalni  Iha  Aral  placa  aniitiig  all  uor  inallMa  an  lk<a  itiUaoL  aod 
It'A  bir  to  ki>c|'  lu  i>Mltl<]ii  u  Ihr  bm  iDtt-Lnuk  on  Un  acClun  of  ttnufc"— jBJla   ff^-*  Bad 

**ln  ia*>9*elal  llrld  It  ImnatBalltd  In  an^  laa(n4ffr,anJ  di>  lltrarj  li  MnpUt*  wttlioiiit  it." 
-Bafito  MaiMral  mad  t^(e«J  ^Mraal. 

"Tlila  It  aniauUitdit  Ui*  noat  pofiolar  lait-lxMk  on  IkecaiiriillcB  lif  an  Aontflcan  author. 
In  lUtvo^ul  (<>"a  Uiara  la  Wi  «i>rk  lH>II«r  llllail  lu  Uacli  a  aludaiiiiliaaaaMittBUdf  loaUrlai 
aad  IbrMprUlrfa."— Hi«  IVi  AVv  KnMittai. 


Fevera 

A  StadT  Id  Horbld  uid  UoriDAl  PhriloloiT.     Bt  H.  C.  WOOD,  M.D. 
X.X..D.   Imuc»  ITO.    Bxtn  Olotb.  •2.&0. 


Thermic  Fever,  or  Sunstroke. 

Bj  H.  O.  WOOD.    M.D,.  IiX>.D.      Awarded   tho  Boflaton  Prlae  of    Oar- 
vard  Volvaraitr.    ISmo.    ZxtTA  Oloth.  tLSA. 

"Waknuw  of  nownrli  iiliich  glTaa  ■□  (all  an  >i|»a(tlan  of  ilila  «0wlJun.     Tba  proftmionif 
nnilM  maaj'  aUlKatl*!)!  U)  Dr.  Wood  for  bia  BXcallaut  BiDUogniib."— A(/*te  Kmkttt  mtd  Saryfad 


■,■  i^Hr  aal*  ftv  Kti9k»flttf»  grurrallg.  or  trtll  kr  ■«*(,  (raiaapirrfaMaM  fraa, 
NpoM  rreWpr  c/  prifm  (ky 

J.   B.   LIPPINCOTT    C07MPANV,   Publishers. 

716  uut  717  Market  Ktr««l,  FhiluUlpbia. 


THE   UNITED  STATES 

DISPENSATORY. 


■With  Denison's 
Patent  Index 


Fifteentli  Editioa 
ninstrated. 


CAREFULLY    REVISED    AND    REWRITTEN     BV 

EORAnO  C.  WOOD.  M.D.,  LL.D.,       J.  P.  REVtHOTOH,  Ph.l}.,j 
8.  F.  SADTLEK.  PIlD.,  F.C.8. 

Bagdaamety  Bonod  la  Oni  Volw*.  Royal  (vo,  coatalalnc  >«*l  P*K*>,     Prl««,  1>J 

Cloth  Kltia.  froo:   Beat  Leather,  Raiaed  Banda,  9B-«a; 

Hair  Ruaala,  Raiiad  Baods.  fg.oo. 


Whf  rbettUf  «/  Ar/VrMaoi*,  JVM(«Mt'«  i^unt  Inrfds  trfll  •«  Ituer-Ird  far 
$1.00  AditM-mal  ta  »bo0m  Frtemm.    (3^  ItlmMlmtUf.} 


"W*  MitdEiiMid  IliU  murk  ^  k  kiMl  ralnatl*  ailJlHoa  pat  onlj  ■•>  f-lioniMCMillokl  IttaMMN, 
bat  K  Ula  mi<llcml  tuutaariau  a>  alniat  InTalnabla.  Iti  lll»nlDni,  lla  ehnnlilr;,  and  III  fhai 
macj  Br*  fulljr  oploanji  atintlar  Work  haraur  al>raad  of  111  klMl.asd  tl»  bl^li  ataMUrd  of  a»cil- 
teBMln  Ib*)<ut  lannljr  anIiaacMl  liT  lb*  IhoTanglilj  ralUbU  and  Itoitiroctli/ work  of  tlia|ilwMl 
Bnaanlli  t4il\«a."~Pt^n»attiM»al Ofeard. 

"I I  lias  Ixso  lb«  Pill  mttmm  nl  tTwrj  prBotltloTiar,  mvn  lalnil  Ikaa,  parbap^aoj  otbarlwak 
Id  tb*  libratj.  BrwjP  adftiaB  haa  baon  Mi  iBpnrnnsiit  «|><in  rb« «««  mwmiIimc  l1,Mid  th««tJ«BR 
bM  tfivwit  IntaJnaandaoopaaalt  hMfniwu  In  Inlb  aad  pdpularil;  *^(MHard**  MmlkalJamiitl 

"  Aia  worksT  ralwi naa U haa ft-  **|U&la  and  naauvvrlon *■  owr  laHRaaiia, udll daw  gr«l 
arwill  lo  Amvriisii  phatuMcjr  and  Ihrraiwulln-"— irflVoSirf*  ilitiital  JumnmL 

"Tba  frt^ntadlllaniiwUtiH  th«  high  npuUllun  of  ftirmw  adllkma."— LonJcM  ftiiirfHtiaW. 

"It  f<iruiaa*ali>aM«  *ork  ol  rvhtriiM  ai  vail  fur  Ih*  pnct>li«D«r  at  Ibr  lb*  ptanucM.*^ 
£utlbt  JmmuH  ef  ITadkiM 

"Tba  book  a**wriiili>l«nn>  tlut  In  bum  werth/  l»  bald  a  plan  la  tha  |iliaiBiiilir»  aalMI , 
Ubniy."— £■«'>"•  f  %>nu(nditcil  jMim  il. 

•a*  Fur  aala  hj  all  Uwltoil  BnohaKllri*.  n-  irtti  !<•  arot,  dnrsi*  prrfiald,  t?  tnali  or  1  i|liMa.  oB  ' 

ncdptof  pd«a. 

J.   B.   UPPINCOTT  COMPANY. 

71S  nntl  717  Market  HU.  I*bilaclcli>tili 


LANE  MEDICAL  LTBRART 


To  avoid  fine,  this  book  should  be  returned 
on  or  before  the  date  last  stamped  below. 


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