Skip to main content

Full text of "The treatment of diseases of the nervous system; a manual for practitioners"

See other formats

Go ogle 

This is a digital copy of a book Ihal was preserved for generations on libraiy shelves before il was carefully scanned by Google as part of a projecl 
to make Ihe world's books discoverable online. 

It has sm-vived long enough for the copyright (o expire and the book lo enter Ihe public domain. A public domain book is one that was never subject 
to copyright or whose legal copyright lenn has expired. Whether a book is in the public domain may vary country lo country. Public domain books 
are our gateways to Ihe past, representing a wealth of history, culture and knowledge that's often difficult lo discover. 

Maiks, notations and other marginalia present in the original volume will appear in this file - a reminder of this book's long journey from the 
publisher to a Iibrai7 and finally to you. 

Usage guidelines 

Google is proud lo partner with libraries to digitize public domain materials and make them widely accessible. Public domain books belong to the 
public and we are merely their custodians. Nevertheless, this work is expensive, so in order to keep providing this resource, we have taken steps to 
prevent abuse by commercial parties, including placing technical restrictions on automated querying. 
We also ask Ihat you: 

+ Make noncommercial use offheffics We designed GoogJe Book Search for use by individuals, and we request that you use these files for 
persona] « non -commercial purposes. 

+ Refrain from autorrtated queiying Do not send aulomated queries of any sort to Google's syslem: If you are conducting research on machine 
translation, optical character recognition or other areas where access to a large amount of texl is helpful, please contact us. We encourage the 
use of public domain materials for Ihese pur|X)ses and may be able to help. 

+ Maintain aHiibaiion The Google "watermark" you see on each file is essential for informing people about this project and helping them find 
additional materials through Google Book Search. Please do not remove it. 

+ Keep it legal Whatever your use, remember that you are responsible for ensuring thai what you are doing is legal. Do not assume thai just 
because we believe a book is in Ihe public domain for users in the United States, that the work is also in the public domain for users in other 
countries. Whether a book is still in copyright varies from country to country, and we can*t offer guidance on whether any specific use of 
any specific book is allowed. Please do not assume thai a book's appearance in Google Book Search means it can be used in any manner 
anywhere in the world. Copyright infringement liability can be quite severe. 

About Google Book Seareh 

Google*s mission is to organize the world's information and to make it universally accessible and useful. Google Book Search helps readers 
discover the world's books while helping authors and publishers reach new audiences. You can search thi-ough Ihe full text of this book on Ihe web 

at http: / /books ■ google ■ com/ 











Prof««tor of Herrous ud UenUl DJaettet In tha H«w York P«(-OrAduAta 
Medical BctaooL i VMUof Pbjilclu lo ttas N«w Torfc Gltr HotpfUL 

IllUfltntod by Twvnty-tKraa Engravings 



Copt mo BT, l«W, 



S«ue timo &iace there wa^i forced ujtou m? an appreciation of the 
litj for a work on the treatment of nervoiiN diaeasea, wherein shauhl 
be set forth in detail the rniLnagemeLt of what are !<ti1l considerei] obscure 
ftnd puzzling affections. Kacli year manx phjrsiclans, after Having prac- 
used their profession for a Icniger or shorter time, oomft to New Vovk to 
freehen their intellectual i^ossefiGiona and to rerire their profeaaiouol in- 
cerasts. Contact with them has convinced tne that their particular 
demand is for sid ia the treatment of sLubUmi cases simJlar to those prt»- 
riooalj encountered and for asaistairi^e in the rtco^ition and interpreta- 
tion of obtcuie maladies. Thej tUso »eek in^^truction in the art as well as 
in tbe ecience of tlietapeutioe. In preparmg this handbook i have 
endeavored to keep in mind these needs of the general practitioner. To 
set forth clearly- and ai1P4]uately the iiiost S-pprovefl current methods of 
treating nervous diseases has Irteu m^^ uj^fK^ioiLs puri>oae. As the troud 
in the tnanagenieut of such cases is to rely leaa upon drugs than upon 
liygietiic and physical meoaure^ particular attention has been given to a 
WHuideration of the^eaud the mode of tht^tr utilization. In the onltnary 
text-book of nervoLie diseases, hydriatic^. massage, rest and ererci&e, elef- 
tricity and psrrhotherapj are bripHj discussed, but, as a rule, nothing is 
said Id detail of the art uf their application. Thud the reader is left to 
gather the needed iaformalion vhere he T"ill, and usually ho in forL-ed lo 
ooDsnlt special works on tlie dilfcreut aubjeotii in order to obtain it- 1 
have a^jsumed that the reader has flufGcieut knowledge to recogiii;te the 
more familiar nervous diseases. Therefore, a brief smmnarj only of 
kheai synjpUtm^ is given. A fev rare, and practieaHy uDimportant afFeo- 
tions of the nervous system are not considered at alh I trust that fluch 
studied omission may a<id to the iLsefulnesB of the treatise as a handbook 
for general praotitionets. 

Ab the iotellTgent and aatisfaeiory treatment of all morbid conditions 
fe"p]ire* 8om** familiarity with their causation^ the etiology cf the dia- 
eaaes of the nervous ayeteni baa been given ejitensive go naide ration. It 
will be noticed that do attempt at ulaseiticalion baa be<'n made. The eub- 
jeete have been taken up one after another iu the following order, which 
b practical if not logical : Diseaaea of the brain, of the spinal cord, of the 
peripheml nerves, of the symj-athelic nervous eystein, and finally tli© 



fuDcttODol nerTcnB digeasea, and the most common symptomatdc manifes- 
tationB, such aa headachftj delirium, convuUions, bemiplegiaf and insomnia- 
Some of the diseasee have been coDsidered at greater length than Dth~ 
erB. It may even appear to the casual reader that a disproportionate 
amount of space 13 given to a discussion of headache, neurasthenia} and 
other functional and symptomatio states in contrast with that devoted to 
brain tumors, multiple sclerosis, and other organic diseases. This has 
been intentional. The disorders of the former class are of far more fre- 
quent oeourrence, and cause much more suffering than the latter. There- 
in, to Bhj nothing of their greater amenability to appropriate treatment, 
is found ample justification for Uieir detailed consideration. 

In the compilation of the statistical data in a few of the chapters I 
have been aided by some of the gentlemen who are or who have been 
aesistants in my clinic. Dr. Carlin Phillips, Dr. L. J. J. Muskens, Dr. 
I. Abrahamson, and Dr, R. E- Peck have placed mo under obligations for 
such assistance in the preparation of the chapters on Neurasthenia, Pa- 
ralysis Agitans,' Chorea, and Chronic Myelitis, respectively- 

Nhw Yohk, Jannary, lOOfi. 




The CmMs and Orif^n&tion of Dlsftwm of tb« li«rrOLU System, . . > . 1 

Heroditaiy and CongeaiUl Infaeoces. 2 

Hie NeuTOpaifaic Di&thealft, .,...-.... 8 

SUgmaU of Dogeaeracy, 6 

AcqaLred And AccideotftL Caueea, ........ 7 

The IWle of Infection* 7 

SyphiUa and Nervous DleeoBe 9 

Tbe Causee of Syphilitic Nerroue Diseaseo. 12 

IntoiicaUoD and Nerrous Dlseeee, , , . ^ . , . . 16 

The EffecU of StiiDulajita and Narcotics 17 

The R^Ie of'AutolntoiicatloD, 18 

Trannui as a Cause of Hervons Biseaae, ...,,.. 10 

P«ychLcaI Trauma, 20 

Belationehlp to tJie Epoch, Si 

Work and Nerrooa Disease, ■■..-,-.- £1 

S«iiib1 Influence, .,,,... Si 


The Prevention of Diaeaaea of the Nervous System, ,...,- 26 

The Prevention of Heredilarf and Fatniliary Factora, . . . , . 27 

The Prevention of Infection, Particularly Syphilis, 20 

The Influence of AntisyphLlitlc Treatment, 30 

The Time and Mode of Administering An tisyphi lilies, . .31 

The Prevention of Disease of the Nervous Syfltem due to ConstLtntional 

Disorders Sti 

InlerdLctJon of Stimulants and Niircotlcs, - , , ^ . . - 37 

Avoidance of Physical and Pajchical Tranms, .38 

Work and Calling, 38 

The Securement of Sleep. . , 41 

The Eradication of Bad Habits, 41 

Educalion and Bringing up of the Neuropathic Child, - . . . .42 


The General Application of Remedial Meaeurf^a In the Treatment of Xervons 

Disease, - 47 

Introduction, ............. 47 



Drags, 49 

Speclflc TraatEuent, 60 

The ftomedlkl Action of Drugs 53 

The Abuse ftnd Ubo of Drugs, M 


Hydrotherapy, 06 

An KBtinuUe of tho Value of Hydrotherapy, , 05 

Effects of the Application of Water at Diffefeat Temperatures, • , .08 

Modes of Applying Water Id Nerroua DloeaoeB, 71 

TheTreatmeniand theTiiueof ItsAppUoatloQ, 82 


Electrotherapy, ,......> B& 

The Forms of ELectrlcltj', 87 

The Galvanic Corroot, 92 

Rheoscai and HiUiameter, 95 

Varieties of Electrodes^ . . .97 

The Static Current, 98 

The Faradlc or Induced Current, 100 

ElectrotonuA, Electrolysis, and Electrosmosia, . > > . > .102 
The Therapeutic Application of Electricity, - . . ' . , ,103 


Massage, 108 

Estimation of Its Worth in the Treatment of Nervous DlseaMS, , . ,108 

The Mode of Applying Haasage 110 

The Stance 112 

Medical GymnnstlcH, ,--...,.,.. 114 


Exercise, Best, and Occupation, . . . 117 

Sports and Gymnastics, 118 

Gymoastlcs, ISl 

Rest in the Treatment of Disease, 122 

Schedule lor Full Rest Cure 125 

Schedule for Partial Rest Treatment, .120 

The Art of Relaxation 120 

Occupation a Therapeutic Ageticy, .,.•..,, 177 

Diet, . 120 


Psychotherapy, 130 

Hypnotism, ,.,,>. 14-'! 



PiUMW of tHe Heniagn uid the Bnin, • • . 146 


'nvTmUDentof Ueoicigitift. ■■ ^ ...... , I4fi 

LepUnoeDingitis. ,-,...,.,>. 146 

Etiotosr 140 

Etiology of Epidemic Cerebroflpipal HenlngltlSt ..... 140 

Eliologr O' Tubercnloiu UeiiliigltlA, ....... 150 

KoQ-Iiifectloiu Meningitis- Psendo-HeDingitlfl; Meningltlj Serosa, , 16:2 

Symptoms of InfecUooB HeniogltU, 152 

SfmpUjme of Kpidemic Cerebro^injJ Fever. , 163 

Symptome of Tuberculous Mfltilngltia^ ....... 164 

Symptoms of SerouH HeningLtis ; Non-Iafectlotae Ueaingltls. . 164 

IVeaimeot of Infectious HeniogliLe 166 

Treftttneatof Bpidemic CerebrospiusI Healngitis 16B 

Treitment of Tubeiculooi MeniDg:itis, 168 

Treatmeniof SerouBHeningitiv. 160 

The Trestment Of Hydrocepbalus, 101 


,TbeTrefttDieritof Encephslltis. 164 

Acute Hemorrhsgic Non-Purulflat Ein»ph«Jilde, 1«4 

SymptODL«» ............ 106 

Treatment, 16(t 

CbrODic EncephAlltia, 107 

Brain AbeceflB. Purulent Eticephsl ills, ,.,,.,. 107 

Etiology 100 

The Rest of Brain Abecees 172 

Symptoms. ......... , 176 

TrtftlmeDt. 176 


The Treatment of Infantile Cerebral Palsies, 180 

Little^ Disease Igt 

Treatment 182 


The l^vatuient of Multiple Scleroeis, 180 

Etiology 186 

Symptoms, . . , . , 188 

Treatment 180 


The Treatment of Tvimoni of the Brain, 100 

Etiologj- lei 

Symptoms, ... 193 

Trealnieni 105 


ExploTftUnr and Palliative Operations, 198 

The Dangers of OperatioD for Brain Tnmor« ^ ..... , 190 
Symptomatic Treaunent, .* , .200 


The Treotmeiit of Cerebral Apoplexy, 203 

Cerebral Hemorrhages 203 

Treatment at the Time of the Attack. 205 

Treatment After an Attack, 207 

Softening of theBr&in from Emboliemand Thrombosia (Enc^phalom&lacla), 208 

ITie Etiology of Cerebral Embolism, 206 

The Etiology of Cerebral Thromboeie - . 20f) 

Treatment of Cerebral EuiboUam and ThromboslB 210 


The Treatment of Aphasia, 214 

Etiology, aie 

Symptoms oC AphaaLa, 219 

Treatment 220 


The Treatment of Tabefl, 227 

Hie Caoaea and Leaiona of Tabea, 227 

Symptoms, ............. 230 

Course of the Dlwaae, 232 

Treatment, 2J)2 

Cauaal Therapy. The Advisability of AnUsyphilltio Treatment, . . 233 

Treatment Directed Against (he Horbid Procasa, 234 

Symptomatic TreatmenL, 235 

General Treatment, 236 

The Use of Electricity in Tabes, . . . ■ 230 

Suspension a Therapeutic Agent of Some Value, ..... .241 

Re-education of the Ataxic Eitremltiea, Fraenkel's Method, . . . 242 
Plan of Treatment, 248 


lie Treatment of the Hereditary Atojltui 252 

1. HeredlUiy Spinal Ataxia, 262 

2. Hereditary Cerebellar Ataxia, 254 

3. HeredLUjyAtAifc Paraplegia, . ^55 


The Treatment of Syringomyelia, 256 

Rymptoms 257 

Treatment, 258 


The Treatment of Acute Myelitis, 2tl4> 

The Etiolo^ of Acute MyeliTifl. ......... 201 


Symptoou, ......,, 263 

TtBaunent, 304 


Tb« Treatment of ComproBBion Afyelitia £69 

SympiODiB 270 

TrfiBtment of Comprenlon Hyelitia due to Fott'B DiseaM, . . .271 

Treatment of Compreuion MjeUtLs due to Spinal Tumors, . . » . 272 


TBo TreatDxeut of ChroQlo Myelitis 274 

Etiology, 274 

Treatment, 276 

Gubacuto AtAxic Paralysis and Combined Scleroala, 273 


llio Treatment of Inflammation of tho Central Gray Matter {Foliomy^Us aod 

Polioencephalitis Superior and Inferior), ...... .278 

1. Anterior Pol iomjel ills, 270 

The Causes of Anterior Poliomyelltla, 280 

Symptoms and Course of the Disease. ....... 26] 

Treatment 2BS 

Prophylaxis, , , . 282 

Treatment at the Time of the Attack .282 

Treatment of the Early ConaequeticeB of the Disease 283 

Treatment of the Remote Effects of the Disease, 285 

2. Bulbar Poliomyelitis. Acut^ Bulbar Myelltio, 286 

3. Aoute Superior PoUoencephalitie (Acute Ifuclear Ophthalmoplegia), . 280 

4. Acute Inferior Poll oeticephalltiSf 201 


The Treatment of the Progressive Muscular Atrophlee of Central OrlgLu, . . 202 

1. Acquired Spinal FrogresslTe Muscular Atrophy (Type Aran-Ducheniie), 204 

Etiology 205 

Treatment, aOTt 

2. ChronicProgressiTeBulbar ParalyslB(LabLo-Gloeso-Laryngea! Pamlysis), 207 

Treatment, 200 

Family Form of Chronic Progresaive Bulbar Paralysis, . 302 

Aathenlc Bulbar Paralysis, .302 

Treatment, ... 304 

3. Chroblc Frogresflive Ophthalmoplegia, . 304 

Treatment, .306 

4. Amyotrophic Lateral Sclerosis, ... .... :i06 

Treatment, 307 

The Treatment of Neural Progressive Muscular Atrophy. {The Peroneal or 

Leg Type of Progreaaivfl Muscular Atrophy), .... .308 


The Treatment of Huacular DyHtropby, 310 

Treatment of the Dystrophies, 312 




The Treatment of Myotonia Congenita (Thomsen's I^Laeaae) 315 


The Treatment oi Tetanua, 317 

Etiology. . _ 317 

SymptotUH, 318 

Treatment, 3lft 


Tlie Treatment of Teiany 322 

Constitutional Treatment, .......... 3122 

Treatment oi Ihe Bpaem, 324 


The Treatment of Multiple Neuritia 325 

Predl«po»ing CauHW. 3iG 

Eicltittg CauKK 325 

Symptoma, 327 

Treatment 321» 

Prophylajis 320 

Caiieal Treatment. 330 

Remedial Treatmem. ......,.>,. 330 

General Reetoratlve Treatment -iSA 


Tlie Treatment of ParalyfllH of the Facial Nerve— BeJI'a FaUy 337 

Etiology of Facial Paralyaie, -iSl 

Symptoma, 333 

TreatmenI 3.19 


The Treatment of Neuralgia, 343 

Topographical DiviBLon of Neuralgia, ........ 343 

Qeneral Etiological Factors. 34-1 

General Symptomatology. . . -(46 

Treatment .347 

The tiae of Electricity in tlie Treatment of Neuralgia, ... . M9 


The Treatment of Trifucijil Neuralgia, 3r>2 

Etiology, 3j3 

Symptoms. ..-....- 3'i4 

Treatment 3«1( 

The Surgical Treatment of Tic Doulourenx .302 

Treatment of the Attack. -!i^ 



Hm TraaUi^Dt of yeunlgim of the Cervicml PlfliDii, . . . > . . 36fi 

TnuiDentof OccipJt«l Neiirftlgi&> , , 306 

TreatnwDt of Cervico-brachial NeiiislgkA. -...,., 3BT 
kiiercostAt Neurftl^a^ ........... 960 

TmtmeDt of Intercona) NeonlgLa. 370 

lUchiilgii. 371 

MunmuT Neuralgia (H&stodynU)* ....... .371 

TreatUMDt, 372 


The Trtitment of Neuralgia of the Lnmbar Pleinii, . . . , . ..173 
Lumbo-AbdomLiial Neonlgia. ......... 373 

Tnticniar Nennl^a, 374 

Menlgia ParsAtfaetLca. 3T& 

Femoral and Obtorator Xeoralgia 370 

Lej Paiiu with Varicoee Veina, ......... 370 


TLeTnaUuent of Sciatica. 377 

Eliologi' of Sciatic P*iff, 378 

SjmptomA, ............. 379 

TrvtmcDl 381 

TTTttment of Recent Cabcs 381 

Tratnieni of Subacute and Chronic Sciatica. 384 

TTie Treatment of Chronic SciUlca. 386 

Electricity in (he Treatment of Chronic Sciatica. 386 

Hydriatic Procedure in the Treatment of Sobmcute and Chronic Sciatica, 3BT 

AcupUEtcture* 389 

The Uae of Coonter-lrrllanH» 389 

Nerve Stretchiog and Compreaaion, .301 

The Sui^ical Treatment of Sciilica, ;J»1 

The Medicinal Troatmenl, 302 

Ttw Treatment of Fodalgia. ... :M 

Treatment of Metataraaigia, 305 

Treatment of tbe Podalgia due to VIai Feet 39ti 

Fodendal Neuralgia, 307 

Coccyfiodynia 308 


'nieTreatment of Neurasthenia* 39f> 

Etioii>g>-. :Wft 

Sjmpiopia, 403 

Treatment 404 

?n>ph J- lactic Treatment, 404 

Treatment of the Attack, .......... 406 

General Hygiene 400 

isolation and Discipline, .......... 400 

The Secorement of Sleep, 407 


Dietary of Neuruth«ii1c8 40B 

The Interdiction of Stlmulaou* 412 

HydrUtic Treatment, # ' ■ "^^'^ 

TbeUaeof £lectrlcity> . . 414 

Rest, KiercLae, uid Occapatloa, ...... ^ , . 41& 

Climalothorftpy 417 

Drugs In the Treatment of Neurafithaula, 418 

Local Trefttment, 419 

The Plan 420 


The Treatment of Hyoteri a, 4SS 

Etiology, . ... 422 

Symptoms, 423 

Prophylactic Treatment, 426 

The Treatment of the DiBwwe Itoelf or the Paychopathic Slate, . . .427 

The Treatment i>f an Hysterical Attach, 436 

The TreatUkent of Hysterical Stigmata, 438 


The Treatment of Epilepsy, . . 441 

Etiology, . - , 443 

Treatment, 147 

Moral and Hygienic Treatment ... 447 

Dietary . . . , , 450 

Medicinal Treatment of Epilepsy, 4^1 

The PhenoDiena of Bromide iQtOTicatlon and Rrotnlde Cacheilaf . . 454 

Medicinal Adjuvants of the Bromides, . . 4'ib 

Treatment of the Attack, 458 

Treatment of Dreamy Stated of Consciousness* ..... loO 

Treatment of Epllepai a Tarda, 4U0 

Trtiatment of Epilepsia Procursiva, 4lM> 

Traumatic and Accidental Epilepsy, ........ 401 

Surgical Treatment, 4*\2 

ThoTreatBientof SyphlliticEpilepay, 403 


The Treatment of the Tic Neurosis, ...,.'... 4Q& 

Etiology of the Tic Neuroais, 4f50 

Treatment of theTic Neurosis. 470 

Summary, 472 


The Treatment of Migraine 473 

Symptoms . ... i • . - 473 

Treatment, 475 

Treaiment of an Attack, 470 


The Treatment of Chorea, 481 

Treatment *»W 



TbtTrMtmentOf FUftlyslsA^Una, 490 

SfiDptoma* .. ^ ^ ^ ...... , - 493 

Tre»UDent 497 


TlieTTntmentof Ezophthftlmia Goitre (Gnw* DisBAw. B««eilov*£ DlaeftM), £00 

Trewment, 609 

Sur^CAl Trafttmant of Exophthalmic GoitfQ, 6015 

Summary. .......-...,, 607 


Tie ItcMmeol of MfXCOdemA, 608 

Treitmaat* 500 


Hie Tratunect of Syiiim«tHcal Qangnae — NenrotAthlc Qftngrenooa Trophoneii- 
ro«ia (RafDAud ^a DiBoaw) , , . . .' . 511 
SjmpIoiDB, . . . . , . . .511 
Tmuoeat, 61S 


l^Trntment of Angion«arotic CEdeou, ........ 514 

Tnatment 515 

luiermiitent Swelliog o( the En«e, 515 


TiBTreiimeniof Acromegalr 616 

Sjrmptooaa, . , , . 510 

Tratment, 617 


TbeTreatmeat of Scleroderma, 51V 

Symptoms. ...,,-...,>,. 510 
TreAimeiii 620 


Tbf Treatmeat of ProgreaaWe Facial Hemiatrophy, 521 

TreatmeDi o2^ 

Bemibypertropby and Local Hypertrophy, ....... 522 


Tbt Treatment of Erjthromolalgia, 623 

Treiiment 524 


Tbe Treatment of Acroparseatheaia, ......... :'i25 

TreainwDl j2S 



Tlw Treatment of Oooupatlon KeoriMW (Oocup«tlon Sp»uu, Crampfli Fftlns* and 

Paralysis), 62 

Treatment, 62 


The Treatment of Beadaohe^ 6& 

TreauneDt, 64 

Headaches of tbe FuiictiODftL Nemqves, 64 

Headacheeof InfeoClona, iDtoxlcationa* and AutoinCoxIoations, . - 64i 

neadaches of DiHuder of the CLrculMion, 5« 

Headachee of Reflex Origla . b& 

Hahltuat Headache, 66 


The Treatment of r>eUrlam» 6& 

Etiology, m 

'Primary DelirLum, 66 

DelfrLum of lafeuCLoos, ........... 5fr 

Deklria of Intoxication 66' 

DelirliUD of EzhauMlon, && 

Delirium of SenUity, 5& 

Dellriimj of Irritation, 66' 

General Remarks on the Trefttment of BelLrlam^ . . . > . . 66i 


The Treatment of Vertigo 6d 

Mtol«re's Diaease, 6& 

Treatment of M^Qlfere'sDiHue, 5d 

Psendo-H«ni«re> Dlaoose, 6fi 

Vertigo of Organic Bralo Dlseaae 50 

Vertigo of the Nearoees, 64 

Ocnlar Vertigo, 6T 

Toxic VerUgo, 6T 

Gerlier'e DlseaM, 67 

Reflex Vert IgOA, 67 


The Treatment of ConTulsloos, 67 

Treatment of the C&ums* . , , ^ - . . , . ^ 67 

Lajynglsmus StridaliU, ^67 

Spasmus Nutans^ ^ •--...,. . ,67 


The Treatment of Hemiplegia, 67 

Treatment, 67 


The Treatment of Insomnia, 68 

Claosiflcatlon and Causation of Inrnmiiia, ..,,,. ,68 
Treatment, 68 









Tbs art of treating diseases of tbe nervous eyatem is doabtleas prsc- 
ti>ed vith more aptitrude aitd certamty than it was s. generation ago. 
Hr>weTFT gratifying this progress may be, it is usTerthelesa far from 
biiaf comiueijsuiate with tlie advauce of ueiirology in other directions, 
ooUblj in the compr^heoaioQ of the stmcture ajid functions of the Der* 
Touflfl^ratem- The discoveries of minutie anatomy andoell physiology hare 
cnthbuted less to the therapy of Dervous diseases than ha^^e altered 
Tiem u to the cansition and origination of pathological processes in the 
VAnroaa system, Tlie most important of dieee is the lecognttion that the 
CUKS nf neiTons diae&ses are identical with thoae provocatiye of disease 
ui Dthu parts of the body. Ev«n the pathogenesis of diseases of the nei- 
vou ayatem is aiinilar to that of other dise^isea of the body. In conse- 
qoaoM of this the treatment of diseases of tJie nerroua system can give 
promise of saeoessfnl isene only when the consultant or physician has 
It hi£ o^Kninand a knowledge of tbe origination aud cau^tiou of disease 
at leut &s oomprebendve as that of the adequately equipped geneml 
fnctttioner. Another noteworthy contribution to the therapy of nervoiis 
BlttiW ia attributable to the general reoognition of the prophylactic and 
irmedial ralne of pbysjcsl measures. 

ka examinatinn of the c&ii»ea and (^nditiona of the origination of 
HTToua diaeasts muat avoid details of pathogeny and the intricacies of 
vrmptomatolc^ and specific treatment. So farad these constitute integral 
puta of this treatise^ they await consideration in subsequent ehapl^ra. 
W# ire at present concerned with the more general but none the less im- 
portaDt medical and social prohtema involved. Even a brief presentation 
(^yicae is surrounded with many difficultieSr and many important topics 


itrill of ndoesBitf be given much less than the full and complete disouMion 
they would reoeive ia a more extensLTo treatue on the immediate and 
remote causefl of neuropathology. Among theae difQculties perhaps the 
most considerable flow from the intimate relationship subeistiDg between 
organic and functional diseaftes of the nerrous system and diseasea of other 
parts of the body. This will make necessary some reference to other ail- 
meuta when the prevention of nervous diseases is discussed. 

The interaction of the nervous system and other systems of the body 
in immediate connection with it causes all parte of the body to respond 
to the far-reaching influence of the diseased nervous system, so that many 
disparate symptoms may result from the same pathological condition. 
Thus the destruction of the continuity of a ueuraxon (axis cylinder) de- 
termines the complete degeneration of the part cut off from connection 
with the cell body of the neuron, whereby a lesion that may legitimately 
be considered alight and trivial in other tisanes will as an affection of the 
central nervous system give rise to profound destructive changes in remote 

Ko less provocative of obeoure and mystifying modification of the 
normal functions is the influence that the mind exerts upon almost all 
tissues of the organism and their functions. Every mental condition is 
undoubtedly the accompaniment of some cortical excitation^ bub resort to 
a description of the exciting agent in terms of mental phenomena lb fre- 
queutly necessary, because psychological entities — ideas, emotions, sensa- 
tions, and the like — are readily ascertained and described, although their 
physiological bases may withhold themselves from our understanding. 
A eimilar guide post pointing the scientific limitations of neurology is the 
differentiation of functional diseases from organic diseases. Although 
this differentiation is still necessary, it is the hope of neurology to be able 
to explain all functions in terms of structure, not necessarily the groes 
structure of an organ, but at least in terms of chemical constitution. In 
the present state of knowledge of the pathogenesis of the nervous system 
it remains not Only convenient but necessary for us to consider degenera- 
tive changes and ameliorating treatment, as these may be directed to the 
structures of the nervous system, to its physiological functioning, or to ite 
psychological manifestations. 

A couaideration of the origin of the diseases of the nervous system 
falls naturally into an examination of (1) those hereditary and congenital 
Gouditions which are sometimes the sole cause of such diseases, or which 
constitute, iu most patients at least, thegroundworkfor their development; 
(2) those acquired or accidental causes which are the active agencies in 
determining the onset of the particular pathogenic process in the patient- 
Hereditary and Congenital Influenoes.^A few diseases of the central 
nervous system take their origin within the lifetime of the individual with- 
out any apparent attributable cause. The search for the origin of these 



Kpntt leuls to ui esunination of the famUy historj of the subject md 
fnof Um conditioDB during or im mediately preceding fcctal MU. It the 
dM*e in question Ikas appeared uader aimilor conditiooa in one or (uore 
lllbtt Mmoteor immediate onoestors of the patient, a satiflfactorj ejtplan- 
Mhb <d ite «xistoikce rof^rs its causation to heredity. The bereditary 
dbviMi are comparatively rare. Among them ve can enumerate with 
MTtaunty only HunLlngtau's oborea, Thcin^Ti^s dLsea^e or Bo-(*^ed myo- 
aaia ocoBsaitat migraine, aud the hereditary ataxia fipiiial and cere- 
lAr. Soano of these are not aUictly heredilary. No satisfactory ex- 
IJMtf^*^™ of tbiO eoDditiona detenuining the tranBrni^aioD of these diGeas«£ 
beta parvikt to oSspnag has yet be«n otiered. The problem of the direct 
blwiCaaF^ of a pathologioal eondition must be referred to the biologist 
fo >olutioa; it is a part of the larger problem o£ the transmisaioa of sec- 
oadiry chaiaf teriatica. 

Codgetiitai diaeases of the nerTOUB eystem are due to causes ivhioh act 
dinotty npOD the fcBtua, or to causes which ha?e, previous to conception 
tt dcring pregnancy, so aflectpd the mother that the child at birth already 
auriea vithiii it those luodificattous of Etmctuie which nill evt^ictuate in 
tbtcntbreak of diacaae indepsTidciit of other causation. The congeoital 
itiiniina of the nervous Eyst^m are more numerous than the hereditary, 
ev«n if we exclude eoDgenital syphilis, which, of ooutee, is liable to eauae 
diMiae rd the nervous syi?tem lar^r io life. 

Sofiallei] famiJy nervous diseases^ — a clas^ vbose number is constantly 
giu»ing krgi^r — require sj^eciol toention^ Family diseaaea are charaoter- 
wd by theit appearauce in mor^ than one member of the progeny of non- 
ainainiiilinnni^ healthy parents, who arc entirely free from all evidences 
of tbediaeaaes and indeed from the neuropathic diatb^is. In some in- 
jUBcea iheM diaeaaea appear m only one member of the family, such, for 
iateuet as an isolated case of amaurotic family idiocy or family dya- 
ll^y. Nothing is known of the real causation of these diseases. 
it other factors are exeludedi they would seem to depend upon nnauita- 
bility of the sperm and the ovum cf the parents. Either parent might 
pniJQw healthy children if mated with another f^raon. The early 
^fa or sterility of patientps in whom these diseasea have their apparent 
ipoataaeoua origiu precludes demonatration of their hereditability. It 
iDotpoeitively deniable that a diaea&e appearing for the first time in the 
vembna of a single gvneratiou of a family with no traces of sueh taint 
EuvDOt be inheritable^ but this would teem to set at naught the enr- 
ifn^y accepiejl doctrine of hioloj^y that acquired characteristica are not 
niiwrited. For the present, children thua coneenitally burdened must be 
boled Dpon aa analogous to tho»e individuals of a epeciea of organism 
towMch the biologists have applied the name **eporta," 

Tha KenropatlLic Diatheda. — Although the strictly hereditary ustvouh 
wstj be few in number, and oonaequently come but seldom within 


tlie purview of the family practicioiier, the inheritance of the neuropathic 
diaLhusb ia of nuch frequeucB as to be of the Gret iinponajiGe. Two per- 
eufia of the samo agd and appaieatlj of the ^ame coiiatiLution iQa.y tuJce a 
Bimll&i exoeBsive quantity of alcohol, or he fiutfjeoted to b similar muount 
of other BtijuuliLlion from tbe enviroiuueat^ auab, for example, as ph^^s^ 
ical rir mental fihoek. At the end of a year or of tlve years^ one de- 
veJopfl perhaps a multiple neuritiH, an ootupatioa neicToaiy, neurasUieuiai 
or some other tiervcuB dlaeatte, Vfhile the other reiuaiaa appihrently on- 
h&TDied. Inquiry iuto the family hietory of thd latter may ahoir that other 
members of this family hav^o offered unsuocussful ri^sifitanae to tho eioitants 
of nervous diseases. Thi» evidence of lui unstable nervous organizatioo 
may not hn luaaifested in the Haiue ilireetiou in oao iodividu^ -as in an- 
other. The repeated occurreaoo of auy nervous disease in tii*ar or remote 
aaeeatorB or even iu side lines is anfficieut to establish the probability that 
the patient has inheritsd the ueuropathie diathosia or conatitiitioTi> The 
real nature of the neural unstability it is hoped some time to dis<x>ver- At 
present, wear^ compellt^d to fall bact f or an explanation upcrn tlie assump- 
tion that with the devr^lopULent of the uervoua system the various con- 
stitueut cells receive an oudowment of euargy which ie in definite correla- 
tion \«itb the aoDStitution uf uuoh neural Btruotute. If tlun <rndowEuentie 
Bufficient to meet the requirementa of normal Hfe, in other worda, if the 
potential energy of the cell is up to the hypothetiL'al standard which iS 
determined by the work demaudtd of it fiom aii average human environ- 
meat, the nervous tojte of the individual is a stable one. If, however, the 
endowment of energy is defident, aotl thus an exc^i^tiive demand is made 
by a normal environment on the ceil, or if the endowment is exacasive and 
nfiulta in the overaction of the cell to thestimuli of the environment, the 
drain upon that cell ur upon other cells of tlie nervous syutem s^iih which 
it ia in i^OLuiectiLiu will ultimately mauileet iUelf in Jiseaaes which repre- 
sent either a neuraL futigue or neural hy percxcitability. This incomplete- 
ness or abnormality of neural development need appear only iu physi- 
ological proaeaH or in mental activity. Upon microscopical examiaatioa 
tlie components of the nerroua system may pretfeut the slrictest anatomi- 
cal jutt-gnty. 

The manner in which the constitution of the parenta determines this 
insufficient or cxoeBsivo enilowment uf the constituent colls of the nervoua 
system ia also but little understood. It may result from the preaeoce of 
ooDBtitutional disorders that exist either before the maturation of the 
germ pliMUi or at the time of the development of the proton of the ner- 
vous system, or indeed at any period between the piotal deposition o&d ite 
complete development. These constitutional disorders operate moat fre- 
quently to impair the genera) nutrition of the parent. This impairment 
of parenta] nutrition may exert its influence upon the germ substance at 
the moment of its first detachment fn>iu the parent or during any part of 



t£t» period of its mdopeudent developmeDt, albhougL these nt^tabolio 
bdots ioik}- have a moro detenDiniDg aetivitj^ iu the iiupliuitatiou of a 
KQiopftlhic dJathefiis at tJie critical LaomeDt of the hist appearance of 
tiififrotonof the nervous system. Thy equable evclution of the f<Btii3 
mij be interfered with iu a Dumber of ways during the whol& periud of 
ift development, tbrougti the ajiopathetic nervoua ajatetu of the mother 
whiphia the controller or regulator not wily of her own nutrilioc, but of 
IhOLutntiouof the £ii*tii3 as well. Faetors acting to impair the nulrittou 
oftbe mf>thar*s sym pathetic Byatem will ftondition an altered metabolism 
of ite fcctus. This deleterious iufiueucie will be exaggerated in tho^e 
piiU ^berciu the meta.boIic procesa is moat actire in furtheriug the de- 
tftiiJjiifleot of the difEerent constitaeut eyatems of the forming iadividual. 
St tL^ fcetos reaches the atag$ of development at which its metabolism 
tugiDS 10 pfooeed in partial independence of the maternal oonnecCJon, 
iltHidaoAuf iUuwii vegetative aysteui inay pn^duce func^tional defidencj^ 
oftho cerebroapinal system. The general development of the fobtns and 
(lth« child after birth pro<'eed3 under certain t^ontrol and guidant^e of 
the forming uervcua system. Fervefsione of nutrition oouditioned by 
the vegetative neriroua system of the mother will be therefore most ex- 
ipliitetj manifest in derangement of the ftntal neural conatitutiooT but 
ihne irill also Uettiriniue perveraJcna aud abuotmalities vi peripheral 
itraottfGd. Tho organism ^-hieh has lieen thus subject to impaired metab- 
diam in the way indicated is endowed n^itlt Detvoua tiasue of increased 
nberability. It will re<]uire only some BceidenUd cauae^ such as in- 
^hetion, inioiication, or eihaustiou, operating in a degree that would be 
^^knlees to a sjstein of standard efSoienoy, to cauna thi« vulnerability to 
■uifest itself in some perveralon of function of the parts involved. 

The nervous diseues that result in consequeoce of normal stimuli 
teting upon a nervous system of exaggerated vnlnetability are appro- 
priitsly designated neuroses of degeneration. They present aymptL>m 
coDjpkies which indieate not only degeiiei-acy of the nervous syriteni, 
kl 1 aiDular slatoa of insufficieut or exceBsive development of other 
■awaited tiasaee. Certain bodily and mental stigmata which are often 
itocuQfomitanta of these degenetativ^e diseases ave indications cf a gen- 
«i] pathological departure from the normal type or standard of the hu- 

Stigtaata of Degeneracy .^The stigmata of degeneracy of the body are 
ttdfib Don easily detected than thoae of the mind' What is normal iu a 
Mongoliui ia decidedly patbotogical in a CauensiaUi while the cranial 
eaofnniiBtion of a Teuton occurring in a Celt would indicate a degi^ee of 
iMunnality. Even the family type of Btructure moat be taken into con- 
wentioiL The existence of any one or of even a limited number of 
*<l4mtignkata of degeneratiou doea not permit of the undoubted a^sump- 
tioQ of degBDencjf but a human being who possesses a number of tho 


wcU-recugnized indicationB of degeoeratioa either somatic or psychical is 
ptoperlf JeaignateU a degenerate. The extremities are perhaps tl^e moat 
delicaie Indk-es of sl de|)aKuie ftom the noi-atal course of development 
taken by the fjunily or ratie to which the individual belonga. In general 
li marked departure of any tiohue from, tlio Htructural notm or average 
of the human rasa ia indicative of tbe poaaibiUty of a geneTal degeneracy 
eutailicg auicng its implications a neuropathie di&thefiis and exaggerated 
neural vulnerahilitj. 

The Bomatio stigmata most frequently pointed out are rnalfonnfltiooB 
of the cranium, tuo largSj too nmall, or cLHym metric ally developed head; 
dofeotWe tobulation, formation, and relative positiou of the ear^i Uie 
occurreooe of a Darwinian tubercle, abseuoo of the helix, deticient tragus 
or autitrapia ; aUucrmal shape of the ocular aperture, a tapering internal 
cauthus, an approach to the Mongolian eye; irregular or insufficient 
pi^eubatioD and asymmetry of the iris; unduly developed, prognathous 
jawRf au acceutuatioa of the inferior auguliir proceaj) coustitutiug the 
Lamaickian hypophjais; defective conformation of the palate, an escea- 
sively vaulted aifih, the development of a ridge along the centre known 
as the toriiapalatiuuB ; asymmetrical or bitid uvula ; anomalieE of dentition j 
disproportionate Jength of the upper extremities, and particularly of the 
index finger j nnduo pnijeotion of the oa calda, excehhively arched or 
otberwi&o abnormal feetj bodily anomalios, either general, such as giact- 
jam or dwarfiahneaa, infantilism or precocious senility, femininism or 
maaculinismp or speciolf as spina bihda. 

The functional stigmata comprise physical retardation and precocity, 
the excess or deficiency of physiological proceaaeSj such as in walking, 
talking, sexuallly, the hyperttsthesia or hypsathesia of any seoHc organ, 
OtC- A mental iadicabion of degeneracy ia found in eimilai' conditiona of 
any psychical activity, instinct, or emotion. A want of balance in con- 
duct, thought, or feeliug in frequently the most noticeable mental stigma. 

Tte abnormalities and deficienciea which constitute stigmata of de- 
generation may be found in either of the two recognized claaaea of degen- 
eratea: tho superior and the inferior. Superior dt^ gene rates are those 
vrho may be pofl5eflBed of euliicieiit mental capacity to command nototjety 
or dietinution, but yet fail to raveal the mental balance iDdioative of 
normality. They are the decadent artiste, poets, reytheies, and soma 
occupying the front rank in all regions of intellectual activity. The 
infarior degenerates, ou the other hand, are pos^eaaed of meDlul qualifica' 
tions below the normal. They are for the most part dependent upon 
others for the maintenance of thcii' existence. This class includes the 
idiot, the idiot savant^ and many members of society who are atamp^d 
with ineffectiveneea. The superior degenerate frequently has as many 
and as Htrtkiug etigmaba of degeoeratioa as Iuh brother, the inferior 


^lliid uid Aoddeatal Canus. — The cfiuaes vhit^h may excite dis* 
of tho nervous syatem in thi>se vhu hnx« or have not ui liihtJiMd or 
lA^tilred aeuro[«Ukic diathtrsts are tr'^til>^ under the foUowiug beads: 
(n iDfecticiLs; (2) istoxicaticnfi ^ (3) pbjsicai trauma; (4) psychical 
xttama — iscluding looral and emotional ehoi:kr tn^atal and pbjsicai crises, 
imUI siid pedagogical mflueaces. Any one of these exciting cauaea may 
bt tufficififit to avalcen nerrous diBease in an enttraly healthj atibjeoc 
Heel fraqaeDtJy the causatioik oE uervons disease embiac«H majiy coiupU- 
alal faclora. In ascertaining Uie causes of disease of the nerroua bvs- 
Mu, Of in searching foe the [Jtoper means to prevent its cccuKuce, due 
K^vd most be had to IhQ poestUe existence of the netuopathic diatbe^a. 
1 looper appreciation of the mauner in which tritling Gtimull may evoke 
pmfbond disorder when a<iting u^Kin c»rrt.utn cHJuatiuaions will enable the 
gfonr*] practitioner to render important service in preventing the occur- 
mce of Uieee diseases or in checking their derelopment before irremedi- 
ibh iajvry has boon doae^ 

Hu Edla of Infecllea. — The role played by infection has only lately 
piDfd the recogniliion which is ita due. Although the nervous fiystem 
]tj ririue of ita embryulogical oiigia o^ers a greater resistance to the ex- 
fhuib el diseaee than do other tissues of the bodj» nevertheless it is sus- 
ecpb'Ue to the same injunoua tnfiaence- The p neumococcuBf for example, 
Gtnsea reactive inS&mmation by preference in the lungs; tbebaciUuaof in* 
hma attacks chiedy the respiratory mucous membrane. Nevertheless the 
iMVDiu ayxt«m is very vulnerable t:i these orgajiinms, the first being the 
OGOiDOoeBt cause of meningitiBr and the second a common cause of en- 
dphtlitifl- The tubercle bacillus may produce myelitis aa well aa tuber- 
ttoinu paritonitia. In shorty the specitJc infectious may and do attack the 
diflaeni ooraponeats of the nerroua system, just aa they attack other tis- 
fliaef the body. The greater immunity u( tlie nervous aysten Ja pui-haps 
doe^Aly tu ita greater iuaocesaibility. It has not yet beBu proved that any 
dJMAse of the nervous aystem is dependent upon aji organism that causes 
« epKiScaily nervo^ia di&eaee. It &^ems unlikelyi moreover, that the 
futon will show that such a disaaad e^cists. Although the prepoaderance 
vt testimony and evidence at the present writing is to abow that anterior 
paZkonyelitis, Landry's paralysis, and possibly tiaint^ other diseases of 
the nervous ajstem, aucb as beri-beri. are dependent upon specific organ- 
ims, theee have not yel been isolated. When they ate, it \rill probably 
be found that Uiey are in reality bacteria which cause more common dis- 
(UB8 in other porta of the body^ It is only latterly that it has been 
iLcvD thai the common infeotionSf such as those of pnenmonia, typhoid 
fcTBT, diphtheria, erysipelas, malaria, and the like, are causative of many 
oJthe acute organic diseasea of the nervous system. It is not yet penei^ 
^7 recognised how important are these in causing or oontributing to the 
ice of chronic nerrous diseases. 



The inicotioua exercise iDJurioua activity upou the rtervoua Bystem in 
cue of two ways. Thus, the iufeetioua ageaey may act specifically upon 
tlie u«rye stibat^ai^e to firoduct^ a chuj'acteristiu inSammiiUjiy or degenerft- 
tivo rf^ction. 3ucli, fur infltanoe, is tlie effect of the pDeuuio<!Dccus upnn 
the meninges to produce &cute leptomeningitia) the effect of the tubercle 
bacilludupon tlie oonatituenU of tJioflpinal oord ti> produce acute nijeli tie, 
and. the efftjct of the lepra bacillua upon the peripheral nerves to produce 
neuritia. The d^^leterioua effects of eiiob infeotions upon the jiervous sya< 
tern occur soon after the aduiissioTi of the orgaaiem to tlie system. The 
pathological changes which they cause in the nervoua system are not a.1- 
waya duo to the immediate preseuce or action of the specifio infection^ 
For instance, there i^ no poaitivo proof that diphtheritic multiple neuritia 
is due to the direct action of the specific organism of diphtheria. On the 
coutrarj, it is generally accepted that the lesion of the nerres is due to 
the action of toxic materiala engendered or produced by the preaeuce of tlie 
specific bacilli in the syatenip It may be said, therefore, thai diaeaaea of 
this kind are the result of the activity of the iafdotLon itself or of poeb- 
infectious intoxicntion. Just how long such intoxication remains of suffix 
cient potency bi) ex c<ite disease within theaystem^ even in tissues that offer 
feeble reaiatacce, no one can say. It is, however, an undeniable fact that 
the infectione are capable of exercising their deleterious effects upon the 
ditforeuG parts of the nervous Bjstcm very remotoJy. This remote action 
of the infections constitutea the second mode in which they operate to 
produce nervous diseases* So far, no adequate explanation has been 
given of tlie manner of their action. They may have only an indirect 
infiuence in depreHbing the nutrition of certain parts of the nervous 
system. Degeneration may then follow or intercurrent and accidental 
agencies may acquire on uawonted power. The most plausible explana- 
tion, however, is that durmg the course of an infectious disease certain 
toxins are generati?d which remain in the system and establish by the 
perversions of nutrition which they cause a more or less permanent 
Bource cf ueui^ iu to xi cation. Thus a persisteui; attack upon the nervous 
tissue is maintained until its intc^ity ia overcome. That thia toxic ma- 
terial does not partake of the nature of the infeotioa from which it takes 
its origin and that tlie Oiuease which it c&ijtsos is of a different structural 
nature are generally recognized. 

The explanatiou that is offered to account for the remote develop- 
ment of nervous diaeasea after infection is analogous to that which is 
given to explain the syphilitic origin and cnusalioti of tabes and geucial 
paresis. These latter diseases are no longer considered syphilitic, but 
parasyphilitif*, and the organic diseases of the nervoita system (such as 
disseminated solerosis and other degenerstioaa which, it is gceerHlly ad* 
mitted, stand in relationship to the occurrence of the acute infectious 
dieeaees, even though the time that eUpses between the oxistt^nce of the 



fEmtM And tliB app^arADce of the latter i^ verj gr«&t) miglit quite Jta 
li^tiiualelj be referred tpO as parainfectious di^^easea. No one tu-day 
b^m tb&t t&bea ia pathclogically a B^ptuiitic disease. Stillr aearly 
trtpj OAe believes that if syphilis Tvere a^ept from tha faca of the earthf 
iofionuitot ataxia would not occar. Betiveea tlie period of the e^iiatence 
d tht typlulitio virus j^er ite and the davclopment of the morhid prooessea 
QOutatutiEig the anatooiical basis of taltes dorsalia there developAapoinoii, 
orvmething dae to the former and provocatiTO of the latter^ What thia 
luiecoiediar; peccant sabatouco is v.^o can ooly coajecture. Nothing ia 
bovn ai its constituticn, and >re are eijually ignorant of the meaaoiea 
liut shouJd be taken to check ltd development. Naturally, it foUowB 
t^ d the syphilitic viniB ia oTercome, the Uixin will uot develop. As 
hu Wn saiJf aouie auch expLauatiou a$ this muat suffice at i^he preseut 
un« to bterpret the relationship betireen infectious di^ace and the re- 
iwte oocuireLfro of disease of ihe nervous eystem. 

Bypliilii and Iferroua Diaeaae.— The relation of syphilis to the occur- 
trWi of fcmctional and organic nervous disease ib such an important one 
thit I shall devote pArljt^ular attention Lo it. There ia no deflignaiioD that 
u applied laoto Ioo8<tly than *' Bypbilia of the nervoiis eystem/' We cod- 
tSDilly hear it apoken and seo it vrritteu as tbongb it vrero a diaease 
Tith v-eQ-deGoed anatomical foundation acid uiivarying morbid changes. 
TLe term must perforpa convey an obst^nre idea or conceptitin of tlie 
pUliolagical st^tea which result from the activity of the sjphilitic viruB 
oipcccuit subsUnces which are the reault of ila existeuce, because these 
in poi only manifold, hut the ditTeront tissuca of the nervous aystem and 
tiltt different oonitK}nents of them may be aEfected. One might as juBtili- 
lUj ipeak of "infection of tho nervous system/' and hope to convey 
in adsquate idea of the morbid eliaoges produced by infection and of 
iLeoIiuical conditions dependent thereon, as he does by using the terra 
^philis of the oervcua system. Yet probably no one -woold apeak of 
iLl«ctioa of tho nervous eystem with the hope of conveying without 
farther exposition the elinkcal or pathological concept of a disease. Wo 
knDv, for instaiice, that infection produces neuritis, poliomyelitis, en- 
c^tulitis* mad meningitis, but we do nob describe tliem, clinically at 
lost, under the general caption of infection of the nervous system. Yet 
ib\6 19 similar to what many writers attempt when tboy epeak of syphilia 
of Uie nervonfl system and give its so-called pathology; etiology, and 
c\m\fki deTin^atioD as though it were s. disease s'li ffemrris. 

Personally I am winvinoed tlmt the result of such attempt ia to oh- 
•eiuethe physioian^s conception of the colossal r6le played by eyphilia 
to the caoaation of nervoua diaeasea. particularly organic nervous diseaseSi 
roqutttJonably the activity of the syphilitic vuua in on& tissue ia mani- 
lestM by morbid changes which parallel those resulcing from its activity 
a Dther tisanes, the Ktruetural differences of the two lesiooa being condi- 



tioneJ fay t,)ia lilatological character of the tissue, by its pbyaiological 
stutOf and by tliQ intcDsity of the syphilitic poiaon; &nd by virtue of this 
fat^t it may be oontended that there ia suffioien'. r^asciL for the designation 
syphilia of the rjetvoua eysteii). On such gTounds alone, it would be im- 
posEible to d«iLy the assumption. But it luay be said that the con- 
aequeacQH of hauterial iafeutiuUf auch aa from the pueuiuocuccusj the 
diplococcua iutracellularis, the bacillus of influeuza. aud the ujidiscoverod 
OTgimifima of uifectioua anterior poliomyelitis and encephabtis, are of as 

iparable couataucy and similarity as thoae pi-oduoed by the at^livity 
'd the syphilitic poison. Moreoverj the varialtilily of the morbid resulta 
in dependent upoD the same coBditjunSr vi^. : upnn the hiatclogitiEil Btnic- 
tore, the physiological atate, and tho intensity of the infection. Thua it 
muat be granted tlmt wo are net justified iu singling out certain diseasee 
of the nervouH system and subjecting them to olaBsilicatioa oo an etio- 
logical basiSf particularly when the pathogenic causation ig really un- 
known, as it is in syphilia, and at the same time neglecting to adopt 
eimilar claBsificatiaD for other ccuditions of which the entity of causation 
baa been establisbed beyoud doubt. Of ccuiec, it may be said of the 
iufeotious diseoaoa that although they are all dependent upon bacterial 
causes, each one of them owes ita existeuoe to an individual organism. 
This, how^'VCT, in not germane to the discuHsion^ for our contention is 
merely that the single iiifectioutt organram, such, for iustaiice, as the 
pneiuuo<voccus, may cause differeot intiauLkiuatory diseases of the nervous 
aysteta and its coveriue, dependent upoa the tissues which are affected. 
Yet no one would think of attomptiog to convey to a person unfamiliai 
with these varioua dlseaseH the pathological and clinical histoiy of th«m 
under the single caption of infection of the nervous system. In order 
to simplify thti matter and to facilitate compreheneion, he would dsBcribe 
them under the separate captions of meningitisr encephalitis, polioaiye- 
litia, etc. In other wotds^ it has been found most expedient to classify 
the resulting conditions topically and cUnioaliy. The tim^ may come 
vheu nervous di^ases can be classified on a strictly etiological basis, 
When it doe» we shall speak of infectious nervous diseaseSf syphilitic 
nervous diseases, traumatio nervous diseases, toxic and autotoxic nervous 
diseases, nervous diseases dependODt upon defective development, and so 
on. While this may simplify the subjeot of pathogeneBls, any attempt 
to apply it clinioally will result in fnonnous confusion; and we shall un- 
donbtadly be obliged to continue classifying nerrous diseaaeBr as well as 
an other diseat^es, to^tographicatly^ 

After these introductory remarha» whioh are made that it may be 
known that the in advisability of considering at any great length ayphdis 
of the nervous system in a treatise on the treatment of nervous diseases 
is fully appreciated, 1 proceed to discuss briefly the commoner manifesta- 
tionB of syphilia of the nervouB cijstem, and reserve for their more de- 



Ulid oOQsidervtJoii apace in th« cliapters on the treatmeut of irtdivtdu&l 
Amuo irli;i;li arj cau£eU, more or leaa frt^queaLly, \yy HyphJis. _ Tiuft 
aiU gLT« AH op|)orttiQi^ in ibis pities to coaaider tho general features of 
^hCQBUBftbon of diseufloa that are conuDOoIy due ta sypbitis, acjd to take 
t hMi florvey of the most ftpprored metboda of treating thetn. Nat- 
sUlly, it is impossible wbea diacussiiig the treatment of myelttis, en- 
O^ihalitdAf tabes, n^uraaUieuiOf oc other diseases that may or may not l« 
iut w sjphili^ to rerert to auy cooaiderable e^t^nt to the most approved 
Mtbotb of tr«atiag Bypbilis, to the timo when cucvh treatment sboxild be 
hgUQ, OF to the dutatioo of treatment, but in a general chapter on 
pfD^flaiifl th?s& topics can be appropriately considered. Tbe most 
to^t raaaoQ for devoting so much Epiice to a genera) coasidenitLon of the 
dbota of syphilis of the neryoua system is that the vast majority of the 
ftpJOG nervous diseases oe<Tarniig during adult Life wbioh are not the 
Knit of infection or defective evolution are due to ByphillB. 

Diseases of the nervous 8yst,em due to syphilia must he divided, 
Bmparally and patholi^ieally, into Bypbilitio aiid paraayphiliiio, Tbe 
tonatt are characterized by their developmeot duriug the period of ac- 
tirttj or Life history of the eyphilitie virusj and by the oecurrcnce of in- 
iaouaatoryf exudativer or productive conditiOBa peculiar to tbe eiistence 
■ad activity of this viroa. The latter occur after the ByphlUtic poiaon 
luaceaied U> exist aa such, or at least after it Laa lost the povrer to cause 
dwaetfirisljc pathological Teactioo in tissues. Tliey are distinguished 
bj ttfl occurrence of primary decay which may be, and frequently ia, 
«ompuabLQ in every leepeet to that produced by other causes. These 
ivo Tirietiefi of ayphilitio diaeaso of the nervous system are often spoken 
olpathologicaHy as the eindative and degenerative; but thia may easily 
levl to confuaiun, as degenerative conditions of nerve tissue may and 
often do occur sequentially to exudative Bypbilitio atates. Paro^yphLliuc 
Dcrroue diaeaaoSp it must be borne in mind, nro degenerative <iA inifio. 
Tb«j ire not preceded by exudative and proliferative states^ iior are the 
bsloaa after death at all cbaraeteristic, maeroseopically or mierosoopi- 
nll^i of a luetio process. 

The ayphilitio virus may attack any portion, segment, or constituent 
of the nerrouH system> It may attack thom individually or collectively, 
iirf naturally the resulte will be very dilferent as it does one or the other. 
Thu, we may subdivide the genuine syphilitic dineaaes of the nervous 
fjBlaiL intot (1) Syphilitic disease of the blood-vessels; (3) Byphilil-ic 
diSMMot the parcTkchyma of tlio central nervous system; ('!) syphilitic 
dtfMw of the coverings of the central nei-vous system, particularly the 
Bttin^; (4) syphilitic new formations of aufhcient ei'^t^ to deserve tbe 
uneof tmaor; and (5) syphilitio neuritis, a condition that is rare, but 
tluBs ujtnal occurrence would seem to he fairly well substantiated. 

The parBflyphilitde diseasea are: (1) Taliea doraalis; (2) general pare- 



Bifl; find {^) HoiQd DeuroBes, including syptiilitic netjraatheuis, epilepsy, 
aenTHlgia, aud poasibly hysteria. 

Topographicallj, syptilia of the nvrvciua systeni may be diFiJed into 
STphilia of the mtracrauial coutenU, syphUis of the intra.epmai contents, 
and 8}'philifl oE the peripheral nervoua Gj^tem. Thia claseificatioQ aerves 
□o uaefulpuiposej unless it he to impress that different conGtitueota o£ 
the iQtracramil or intfaspiual contents may be aimultaneoasly affected. 
lu fji[;b, Ji ironditiou known a^ cerebruapinal syphilis has come to be de- 
HCrib«d tta a pathological and clinical ectity. This has been nec&aiiary 
because the morbid conditionn forming its baaia^riz. : a diiiu^e guzamatoua 
meiiingoencephalitia and meningomyelitia, the basilar portion of the brain 
and the oenrieal spinal eord being especiaUj liable to involvement — and 
the aymptitms dt^pecdent thererm do nat really parallel any other diaeafle. 
Suffieieut has been snid, therefort), tu ehow that th^ term ayphilia of the 
nervoufl sTstcm ifl applied to Tery differently located pathological proc- 
esses, find that no excuoe for the use of such ntriaenclature to indicate 
a particTilar lesion or an individual pathobgicid change can be pot foi- 
ward' The only generic term at this time that is warrantad is multiple 
oerebrospinal aypMIiN, whii-h ataiids for a difTuse, widespread, ^ummatoua 
meningitis of tbe brain and spinal cord, with Eecondarj involvement of 
those organs, It constitutoa a pathological and clinical entity, the 
symptomatology being that of syphilitic meningitia, plua ayphilitio 
encephalitis and myelitia in variable and varied amount. 

The CftQflea of Syphilitic NervoiiA Dlaeaiei. — On first sight it might 
appear that a diM:ustiian of che eiiulogy of syphilitic nervous diaeaaefl 
waa unnecessary, as they are all due to ayphilia, but when we conBider 
tJie vast amount of eyphilitic infection and the comparatively small 
amount of syphilitio nervous diseases, despite the faat that so many 
nervous diseases are due to syphilis, it must be seen that there are 
otbu" facU'i-B Ibfin the existeneo of syphilis that, materially preilii^pnae 
to or facilitate the occurrence of syphilitic aiTection of the nervoua 
system. Infectiou by the fiyphilitie virus ia the sine qua non. The 
poiot of entrance of this infeotii^^u into the eystem may be any exposed 
part of the body which has au abrasion npun it, but cominonly it is 
the external geriital organs. Tradition and widely accepter;] belitf both 
have it that the local iraiiifeBlation of such infection is an uker with 
firm base and indurated inargms^ to which the name true, hfird, or 
Kunterian chancre ie given. It is raore than likely, towevcr, that the 
lyphilitie vinia may inoculate an abraded EUtfaoe without being followed 
by the occurrecce of what is considereil to be a true HnnteHan chancre. 
In other words, there caa scarcely be any question that the soft chancre 
Is sometimes the local expressioa of syphilitio inoculation or at least the 
point Uom which the syphilitic virus entere the system, I take it that 
few will deny that the arbitrary di iTerentiatiOD made hy many syphllog* 



nben betr^en liord and suft cbaiicre, as aypLiliti^^ and uon^yphUiti^, 
jmokng^ tenable. This ia tan1aini>tiut to tb« Admission that the in- 
otniatitti of sjphilis do«s not nfioessahly pntOuca a cliaractenstic Iim^I 
Imou* ««~^^ tHoi^b tbd vast majoritj of instancea ar« cbaract«ri£eii bj 
ibDOoaurreuce of a more or le^a t^'pical uloer to which the came hard 
^btfUM id given. 

Tb< period that eUpse^ between the initial leHion of sjpbritic infec- 
tio!] ud tbe eiuilativ« mtuiifesUtiona of syphilis iu theTiervuua system 
VII Eozuerly considered lo be mach longer than wfi now know it to te, 
Wa the phe&omena of ajphilis vere classitied uniforaJy on a tern- 
fOrU baaia into prijnary, aeoondar^, and ternary, it waa ^ustomury to 
Ato that involv^m^t of the nervona Byst^m (meninges, blood-T^^seU, 
or |i«zmchytna) waa a ]at« tertiary mauifesUtioD. Si^ch a posiUoci ia 
^oiantj ontenable aud it ia Lold at tlio preaeut timo by t&w writers. At 
Inst oae-balF of the caaes o£ true syphilitic diaeaae of the norvous syateia 
oceurwithin the first three jears after infection. Braii% basing hia state- 
Dttita cn investigation of a largo number of CBses, atatea that forty-two 
ptf cent of eas^a of intracraninl Byphilitic disease iKH^urs wilbin the firsc 
jtax; and Uaotiac found aa tho result of his sludiea th^t forty-tbree per 
•enl of caaea of cerebrospinal aypbilis occurs irithUi tho first two yeaia. 
It nuj lb*wfore bo aaid without fi?ar of contradictiaa that the Imbility 
tolme ayphilim u^rvoiis disease ia ©uormously greater duriiLg tlie litst 
tea f sarfl succeeding infeeiion than in all the other yeara of tho infeoted 
puBOD^i lifcif and thjit the liaLilitj' dunnjf the first five years after iufeo" 
ttniBoniioh greater than during the neat fire> Paras rphili tic nervoua 
^soMfl, on tbe other handf are much more likely to develop during the 
litter half of the first decade after- infection, the average period that 
dqwi betveen the origlual infection and the first manifestations of 
nsb disease being aliout ten years. 

Thtt predisposing factors to the occurrence of pyphilia of the nerrons 
lyitmi are, ao far as the3' have been determined, hrst, the intensity of 
CLfHtioQ^ jddged principally by oonatitutional manifestations ■ second^ 
OBifficiency of antisypbilitic treatment^ third, the age of the patient^ 
foarUir the aeat and A^t^rent nature of the initial le.sbn; fifth, individual 
pHidianiies or constitutional conditions; fiixth, physical injuries ; serenbh, 
tteotU eicitatlon, eicbauationf enerTatlng habiba and vicious indulgences, 
uaitt which may be included excesHes of all kinds ^ and eighth, infeo 
tMiuj diMasea. 

Tliere is a wideapread belief, based upon the eEperience and state- 
lUDlfl of trustworthy obaerverd, who have had such exponence with ner- 
vous diseases duo to syphilis that their opinions are entitled to ^reat 
'eight, that sypbditio diseases oE the nerroua Byatem are much more 
\^M^ to oeear in individuals who give a history of mild ayphilitio infec- 
^ob, maoifested by local and conatitutional effect. They base their con- 



viotion not aloat Lipt>u the historiefl of patianta, bikb upou the etatementa 
o£ sy philologists. It ia geueraUj admitted by neurologists that the ma- 
jority of patients who oome undap treatment for syphilis of the uervouB 
flystem do not show, in external tissue op fen.tiipflj Higua or iadioationB of 
the previous exiHteuce of Llie disease. It ia easy, however, to be misled 
iuto drawing wrong in fere aces from such experience, for, beating in miud 
what has been Baid conoerning the time of ocourrenco of tho mfijority of 
syphilitic iiervoua diaeases, it will readily be seen that involvement of 
the nervoua system oecui'a before the period tvhen cutaneous, oculat, 
osseous, and membranous matii fetitatii^Da of the diseji^ne m^^y tahe place. 

There is a firm and appareutly uudislodgeable belief on tlie ^>art of 
moat phyfliciaas that thd most influential fa<;tcr ic the occurrence of 
genuine eyphilitio diseases of the nervous system ia improper, ingi^tticientf 
aad inix)mplete antiayphLitie treatment. This belief is largely the result 
of the teachings of ByphilolagiHta, and partly of the experience of general 
practitioiiers and iieHrologista, Deapite this wiciespread bulief, partly 
based o& tradition and partly on experienoe, there would seem to be a 
eouvietioa on the part of some, perhaps many, of whiob the writer ia one, 
thtit the Lnduenoe of aatmyphilitio treatment, even when carried out in 
the most orthcHlox and approved way, la not so potent a measure in the 
prevenlion of true syphilitio nervous disease aa it is generally believed to 
be. This ahoiLld not be construed to mean that the lucuiubency is any the 
less great on the part of the physician to ti-eat his syphilitic patient along 
the most approved lines and in the niost thorongb and systematic man- 
ner, Tho reiiflon ioT theinsuffioiencyof antiijyphilitio medication we shall 
speak of when dcscussrng treatment. It is merely the statement of a fact 
which tieems to be supported by statistica. Coiicendug the etUoieuoy of 
treatment in the prevention of parasyphilitio nervous diseaeCf we may 
speak With much more positiveneas. My own belief ia that autisyphilitio 
treatment has litrle if any mdnence to pi-event the ooourrence of para- 
ayphilitic disease of tho nervoua system. This opinion is baaed upon 
most careful study of all t!ie cases of parasyphilltiu nervous disease that 
have como under my direct personal ubeervatiou in hospital, dispensary, 
and private practice during the last ten years. Starting with the firmest 
beLef that autisyphilitio treatment %raa the moat powerful intlaeace in 
the prevention of parasyphibtio nervous disease, I have been compelled 
against my wiJI anij inclination i^o the acceptation of the facts as stated 

Syphilitic infection is comparatively arare rooditton after the fortieth 
yeaTi and consequeatly experience or etatistica on which one may found 
a belief L<onceming the influence of age on the occurrence of syphUttiO 
disease cf the nervous system is limited. It iH generally conceded tbat 
individuals who acquire eyphiliB aft«r th1a period aro nuirti more liable 
to the oecurrenoe of syphilitic affMtions of the oervoua system than those 



vha bvcocie ini^pcted earlier in life. Mj own exp^rieace ia in fullest 
Knxdvilb this view. TLere is by uo mcaus unaDimity on tfao part of 
muflkigiBta Qonoerntng thist however, and some recent iuTestigatora havo 
Mtedftd that it ia not troc. Like some other oplnLoQa ia Bjphilog- 
aiibf, it may <lepend largely on trajjition, buL UDtil fiirther proofs of 
ib falsilj are forthcoming it must be accepted. 

tetistically it ia not difficult to show that peraooa ytho have had Tot- 
00BaD ftvenued of icifectic^, estragenitai ohtmoraa, devdiop alfection of 
iheMTTCKia Byatem oftener and earlier than those in vhom the chancra 
bu bvn of customary Iwation. It may be that the curr«Tu'y of Urn 
rinv b du€ U> the factthaUeuch leaiona are often er unrecognised and 
oatieiled, althooght of oounej it la appreciated that this statemciLt ia out 
d hATtaoDy with what ha9 b^^n said eonoonung tha intluencd of treatment 
n tb» ooo u r r ence of syphilitic disease of the nerrous Bystem. The fact 
dutthe sypliilitio rirus enters the system through aa abi-aaion around 
vtuch develops a soft chancre has already \teea mentioDed. To again 
iBTort to this subject would be only to reiterate what has beou aaid. 

Toder the heading of the ttfth predispoeing cause, of indiridxiAl 
pwdia/jcy or conatitutiOQal idiosyncrasy, but little can be said, aaide 
fion the fact that an inherited neuropathic conatitutioa and acquired 
HUM of nerroufl exhaustioD «eem to predispose to both the genuinely 
ijjilihtLG and paraeyphilitic disea^. 

The frequency with which slight and severe trauia^ to the h«ad and to 
tiktipmei profound physical exbaustioUf and eiposure to cold, ^Tbich act 
prmdpaUy upon the spinal corU, precede the development of manifestation 
of i^rphilttic disease of the nervous system jnstifiea the belief that these 
IK Important factors. In the simimer of 1898, 1 saw two eaaea of 
ijfihibtic spinal paralysis in one regiment of the National Guard develop 
i^pifeaUy aa the rceult of the exhausting effect of prolonged drilling 
ud DiBnceovering to vhteh they aa sedentary men had been tmaecus- 
tmtd- No other cause, such as exposure to wet or cold, cotdd be postii- 
lilBd. Doe of the patienta had had the initial lesion a year previoiialyj 
tie other four years^ Iktthof them bad been under cootinuoua treat- 
omL Trwuna facilitates the occurreoce of syphilitic involvement of the 
Mrmia system by causing more of less local depreciation of (^ircutation 
ud nutjiticn, which gives the ayphilidc potion an opportnuity to moni- 
taits sLnister activity in some se^^ent or tissue of the nervous system. 

?erhap9 the most important factor in predisposing to syphllitio dis- 
sue of the nervous system or the moat vicious antecedent condition may 
teiiLGluded under habits, customs, and eictsses. Of these, by Islt the 
auu important are excenses of alcohol and tobacco. The depreciation of 
valitj and nutrition attending the intemperate ingestion ot alcohol and 
HiteEjdeacy to caoae parenchymatous degeaeration coincident with oon- 
wdrra-tkssue iucreaee all over the body mahe it the most baneful piedis- 



posing cause of eypldiitio diaeaao of t}ie iieur&l pfLrouctyjna* Tob&cco 
exeroiseB it3 pernicioua influence mainly tlirough depreaaing the circula- 
tion. In a much smaller nuiut«r of casea aexuol e^cege se^ms to play 
Eome rr>le, espeoially in cau^iu^' disease of the apiual cord. Exhauatiu^ 
mental or physical work, ajid paiticularly both combined, eDctvating 
habits a:xd indulgencea, worry, fright, and anxiety, eome one or all of 
them, often form a coDflpicuoQB feature of the period elapsiog between 
initial infection and the oecurreni^e of involvemeEt of the nervous Byetem, 
It 13 easy to understand how and why they aTcrclaa a i>ernicious influenee. 
These factora seem to Im as potent in predi&poaing to the occurrence of 
ordinary syphilvtiic nerpoiis disease as they are to paraayphilitio diaeaae* 
The greater liability of the male oeic to these explains in a meaaure the 
more common occurrence of syphilitic nervous disease in men than in 
women^ although it Btill leaves a great hiatus iu attempcing this explana- 

The rtlle played h; mfeubione diseases, such as malaria, t) phoid feTer^ 
dysentery, pueumonia, and the like, in prcdiapoaing to invoKoment of 
the nerroua Gyatem by the syphilitic virua is muoh greater than one 
might infer from a study of the writinga on thia aabject. Indeed, very 
few of them refer to it at alh Yet in my own experience Ihey play a 
not infrequent and unimportant n'^le. It is parlicnlarly in jiredUpOH- 
ing to the OGGuirence of syphilitic diaease of the hlood-T«aaeb that they 
have their moat conspicnoua effect' 

A word must bo said concerning the diaeaaes of the nervous system 
due to congenital and ao-CiiUed hereditary syphilis. Congenital syphilis 
may produce the aame syphilitic and parasyphilitic diseases aa ac<|uired 
syphilis, and these diseaj^es any show themaclTea at auy time from bafore 
birlh until aftor puberty. Like the acquired neivoua diseaaca due to 
ayphilis, they are prodiaposed to occur comparatively aoo^ after infection. 
A conaidei-ahle proportion of the infantile cerebral palaies, of idiocy, and 
of lesions of the nervous system aasocinted with maraamus, are dne bo 
congenital syphilis. Statiatica seem to show that the majority of cases 
of general Byphilia of an exudative nature occur between the £ fth and the 
tenth years. The modni' ojtornndi of congenital flYphilis in produFing 
diaeaao of the nervoua system is the sanie aa that of acquired syphilis. 
The only differences are thoae whinh are determined by the immaturity 
of the nervous system upon which the virus aud the f^jxiris act in the 
former case. The term heredilaiy ayphilb has fortunately b^un to dis- 
appear from the literature as the result of the gencriU aci?eptaaee of the 
bcJief that ayphilia la dependent upon a speoiBc infection, ffaturallyi it 
ia abanrd to speak of on infectious disease as hereditary, inaBmuoh as the 
development of any characteristic properly designated as inherited is due 
bo atruotural moflilicatioti of the germ plasm of the parent. 

Intcxication and ITervous Disease. — The relationship of intoKioation 



to th* oecorreQce of Dorvoos diaeaao is exlrem^ly important. It is oft^n 
dvffipult to discriminate intoxicationa froia in£e^:tioiia. Intoiicanla of 
ihe TLerrcitia system iaclude pd»0U9 taken in from withoat the system, 
<r aogeoous pobooa^ and poiaoua Lavinj^ their origin vritLiu tLe sys- 
ieau or ftndog^noua poiaona. It has already been aald tltat aulointoii- 
c&ti^a is IrequeuUj the resolt of the QEiatence of tho itifootious diaoases. 
Ttw TUt majority of pnieona of external origin &ct iDJitmusly upon the 
wjpber&l nerves to oause inSaramatioQ or degeneration^ or upon the 
nutiiticD of the different coixiponeiits of the cerebrospinal aud sympa- 
thetic «;Fateaia to produce dibtiu-bani^ of nutritional cquilibrinm which 
Qonatitut^s fimctionai diBCOfiO- I'hua alaobol, lead, arecnio, phosphorii^, 
budptude of e&rbon, and the vegetable alkaloids, such as tbtj^e of opium, 
tea, tofiacco, cao&o, and the like^ F^^7 ^ uiost important iCle in the can- 
ntion of multiple neuritis and Euch functional nervous dir^ea:^fs }i^ nen- 
rastheuia aud hysteria, None of tbeae Bubstfincea has as yet been shown 
to stand in direct relationship to organic dis^^iiae of the eeuttat nervous 
*7BtMn eicept in so far aa Ihey leiid to vaaculat degeueration by pervert- 
ing ih» fui>ctioa of the sympatbetio nejToua system. It is not at all 
impniljabla that the way In which intoKicants m common use, articles 

eof di«b And luxury, such as t^-a, coffeo* tobacco* and alcoholic drinks, act 
tD produce nervona disease ia by bringing about a general dUorder of 
iDtrjtioA which is presided over by the sympathettc nervous system, 
Ktia leads directly and indirectly to oeurtislhenia, epilepsy, hysteria, aud 
naomotor disorder such an an geio neurotic cedetun. Thti individual ma^, 
iy piTPilispoaition of heredity or acquirement, tend toward the develop- 
ttieot of one or the other functional disorders. 

The Effects of Stimolanta and]fQrcotics.^A5 therein a group of causes 
vhLch pasa from infections into intoxloationa without a elear distinction 
being possible between the two, so we pass from the intoTif^ants as causes 
of Ljerrous disease to such social habit^i as might be classified as intoii- 
catioiLs, persisted in until they £nally initiate degeneration. I refer 
to the indulgence in alcohol, tobacco, tea, cotTee, morphine, cocaine, 
chlural, and other narcotics- Alcohol in particular is a very frequent 
cause of nervous disease. Clinically and experimentally it has been 
ahnwu to be often the sole cause of iuflammation of ttie nerves, acute 
degeneration of the nenml parenchyma, and decay of the blood -vesflels. 
^Alcohol taken in aiaalJ qaantitics is unquestionably a food and is dis- 
^^Kbed of in the system to the advantage of the general ecouoiny^ It 
n not with the effects of alcohol in such quftntitiea that we are here 
GUDcemed. It haa been coniended by many that alcohol and the nar- 
ootice are injurious no matter how temperately tbey may be used. That 
ihia is not eo is sufficiently attested by the social history of the most 
'jdvaneed peoples in whom the use of alcohol, tobacco, tea, and co3ee is 
oaiverggl. That the excesfltve use of any of the ^boTe-named narooties 



is injurioust LUid tbnt the effects fltq often most calamitoiis to meDtol And 
physical integrity do oud c^n deny. All of tlia u^rcottcs t^en in iLoy 
quantity BtG iiLJLii'ioua to the connal individual before complete maturity. 
After maturity the nicilj'Tate use of tulaccti, alcoholj lea, aiid coffee is 
iLOt on\j devoid uf injuxioua capacity to the iudindiia], bab it uiaj assiat 
him is the eajoymeot of life aud the perfoimanci? of hia dutit-'a witl^- 
out in the leant jeopardiziug bealth or iJiipainug physicaJ or mental 
vigot. To this rule there are oerlainly excejitioDa, There are Ihoae 
who (Cannot take any of these Hubstant^B without in a measure makiug 
it more diJliouU to mainUia the balance bi^twei^n health aud disease. 
8ucli exceptions are constituted in the luain L^y those ^!io have inherited 
ot acquired tho ncuropathle diatheais. It may truthfully bo said that 
the use of stimulants aud uareotiea by those who are of the neuropQthic 
eonslitutton is jiijuHoua, Many of thia elasa, however, TDay at timta 
with advantage use the&e aubstaii^^Ji temporarily for Uifiir stimulating 
or sedating eSectSt aod for the aid which they lend to the establish- 
meut or maintouQnce of the general nutrition. Further than this it ia 
imposaihle to generalize. When it becomes necessary ta decide v'hether 
or not the temperate use of auy or all of thei^e Is injurious to a given 
individiud, tlie safest way to determine is iiy iriaL If the moder- 
ate use of tea, coffee, tobacco, or alcohol causes toxic symptoms, be they 
ever bo alight, it is injurious and should be stopped- The individual 
may bo assured that their eontinued use wilJ surely work ntischiet. It 
must he Baid, however^ that many individuals who would otheiwisa be 
unable to indulge in the n^ of these luauries without jeopardy to their 
health nmy^ by strict coi] foru^ation tc the laws of general hygiene, use 
them temperately without injury. The individual equation is very im- 
portant and must bo constantly taken into consideration. Oue man may 
cciLsume n quantity of tobacco or of alcoholic stiniuMut during the span 
of an entire lifetime which would be most dianiatrtnia to another. The 
latter may regrethia limitations because of thecouvictjoTi that it iucreasea 
life'r^ handicap, but he luust be taught to look upon compulsory abstection 
as a virtue, or he may if he chooses consiiler it ark individual infirmity. 
It really OLattcre not how he interprets it so long as he can l>e made to 
realise that such indulgence is inimical to the mamten&ace of health. 

The Rile of Autointoiication.- — The influence of autointoxication upon 
cervous has within the past ten or twenty years called forth a 
Large amount of research, lb still oQera e. fruitfiil field for investiga- 
tion, as the question of how important a part poisons gotierated within 
the system play in the causation of functional and organic nervous dia- 
eases has liy no means been satisfactorily aiii^wered. Indeed, at the 
present time we are uuuble to say that any organic of the cen- 
ti^ nervous system is caused wholly by such intoxication, save possibly 
sclerosis of the posterior columns cf the cord occurring with pemicioufl 


iDiuiiia^ Tho difficulty of determining exactly the influeDce which the 
iOttHiinaicuil3 have izi causing funi^tioDal and organic ueri'oua diseaaa 
iitftormoaflly added to l>j the fact that all such dii^eaaes are attend^ 
froQ Uie Tciy beginuiag by disturbanoe of met&boliam -which allows 
itf ody thd production of thes« intoxicatlona but facilitates their acttv- 
lA. Ortait) it is, as we shall have occasion to say later od, thiit treat- 
ocot dirwted wholly to cauutfiracting autointoxication in certaiu dia- 
fUA «acL &3 nearastheaia, epilepsy, tyateria, the Tasoaeurosea, and 
«dier fo&ctional nervoua and mental diBcaBes taoftei^ so beneficial that 
Ibr KLOSt SL^eptical b«<]onie convinced that a clo«e relationship esiata 
bBtwvQn aubointoii«attoaB and tha oceuTr«bce of these diseases. This 
iiiH>vbere lietter Rhowii than in the tre;ii.inent of epilttpBy. Strict at- 
tsbGti to the eoadition of the avenues of teconfltruotion and elimination^ 
cniEi^iiied with carefol sapcrviaioo of the diet, is often attended by aa 
beneficial influence ou the pheDomena of the dlGease as is tb9 moBt 
dtbiJrate therapy. 

The manner in vhich diseases dependent upon defective metaboliam^ 
uch te gout, rheumatismT diabetes, and the like, produce disease of the 
pmphera] and central cerTous system cannot alwajs be explained other- 
vise than by reference to the resultant depreciation of nutrition in 
NrtUD parta or tissues of the nerrous system. There are many reasons 
for brlicTing, as has already been auggcsted, tbat these diseases them- 
lelvMare freqoenily, if Dot always, immediately conditioned ly perverted 
CvKtioiks of the sympathetic neiTooa sjstem, although they may bo other- 
w\K remotely caused. The loss of metabolic balance which they repre- 
•mt ud Ibt' dissociation in the compoQcnts of the blood with which th«y 
m Mcompanied are tbe r^ult of glandular and metabolic functional dis- 
tafboiocs which are under the imiiiediat:e control of tho sympathetic 
oervoQS system- When these diathetic conditioD£ or diseases cauae d is- 
latbaaeeof function in the general cerebrospinal Bphere, manifested by 
ftmcbonaJ disease or hymore profound organic discjLfie, a pemicioua oitcle 
is fbrmed around the nervous system. Tbe diathesis is merely an are, 
tuntiTa on the one hand^ caused on the other. t 

Tnuna ai a Cause of IVeiroai BiAease. — The part played by physical 
buma in tho production of nervous disease is generally admitted though 
cAn insufficiently emphasized. In recent times the causal relationship 
nbnsting between bodily injury and tbe occurrence of neurasthenia and 
bpteria baa given riss to a new class of diaeasea, the traumatic ueEiroBee- 
IjtacTil paresis L5 sometimes caused by traumsi and the development of 
hnun tumor after injury to tbe bead canaot be gainsaid. Tiauma of 
n^kind and another is very common in children; happily it is usually 
vithfint ulterior results. But it has been shown coneluaively that serona 
meningitis and acute non- hemorrhagic encephalitis, lioth in the child and 
btbtadalt, aie sornetinies due to trauma. Bemotely antecedeut trauma 



TDUBt not btt allowed too groat importauce iu eetiinatiiig iis etJologi' 
iDf]iieT)(;e in nervous disenae unlt'^is tlia IraunjH Le re|;eateiL Repeal 
alight blows &r& nob iafrequentiy a part of the patient's previous hisLoi; 
ia general paresis. No ooe can deny the oapaeity o£ penistecit ali^ 
trauma, au<^h sis the wbratjous and agitations to wbi«h r&iEws.y rnj^ineei 
and others are liable, to produce fujifrtional n<*rTOua diseases suoh aa d«^ 
raffLlienia and iLy^teria, eapet^tolly in neuropathic individuals. 

TIlo ii^latioujiliip of (K^oupatiou or calling to tlie occurrence of norrOfl 
disea^ is of uo particular unpoftanco savo us Jt exposca the inJividllAl^| 
the c^auBeQ and intluenoes which wo bave already pointed out are injurlon 
to the norvons system. In discussing individual diseases^ ^g ehall bav 
CHK^Hsion toHpenkof the occiirreui:e uf pro^ressire luusi^ul^r ^liopby iDaiti 
BnaB, such aa gold-Umtera and embroiderers; of nentitifi in wotkerH vit 
lead, arsenic, aud bisulphide of carbon; of glosao'laUo-laryngeal paralysi 
in cornet-players and glaBfl-blowera; of neurasthenia iu professional men 
of the eouGtantly increasing clasa of prore^aional neuroaes : all of IheM 
and others that njight be enumerated, act in the pn^uotion of nervoufl dii 
eases by the emplcjinent of agencies and conditions which we have si' 
ready consideredn 

Psynhical Traana.— Important ae physical trauma bos been showni 
be in the initiation of diseofie of the nervous system, it ia by no meaua a 
potent for mischief as are the ineotal Cranoiata^ L'nder this Latter tan 
are inclnded fright, worry, grief, emotional eialtatioc, protracted mraitl 
actdvily, excesaive social and pedagogical stimulation or ile opposite 
ennui and idleness, and also perverted and exceaaive activity of tha 
ual functions. 

The shock due to fright or other sudden and escessive emotion ia 
lieved to exert it-s iiemioLOLia iuflueuea by causing a varyirig ilegrce d 
functional overthrow of the aympathetic nervous system. This deran^ 
meut of the sympathetic Dervoua system produces not only many of tb 
immediate aubjeetive and objeHive phenomena of shock, but also remol 
coDEequenoes, which appear as disorder in the nutrition of the oellt 1 
^ the eerebroapinal system. Wlien the nutrition of these cells beoomei Id 
capable cf n^oouplng the losaaa of the cell due to its functional tsierciiep 
cell fatigue and Hnally diaease are initiated. Upon the mental aal 
physical disposition and temperament of the eubject, quite as much ai 
upon the cells affected, will depend the clinical features of suoh reaullonl 
disease. They may be predominantly psyphif-al, presenting a retrogiadi 
dlssoeiation of the mental couiponeots of memory and ideation, or the 
may show thetuselves in a lose of inhibitiou, in inefHciency of execution 
or in the total impairment of certain special functionSf as in hyateiict 
amblyopia and aphonia. 

The other factors that we have named under the caption of paychici 
trauma operate to produce functional nervous disease and to predispoM 



ixrgutic diaease in the uune manner &s doea shook. Their immediate 

[ifrKto ATft distarbanc«a of ceU metabolism, and to Bcmie extent of the 

metabolism of thf^ entire body. Thiis are to be explained the 

of grieff worry, and protracted emotioDaliamj as these are mani- 

[faUd in loss of strength and health, with the attendant physical veak- 

Moompanied by depreciation of mental vigor, oioessive emotionat- 

&ud ideaa^ melancholia, and hy^^ochondriaais. 

BflUtioiuhip to the Epoch. — The impieesion seems as strong in tho 

.^MniooA of the laity aa in the minds of many phyaiciaiis that the Ire- 

[mocT of D^rvoua disorder is & aign of the timea, demonstrating that 

tm liring iu a world whose bustle and hurry inevitably t«nd to 

Iftf produrtiou of funotional aJid o^ani? nervons disease. While there 

% |troIaLlj more tratb than error in this conviction, there is yet 3, sufB- 

flBOimt of error to prevent an onquEiliiied aubsoTiption to ita ti^rma 

MfifloqaencdB. Fiinctional and crganio nervoua diaeaaea are rela- 

kftlyiaora freqnent to-day beeauae they are more readily detected and 

^tkeir pathogeny is Iretter uuderstood. Bttt the faet that neurasthenia 

\)m liasn Lnown only to the present genemtioa should not be coaairued 

scan thai it did not e^dat beforo the time of Board, nor ia one jus- 

,b£i«d in ihe belief that tabes dorsalia did not exiat before the time of 

Neurasthenia was th^ legitimate aucceaaor of the same eicit- 

Daiuei a thousand years ago as it is to-day, and tabes dorsalis^ liko 

English common law, has its sonri;es in a peritxl prece^liiig the kuonl- 

idi;e or laecooiy of maa. Xhe iuciease of wealth and the greater inteu- 

'lil7of tJie struggle for exiatenco have augmented the labore, the did- 

aod the idteDeefl of men. The growth of large cities eurtaila 

UDOuntof phjaical eteroise in young and old, while inereaaed facility 

{didacaiiou makes the burden of the growing organism a diffioiilE if not 

ilju^roLid one. 

Work asd Ncrroas DieeaM- — It ia impossible to say in so many words 

kt eonstitatea the Umit of work or iudtilgence that each Ktust set for 

with doe regard for his own safety. IndividitaJization ia more 

mt for the just apprei^iadcm of the combination of the fautora 

determine Uie onaet of nervous disease than it i» for the underataud- 

of tho causation of any other of the bodily ills to which some are 

ible while others appear exempt. Certain it le that no human 

can exceed the measure of his physical and mental strength with 

iptniity. To borrow from rest and sleep and the other factors of reeoo- 

ion ia to lend to dist^ase and death. 

Sexual lufluenoee- — Before takiag leave of the psychical factors that 

'»» operative m the causation of uervous diseaeeai it will be neceeaary to 

glT«Hniie eonaidoration of the inQuence of the functione of the sexual 

Qpon the neural economy. I sh.iTl have occasion to speak of the 

tp of etoeaaive and perverted sexual indulgence to certain par- 



ticular diseases of tlie nerroua system when upeaJEing of the epeciid treitt- 
ineot of D&urasbbenta, hysteria^ and locomotor ataxia. I am led to tlie 
pruaeut coDsidemttoEi b^iuise of the exialeuue amongst tliu laity of ii weTl- 
Bxed coEiviotiou tliab uunatur^ scjiubJ practiu«s, aa vrdl aa ^xcuaEiive uat- 
ural mdulgsnco, are axbremelj mjurioua and frequently the cauBd of pro- 
found digaaaen This conviction has been eiigeudcrecl to a certaiti oxtent by 
physicians, and thtre are tliose who still contend for its substantial jiiBti- 
lif'fttion. DiJnbllesa thi* early atousftl of tlie sexual functiop, eapeinally 
JH^ore tliQ }»Finod of aduleaoeuce, aud iti4 uuuaturjil indulgence, paiXicularly 
in oitBJtism, enter largely into the etiology of auch fLinctional dl^eaaea as 
nenmetlienia. The nicro physloal act of onaniBni, howbTer^ is not the tnosb 
potent etiological faotor. Indeed, if thia wers all that perverted sexual 
gratiSnation involved, the history of siiph sexual iodulgcini^es would ael- 
dncii pn?»eiit nervous aymptoroa. The mental fai^-tora are much more 
potent for harm, and theae are more likely to be augmeiited than allayed 
by intemperatd and unw&rranted advisers. Too often the terrorizing ad- 
monitions of veil-meaning but ill-adapted teachers or pareuts, the gbafitJy 
literature that wotoir Its pemJeions way into tlie hands of school boyi 
and young ni'Ti, wbt^rein h portrayed liy word and piiiture the physioal 
decay and nieutiil agony that hare followed such practices in their prede- 
onaora, are more harmful to the mental and physical economy than the 
mere indulgence itself- 

If we set :iGide our own moral and esthetic prtijjdioes, it fieems indeed 
diMcult to believe that uccaAtcnal masturbation should in and of itself be 
any more harmful tbait other forms of sexual Indulgc^cei The mdividual 
who has piLsacd the age of puberty with the common sentiments of a 
ejvilized oommunity may be expected to consider onanism disgratreful, 
fifthy, and injurious. He probably also regards illicit eexual iuterccuriie 
as both sinful and dangerous- The motives which lead him to self-pulhi- 
tion may he ninuE^rotu. He may intend neither U> masturbate mir Ui in- 
dulge in jsexual intercourse, but falls a victim by the wayaide to tempta- 
tirm^ offontliog hid own inherited and moral sense. He feels himself 
walkmg aixiut among hla fellows wir.h a feature of his life which h^^ must 
conceal, an object which all men would despite could they know, a whited 
sepulchre full of unholy desires. Small wonder if tho consciousness of 
himself as a monster of evil should lead to emotional deprcbsiun and con- 
dequenb disturbance of nictabolio equilibrium, On the other hand, he 
may indulge in masturbation because he regards illicit sejiual intercourse 
a greater evil or because he is over-shy and modest with the other sejt, or 
fearH the moral, srjcJal, and personal cousequencefl. Whether he yields to 
fear or other motives, he is likely to heap repruaches upon himself be- 
cause of his unfortunate situation. Of course, it is quite possible that 
he may arrive intellectually at the conclusion that there ie nothing wrong 
iu onanism, and he may convince himself that he may indulge in it with 



iapQid^- Though be gire hiniflclf no moral offeni^ and suffer no re- 
■ora^ jcl Lis iaheritod aad aoquired luoral nature vill revolt, perhaps 
utlbowo to bimaclf, at the action vbicb liia intellectual oociacioasness 

lAotber coDsideration not to be oTetloobed ia that the iraat majority 
flf bojiwlio iuilulga iii this practi^^u ceiLse U> do so before it can possibly 
biTedone Ihem^Qj harm; but iimoiig those who haveeotiroly given over 
njch pmcticea the aforesaid terrorizing warnings of the teacher, thoquockf 
ijLd Ihfl physician are not iufraquently oporativp, and thi^j nurse though 
lltff GOTii*Hfil the fear th^ they have through past error laid the founda- 
ftOD of fterioiis disease. It is lEicumbent upon thi^ phjateian to plucb 
(rcNB tbe Eoiuds of thoao who have been so improperly oriented the thorn 
vbch KQAUis in the shape of terror that aach indulgence is li permanent 
taarr^ of injury and the cause of many nervous diseases. This is not to 
Bimuin that tnasturbation is harmless to the physical and mental welfare 
cf the mdividual. The sexual function ia intimately associated witli the 
kigbrt u well as the lower natnre af man. The appi^aseinent of the Kf^xual 
t&otion which the psycbo- physical organi&m dtmanda cannot be obtained 
uil«u G«xaal erethism be the resultant of a. manifold appeal to the in- 
tellvcttialf moralf and festbetic faotors^ and not restricted as in masCurba- 
iMMi Ui the dermal si^n^e and dermal stiumlation alone. The physician 
ihould be keenly alive to the faet that the great majority of those who 
M^g^ to practiae masturbation or other perverted aexu&l indulgence 
9ff40j have apprized themsclTCia or been made aware of its viieneas 
iiid loathfiomeneaa are mentally and physicaliy pathologionl. In the 
pNaneeof disease which the patient or the laity may be convinced stan da 
b iriaticinship to such indiLlgenre, the physician must be on his guard, 
boverer, lest he mistakenly confound cause and effect. 

The pbjaieian ia often called upon to advinc in caaes in which the 
ehwMseema to be between a doubtfully servifloable «esual indulgence and 
tirt effects of oontinenee. Kan is endowed with a aexual function which 
toikes greater demand upoti the org:initim for its physiological exercise 
tlum does almost any other function of the body. To restrain it to the 
point of abnegation calU for an amount of inhibition that ta iujurioua to 
Mat, even though theae be rare cases. A very (irm ccnviotion prevails 
atba mindii of many physiciana as well aa of the laity that the human 
bsiag, particularly the male, recjuires for the preuervutiuu of his physio- 
kgical well-being an amouuG of sexual intercourse that ta measured by 
^ti sexual ener^ of the individual. Thia belief ia fostered by an 
ippril to the naturalneaa of sexual intercourse and to the oonflequ^nces 
thit are auppoaed likely to follow upon any interference with or cessation 
d Mture^a laws^ The beHef ia entirely unwarranted, and no pbysiciaD 
MOdhoaitaie to enjoin or to recommend ctintinence because of poaaible 
BQliy to the nervoua syatem. fsor need he feel colled upon to olfeud the 



mora, aense o£ the oommunitrf bj advumg eeiual iDberocura^ in oaaefl in 
.which it ciuinat he procured ander the rscogniaed forms of society . The 
physician whoee advice Ijj Bought iu fluch aituntion can only lay tho jft^s 
and c&jts of the sittrntion in an impartial way befora the patient, permit- 
ting him to ho the arbiter of hia own sexmil destiny. 

In the tii!Xi)&L life of the female there are two Tery inportaut pericrdrt, 
aexuiLL inaturity and the ocssatiou of roproduotion, both oE >v]iiGh descfvd 
mentiDti here. Menstruation and the fuuctiona that it bespeaks ai^e 
normal physiological functions of the female sex^ nnd were itiv>t for 
parental ignor^mce and willingneHs to sacrifice daughters to conventional- 
ity, the initiation and continnaoGa of this fimction would hare no depre- 
ciating effect vipon the vitality of the organism nor contxibuto in any way 
to the development of nervoua ailments^ But errors of diet, dresB) 
hygiene, work, lank of rest, and various indulgences rauae this period to 
play Brjiuetliing more thau a tnf^ii^g part as a catisative agt-ncy in the 
produotioD, of what are sometimes permanent afEeotions of the nerroua 
aysteTu. At no time after the birth of a child is the intelligent care of ft 
well-instructf^d mother more neoesaary or the Jack of it more stattlingly 
frequent than in the years immediately preceding the period of sexual 
maturity ia the girl. Not the body alouo recjuireti mors than UHual oare: 
the mind an well is iu a stato of irritability and experiencing changes of 
emotion and thought for which all poaaible vitality ia needed. It ia dur- 
ing these years tliat a child who pOBBesses a nervous temperament, espe- 
cially if she bo piecociouBj or introspective^ or mt>rbidly conscien tiouS| or 
not fully rabnst or able to enter into the sports of her compaDions, ia 
most sensitive to imprOHsiooa. She is in consequenci^ apt to he eubjeot 
to unaccountable outbursts of temper, to spells of despondency and 
melancholia, to have recourse to excessive indulgence in romantio faiiciea, 
to violent attachment and enthusiasms, and to all objects that encourage 
her morbid sensibility aud iutmspeotiou. Even if the mental, moral, and 
physical pW-k of the beginning of menstruation is not n (xiiisiderable one, 
her natural development dit ring th^^ea most important years fie-quently 
takes up much of her vitality aud aends her into adult life handicapped 
with unreal ideals and stoitdarda that will make her £truggle with the 
duties bflfore her a severe strain uiion her nervoua stability. In the 
same degreB to which the child is susceptible to deprdssiog nuggeations, 
to fright, terror, remorse, diatreas, and revulsion, is abe aineuable to the 
beneficent action of the antitheaea of these, The mystery which seema 
to Burround her can be so cleared away aa to preclude the poostbility of 
shock at least, and she may even be taught to regard her Htrauge vagaries 
of mind and disposition an weabuessea whieh can be overcome aud will 
probably bo outgrown* 

It is paiticularly at the menopauso that nature exaota a penalty for 
errors of training and living^ at this period mental and eniotional dia- 




SI9 ajfl to lippear in pathological degree- The woman also 
vita £bads herself eompanioDed with the ghoBt^ of imattained ambition, 

lad she realizes th^t thd opportunity for adiiering them has etipped 

tTtj- Ideals vhich bavo b«eu moral, mentalj aod physical aTiiiLuli hare 

tan rathiesalj uprooted, and tL^re is left a soil fertile for the growth of 

fraimism &od despoadenoy. The abrupt awakening to oncoming old 

lA^ urilh its entailmeot of wh&t ao many believe to be onattractiTenesa, 

IflDmes 10 aom& aa the white woman^a biirdeu. This period alAO with ita 

:tatio& of physical aud mental Titality finds many alone and DDpTO- 

[lidid for. It is Giuall wonder, then, that the period of the meaopause 

ihubea mote Ll^n its ptopoition to the ranks of nervous invalids. 

AltboQgh the wonmn of the peiiod haa the advantage of her eiater of 

ifcnerutioti a^ in that she haa sucoeBsfoUj forced an entry and main- 

[lUDi a gmc^ul place in the eporta and occupations of her brotherai these 

laBKmpIifihmenta have not brought the developmeiLt and stability of the 

MTfOOS system which theoretical ai]vocatea of the advanced woman 

prosnaed. The eaplauation of this is perhaps to bo fouud in the fact 

fthlt to proportion aa woman has gone in for modem sporta and activitiea 

<ibe haa Delected many dutiea and occupations that had a wholesome and 

p wa tfvative indueno^ upon the mind as well as the hady. She no longer 

mrstt her f^ildren nor waits upon her ai(!k. She netLher euiertuina her 

[ncsta ma directs her bouaehold. All these fonctiona ehe delegatea to 

koehoga. And then eho marvels that .she ha^ Jrehs/:^, mcrsj and attacha 

oi tterrM. Improved edue^tional facihties and eularged spheres of aotiv- 

ilj canaot acoompUsb their meed of benefit to the woman or the race^ 

a UuM are attained at the expense of duties for which her paycho-physi- 

nl oaganiam is a>lapted. 

Tub general practitioner has no mere important or diffloult duty thaa 
to eji:eT<;iae the requisite Hltill and to employ aileqiiate uieaaurea to pre- 
veot diseaaea of the uurvoua sjatdin. The fact that functional mud luia- 
tomical restitution of the central nerroua ayatem is but BeMoin Attainable 
after tte components have been aubjeoted to d^gentii&tive inHuenoce, makes 
the demand upon tbe physician imperative to pravent, if possible, Hnd at 
least to cut short, tbe course of these degenerative processeft. The proph- 
ylaxis of Dervoua diaeufie is bepet with otiHtacli*H that in snnio caaea are 
iuaurmoim table. The majority of patients come within tlie ken of tbe 
neurolcgiat after the functional or organic diseaaes from vhic^h they suffer 
have f^paaerl to be amenable to <'atisal therapy. Although the factors 
upon which the existence of the disease H dependent have perhsps ce&sed 
to ex art their baneful ioQueuca, tliey have nevertheless already done all 
the mischief that lay within their power. The period nittiD whiri 
cauaal therapy could have been clbcaciouslj employed may thus hav« 
long Biuoe passed. For eiampie, anterior poliomyelitis is geuerally 
seen by tbe neurologist oaly after the acute infection or irjtoxication frum 
wJiith ittook its origin bna ceased to exist. The patient anlTering from 
alcobolio juultiple neuntis has as a rule stopped or moderated his bihulous 
hflhita before he conaiilts tbe Biieciulist. Tbe same ceaaation of the ex- 
ciliiip caujie is frequently deteniiinable, in cnaea of neuposthoaia due to 
overwork, cf hysteria traceable to psychical traiuna, and in a considerable 
nuiuber of otlwr diseases. It ts therefore btiyoiid tht^ capabitiTieB of tbe 
neui'ologi^ib persoucilly to live up to the rei^uirements of the Grst principles 
of thorapeuticSf whi<:h TCquiie^ that the cause of diaen^c be asoertaiocd 
artd removed. The ^ueral practitioner, howevcri is often consulted for 
some trifling ailment which he readily recognizes as the product of over- 
work or other injurious exfess. Ht* should also iinderstnnd thnt tbese 
agpiriciesr unless Inter die ted, will surely lead to that prnfonnd ilepravity 
of the nervous system known aa neuraathenia. An intimate acquaintance 
with the causal dependence of nervous disease upon many of the eimplo 
and profound ailments which he bo frequently treats will enable Lim in 
many cases to avert their pathogenic activity- Many exceptions are of 
course foutid Ity tbe rule that causid therapy \» nut inilit^rttpd in fully de- 
veloped disease of tbe nervous system, as may be seen in tbe several page^^ 


dfTOted tD the consideration of tlia treatmoDt of thd Taiions sp«oifio 

Thr fantilj phjsician taa many opportuaiti«« to plaj a very signifi- 
ontpatt m the prevention of aervoufi diseases^ So many of tbe gcudnd 
toiMa whieli oume imder hifl imtnddiate observation hftve a XDoraentciifi 
dirwt ud indirect bearisg opon the etiology of cervons diseases tLal, if 
pftfA with onliiiary fcire^iiglit and the aljility to interpret the phenomena 
of diwase, he may forestall the developiueDt of diacaus of the ncrvoiia 
ijiUa vhoee beginnings are indicaticd to his traiood eye by very trivial 
lymptoma. The Dirurologist who aepirea to eoiopete with tho general 
pnftiCioner in this rola must bo learned aad cxpeneneed beyond his 
Ipwially in general medidne and pathology. The «arly recognitioii of 
(owphalitis would prevent, at leajit in part, many cases of idiocy, epilepsy, 
tnd other n^ental diaeases dependent vpon or asaociated with post-en- 
c^&Utic lesion. Such symptoins alao a^ eouvulsioiis, pavor nocttirnue, 
ud BOnjnaxabuIiani In children oftentimes give evidence of an unstable 
Mmms system and bespeak the uei^ess^ty uf Hgoroufi hygienri: and meiita] 
discipline. He who would successfully insure his patient a life free 
fivmoeTTonEi disorder mast lose no time and epaie no effort to counteract 
tit» effects of icfoctioafl, iatoxieations^ traumata, and the like. The 
^pliLlo]ogi£t paniculai-Iy ebouJd recognize that the treatment of syphilis 
TMommended and pnuiised to-day is far from efficient when judged by 
the standard of tbe neuroln^st. T\. can scarcely be denied that the tc' 
quimaenta of a completecure havei not beenattained so long as locomotor 
ituia and general paresis coutinue to occur aa frequently in those who 
iec«re full and orthodox antisyphilitic treatnient ae in those who receive 
i» met treatment- 

Tha FreTention of Hereditary and Tamiliary Facton. — In the pro- 
Cttling cha^rter I distinguish the hereditary and cuogeuital ctjndititnis 
t\dch, together with tlie neuropathic diathesis, furnish a rich soil upon 
vfaifih aerroua diseases develop from infectionsT intoxications, and from 
pLyucal and psychical trauma. Many diseases of the nervous system 
us thus dependent apon nonditiotts that prevail before the pai:ient*a 
Itrth. The number of those diaeaats ivhich comprise the claasea known 
u hereditary and familiary diseases is yearly increased as progress is 
Hftdfl in the interpretation and understanding of the laws of heredity* 
Tbe nature and origin of the^e diseases call for prophylactic and indeed 
mrstipatreatmentibfllinustbe begun before conception. This, of course, 
doanot mean that tri^Mment should not be carried on during the lifetime 
if tbe individual thus afQicted, but au efficient prophylaxis of familiary 
mdhereditory diseases noceasitates a discussion of such questions as the 
ait*rdietioo of marriafiCj the cessation of procreation, and the bringing 
^p of children. These are topics whieh in a measure lie beyond the 
frvriace of the physician ; but the family physician at least may be ei- 



peoted to hiive an innight into thd social and hygienic cnriroiiment o£ hir^ 
patients, and perhaps aJao a knuwled^d of thoir heroditary fihortcoiuingj^ 
ojkd affiictiona. Xhia being bo, he is pa^rti^arly choi-ged with the pj 
v&Qtion of hereditary nervous discuses. The quality of his advico wi 
deper>d not only upon his profession^ knowledgef but also in large p 
upon the ethical and soci^ sta^duda to Tvliich he refers hla ootiduct 
Tlio epecialiat whose counsel may be Bought in euch ca£«a ia able to 
A iJiure unequivocal etand than the general practitioner, because he 
expected to ha.vQ a. more autliontative aoquamt^noe with the genesis and 
outooma of diseases of il family and hereditary type. To tba b^st ol _ 
their respective abilities&ud opportunities they should unite to disrouragttH 
msLrriage of tJ:ic uniit. This claas compriaea aJl tbotie whose meiibal and 
physical short^ummga are calculated to produce in otf spring traits and pes- 
sessious that will render them unlit to bear the buvdeus of life and meet 
the requirements of modem civitization. 

There are many family and Lereditary diseases, auob as amauroUsJ 
family idiocy, ooDgenital spaatio diplegia, progressive muscular dystrophy^ 
for whose prevention no other means have boon suggested aave the radio 
measure cf surcesaioa of procreation. No one wilt be likcily to contend 
thatthiB measure is not wholesome and legitimate, how ever difficult it may 
lie of adoption. Some of tlie bei-editary dlfleasea, however, do ni»t com« 
within this category. For exajaple, migraine is exquisitely an hereditary 
disorder, and yet few physicians would cars to advocate the celibacy or^ 
childleasneflfi of the migrainous. Tlicn, again, there are family diseaau^ 
such AS Huntington's oi- degenerative chorea which do not manifest them- 
selves until the advent of phyaiological aenili^. Before one is jiistifi»i 
in advising againat the production of offspring for persons whose heritage 
ifi froighted witli the burden of this awful disease, he must first convioi 
himself that he is not refusing birthright to an Isaiah, a f^apoleon, or 
Shelley, all of whom enraed their laurel leaves before their fortieth yea^. 
Again, some of those atHieted with the Btrangs family disease myotonii 
congenita are endowed with exceptional mental qualities, which may bfl 
accepted as offsetting the pathological burden o£ this disease. When the 
physiciaD's advice is sought in regard to the question of the propriety of 
givtug birth to oSspring in such Inherited or acquired nervous diseases as 
epilepsy, hysteria, hypochondria, and eo forth, no hard-and-fast rule can 
be laid down. Whether or not snch perscjns slioold allow themselves the 
luxury of progeny is a question that they must decide for tlienjselven 
after they hive been fully warned of the danger of bringing children into 
the world likely to become a burden to thcmeel^ea and to the community^ 
The neuropathic diathesia or even a profoundly neurotic parentage does 
not^ unle^JB other ohntaclea apfrea*-, sufflee to justify advising against 
procreation. The ains of parents must be paid in an many ways 
it is far too much trt require that any oiia shall live a IJfe of celi1 

1*. ^M 




Dtfif chlldJeaa matriinoDj becanao he himself siitTers from neiinipatliic 
bMfldiury entailmenis. 

The PrcTtntloa of the Influejicv of Infection. ParticoUrlr S7phili«,— 
The momeiitouA r51e of infeolioD in the CQUsatiou of difleflMe of the 
ufTouA jLjstem calls for g«Qera] and sf»eci£o mcaauns to prevent tho 
nemua aystem becomtDg subject to pathogenic proceflsea, either directly 
fftm infecLitii or indirectty in conseifueucn c>f tlin development of tox'm^ 
mnttuit apon infoctiou. Malaria, iiiBueu^^ pueumottia, ajphllb, typhoid 
itrv, Boarl^t^ fever, roaaalee, diphtberio, &I1 act directly upon the nenroua 
EjBian or render it suaeeptibie to autointoKJcatioii. So imperative is the 
dwaaod upon the practitiouer of medicine and the pmctical bygienist to 
aercisetboKRighgciiig prophylactic measures that I abalL be compelleil 
to direct particular attention U> tbo deUu]s »a well as to tlie gencTal 
ffflturea of prvT^ntive treatment. Of these infectiouar fljpbilia baa 
becQ ehoeen for most e^tdoaive ooneideration, beoansQ no other source of 
mfficdon Imown to the neurologist acta with such frequeocy aod with 
inch paUtogenic virulence, Altha^gh this fa^-t is often enough empha- 
fiffdby the iieorologist, it baa not yet produced the impressiou npoa ths 
miodB of the general practition^ i and Bypbilologist that it deserrea. The 
genoial scope of the prophylactic treatment of n«rvoua dise£kse» due to 
Bjphditio and post-sypbilitic infeotioQ is such that eitenaive considera* 
tidD of the treatment to be accorded other infectious sources wtIL be un- 

The prevention of syphilis ia in reality the avoidance of proniiscuoxis 
SBinal intercourse. Syphilis of tho innocent comprises such a small 
proportioa that it can be neglected. The treatment of syphilitic disease 
of the nervoua system (and here ouly the genuine syphilitic varieties are 
iDt«aded, &i the parasypbilitio diseases are in no way amenable to anti- 
typhilitio luedicatiou) might be dismissed with a line' maintain the 
nialitj and increase the uutritiou while poshing TJgoronaly antisyphilitic 
medication — mercury and the iodides. Althongh such are the ludica- 
bona, and although to eiicompass sixeh reevlta the physician must bend 
)a& most strenuous efforts, the matter is of such ra^t importauca that it 
amt be considtfred in more detail. It may be platitudinous and com- 
monplace to rererb to the prophylactic treatment^ but until the family 
physician becomes imbued with the fact that he owes to himself and 
to tho^e who rightfully b>ok to htm for instruction and orientation cor;- 
cenung the avoidance of diseases the duty of bringing forcefully to their 
eogaisance the widespread dii^emination of a diseA^e, syphilis, that ia 
man potent in the production of misery and the entailment of suSering 
than any other prerentable disease, such truisms aud platitudes must 
continue to be «poken by those who appreciate the euormit}' of this 
>or>iirge and the force that it makes for mischief. No one can have had 
lOQch experience with syphilitic diseases of the nervous syabem wtthont 



being soon convim^ed that uiifortimatelj it ia not he who indulges in 
riotous livio^ and gives liimHuJf over to debauchery that becomes infecbod 
with syphilia so ftequentlj &b it in tho initoccnt, uninitiated youth. Too 
muob emphaaif^ oannot l>e laid upon tha ^vfimiiig given by a. pereou of 
autbotity, euch na the family ph^eidan should b«, that the jeop^dy in 
which Ruth indulgence placea the pers^jn's life, liealth, and capacity for 
usefulness said enjoyiuect is ccjjjpatable to no other cxperienco which 
he oan poaaibly have in erery-day life. 

The Influence of Antuyphilitio Treatment— Once the individual has 
bacome infected with Gyphili.'^, there is no treatment that will abso- 
lutely assure him that the nerToiia pystem (the blood-Teaaels^ the pa- 
renchymaf or the coverutgfi) may not become diseased. There is much 
that can be done by way of diminiahing the risk of such involvement 
of the nervoua aystem. Pue appreciation of this and the avoidauco 
of ffiotors that have been pointed out as oonduciv© to the oecurrwioe 
of syphilis of the nervoua system constitute what may be termed the 
propliy]actie treatment Tha itiust important meai*ure for the preveo- 
tion of implication of tho nervous Hystem is thorough and proknged 
administration of mercury and iodide of putaeaium. It seema neceasary 
to mate thie unquatihed Btatctnent before pi-oceeding fartht^r, in view of 
the fact that I mu^^t revert to the inuumerable instances in which eon- 
formation to this practice fails to give anything approaching immunity to 
the nervous ayfiteni. Although nuch treatment has little or no capacity 
to prevent the paraeyphilitic diseases of the nervous system, it can bo 
justly maintained that it does much to prevent and to overcome the exu- 
dative or true BypbiHtic leBions of the nervous syHtem, the same as it 
does simitar lesious of other parts of the body. Yet that it do«9 not ac- 
complish this CHd with the certainty that syphilographers the world over 
would have us believe is known to every neurologist. And the pemi- 
eiomtnes9 of the teachings of such syphilographers is so great that it is 
necessary to revert to the matter at some length in this conne(?tion. It 
IS OEie of the commonest experience's to read in medical journals and 
books, or to hear in tbe discussions at mediciil societies from the pens of 
lips of prciioineiit ey philologists that sypbilia is an eminently cu ruble 
disease. Stick statements are apparently substantiated by convincing 
statistics, and few will dvny that those who diaaeminate them are en- 
tirely convineed of the righteousness and tenability of their position, 
Yei wp who see phases of sypbititio disease entirely different from th&j 
manifestation of it in auperficial tissuE^s which forms the preponderant 
bulk of the syphilologifita' practice know that they are wretchedly in 
error. It ia a duty of the neurologist to counteract the banefulness of 
such teaching, and to point out to the syphilologist tbe crToc of his way. 
At least one-half of the coaea that come under treatment for genuine 
syphilitic disease of the nervcius system have been subjeeted to wimt ia 


oitfidBr^ tiie modt approved plan cl ftntisjphilitio Ueaiiuent. It is col 
iiffcnlt loehow thikt tbo dicUiin which bA3 received suth vide diaAeiaui&- 
ttobuidacce|>latioa, viz., that involvemcat of the nervoua 8jst«iii ia a Ifite 
ff lertury mamfesutioTi of syphilis, has stood m the waj of a proper 
(covption and utilixatton of the preveotive treatmevit of iTitraspinal and 
JDOiciaiuA] sjrphilis. As & matpter of fac^ the dbbeution of tht; perivaa- 
cultf >puwd with small roniid cells and a formatiuc of a coat-aWve-Uke 
^Mth around the vessels of the meninges or of the pareac^hyina of the 
ELArroas systeixi are oftentimes amoag the earliest constitational mauLfea- 
odnuof Bjphilis- They may md**<l be contemporaneous with the de- 
lelt^iQDnt of cutaDeoEiB aitd mutious-iiiemliniuo atfectioiia usually G|K)ken 
of S3 Beco&darj- The majority of sj^philographers cuDtecd thut the con- 
ftitutioual treatment of syphilis should be delayed until the appearance 
of " tMondaries, ^' and if this plan is followed, it is easy to underst^Jid 
ihiitiie orthodox treatment of sypbilia does not prevent what ii ordi- 
Eirily called syphilis of the nervous aysbem. This fitatement shoidd not 
bscoDstnied to moan that antisyphilitio treatment i» not capable of cur- 
ing lypbilitic disease of the nervous ejatem. As a matter of fa^t, unices 
ualeeioQ be of such severity that it causes the death of a cc»mponent of 
ibscerYCMis system, such treatment fortunately ia at times sufGck'nt to 
effect a cum. The fact that antisyphiliiic treatment la not so sucoessful 
ID curing syphilitic disease of the uervons system as it is in curing syphi- 
litifl diaoaaeA of other tissues of the body is explainable on ttie ground 
thU tiasoea hariag highly developed fuactiotis do not tolerate so muah 
tfrutural etieroachmeiit as do those that are sCrueturaUy and functiosi- 
aUj less Itjghly developed. 

The Time and Mode of Administenng' Antiflyphilitica. — This leads 
Q to a few remarks concerniug the time when auti syphilitic treat- 
Bat should be begun, the plan whieh should b» followed in carrying 
It cat, and the duration of such treatment. Naturally, this is not the 
plv« to consider tliia laatCer iu gieat detail, nor does the writer feel 
ibi bia words should hv given any weight save as aii ejcpresaion of 
onnctioD baaed on personal experience, which is small compared with 
ttial of manj syatematio writers on the subject, Neverlheiesa, it is ei- 
{•nrara that baa been gained in ths treatment of syphilitic lesions of the 
tTUnan body ^noountered in general and nntiro logical practice^ As the 
ptiuit uf vi^w of such au one is quite different froju that of the syphi' 
lalogiBt, aud aa hia is the vantage -grouud^ these may eotitle bim to a 
lesrmg> Granted what baa beeu said above coooerning the temporal 
wJifjrtfU^hip of syphilis of Uie uen-ous syatem^ it most be readily aeen 
Uatths urgency is to begin antisyphilitio msdication at tlie earliest pos- 
nbl« momeat, if the object is to spare the nervous system- This does 
jMlKiMn tlmt Antiayphilitic treatment shoold be begun on the day when 
thi inititJ lesion is discovered, unless it be that one can theo oonvinoe 



himself of tbo real nature cf tha imtiol lesion. Sy philologists eaj that 
it is useless to b^gia treatmetit at suf;h a time because the system ia noi 
jeC itifpfited and bepause anliayphilitiu meditation gives no immunity to 
the cells which iQucit hcittle witli the ayphilitlc viruH aa sooa aa the poison 
ig absorbed into tho sjstom. In tlie tiumo broath, many of them aay that 
ono of the most oogeot reofloiid for delayiog auti syphilitic medii^atioa is 
that wd may not obscure tlie diagnoatta woi-th of the secondary nmnifesta- 
tioQs, Th<-n we are afik«d to believe that there is no discrepant^y in th^o 
t\vo atateiuiuits. If antiByphilitic medication has no virus to unt upoD, 
how can it in any way prevent the appearance of aecondory manifeata- 
tioDfi? Any one can eee that there 13 a tacit aJmisaion ou the part of 
Biieli writers that antiayphtlitic medioatioa does prevent ench"second- 
aties/' and just m bo far ag it does, it tends to attenuate the eypbilitic 
vims find make syphilis a moi-e curable disease. AiioLher objection to 
early njedic^ation^ so puerile that it scarcely needs consideration, is that 
such medication tisea up the rccoptiTity of the gaatro-inteatinal tract 
for the Toocption and absorption of mercury. Granted that there be a 
grain c* truth in this objection, may we ask, Is the receptivi^ of other 
avenues atao exhausted? The time to begin antiayphilitio meiiiention is 
when the rllagnoHia can be made. This rule holda gL>od iu the treatment 
of all diaeaaee. If we were dUcasBing the measures that ahonld be 
adopted to grant immunity to syphilis, then we might apeak of the ad- 
ministration of a syphihtic serum or antitosin. JJut until such fi sub- 
fitanoe ia discovered we most speak of the utilization of measnres that are 
at hand- Unfortunately, it is cften urcesaaiy to wait for more pathog^ 
nomonio manifestations of syphilis than ihe initial lesion. But it ia im- 
possible to beguile us into the belief after the teachings of generations 
that the initial lesion ia not oftentimes absolut^'ly pathognomonic. How 
little hesitation do we have in putting a patieDt through u most rigorous 
and elaborate plan of aatiayphilitia treatment when be comee to us widi 
symptoms which we believe, but which we can in no wise prove, are in- 
dicative of visceral or vascular eyphilial Then compare such procedure 
with the abhorrence and studied protestation whi(?h many writers on the 
subject of syphilis manifest against putting a patient under an ti syphilitic 
treatment who hiis demonstrfible hut not abaoluteFy pathognomonic lesions 
of syphilis until they can htt corroborated by tJio appearance of mani- 
festations which even the laity recognize as syphilitic. Of what use is ex- 
perience and diagnostic insight if we cannot avail ourselves of them for 
the benefit oE our patients? This is the first article in the writer^s confes- 
sion of faith in antiayphllitic medicatjour and now to pass to the second- 
We not infrequently encounter the statement that mercury is the only 
real antisyphilitic medicament, arid that iodide of potassium is an absorbi- 
facient aa potent to canae the diaappc^irance of any cellular cxndate as a 
ayphilitie one. This do doubt is literally true, but at the same time it 


iopA lomcst i>eniicious and faulty interpwtauon and application. AJl 
ITpbikJogiata ^re in iicconi in teacliirtg tliAt the e&rij result of tlie cxiflt- 
BTfl villuu the syatem of tLe diHuaiblts poistni of syphilitic iofeotiDii lk 
tbfi pfcdoction of hetpcrologoua novr cells. It la to facilitate the reutDval 
of Ibaeaevr to^Es, or to cause integral changes in them tliat V'Ul aLJov tho 
^Aorptive tiuida of the Ixxiy t4> remove ttienj, that iodide of |>otajsaiuni is 
prejL If this i:^ granted, iodido of potussiuiD in not unly a real aiitj- 
s^hLlitic ageui^y, but jr, ^Lould bo giveu in the earlier goui^g of the dis- 
M3e, not aeceasarily during tbo fir^t veeka. The writei^s desire ia 
Bn«ly to ahov tbat tlic admlDistratioa ot iodide of potaasium should not 
teddayed until the apt^earance of the so-ealled tertiary Bymptom&j or 
imtil >Jter two ot three years from tlie time of infection have elapsed. 

The mode uf adniiniabering mercury and iodide of potassium need be 
tut tari^3' cotialdrred, and that for the purpoae of ni^iii^ mention of 
|ttMitftl preference. The vril^r has had bet;ter results from the uae of 
aiwncy by inundations and hypodermancally than from any other pro- 
ttdur*- No definite rules concerning tha dose of mercury can be laid 
dn«-n iliat will apply to every case of ayphilia of the nervims system. 
For one pAtient it may be a drachm of blue ointrueiit nibbed in every 
d^, continueti for from four to eight ^re^ks \ for another it may be a 
ULf ounce, ai.lin mistered for the same time. A youth imder ttie vriter'a 
cv^ for meningeal and cortical gummatous deposit, which h:ul failed to 
ispfove ander mercurial medioatioti by the mouth and skin given in eon- 
Trntianal doaes, haa nearly recovered under the use of one-half an ouni^D of 
biuAouiLmetit, rublixl into the skin ea<^h night at the expense of one hour^a 
bns and proportionate ener^ on the part of n nurae, and three hundred 
(nms of iodide of potafisium per diem. The patieot has bad two (^ouraes 
tf fcitty days each, with an internal of on© month between them. Almost 
M mporiAtit as the administratioTi of nteroury in the trejituLcnt of exuda- 
tiie syphilia of the nervous system is the adoption of nieasurea for the 
Oiintcuuice of nutrition and tone of the patient. The results thot can 
h*i4itained by devoting close attention to the digestive and osaiinilatiTe 
otfUis and to Lite einunctories are ao much better tlian when these are 
DCftfctid that they need merely be raentiooeji- The moat; assiduous 
Mn should be gireu to building up tbe patii^nt^s general Dutrition. 

When there exist reasons for the prompt and thorough bringing of 
lbs patient under the inHoenee of mercuryf the drug should be vaed 
iticaUy. The preferable salts are the biuhlonde and the tanuate 
mry. My individual preference is for the former, as I have not 
vroontered the disagreeable effects from ita use, principally pain and 
laalited cellolitis, that are BpoKen of by most writers. The elected do«c 
Aodd be given in connection with ten times the amount of sodium chJo- 
Hdl ud injected into the muaeles cf the hips, not into the subcutaneous 
bla Therefore in an adipose individusl it is necessary to itse a long 



neuLlle. If th^ apyilicatiou proves painful^ a small amount of morphine 
CAa be inje<:i.e(l previously or aiimiltiuieoualy, Tlie patient ahoiiUl be 
brought under the iufluence of uictcui^', hut ihia doea not mean th&t he 
should be brought to realize tither the i>t'ofouQd licute or chrODia effects 
of luorcuriuJ poiBoniTLg^ It is not neeeesary to t^auae active ptyalif^m iu 
order to get the eS&ctB of the drug, no more Ig it necesfiflry to givo it 
until it causRH great ci**pTPtuatioo of nutrition. There are milder aynip- 
1,umstbau thosa uf uitiicurial iutOAicabioa, aud tJi« uppearauce of theiu 
should be interpreted us a sij^al that the patient has bail for the time 
being all the mercury that can safely be given. It is injurious to cany 
tbe prucBHs further, unless the ooiiditiou of the patieiit*e nuttitiou cati be 
BO improved that more of the drug can be utilised. Aa a rule^ tlia requl' 
altK degree of mercurialization can be biought about in from four to eight 
vref^ks, mid iJifu the tieutiueul tibouM be entirely inlfciupted while lueaa- 
urca devoted to the tonification of the evBtem are adopted, or the drug 
dhuuld bt* administered in small quantities during the utilization cf the 

It is ofleniinjfs adv^utagfous Ut administer iudtde of pota^Biuni i-.rrrL- 
temporaneuUHty ^vith thti li^e <jf mercury, pLovjdLn^ that the two together 
do not too Hcnously dt^preciati? the patient's uultitioa and vitality. If 
they do, the mercury should be given lirst in i'^udative sypliilitia nervovie 
diaeaae, while the iodide of pritasaivim should invariably be given prece- 
dence when the lesion of the nervous syfltam ia of the nature of a granu- 
luma. Afl a matter of faot, mercury has very liille elTfct in causing 
disappearani-'e of the latter, althouj,'h it may havL^ to bo givi^n to prevent 
the further formation cf such deposits and increase of si/e of those already 
oxiLiting. It is impoesLhle to atate categorically what the dot^e of iodide 
of potassium fur different individuals with gummatous formation in the 
nervouH system may be, For one patient the dose may be fifty grains, 
while for another it may he five hundred. The rule is to begin with a 
comparatively small dose, aay twenty grains thre€ times daily, and iiL- 
crease from five to ten grains each day, depending upon the urgency of 
the symptoms. It should be borne iu mind that in aome eases in which the 
smaller doses, sui^li as half a draelim three times a day, do not liave any 
effect, a dtwa o£ one hundred grains or unji« three times h day ia quickly 
followed Lry beneficial results. The duration of aniisypbilitic treatment 
given to overcome disease of the nervous s^'Stem or ite coverings will 
dej^nd largely upon the readmess with which it responds to treatment. 
It is needless to say that it should ba kept up until the sympiotna of such 
involvement have disappeared or until it hiis been conclusively shown 
that they are unamenable to treatment. The treatment ehould be con- 
tinued iu milder form for several months after the cessation of symptoms 
bespeaking its activity, and the patient ehonld be advised to talfe a 
"cure^* of silt weeks' duration ^very year for the remaimier of his life. 

fHS PSSVKTmoii nr diseases d^^S^ECKBvoijg syvteh. 35 

Tbe GcncT&l Trestmertt af SjrphiliA of th« Kervoos fiysteni. — Tho 
jen^ tr^Atment of ejphiha of th? nervous ej-sl*iii, asitie from the 
ubijphUitic medicatioa Bpoken of nboTe, mny be jdumnamAi in a few 
«fdi- It is practiraliy the sauio oa Lhe treatnneab of tha> depressed 
irpei td neoiastLema- Pbyaical and mental fatigue or uijlliiitg ap- 
rroachuig eicccaBeo is to be Btrennocslv avoided. Tha neccasitj of at- 
ntun to Uid reooastructivQ forces of tha system aod to the state of the 
f w aaw j r org^jia and avenues has alre^iily been spoken of. An easj life 
gat of doors, vith aufflcieiit exercise to keep the body in a state of good 
Eilijucal development^ with indulgeooe la occupationa that dirert the 
patifat'a oaind, keeps him from brooding over his ailments and antieipat- 
isg<LireTeBuItsnndhaBthoaamo usefulness here as it baa in nearasthenia. 
Othtr caMS will bd most benefited by putting them through a mild rest 
pivtk of treatment, the utiliTation of simple tonifying hydriatic measures, 
pbia, nourishing diet, eto. The special treatment applicablo to each 
raw will depend largely \t\xni the intensity and seat of tho lesion. It ia 
notU) W BOpposed that the treatment which would be applicable to a 
mOd degree of pAChymeniiigitis or leptomeningitis of syplulitic origin 
ibosld ba tbe saiue as tbst for syphilitic spinal paralysis nr syphilitic 
adsftmtis of any y*art of the nervous syatem. Ia other words, after 
ibe idmiuLStration of the aEtisyphilitic medication and tl^e measnrcs 
Ulw to Enaintain the nutritiOTi the treatment consists of individualization 
nd ttie adoption of meaaures to connteraot individual symptoma in dif- 

It is diflOcnlt to lay down rules for guidanoe in the symptomatic treat' 
omtof ayphilia of the nervous syatem without particular confederation 
df each syphilicio disease- For example, the eymptom that demanda 
nltff most ttrgently in syphilitic spinal paralysis may be incoututenoo of 
viMor fsces; in cortical meningitis it may be attat^ks of epilepsy ^ in 
biilir m«ningiti^ headache and optio atrophy. Eat^h symptom calls for 
ipKial treatmeut or inedicatioii ; it remains only to be insisted upon thaL 
i^iaplom occmrinff with ayphililio diaea-^ of tho aervous syateoi calls 
Iirthe aame treatmejit that would be accorde^l it as the result of other 
«Ma. For instance, the occurrence of epileptic attacks with symptoms 
mdlcadng a conical pachy- or leptomeningitis calls for broinidf^ in addi- 
tuioto maistent autisyphili tin medication or extirpation, si3 though the 
epilepsy were dependent upon sotno other caii»e. Headache, which ia so 
oftea a moat uncompromi^iDg symptom of syphilitic involvement of the 
Aura or pia, is ameliorated by the administration of phenacetin, antipy- 
rin. or tlie like, and by the applicjition of cold to the bead. In some cases 
khe adminiatration of even niorjiliine may be required to grant temporary 
ntpittf;. Sleeplessness Ls similarly treated aa though dependent u^wn an 
otinly different condition ench as neuraathenia by hydriatics, massage, 
fvpecUU/ stroking of the throat, and by the administration of hypuotiOB, 



Derelintioa of the Bphincters^ aptomineiit symptom in ejpiiilitie myelitis, 
rf^uirea tlie fia.iue treatmect aa vhen it occurs with ether vaneLle^ ci( 
myelitis. As the oame may ba said of the symptomatic triAtmeiit fci 
oilier coaditioQH, bed-soree, fmd epastioity, further discusaioa would acem 
uiinecBssary in tliia cbapt^T. 

The ETeGcaslty of Treating and Curing InfectiouH DuefliCefi. — The re^taous 
for not giving e stftnled couBideraLion lo the ilelJiils of prf^vt^titiva treat- 
meut of the diseasea of the ncitvous ayatf m due to other inEectious agenta 
have booD. etatod before. One other topic in this connection deset\ea 
brief mention. The idea that it ie well for ahiJdren while they are etlU 
young to go through aa many aa pOHaible of the leas aerioua infectious 
tliseaaea aueh as measlea, chicken-pox, whooping-cough, and ao on, baa 
net yet been entirely eradiuated from the minds of the laity. Nor, 
we fear, is it taught with auf&cient insistence by the physician that theae 
seemiogly innoouovia diseases eanaot be loft to run their own course with- 
out treatment. It ia often true enough that these mild infectious dis- 
efises require no treatment; but it is none the less a fact that theee 
dirieaaea should he carefully treated when they occur in children afHicteii 
with tha neuropathic diatheaia, and that eyory care shoidd be taken to 
fjwrilitato the removal from the eyatem of tiie toxins which they always 
create. The ways and means of doing thia do Eot require consideration . 
Little more is demanded than proper attention tu the eliminatory avenues 
and to the state of the gpusral nutrition. It ia the duty of parents to pre- 
vent their children fioin roTitrai'ting iufectiowa ilrseaaea, as it ia the duty 
of the commonwealth and those who fierre its department of hygiene, to 
prevent the diaBemination of these diaeasea. 

The Prflvention of Disease of the Hervous System Duo to Constitutional 
DiBOrders. — Within ihe last few yidsia it ha>4 been thown that a few of the 
diseaaea of the nervoua system stand in elose pathogenio relalionahip to 
Bomo blotrd diseases; midi, for example, a» solerodia of the posterior eol- 
umna of the spinal cord occurring with pernicioud aacemia; atiixio para- 
plegia dependent upon diaseminated myelitis ooeurring with antemia and 
condition a that are productive of auEemia, such as cancer and Bright'a dis- 
eage^ and the peculiar trophic c^oiirfitifjn called hypertrophic osteoarthrop- 
athy, with chronie pulmonary tuberculosia, I^ittle can be said concern- 
ing the prevention of tbeae conditions save that one should he mindful of 
the possibility of their occurrence when such constitutional diseaaea extst, 
and that every piecaution should he taken to prevent tliem- It is not at 
all improbable that some of the cases of ansemia that areooniplicated with 
decay of dilTereijt segniecta of the spinal cord are amenable to treatment 
if taVeu in time. ' 

The chronic constitutional diseases that have particular relation to the 
oooorrenceof nervoua diseases are few in number. They are particularly 
gent, arthritia^ diabetics, obesity, and tibrotic diaeaaes of the viscera, suoh 

Tax PKcnwnoN ok DiSBAfiSd of thr nkrvuus system. 37 

atba baut, kidneya, ftnd liver. The ldSu^&co of gcut and rheumatism 
istbsprodQCtioii of uerroua dis«aA«s his b«ea very diScTciitly estimated, 
Jfi Fnaec^ the arthritic diathasis is giveo verj gre&t importaDiw. In 
bglttd, same vnters contend that tb« ntlc-ocid dijiLhtrstd and tb« 
of uric ftcid M the svAtetn aie tho conuaoucat causea of func- 
serroua disease- In thia countrT, neither of them has been found 
•ftplij^the important role indicated bj tLese irrit^rs. It isundeniaUe, 
lUMiiu, that tbera is a clo«e if not a ^^cent relationship bMween the 
|ic»n3Co of wtii^ acid m excesaive ajuuuut^ the rh«amatic dj'aciasiaf anil 
ibe exiAtencc of fuactional nervous disease. But it must not be for- 
pXko that oftentimes fiuch manifestations of perverted and incomplete 
Mtabolistn ate n pait of thd functional nervous disease and not ita caaae. 
Vhaiher it be one or tho other it require treatment; but if ic be a part 
filths DfTTOQs disoase, and not its oause, treatment directed against the 
dilOBe itself wiU be eu^cient to overcome it. Diabetes sometdices pro- 
daen disease of the peripheral nerves and quite a^ often tnvolvenjent of 
tlM Spinal cord, similar Xa that oecurring with pernicious ansmia- Dia- 
IwOe mtilHple neuritis causes a clinical picture not unlike that of tabes, 
■nditia therefore not infrequently Hpukeu of as pseudo-tabes- It maj 
aho^ by leading up to degeneration of the blood-veuels of the brain, be the 
and important etiological factor in the twcurrence of cerebral apoplexj^, 
sriadsed oi spinal apoplexv. Knowledge of these facts makes theneces- 
sttj of applying the most; approved traacment for diabetes eveu iztore 
tffpnt Jusl what tliTs treatment m^y be need not here concern us, 

hiterdiction of Stimulants and Hamotici. — Tlie rule pla>ed by al- 
cohol, tobacco, tea, and coffee in the causation of nervous diseases haa 
bus indicated vith sufficient exphcitDess in the preceding chapter- 
liLlls remains to be said in this pLiee regarding the ueoessity of using 
Ihflm temperately or not at all, if the nervous system is to remain in- 
Qd, Just in proportion aa it ia realized thaL narcutica and atimulantfi 
cf ererykind are always injurious to the immature ncrvoua system and 
Ikl the necessity for aelf-control to avoid excess is more u^ent for the 
DSnnpath, just in proportion will these substances become innocuous. Un- 
flBtanately, those of neuropathio constitution, for whom alcoholio drinlcs 
andtDbaocn are most injurious, are the very ones who have difficulty 
ia exercising the necessary restraint of their appetite for narcotics and 
rtHDtJants. They often consume lar^ quantities of both, not only with- 
out ipparent injury for some period of tune, but frequently to the ac- 
complishment of more work. Chain smokers and tea tipplers are often 
mm ui^ women of highly organised nervous aystem and of more than 
canutoa mental eudowmenL Unilcr normal conditions their supply of 
nettaos Aiergy is quickly exhausted, cind the eScct of the stimulant or 
ureotic isMemingly to delay this. Such temporary stimulation is at the 
opauft of neural integrity, cot only of themselves, but of their progeny. 



Avoidance of Ph7BiCfli and Ftychical Tratima. — FoUf>wii]g th« coii- 
aideraticjii of preventiye ineaHurbti directed tu herKdiUir/ coDdilions^ U> 
iafectionB auil iiitoiicationH there remunfl for examinatioa the me&Qs 
oE preventiDg the patbogeDio actiTitiea of phyeical and psychical 
trauma. In bd for as either physical or m^atal shotrk may be acci- 
dental, the trauma is of course incapable of being prevented. It ie not 
within the province of prophylaxis to conirol the operations of chance. 
Many profeasioaa aud occupabions offer uiiusiLal opportuxntj for either 
physical or mental trauuja, or both. Tboso who take them up axe poa- 
aibJy better aware than others of the imminent dangers to which they 
have expost^d themselveB. A warning to those of neutopathLO heritage of 
their increased EuEceptibility to the pathogenic resuJtacts at accidertal 
shcck is the only practical prophylanlio measure. Other ocpupatione, 
however, either becauB© of exceaBive demand of time or toil or Wajsr 
of the incidental von-y, are specially deleterioua to the health of those 
with tha neurepathio disposition. While lack of interest in life and 
v'ork is oftentimea a fecund soil for the development of depressing cer- 
vons diaeaRe, it is alsu true thFit there is uo more considerable drnin upon 
the nervous system than that which results from tlie worry due to the a^'- 
ceptance of responaibilitios in the a bs once of the ueceasary intellectual 
aud moral <]ualificationa» 

The mode of life ia an object for prophylactic regard, not only in 
states of health, but in many diseases which do not themselves fall within 
the nlaas which are receiving consideration in this volume. All nervous 
disease ia accompanied by impoired metaboH^m and mental depreDHion; 
these couditiona may be aufticjent to lead to functional depravity, like 
neurasthenia, particidaily if they occur conjointly with a mode of life 
which furthers BUoJi palhogenie devylopmewt. It ts often extremely de- 
sirable tiy mwke decided rhange in a patient's mode of life, and in the 
Mirrouudingij wbich may bo contributing to the cxiateiu-e or occurrence of 
a dieease* It i^ tiub sufR^'icnt to auggC'st that suoh chongo be mado; the 
physician must give precise and accurate inBtructions with the purpose 
of removing as far aa possible all Bouroea of irritation and depression. 
He must eKaiiilEie with care into the locality for possibLe dampness^ 
malarial couditiona, etc- He should familiarize himself with the pa- 
tient's habits, with respect to bathing, clothing(of especial importance to 
women), the nniount and quality of food, sleep and rest, moutal and phys- 
ical application, relaxation, capacity for enjuymeat, lime spent in open 
air, amusements^ aocial position^ and its entallmenta. Transgression in 
any of these directions shmdd be counselled against and if the physician 
is unable to secure conformity to hia inatructions, it is his duty to with- 
draw from the case. Otherwise he jeopardises the chances of his patient a 
return to complete health and hia own reputation. 

The Avoidanoe of UnpropitiouB Enviroament,— Many diseaa^a of the 


piTTOiu aj^Ht^m which are thentJielv's iiinoctioua foster st:Lt^a of dt-pressioti 
tflbjpot-lioDdriaual teudeuciea tbrough thv ti^atmi'ut that* is accorded Uia 
pUmt at h(Miic> Ifc muat often transpiro that maDv patients in whom 
iKb 7^17 first Bjmptoius of neurasthenia depression manifcet th^mi^elves 
■QuId be better treated upart frum the immediate envircunieiit tii which 
Ibfj or^MT and avay from the s 11 rrouo dings, social and fanLily^ which 
m a^it uiiQOCsoasarily to prolong theic period of cAtsteuL^e. Outside 
o[ tlio home, prirato hosi^tala, aanalotiA, babha, iratcr cures and in- 
uoioarable iDStitutions devoted to the purposes of speoioL modes oE 
tivatmeat oQ^er themselves. Xhe^ perhaps have a healthful and toni- 
fjing effect upon the patient, in ooiD[ielliiig him to rec^ogiiixe that 
gM^iig well is a Eerioua l)u&iiie^A whirh ia to he an^complifllied sa soi>ii 
tf ponibleH But there are man> drawbacks aiid daitgera connected with 
ibe IB discriminate rei^ommendatioa of comnLercioi oacmtoria for the treat- 
iKai of the majority of nervous diaeaHea. The eff&it of stu-h inoar- 
offttion upon aome minds is an impression of invalidism. Mor(K>rer 
ibfl rolleotion of large nnuibera of peraona in oaa lotrality where they 
fnteiiiiw and dioctias their infirmities inbenailiea &11 the suggeatlve fsic- 
tofs irhieh produce such a strong psychical inipreaaioni TLe wanl; of 
sufticieiit mental and physir-al activity neocsaitfited by withdrawal froia 
Ha Bormal activities of life is also debilitating and prodnctire of hypj- 
duDdnicol iotrospeciion. Eljibjriitd routme treatment in many of thear^ 
iutitutioQip without sufficient effort ut the strict individualiuiticn so 
iit»ssAry in nervous diseasta, causes agencies which sse good enough in 
tliemselvea to bet^ome baroiful through excessive application. Imitabon 
ilio plays an important rc'ile with patients of neuropathic disposition, and 
tflQfasthenics and hysterica ai^ often led to \tox. the compaHa of real 
and imaginary syinptofljs. Close contact with patient'i MJfft^riug from 
Uritus diseaaes may olno tend to Lhe dfvelupment of aimilar symptoms 
tnthue who have bad no trace of fhenx beFore> This is true not only 
ofiDftat&tioDal hfe in genera], but of the publitr rcBorts, hydriatie insti- 
tiilw, and even of fashionable health resortg. Whatever commeniiatioi) 
aa; lie extended in future chapters to liydriatic, electrica^lf or ZiLrider 
iaitltates, it must here he admitted that they are more Hkely to be pro- 
doflhre of injury than of well-being if the difEerent physical meaaurea 
UKfeia applied are not taken with the special advice of tho physician in 
fihvge ind with strict regard to the individualization of the patient- 
Work and Calling. — We cannot pass by the topic of the mode of 
Ueaa this may lie modiiietl to the avoid'inre of nervous disease wiLhout 
^litUing upon the factor of overwork. It ia true that many nervous dis- 
«ata, especially the ao-calied functional nervoua diseasoa, are often attrib- 
uted ta o^'erwork. In the majority of sut'h mstancesT however, it ia not 
lhe ncesaiva work alone which ia reapouaibk for the disease^ bui: the 
itiuBd nctioi* of overwork, dietary errors and tranagtessions, indulgence 



m sttmulants ftad iianjctiva» iusufRcieut aleep, lack of exeTt^iae* an*} neg- 
lect of many of the rules of general hygiene that ia respoueille for tht; 
occurrence of the diaeaae. If the letter causes v/ete not operative^ it 
would be almost if not quite imposaible for any amtatut of work to which 
tlje iDdividual is capable of applying liinirieZf ti> jiroduca eveu Huch a 
diaeasQ aa ueuraatheuia. Work^ Lueutal or physical, if divorced from 
varry, u^ed oot be coasidered an etiological factor in the causation of 
uervoue diseases. It :s impoSBtble for the pbysiciaa to rec-oi^ struct the 
social and political systeiuH of this country which are go conducive to 
transgresaiouB of hygienic principles and bo ppovijcatl i/b of nervous dis- 
eases j hut be can orient tboHC bai]dic&p[}Cil hy heredity or acquisition by 
pointing out to them that the iDalntenaQce iif liealtb for them lies iti 

Youths of either aest outlining a oareer that shall ret^ult in fame and 
fortune ought to remember that there i^ another side tfi the '* self-made'" 
mail, one that the geueral practitioner and neurologist imfortimateiy ofteti 
Bee% thaa that depicted in the heroics of those who seek to atimulate the 
ambitiona of the youthful sluggard, and by the laudatory obituary writer. 
One of the moet pemicioua and far-rcachuig eolailmeuta of overwork or 
engrossing routine is the diataste it develops for indulgence in pleaaurablo 
enjoyments aud relaxations. And »s these are easential to the mainteu' 
unee uf health, pDtUridarly after a certain periixl in the life of tnan^ it is 
disastrous to be led into such ^ slate. Occaaionally we eucounber to-day, 
|t unfortunately too rarely, a certain quality of teraperameot or of habit 
lioh 18 best designated as " reserve force/' The indivjdual who poa- 
sessea this quality makes the impression of one who holds the balance, 
as it were, of all of the powers which he possesses iu such a way that 
they are must readily and easily at bis contmaijil. There is a fiuggestion 
of aocnrity, of evecnesH, and of force which for comparison may he likened 
to that of the man who lives well within his income, with a subatautial 
ospttal iu resepve^ ujion which be may draw at will. The nervous man^ 
on the other hand, the restless^ breathtess, hurrjingj worrying man, who 
never niifwes a cs-r, rtevpr gives himself up entirely to a moment of pui- 
]joaeless amuaemcnt or rest, who never altogether rclajtcfl nci ve or muscle 
and who couaciously carries over the account of jetiterdav's mistake, loaa, 
or worry to add to the fund of to-morrow'a care, is like the one who is 
daily living up to the limit of his income^and a little beyond. Thia 
restlessrtesa may be constitutional ; lint even granted that t^ojue ca^ea are, 
oftener by far it is acquired. In tlie latter it can ho avoided, like all 
bad habits, and in the former it can to a great extetit be prevented or 
overcome if taken in time. The overtaxed men or womeu who rush 
breathlessly through a life of care and responsibility would lighten their 
burdens and avoid the entailments of nervoue ei.hau9tion if they would 
resort to common-senae relaxation at times when nerves begin lo tingle 



'EH. 41 

jiidio TibraCe to each pnsBing impi'esaicni hko the stimga of a musical iu' 
fimmeot drawa to the highest Uasiou, aud the lini^a of the face express 
liv plainly the suppreaaed outnry of the tired mind, " Ta it worth whilel' '* 

The Securemeut of Sleep. — Oue uf Iho surest waja of uvotdiug the de< 
Tebpmetil of the iLturLrpattiic diatheais oud iiapairmeat of the integrity 
crfthfi necvoiiS system is by securing an adequate amount of refreahing 
ileep. No function of the biuaan body ia so tolerant of infriogemect &s 
dMp, and the average man aud woutan of affairs and duties encroach 
i}p(m it nithoQt compuDCtioii or serious thought of the coaasquencea. A 
oonuAl adulwoent indiTidual nhi>isable to recuperate hia vitality througli 
da^UDCstaiy trai^'t and by means of exercise^ b^ithiug, and coafonnation 
U other bygienie principleg may go for- a bug time aod vitbout apparent 
fTil oqnaequenoea while sleep is very considerably retrenched. But eveo' 
Qully the loan must l>e repait], and if the funds from other aouri^ea have 
trm »Qialtaueoualy expended the conaei^ueucea are made kuowTi not otily 
]ij disorder of general nutrition mantfeat iix loss of weight, impairment of 
^1^9 ical Strength aud mental energy t but by perversionof tunottonof some 
putof the nervous system eonstiluting tht? phenomena of functional disease. 

Xo general rule can be given by ^hich to estimate tlie aniouut of sle^p 
thitis re«iuiaita for a normal individual. It varies with the peraou and 
wnb>^. Oneaclult may require nine hourSf another but seven ^ iorchil- 
drtDauil young adults the amount is greater: pi.'rso us cf mature age can 
oft^o spare eonaiderabte and prolonged sleep without apparent bad effeob, 
whilp very old persona require a great deal of Bleep. The amount varies 
ilsiiTiili the mental constitution of the iudividual. Fet^hUvuundedperaoDS 
tvquiie more sleep than thoae of stronger mental (^onsbLtubion. Neuro- 
psthie persona are apt to secure too little eleep, although the oppc^ito 
utr^me is taken by some. With these, sleep aets like a uarootte drug to 
■inl] their mental and physieal activity. 

Kealthy ehihlren need prolonged sl^p taken at regular Interval!. 
OuI'lrML of Deuropathic parents stand in double need of Jt, and its attain- 
ciajt should be made the object of special effort on the p&rt of parent 
Vii physi^iaun One of the evidences of the neuropathic constitutvon in 
riildrao is an accession of phy^iual and mental energy ;n the late after- 
num ind a desire to sit up late with a corresponding sKiggish^e^a in the 
tnomiag. Normal children sleep early in the evening and awaken early 
n lie morning- However inconveniejit such habits niay be for its parents, 
lit^hild'a health demands that a strict regime Ire adhered to. 

The Eiadicatian of Sad Habits, —Sutfie vent has been said conesm- 
b^ llie influence of abnormal and excessive sexual indulgence in the 

.pier on causation of nervous disease to indicate the eiMjrae that should 

pursued when such aberrations have to be dealt with. It is not 
*^tDeii necessary to conaider here the various means that have been 
^pt«d to break the patient o£ sacli habits. It may be said that as 



a rule physir^l resUaint is more serviceable in cases of onaniBm m chil- 
dren than are movAi or medicinal measures. Tr either Lojs <it girls the 
pattcnti maj be required to wear canraa breochea> faateucd at the uppar 
end to a, circular steel baud provided "n^itb a lock. This is worn coatinu- 
oualy, fuid removed by tho nurse only at stated intervals in xesponae 
to natare's calls. In older children and in young adults, it is eome- 
umea necessarj to adopt what may appear to be barslier jueasurea in 
order to secure a temporary ueasation vi the practice during which time 
appeal caa be made to the morale and the physique^ Among auch meas- 
area may be mentioned blistering the glaua penis or clitoris with can- 
tbaridal coLlcdioa or email cantharidal bliBterSf &ud passing a piece of 
Silver wire through a portion of the foreakiu at the edge of the glans^ 
If tlm habit ia really itiprailirahle neiireototiiy of the dorsal nerves of the 
penia 13 a. justitliible prOfOtlure. Unnatural aexual indulgenct^a, aside from 
masturbation, need not be considered in any detail. That such practices 
aa coitus reservatnSf '* withdrawal," and other methods of irregular sexual 
intercourse practised for religious or economic Teasons, are iujurioua to 
both participants, every physician fully tmderstAnds- Not a few cases 
of neurasthenia in the male and of hyeteria in the female are traceable ttt 
aiioh indulgences. 

Bduoatlon aad Bringing up of the Neuiopsthio Child,-- \^itb the 
eicceptiou uf the prophylactic treatment of syphilLB, no preventive meaa- 
ura in the treatment of nervous disease is so effective as the proper 
education of the uaaropathie child. This education need not differ 
bpeciQcally from that of other children. Its chief feature should be 
an intcnaiGcation of the common sense that should be manifest in the 
mtellectiial and emotmnal trainmg of every child. formal pbildrcn 
b)iow fiequenlly enough the results of parental ignorance and pedagogical 
iueMcicucy. Those factors that tend to make the education of the aver- 
age chilli less effective tu ec^uipping him \\ itb a character which will 
enable him to cope with others successfully through the alruggle of life 
^ill bo more noticeable with children of neuropathic diathesis* The best 
training for the neuropathic child would therefore be the beat training for 
aiiy child; but lu'verihekas to produce equal results in normal and neuro- 
pathic children the parents of the latter are required to ciierciBe more 
intelligeace and self- restraint than in demanded of tlie parents of normal 
children^ Uiihappily, theae educational factors arc apt to be wanting 
in the parenta of neuropathic children, the very presence of the neu- 
ropatlite diathesis in the child b^ing an evidence of its presence in one or 
both parents. The dictum of Oliver Wendell Holmes^ that IIih education 
of a child should be 1>eguii two hundred years before it was boin, may 
appear exaggerated to those who believe in the possibility of tlie modern 
school to develop the facultaca of the normal child, but with respect to 
the neuropathic child it is rather less than more than the truth. The 


pijeuta of n^^uropalbie children who try U> do their duty by their children 
»rt(reqaently Jed by th^ir own vagaries of emotioti sod oonduot to make 
up iD eaerr&tiiig syuijiathy for the cliild what they lack ot emotioual 
bikice aud self'iontToh Tlie aatijral veakueafiea of DerTotis children, 
aBpeci&IJy vhen combmed with tho extreme seii^itiveneBS which so often 
■ccompuiies this diathesis, make a leadiog appeal for aympachy. This 
uMTiditg ©tirironment nourishes the v^ry fthortw>mingB which give oDca- 
noit Ui thfi eKpressioD of the sympathy, and thiia a vivioiiH arc is formed. 
>'tit to excessive coddlmg, nagging is perhapa thd most frequtnt «vl1 
wflicted upon nervous children hy nervous parents. Expecting more of 
Iheu children than they ar^ Bh\e to accompUsh themselves, they abow 
Ettleer no comprehension or leuioncy toward their moral and emotional 
ptfrenitira; indeeil, tliey Beem tu M\^^l the child doid»1y fcr their own 
abL To sucih a degree is the reaction disaatroufl that is awakened in 
DroroptlhicchiJd:re& by parents wanting in self -control, and not possessed 
(f Iboee qualities of charaL-ter tJiat aerve aa a commeudaMo model fiT 
thechild, that it can be said without pciadventnre of a doubt th[ht many 
fhildr^n who develop nervmis diseasea and perhaps lead a life of ineffi- 
cipLcy, and even crime, could ha^e bt'pn reared to a statu a uf physical 
uidDoral normality if they bad been removed from their parents and 
ftlmd under the guidojico of ethers whoeo knowledge and chai-ncter tit 
Ibwj for the task of developing satisfaetory t^^pes of human kind. 
^pccLtii^ edijr'atTrtn is but a sutaU factor in determining what the child 
stall be hke. ft ia ttierefore not ei> important that tbi^^iarents should 
be learned in ideals of education and approved iiedagogic-al subjects and 
meihodBof instruction, aa that they should in their conducb toward the 
tfciEd BO act ail to develop those insticeta and impulses and ©niotiona that 
vill If^ into channels of mental and moral health. Parents who an- 
nj^oijant of neuropathie posseasions should strive to maintaia their 
WLb, so that thi^y may bring forth aound progeny. Hhn same attan- 
tun should be given to pri^gnancy and to the early yeara of childhood 
ihM'n bestowed on the hysterical and epileptic. The physif^al and moral 
tducttioD of the child should he conducted »o as to result in the haTmoni- 
ooa develupmeutof the Individual 'a ^^fyr^/ts and sotmi, and particularly the 
dflrelopment of general equilibirum cf the organism, From the begin- 
ung meaaores should be taken to inerease the phyaiological resistance of 
rts aervoua system and to fortify the energizing capacity, by bringing 
Uieiyfitems of the Itfuly to the highest possible point of development. 
A hi|fh degree of physical health ia incompatible with the neuro|inthic 
Jialif«ifl. Outdoor life, in the country if posaiblo, with its anperabund- 
Mceof air and snalight ai»d opportunity for physical exercise, is natur- 
iliymoie eondncive to the development of reeistanl phjaique tlian the 
^ofa crowded city, with its enforced limitations in all these directions. 
ColorbinBtely, such environment is possible only for Ibe few; but never* 


thele» muoU can be dODo ia the waj of securing some of tlie adwi- 
tag«9of the couQiry by tlie utili^tion of the parks, thd aquatio aod Cerri' 
torUI flDvipounieirib of every largo city. Cliildren born of neurop&ttir 
parents ehoiild ha giveu plijsical ei^iioaiioii livat, and ineotal education 
afterward. It is uof ea^ible to reform the methods of education which 
bare been found to be of greatest beuetit to the greatest number, in order 
tbat the few whose inherited fitoncomiogK are an unstable net^'ous cr- 
ganiTatmu may he berieHteil; but aiirh individuals ahouUi not l« required 
to conform to pediigcgical formiiUry at the expense of tLe development 
of their bodies. Outdoor exernae should be supplemented by gymnaAium 
practice ^hich will develop phyaical atrcn^h aud endurance. Moreover, 
childraD of uervoiis patents ahould have greater care bestowed upon tbetr 
personal hy^^^ne and alinentution than those sprung from healthy par- 
ents. They should be accustomed early to hftliitsof bathing, especially 
in cold water, so that they may receive the toutfying and aedative benefit 
of such application^ which contributce ao nturh to the prevention of 
fEittgi^e ajid exhaustion. Luxuries of diet, stiintilante, and aedativej must 
be abflolately eTcluried. 

The moral edm-ation of such children is quite aa im[)orbaiit aj4 the 
phyaical educatioui in jnany inatancea, indeed, it is more iinportaitt. 
UnfoTtunately, it is almost universally neglected. It ia ditticult to state 
in a fuv paragrapha a formulary' that shall encompass the proper bring- 
ing-up, from a moral point of view, of the children of nervous parents. 
It would aeeT# almost unnecessary to at.t**mpC to do ao, not only because 
this is heyoud the province of the physician, hut because parents havi> 
their own views on the matter. Nevertheless, the physician may do 
much hy emphasizing how necessary it ie to inculcate habits of obedience 
and self -repression, eradication of egotism and eeltiahnessT restraint ot 
temper and oapricionaness, and the development of moral courage and of 
physical and meuUl self -confidence. I^ad habits should he thwarted by 
eiiggeatiou, by precept, aad by example. The ut-cesaity of strict discipline 
t« eradicate puch habits as nail-biting, gasping for breath, grimacing, 
tolling tho eyes, blinking, and the like, needs no particular mention. 
Of themselves, such habits are not injurious or objiiccionuhle save from 
an esthetic standpoint. Their inhibition, houerer, is desirable because 
it is attended with a strengthening of the will which is much to be do- 
sired: the etiateuco of such habit indicates nervousness and vohtional 
laek of control over antomEktie piooeii^sea, Inclination toward bad humor. 
sadness, pes<«iniism, egotism, and siiperoiliouaness should be combated 
early, ami the youthful person taught that Bentimerit"? of uu«ocirtbiiity, if 
allowed 1>o develop* aie more potent to produce personal unhappiness than 
almost auyothei- factor. He atiould be taught to accept adverse decisiona 
without black looka or mean resentmentj to take bajiler as well as to 
give itj to eontrol a hanty tem|>er and to atunp out a siilky one; to bear 


fuJniv ind dlsappointmeut with a emiltng face find a determined wlU, 
foo grefit care caunot be directed toward tils harmunioua development of 
tact iudiviJuals* cmotioDal life. Premature kaovrledgs of sex, which 
luJOrtmiBtelv' they oft«n gather fruni literature, the thentre, aiid tlie 
pdp^t, i£ not infi^iuently the means of dwakeaiog morbid aiid introspec- 
tir« tieudencies- 

It mufit not be inferred from what haa been said that the life of 
tbtf (Lfluiopathic child ahould biiD^ him perpetuaJly in ountact with a 
**(i<B'l." Formula expresBcd as ** don'ta " are much more eaay to framo 
thit tfauee which gLve direct and specific directiona of a positive na- 
cortv Such lormulae, however, coastitut© only llie beginning of what 
ibJHild be this sj^tivB effort of those who are interested in the traiii- 
inf of tbo child- Kotbing ia more di^a^lraua than a life of i^ontinual 
itfpmsioD. Indeed, when euch represaion sceoia necesi^ary the wiae 
parcot will check emotionalism tjot by rulea and preoei>tfl, but by sng^a- 
boQ. e.TBmpl^, jiidic?iiiu3 Eilenc^e, and indifference. Children aulTer as 
niQch fraui liability to eicpreaa what they ate ah]e to ppri^ei\« and ft^l 
u ftuui the crude «ipre3sLoa of almo^ retleA. reaction to the stimuli 
gftlifir auvironmeut. If they are to be led to atability of purpose aitd 
MnudMfld of feeling^ they must bo taught to give expression to those in- 
xantU tnd emoliooB whieh are indicative of the beginnings of the growth 
of a Dcnnal healthy mind, and to oonduci themselves in accordance with 
tie standards of their elders. The girl perhapa auffera more than the 
boj from the repreaaioa eiercieed by tho^ placed abovu them. Tbe girl 
wbofeela the Dcces^ty of mnning off surplus energy is told not to be 
awkward and nngracefal, but to sit quietly in a L;hair with baiida folded^ 
ut a Udvlike maimer', whereaa the boy ia ordered out of eight of those 
whom he anooya, and fliids romfort and adequate stimutatioo witb his 
miorades in the slieet. This failure to train the girl of neuiopathlc 
l/nperameot to the exercise of individnal volitiou ia perhaps quite aa 
effifoeat a factor in determming the greater emotionaliem of the female 
Hxu eompared with tbe male a» is any other faetor of physical or moral 

Tbe last word that van be said on the training of a ueuiopathlc 
tMd, And indeed tho moat important one to be emphaaii^d in the proph- 
jluia of iklmofit all norvous diseases, is the recessity of engrosGing 
woik that ia not beyond the measure of individual capability. It is not 
QLf^t by this that a child should be kept in hi^IiuoI and rigurously re- 
(juired to conform to tlie etandards that have been aet by educational 
uAoritie*- Engrossicg play is work in the sense in which tbia term 
ti here employed. The child's entire being should be kept in actlv- 
itjt Euidahould be called upon by the environment, by its parents and 
eduattiM, to give expression to a consistent, unified, well-balanced 
^^MtUl| moral, and pbyaical character. 




DftrttS ve ordtu:iri]Y preacribed in the treatmeutof liiseases of Uie 
vefTDHS ^rateoL to obtain a supposed specifio effect upon a definite patho- 
IfigLcal coadiuon. Tb«/are inooosequertceoft^n contrasti^l with phjsic&I 
mcuuivs suph na the application of water, electricity, aud mas^^age, to 
wWb is ascnb«^ onlj a general effect upoa diaeue. Many drugs. Low 
CT«r. to which no precii^e apecitic actioa caa be assignrd are o<^Dstaiitly 
CBpJoycd in Lbe treatmeDt of diJiBaae o£ the uervotis sjsteoi. In some 
miUAces, drags are reoomiuended fur do other reason than that the? have 
bm demoDstrated by experieDce to have a beneficial effect upon the 
^mil iMinilitica of the patient QC tn h&vecou tribe ted to the amelioratioD 
of ijEuptoma appearing in Uie course of the disease. The Grst chapter of 
Vulli. vill therefore be devoted to a consideration of the appHcability 
rf dfuga to disBOBea of the aervouB sjfilem in general. Suctecding chap- 
UnviU deal with hydrotherapy, electrotherapy, massage, exercise and 
[vat, ujd diet. In a coiKdEiiIiiig chapter ou i>sSyi'hotherapy an eatimatd 
of Lbe tlierapentio value of suggeatioEi and other mental tneaauieH in the 
tiAitiiii'iil of ner^Dua diseases -wiU be attempted. 

Though the beaelit to be derived from the phyeinaL measures jiiet 
uieniiMiftd is at the preseiit day si.'arcely questioned, still they are by no 
menDS aa generally employed as their naefiihiess would fteern to demand. 
Thu is probably due to the fact that their use is in>perfectly taught or 
nlirely ignored in medical hooka and text-books of therapeutics. Such 
LdQnn&tion muat be gathered almoat cnttrdy from the personal ezpehent^ 
uf tik« physician who would avail himself of the^e measures. This is a 
pumtakin^ task, and necessitates jnucb ev|ierinieiitatiou ; uto often the 
ffljiiisite knowledge and nkill are not aci|uired- On the other haiid, it 
cuEot bo denied that a whoMy unwarranted place ia often given to the 
rpiGcaiti^e of physical measurea and aho of mental measures in the 
cuieof disease. A temperate estimate would indeed hold that phya- 
icaI mM£ores, eompared vith medicaments, are of greater service in 
1^ tRSOnent of chronic disease. But nevenheless, drugs and physical 
atuummiu^t be employed simultaneously, tlie oue to supplement the 
ttlcr. Elect roth erapeutists, hydrotherapeutisls, hvpnotistST and maaseups 


habitually exaggerate the rdle which these agents are capable of playing 
in ouriDg diaease. The intemperate claims made by such irrational and 
unwiae advocates are largely responsible for the apathy of some and the 
antipathy of others. 

No one who baa had considerable experience in the treatment of ner- 
Toua diseases fails to recognize that at the basis of them is a deprarity 
of nutrition, looal or general, which must be overcome before the disease 
can be eradicated. There are many substances in the pharmacopceia that 
are reputed to be of service in the treatment of every one of them. But 
we are quite at a loss to explain the rationale of their use. Very few, 
if any, have a specific action. Their beneficial effect is due either to the 
fact that they supply some elemeut in which the system is lacking or to 
the aid which they give to metabolism. Jn this way is to be explained 
the therapeutic efficiency of iron, phosphorus, arsenic, quinine, and the 
like. Physical measures act in quite the same way. Their phystolc^cal 
action can be, and in a measure has been^ determined with similar accuracy 
to that of drugs. 

It is impracticable to make a judicial estimate, in the chapters de- 
voted to the several physical measures and to psychotherapy, of their 
respective therapeutic values- The general practitioner needs such ad- 
visement quite as much as he requires specific directions to guide him in 
their selection and application. This task will be postponed to the chap- 
ters of Part III., devoted to the treatment of individual diseasea in which 
an attempt will be made to estimate, at least approximately, the amount of 
dependence that ran be placed upon each, and the combinations in which 
they are mo^t useful and reliable- 



LtTTKN-T it I1&8 beicoroe tbe fashioD again U> decry the use of drugs 
Hiflectire agents in the treatment of Derrous diseases^ acd to deny tbeir 
Mfvkaability. The modem therapeutist, and patticiularly if he be a r«- 
Mit tMMil, BeeiQ3 oftfDtimes to be burdened with the ide^i that be owes 
adn^to thfi profe-BsioD to apprise it that the fiueees&ful treatiaeDt d 
iadme Dunsifits iu the utiltj^atiou of iiciu-]ue>ili[!irial mesisureSt arid that the 
fttoltft to beobtained from tlio u»e of physical meaflurcfi are incomparably 
gittMt than from the nse of dniga. Such advocates write and apeak 
oftotimea intern perately of the efli«wy of massage, hydtiaticB, Swedish 
jBOvtatfnU, climatji." ^judiuona, and pay<!tiotherapj, apparently in entire 
forietf nines* that tlia applioabilUy of many of these agencies has been 
racofaiSEed from time immemorial, and that in some insUiiced thev were 
tted Id beneficially a ^neration or a ceotarj ago a^ they are to-day. The 
tbmpeutic possibilities of phytiieal measnres are not being derried. That 
ibivnter believes them to play an eEtretnely important p^irt in the treat- 
wttt of nervons disease 13 snfReiently evidenced by the suei-e^iding pagcs^ 
Ba 19 merely making a staleuient of fart and at the same time a coufes- 
vm of faith in dmgs as remedies. The attitude of great maatera of neu- 
n%j, Buck 03 Charcot, S^guin, and Gowera, oa this subjeet is \erY in- 
stncttT^. Each of th^m during the zenith of Itia fame has recorded 
bafiith in drng therapy, and has urged the profeaaion to persist Dot only 
m atui n called rational therapy, hut in empiri^-al therapy. 

I>rugs are given in the treatment of nerrona diseaaes foe one of the 
Wbriog purpoeea : 1. Speci£?ally, to counteract or overcome a specitic 
afgutim w the noxious sabatanees produced thereby. 'J. Directly, to 
vtKBce the morbid state or disease, as the adminiRtrntion of indide of 
pi^—itun in sYphilitLc eiudatiuns and arterio-capillaiy fibrosis^ silver 
Q ubcs dorsalis, th« bromides in epilepsy, and arsenin in chorea. 3. 
SjaplotaaDcally, to meet |>articular indications thus (a) opiiun and its 
tlkUtnds; the synthetic analgesics, such as phenacettn, antipyrin, acetan- 
iHd,fialgin,phenooo1, and also aconite and veratrine, to relieve pain; (b) 
Ihs intispasmodii^, sutnbul, valerian* and mnsk, and the nitrites and 
^raaidiGs, to relax spasm; (r) the hypnotics, chloral hydrate, aiuylene 
kjdnte, salfonal, trioual, tetrona], hypnal, and paraEdohydCi I0 produce 
lUqi; Iff) the sedatives, geUemium, belladonna, duboisme^ and coninm, 
Ic effwt motor sedation; {*^) iha stimulants, dux vomica, kola, coca, al- 



f*ohol, oamphort etliET, atrophanUis, aparteme, autl uaffeiD^, to cftnso 
stimulation in aCnt^a of depr«9sion and exhanstioii. 4. To ansiat in tissue 
reconstruction: the adiuinifltration uf iron when the hjEnioglobin iB defi- 
cient, of BTsenic bu prorjiote Laemogenosis, and of substances that f&cili- 
tate digestion and ahaurptior;. 

Bpeoiflo Troatment. — Spectre medication p)a}-s n very Bmoll part in the 
treatment of net-vous diseaaes, eTcept in the manifeatations of sypbilia, 
Ttiere B,re no uervous diseases caused by orgfinisnis ar factors peculiar tn 
iU save tetanus and hydrophobia, Thebacteriathiit cause ho manj of the 
acute organic diseases of the nervous Byatem are the flame as those vbich y 
<muse disease in other parts o£ the body, and bo far no immuniziiig Beruxa t 
or antitoxin has been disoorered for item. Tetanus and hydrophobia give 
opportiinit}' for epecitic cneciicatiun ; and without entering int'Oiidisc^uaaion 
of the treatment of the latter^ we may say that the admiuiatration uf ' 
tetanus antitoxin ie at the present time the most reliable way of thwart- 
mg the disease. The results o£ its use do not compare favorably with 
those obtained from the nae of antitoxin in the treatment of diphtheria; 
but as the obstacles in the wny of preparing a serum of sul^nieiitly high 
immunis^tn^ power to make uutieceaaaiy it» administratiou Lu large quan- 
tities are oreroome, aa they undoubtedly will be, the antitoxin treatment 
of tetanus will be dosorvioK of all eotitideoce. One of the greatest draw- 
baal£S to its use at present is tbe large quantity that is neeessary to give 
immuDity and to overcome the efFecta of the bacilli and their toxins upon 
the par^nnhymaof the rord ami brahi. Ti/./cmi entiinaJ^'d that 70 c.c. 
of hia antitoxin would be a beginuiiig dose for a case of moderate se- 
verity, and that thia (]uantity could be repeated at intervals of from lii 
to twelve hours, la severe cages the dose ehould be even t^ieo this 
quantity. There are a number of tetanua antitoxtna npoa the luarhet, 
but we ahall apeak hei'e only of chnt prepared and furnished by the New 
York City Health DepartULent. This is pub up m phials containing 
20 c.c. of the serum, which is an initial dose given st the fitut appoar&nco 
of tetanic sytDptoma, Jf the case is severe, and especially if the treat- 
ment haa not been begun early, a very much larger quantity should bfi 
used. Fii.>ni 500 to TOO c.c. oi' more may be required in a single case. 
Even in sm'h large amounts, it produces few or no disagreeable aymptoma, 
Tbe remedy is adminiatered by deep hypodermatic injections into some 
portion of the anterior surface of the body where there is an abundanoe 
of subcutaneous cellular tissue. As the results of adminiatering tetanus 
antitoxin in this way have not been entirely aatis factory, Roux and Houirel 
suggested the intracerebral injection of the antitoxin, and performed it < 
successfully in animals. Ohautfard and Quemi Y'ere the first to use this 
method in man. The reSLilts of their experience and of numerous other 
Trench physicians would aeein to justify the procedure. During th« 
summer of 1899 an nnuaual number of cases of tetanus occurred in New 



V«rk Ci^< uid in the treatment of soiijc of them iotrarerebnil injectitma 
*rj« tri«^ bat the results w«re nnt so s&tiBfa>?tory aa w&s anticipaUid, 
Iliif method of a^lininisteriiig aiktiloxm must therefore be considerad as 
^1 ander judgmeot. 

Doiiag the post few years it has been fulty detDonstrated that oertain 
^^me^ which are participated m bj the nervous s/stem ore caused by 
kk&^ieccT or exresa of certain iDtemal s^:^tio&s. and that they develop 
ta oHi&MTtioQ with disease or disordered fcitirtioii of t^rtaln durrtlea^ 
gtvdj. The most conspicuoiis of these diaea&ejt are nt^ic^dema, acro- 
of^y. and Grares^ dbease ot exophtbatinic goitre- It is barely poasi- 
Ue that the djMrophies have some pathogenetic relaticraship to disease 
a mdrbid activity of the thymua gland. The fact that the teeticlea and 
tbtpranee have a trophic int1nenc«' upon the economy through their in< 
ttTHAl lorivtioD, which is apart from their Bperm and germ-plasm produc- 
tidii. isHuf&ctenUy shown by the results that follow the purpoaefal reiooval 
VKCidmtal dcstructioti of these orj^ans^ 

The preeent-day treatment of myicedcina and cretinism is one of the 
lu^eteeotb century's inoA brilliant therapeutte auceeBfted It hu been 
4bnnituilJy proven that these conditions r:in have their progress stayed 
ad slmost if not quite complete resturation brought about by the ad' 
Biaiitiation of thytoid gUnd or an extract of it. The thyroid ae- 
ta/aon i« a complex body, ani as ret ve do not know upon what its 
nuAable properties as a preservative of the nutrition of the boily de- 
hdI It i« known that it contains several important proteid cooHtitu- 
vsttind tocline. And at one time or another it has t>een thought that 
tte diyreoproteid, the nucleoprott^id, the iodotbyiiiif or the iodine is the 
evutial constituent, but it has been amply proven that the results of 
itlqrnndiem aie not prevented by the artificial use of any of these con- 

Thyroid theraj:^' has not yet shown itself to be of conspicuous service 
^ the treatmeut of any purely nervous disease. Tt has been used to 
UEU extent in the treatment of eiophthalmic goitre, but a judicious esti- 
wite of the results does not jviHtify us in assigning to it a place among the 
Tiod aervtceable remedies in this disease. lodotbyrin in from three to five 
piin doses per day in the beginning, and increased to four times this 
UKKmt, has been used sm^oessfully by ^'eyler in the treatment of Graves' 
IW KC after the customary methods of treating tliia neurosis had failed- 
He ncommends its administration in tablet forut. Thyroid gland ot a 
|Mparition of it haa occasionally bei^n used beneficially in scleroderma, 
isaiiporis doloroaa, and in some cases of mental disease attended witK 
itlautiDg mania and stupor. So far, no satisfactory explanation of its 
Mtutt ID theae cases has been ^veu. It is serviceable in reducing the 
Ittdf wn^t ia simple obesity; and if there is no organic disease of the 
nmrt there can be no objeotion to its utilization for this purpose. 



Tbjroid ia adminiBtered in the sliape cf the raw gland, oae-half of a 
alieep's thyroid e/cry third day, and itiereaacd in fiequenoy and antount 
until effects are obtained. The drawback to thia mode ot administration 
i& that it a^xiD disgusts the patient, evf a though the glaud^ are slightly 
uooked cpii the cutaide, wLich cau he ilone without iiufjairiug the elGciencj 
of the thyroid substance, Aq extrai^t of the thyroid is now piepared 
and put up in tablet form by many of the manufacturing chemists, and 
if it is tcept frojii becoming damp this ia the most coMvenient and effica- 
cious way of administering it. The beginning dose is from two and one- 
lialf to five gruins- Powders of thyroid, prepared by mitudug of the 
gland with gljcerin aud alcohol and theo evapuratt^d, may be given in 
from ten to fifteen grain doaes, enclosed in capsules or keratin coated 
pills. lodothyhu, from live to thirty grains a day, haa also been used 
with gratLfyiag rpsulta. 

Ejctractfl of other glanda, such as the thymus, the pituitary gland, 
and the testiiOCf have been exteniiirely tried in the tieatraeut of mauy 
nervous diseasest but aa yeb no vesuJta have been forthcoitiiiig t^j warrant 
other statement tkan that further experimentation and uao of them are 
justitiiLhle. Thymus extract has been tried in the progreasive muscular 
dystrophies, but without result. Some writers have t^poksn of the bene- 
ficiial effec't cf pituitary extrart in the treatment of aiTromegaly, and H^il- 
lefitoiL haa administ'ered amixture of thyroid extr&ct and pituitary extrac^t 
in this disease with pi-ooounced relief to the headache and other svibjec- 
tive aymptoma. It did not, however, ueem to have any effect upon the 
course of the disease. In my own Lands it haa been of no service what- 

Tbeaiiuals of Ao-calied tefitiuidar therapy (^oustitute a memorial to the 
fatuouanesa of man, aud indicate the auscepbibility of even profesaional 
opinion to su^estion and iitutation. Every age has sought the where- 
withal to ej(preas ^n elixir which should give to those who drank it the 
gift of yuuth, bealtl), and beauty. It remained for an illustrious physi- 
rianof our ownponodi Brown-S^quanl^ tu Itoldly affirm aiiduuBwervingly 
contend that he had extra<!tcd from the testicles of young animals a Bub- 
stance which wheu injected iwtotlio tissues would eerve to rob old ago of its 
infirmities and deal even death a staggering blow. Out of this affirmation 
grew a mushroom literattt re which it were better that it never had eitistert. 
Even to-day teeticuliLr extract in t!ie shape of spermin of Poehl, which ia 
identical with Boettcher's sperm crystals, the specifio constituent of the 
prostatic secretion, but foiuid in all the orgooa of the body, and a normal 
eoustituent nf the blood, is very coQaideraLIy used, especiallv in parts of 
Europe, in the treatment of neurasthenia, hyateria* diabetes, and even 
tabes. In this country different so-called animal extracts or tissue ex- 
tracts, fiuch as of the brain, the spinal cord, ovaries, pancreas, and " goat^s 
lymph/' have been used, Not a scintilla of acceptable evidence haa been 


a w&nukt tlie oootinuatjco oC their uae, and tbey nre mentioned 
Uy to be vkm^ against. Their use «Epo6«^ the patient to septio 
iDjniy. uicl is an uajuBtiJiable procedure. 

Hie UM of men^urj i^ a AptMjili(3 in thfr Ireatnieut of syphilid has 1)««d 
ooOMdend in tho chapter oa the prevention of nervQus di»«>A«a, All 
tbal naed be «&iil hero ia that unf<»rtunAteIy it does not meet the require- 
BBBtc of a true fl[>ecjfie. We ca£u»at Bp«kk of the speci&e action of 
^imine in nertislgiaor in disaeminal^ !4<?Iercsis, ev«n though n^uralgiA 
n oftentimes an expresaioDcf malarial poisoning, and though diBSt:'[n in ated 
idnvBli ocx&aton&Uj followa in the iraka of malaria. If it could be 
invm tluU a disease of the neivous syataat "was caused solely by the 
aiakija] plaataodinm, as it has been euspeoted that a variety of periodic 
ptiilrffifl i«, then quinine would I* a specific in its trMtmeat. 

TliB ^medial Action of Bmgt^ — The way in which cErizga aet rerDedi- 

lilj need tuA here concern us. It vroidd aeem that some consider- it an 

op^nbrium that drugs act through the psyche to bcaetit the soma. That 

nie!na& and asafcctida ofteJi give relief in suuje spadmodio disorders of a 

hptincal nature and oth«r hysterical syiuptoms is UDirersally conceded. 

^^t ut imfossible to say how they ae^^-omptish this iiuless it be by sugges- 

^BlDa, for thej have neiLfaer chemical compofiitioii nor constitution that will 

^Kvtoit explanation upon auy other grounds. Itut thia is no adequate rea- 

^Pto vby we should not use such drugs, providing they accomplish the re- 

tullA fcrirhieh they are given and do pot produ<.^ injury. It matters ndl 

hov a drug acts oo lon^ as it relieves symptoms and ameliorates or cures 

l^diKMM, and so long as it may be gi'-'f" without causing iujury- This 

^^Uuuld not be c^^afttued to mean tliat BLibs^taucea or compounds whose con- 

^^■fa|iDii and nature are unknown are recommended, or that there is any 

^HB^t Cor the use of suhatanoea vhose aoiuposilton ia knowo only to one 

pnra or association, vrho advocate ita use and attribute to it virtues 

vhieli we hsve no meuitd of knowing that it posseswa, solely for persoual 

|fi)£L There is yet to be ooui5K>ui]ded the medieitial preparation whoso 

formali is vitliheld from the full knowledge of the profession which has 

been thown by eveu its mo^t inl^reated advocates to have remedial effects 

tfait ue Dot possessed by simple drugs of the pharmacopoeia. 

^Hi In administering drugs it is Tcry much more satisfactory to know how 

^Hhr; a^'t and how far they can be rt-lied u|ion to produce certain results 

^Bftui to gi^e tliE'iu eiupincaJlj. But there are few Euhatauces in the 

irfiinilCOpoeia that lueet these requirements. The admLaistration of the 

^ufKoui tDedicineGr sedatire and sttinulant, ia based upon experimenta- 

Um in animala and experience in man. The repute of disease mediHnes. 

ca tic ether band, is based almost ^utiri'ly upuit tlte iuherited aud ac- 

quind oxperieute of the physjctan^ The latter are oftentimes given with 

^te u mncb certainty and a^sutauce of success as the former. 

Tha value of manv drugs that are now in utiiversal use was dTSCOvend 


quite by artndenf. They art^ to-iiay aa tPiiai'iouH of t!ie utrttft of their 
aalutary acbjon nh t.liey were lu the Le^iiuiiug. Vot iusUuco, the discov- 
ery of the vnlae of the Ijromiao anlts in epilepsy by Lajcock a. half cen- 
tviry £^0 waa the result of deliberate and tlioi'oiigh trial o£ ev-^ry drug 
that had been recomiiiei^ded or auggeuted in the trentitietit of this myeteH- 
ous disease. Although the brumidey aro not adoijuate rflmedips for 
apilejiay, their value exce«da thatof all other ^Titi-epilefitic ageuriea cnm- 
btD^. la a similar way Gowers diacovertd ihe value of bora^x in cer- 
tain e&aea of epilepsy. It fieems hij^hly probable that nature hae provided 
aubatanoes whii^h, if it were possible to diseovi^r them» woiild overcome 
the diseiiaes to whieh mankiad is lUble, just aa she has provided opioDi 
to relieve paiD, quinine to cure malaria, aud thyroid extract to counterut 
ray xip lie 1 1 in. It ie our privilege to prcwe ou m the endeavor to force her 
to yield up these aec-retn \ end though groping in the dark may bo weari- 
some to the weak and even hopelena to ttie impatient, the sunceBa that hu 
attends <^fff>rt.a of thp p^Ht should Veo\i ua from bei'oniing dishfattened. 

The Ahuie and Use ef Dru|rB^ — lu order tu aenure the full aitd legiti- 
mate effects of dniga they must be given in adequate doses. The amount 
of any drug that conatitutee an adequate dose depends upon manj' faotora, 
sueh as the age and ses of thapatieut, tempi-ramont, environment, idiosyn- 
oraay, and quite as niiioh as auything else upon the nature cf tlie disease. 
The doi*e of rtny drug n» givfii in text-lxfiks of materia medica is the 
tpproxiniately eHUni^ted anioimt that will produce nerlaiii effects in the 
avt^rage individual in states of health and disease- The modifying icflu- 
encea of the abo^e- mentioned fnetors have beeu taken into consideration 
as fur as posaibte, but of course they can bf» determined ae<'urately only 
for the iudividunl- Thppefcire when we s|jeak of the dose of one of the 
bromine salts in epilepsy* of arsenic in choi'ea, or of iodide of potassium 
in gumma of the central nervous system, we mean the auiount that will 
produce beneKoial results. All drugs given in eseess produce Harmful 
results. It is the amount thatwUl result in the former and avoid the lat- 
tev that eonstitutee an ade<|uate dose, 

Mo^t of the >^ynipton] niediclues aud some of the dtAeaae medimnes 
need m neurological practice are of such potency that theii- rei^klesn 
and indiscriminate use IB fraught with great danger to the economy. 
Many nervi^ua diaeaaes are manifest by symptoms of exaltation or depres- 
sion which are readily relieved by the admiuistraiiou of ayuiptom medi- 
ioines. There is always danger that they will be given in this fashion 
until tt IS seen that thi*y no k>[:ger meet the iDdioHtniim fur which they 
were first administered. By that time they will have impaired the pa- 
tient^a health or he will have bpcume dependent npmi them for even A de- 
gree of well being. Thu»i it la a very easy matter to relieve insomnia of 
almnnt any kind by giving oldoral ; to rub trifacial neuralgia of its agoniz- 
ing pain by the mlministration of morphine; to ameliorate or stay the 



fhnoovfift of epilepsy hy tbe e^ibition <if large qoantitif's of broiQide^ 
^ to d^pnt-d cborea of its most cocispitruoufi Eympt(>m, the <Lanpe move- 
MisU. bj X few fnll doses of exalgin. Ikforeover, the i»qe of theso dmgi 
mxas into the legitimate tbenipy^ of tLieae dise&ses- Bi^t lo give them 
vitloiJt proper beed of the possible injuriouADeas to tL^ eronoiuy would 
Eflwlt in the fon&atkrti of the ohloml or morphine habiti* the pheDomena of 
profooDd broaiide intoiicatioD, impBirment of ntiditr incoosistent wiih 
liE^ ud luBmhlTns itteuded with fllarming KjtnptomB. Indeed, cue of 
tl« moBt important things to remember in recommending such drugB is 
\!Lt gn^i liabilitj thoy have to impair vitality* to disorder dig^tiuu and 
perrut DUtnttoa, a&d to lead U' the formatioQ of a hnbtt. 

Tha drags moet commoitly abused are the fleep producers, opium and 
TUd«riTiLiivefiajid tbeaaJtsof bromine. The latter are perhapaglTen with 
tcftdisrrimiTiatioD snd recognition of possible untoward consequenoe? thun 
uf of the others, although tHeabiiaeofhypuoticsandnarcoticB isc^xisiJcr- 
iblA. UAoemisnecesaary to dwell at aoiuelengthopon the abuse of the salta 
ofbrnniner f<>* although it is not so great nor so widespread an evil as 
tiitibosu of morphine, the admmiatmtioa of the former is entirely in the 
hiDila of ihe pbyaif^Tan, while the Ia.tter is not iofretjuently taken by per- 
mu QQ iheir owa responTtibilitj. Physicians seem oftentimes Dot to bo 
snfficifiitly apprised of the therapeutic ImiitatLt^na of the bromides, and 
of the harm tJiat may cum e from their mjudic-ious admmistratioo. Ju 
Ha phiipter on epilepsy reference is made to the aonte and chronic toxic 
AtM that may result from the excessive and long-eon tinned nse of these 
mIu. Here i^ tiiuy bt^ ^aicl that the salts of bromine are very useful 
in very few diseases — epilepsy, migraine — and in the treatment of cer- 
ttiu babilB and detiria, such aa those of morphine and alcohol. De- 
iprt* the fact tbat few deny the truth of this statement, tlie bromides are 
pn>bablyuaed to eombat all sorts of nervous syniptoms and conditiona 
nan uften than any other drug. The apparent expl^iation of this is 
ifau tliey produce seJatioD, and therefore the immediate results of their 
idniakstratfon are appaceiitly benelioial. The real explanation, bowerer, 
is tint the practitioner who preaenbes bromide in an indiscrituinate 
nj u a " piek-rae-np " ami to relieve sympt<:>mB la freijuently the one 
vko treats disease without first diagnosticating it. ff the deleterious 
«feGta vhieli tlie bromiiles often have when given for a ronsiderabte time 
ind without aimultaoeous use of meaaures to r'ombat them were more 
IttettUy recognized, the adminiatratton of thia drug would he eontined 
^ itt proper limits. Naturally, the bromides are often useful in the 
matirtait of nenrasthenie conditions, headache, ei^lampsin, and the like, 
udlbiyahould be given aa symptom medicines. It is their more or \^s 
<«ntiaa»d and indiscrinjinate use, particularly in functional disease at- 
tendeil with loss of the mitritional lialauce, and io o^anic diabase of the 
anrcBiB ayatem rf-haraeten/ed by marketl impairment of vitality, that is 


wnrntHl againet. In the vjirieil manift'statinnH of the neurasLheiiK^ sUit>e 
the brotaides ure often gheu uawisely, ba(?&uae here tlii- immediabn &ed&- 
tioD whicli atteudfl their use ia often very gralifyiDg to the p&tient. If 
it 13 nnc-ossary to restore neuToniuecuIar tone and to o^use mental ef^dation 
m exhausted atate^ there are wi^ya of douig this more in banaouy with 
nature's method tliaii \ty giving a Bubstancie whii^h^ at its best, tenda to 
disorder (ligestLou iiiid to impair assimilattoii. ^\ltea it is neceaaaiy tu 
give tli» tiromLdi^a coiitiuuDualy aud f^r a long period, »s m the treatmuit 
of eoDgeuital or essential epilepsy, measures must t« eitiployed eoatea- 
(Ktratieoualy to ^ouuteraet thair p^rtiicioiia eftects upon the general vitality. 

The «s1sctioii of the particiuiaT salt of bromine to be iis«d iauotflo 
iujportant as the novice might he led to believe after readiui^ the lileratur(< 
OD the subject. If h^will bear in uiiod that tlie bromidvi of sodium is leAa 
apt U> diaord^r the digestion and that it contamts a greater percentage of 
utilizable bromine thati hroniidc of potaasiura^ he need not concern him- 
Bplf partionlarly with any of tbe otli^r bi-omme saltii than tliei^e two. 
Bromide of at.nmbium haa h^F'n highly leeommended. particularly in epi- 
lepsyi but after prolcugi^d trial witli it I have reached tlie conclusion 
that it ia mticb i^es useful than tho two bromidoa mentioned abovoj 
Nor does a eombinatiou of the bromidea rl-vih in have any virtiiea that are 
not posffeeseil by single salts. Tht^ hrouiutea of araenic, s^ino^ iron, and 
the like have been widely rerom mended in thw lielief that t]n?y combine 
-the eifects of bromine and Lhe other riietnlbc sulmtrUiees, Lutle reliance 
should be placed upx^n thmn for any therapeutic piirpoee^i and they are 
in no way to bo oanHidercd equivalents of bromide of potiiSHium <jr sodium 
in the diseaaes for which the latter are especially useful. 

The dose of the bromides cannot be reckoned in grains with any de< 
gfee of reliability. It varies greatly with tbo person and tbe disease. 
It is the amount that will acuouiplish the results ^or approximate tbeinj 
for which it is given, withtfut producing JDJary. What this amount may 
be must be determined in each instance. The bromine salts should al- 
ways be given largely diluted witb water, preferably some mildly alltaliuf 
wai'T. Tljt-y are usually best tol*"rate:l when givtin after meala. Often- 
times, however, by depreciating the proteolytic action of tho pc(>sin they 
cause greater derengemenb of digeatiou when given at this time than if 
given between oi' before meals. Their deleterious action on the skin lb 
beat combated by attention to personal hygiene and ly the admiui strati cm 
of Hrsenioua aeid. The latter incre&ties the proteolytic action of pepsin^ 
and in this way dirertly combats one of Uie injurious effects of bromide 

In no (lepartiuent of therupeutioa is there greater rink uf using mor- 
phine to the detriment of the patient than in the treatment of nervous 
diseasCH. There is no pain cemparahle in severity ]ii:d intolerability to 
that of genuine tic douloureux. Many dig eases of the nervous system, 

aofiL ts Ubes, ikeimtia« ud pacbj-metLin^tis, are atbeaded bj excniciatitig 
piic, wtcmirog over a prolooged period. The phyaiciaa is ofteDtimf« 
wnl); obltgtted to r^li^ve «uch p&m hy the usd of morphiae- But ho 
ibntld alvaya have in mind vhea emplojing thi^ ^riig for this piif- 
pOM that these diMAses are of & chnuic nature ami Uial tbe pain is sure 
tD ffcur. Thus ho ]s borrov^v&g temporary pleasure to lend to more or 
Ics p«nnaD«[tt pain, for eventually the drag vill loee its cfiicncy to 
,-«Jj(rTe the pam, and the patieikt tviU in the mean time have formed a 
hibit which will tnatprially add to tl^e riiBc-ulty of effecting a eare. Tlie 
j^Tiii^iaD should in every eaae e^iliaust the capacities of the leas injurious 
dutgwica Uffure he essays to u^e morphine. 

Litdeneed be said coiK^ernm^ the abuse of the mmiem analgeeioor 
tuh U phetiacetm, eKalgin, aDtipynn, acetanilid, salipyrin, and the like; 
for they are not often used dptrimentally by the phyaician. He fully 
ippmriatm the delet«rioiisi)i:^s?< or their iiidiscniuiniite auil exoeAsive 
vft, ud is governed in their therapeutic application acccrdiugly, A 
«cr4 luiut he said, howeveri concerning the teudency of patieuta to use 
lk«o drug9 without coosulting a physician — a tendency that iB fostetcd 
bf druggiflts and manufaeturin^ ohemists who strive to keep in the eye 
of thepuhlic difTerent pain relievers made up of oue or more of these 
dngs in combiaatiou. MiUi; paUeuts with neurasthenia aud tt&uralt^ia 
of different kin<la materially impair their nutrition and jeopardise Uieu- 
diufoe^of recoTery by csaaying to relieve their Bufferings by the use of 
iwfa flceCrumri. tlie capacity of whit^h to ameliorate pain depends largely on 
their effects upon the vaseular supply of the brain and spinal cord. Some 
ofth^nifSuchaaezalginr At^pi^fcundha^molytic^, andtheeSect^ that tbey 
prwluie need to be carefully watched so that meaaurea may be taken to 
iDmbit thrill. Methylene blue hae obtained eome teputaiion as a pain 
nJiflrer, particolarly in sciatica, but it is not so reliable as phenacetin, 
iltboagh it is much le^ depressjint. It may be given iti lio^ea of from 
tbnetofiregrains, preferahl^ incapsule form. ThymaceLin^ ^derivative 
rftbjmeKf ia another of t'le modern remedies that has given satisfaction 
a ame co^ea of pure neuralgia and iu habitual headache. The ,dose b 
fejin li« t'> leu grains given in ^^'ater and simple ejrup, 

i^f the other }>ain relievers and sedatives, aconite is one of the moat 
iB|!urtant. It has well-dehned indications for its uee iu the treatment 
of ft few tierrous dtseaaes. Prcperly acUmoistered, it is capable of great 
terTicc in certain forms of neuralgia, tic douloureux, tiichjcordiai ex- 
^plitbih&ic goitre, and eome of the manifold encephalic aytuptoms at- 
taoding eases of extensive arterial degeneration. The prepai-ation that 
fsn lie used moat adraDtageously in alk of these save the last i^ aconitia. 
UiWfinally rM»niniended and prepared by Duquesnel, which is nov to 
)m bid from any of the manufacturing chemiata. In the administration 
«f l^ia powerful drug three things shoald be kept iu mind : these are 



th&t iDdividaala respond to it very differentlj ^ that the pr^i^rationa of 
different chemiflta have very different effects, aomo being quite inert; BOii 
that the dose ifi tho Amount of the dnig that will pruduce p liy Biological 
flffeots. Haphazard adniinistt-ation of aoonitia disregards th^se factors 
and is naturally worsts thuj) no treatmentj fur it may be inJLiriouB. 

GeleeuiLUiLi is frequoutly usvd aa a sedative aud aualge&ic iu neuralgic 
affection of the fifth nerve and aomctiiues in migtauie, Itfi physiological 
effect ia tirst to paralyce the eensory fibres and then, if its adiuitiistration 
18 continnedT the motor fibres. The fiuid eitrar-t is The moat reliable 
preparation. More than five dro^ia ahould nexer be given as the initial 
dose until the reaction of the patient and the ri^liahility of the prei^&ra- 
tion have been determined. Thcu the drug may be ^iven until it producea 
marked physiological el^ei^t. During its admiinstcattonttieiiatient should 
Im kept in bed nnd^r olose obaervatidti, aa the drug acts depreciatingly OQ 
the pneumogastriG nerve and diminishes blood pressure. 

Th^ lifltof reliable hypnotics h^is Ire^n iziiLttrially added bo during the 
present generation. Salfonal, trional, tetional, aamnalT hypnal, and 
ftiDjkne hydrate ore tho^e chiefiy deeerving of mention. Sulfonal is the 
iDOBt reliable. It ia less a|it to prndnoe unpleasant after-effei-ts and to 
derange digestion. Its sleep' producing eflfcts are often delay<*tt^ and 
these may be unpleasantly manifest on the following day. Like tiioual, 
it ie moat useful in :stat<-.s of c\haustiuu and depression not aasoriabcd 
with pain. In many instances their action ia expedited by giving them 
with a large quantity of carbonated water. Tetronal i& not so reliable as 
either of the twu lirst niejidonetl, although it is ^eiy often efticarious, 
even In oases in which the others do not aet. Hypnul, a eomhination uf 
ehloial and antipyrin, haa tlie advantage of beiug tast^l&^sa and odoHess. 
<*ombining aa it does the dleep-prodnuing tiualitiea of chloral and tho pain- 
rtdievinjj properties of antipyrin, it i^ oftimtLmos the most efHc^riuua 
hypnotio in sleeplessness dependent upon pain. When iu^omnia is not 
associated with pain, aomnal is a reliable hy(motic. Amylene hydrate is 
einiilar In its action to chloraU and is an elticieDb aeosory aedative. It 
may he given in from one- half- drachm to two-drachm dospa. 

Formerly the disABtroua etfecte attending the use of the hypnotics 
were more endent than they are now. This is due to the fact that rh» 
modern aleep-proilucera are less injurious even wh<-u taken rontiniially 
than are t^hlorol and hminidia. The latlnr is a conibinali'>n of bromide, 
chloral, andcannabiaindica v'htch has come into considerable use in differ- 
ent parts of the country, Chloral hydrate is a drug which ramiot be 
taken for any considerable length of time without producing profuund 
^TsorganizntioQ in the components of the blood, and creating tu appetite 
for ita continuous uae which in spoken of aa the clihu-Rl hahit. This 
habit is even more ditHiiult to mre than the morphine habit* and tbe in- 
roads vbich the administration of the dntg makes upon the system aro 



^b jvofoosd tbui those attentiiag the use of morphine^ Id fullest 
Kuf^lioD of this itin]i5tDevertbelessl>«adiuitL«d that despite tbeeffioa^- 
end wider field of Uflefulncss ot the moJeru hjppotics. chloral ^till uiaiii- 
ttiw ill pi>aitioa as the raost reliable hTpnotitr. it ahuuld never be giTcn 
cjtept imd«i the phygiei^m'a control oDd with a keen appreoiauoo cf the 
tv^oltA Ihnt m&j Attend its indiscnmiriBte us«, 

Tli«re &re a few dru^ of such ooniipLCUOiiA vi gfmc-T&l uae in the ueat- 
umt of uervoLJs diseases that speci&l meutiou should be ma'le of ihem. 
TbBM Bre uux vomieAf arsenic, phosphorus, iodide of potasfliom and of 
jodiuDiT ^^d conium. 

5qx Tomica with its alkatoids, etiychnine^and bructne^ is among the 
oast reliable dn^gs of the neurologiHt'HarTDRmentariuin. It is one of the 
bat iUonacbicSp one of the most reliable cardiac stimuIaDtaf one ot the 
oartfdScacioaatoELicH to the ajm pathetic oerTuua avsteiD, and it exerciaeb 
t ipNial influence upon Etriated musculai fibre. The fact that it baa 
Tide applif^atioQ in the treatment of u^r^ons diseases should not make 
.1 {urg«t tliit it had its limitations aiid that there sire many diseases of 
lbs DctTous system in which its uee is jKisitively coutraindicaled. Of 
[bsM. we may mention states of eiolted seusibilttf atjd spasticity. There 
udm^in ita too early admiaiatratioo in inSaiumatory coaditious of the 
rfTvoua Hystem^ such a» neunti^ poliomye litis, and enoepbalitia, before 
Uw inflammatory state has c^^tnpletely subsided. It has thd advautage 
that it Toay be given hypodennatically, and in the treatment of some dia- 
flvrs, such as spinal progressive mo^cular atrophy, atrophy following 
^hclJG multiple neuiitis, and tic doulooreni, it scema to hare peculiar 
fffiocf when given in this waj^ The mo^t important contraindication 
10 iti OK are the cerebral palsies. 

Aisraie is m drug of deserved rflpiite in neurological therapeuties- 
It hu gained this repiuatton largely because of itfi naefuluesn. in the 
trtUment of Sydenham's chorea aud different fi^rma of neuralgia. )t is 
Um of Bervice in the treatment of tabes and chronic mycliti>4 of Don* 
ijpbilitic ori^Q. It haa long hesn known that arnenio poflseeses the 
prapatty of promoting the formation of red Hood eorjMispIea, and it has 
ramify been proven to have an almost specific acLiou in some blood diA- 
casei neh a^ leucocylhxiuia, 1>uring the last few years it has come to 
WMogntedd tb?it there are certain affections of the spinal cord of the 
ptiliolcigical nature of myelitis and of the cltnioal nature either of tabes 
V tiuie paraplegia which are associated with stat^.s of profound anemia. 
U is believed by mai:y that the lesioTis of the nervous system are see- 
<ttduy to and dependent upon disease of the blood, but there is much 
Mtuwayin faror of the view that the vascular leaiona and the cord 
laoaiifl are due to one and the aame toxie eub^tanee, although tlie affection 
(it Ike cofd may be aequential to thatof the blood. Whuhever be the 
tra« explanation, anraio is the most valuable drug in the treatment ot 



th«Be diaeaae^i and it owes this r^putatiorL to ita eff^c^ta in promoting r^gen- 
^ratidD of tbe blood niid iu delay iitg its dissoc^iation and da^oiD posit ion. It 
isDot uulikely that it ia in thi^ ivay that arsenic aetH beLeficlally in chorea 
auil in neuralgia. Iu both of these diaeasea tbe blood is invaiiablj dis- 
eased. Tbe preparatioti^ of atRcnic tbat are luuat reliable are Fovrler's 
solution, arseuioua acid, and araenate of flodium- The Mter caa ofteu be 
given when the former is not tolerated^ owing to nausea, lachrymalioD, 
and pLifHneHS of the fai^H, which It ia apt to produce. Wbatever prepara- 
tion ia ficleoted for ueo it must be gis'eu in adequate doaes, for it is now 
generally believed that email doded huve liHle of the benefit^ial effects 
that attend adininicitratian of the drug in iatge doaes, Areenic Ib one of 
the causes of multiple neuritis, but there h slight danger of such oou- 
plioation ill its therapenfjo use, 

rhoaphonis hus attained inideserved prDmineuuB in the treatment of 
mauj ncrvouB diseases such as neurasthenia, neuralgia, insomnia, loco- 
motor ataKia, aud different forms of paralysis. This ia in a measure 
due Co the ffLut that beoauaa It ia an imponaut t'unntituent of the nerver 
tiasna it was Wked upon as a icjird in nervous diseases. Aa h matter of 
fact, its Utility is not \ery great. It is merely a fair restorative in states 
of OKhauation, wliether due to fnnctiona! or ofgauiv- diseases. It should 
be given in the form of pure phosphorufli difjsolved in ah^ohol and glycer- 
in^ such as Thonipaou's aolntinnj of whieh a draehm represents a twenli- 
etb of a grain, or Ui pill fonii^ from on h -one- hundredth tri oiie-liftieth of 
a grain. Begiiniing with a flinali dose^ the patient houn gets so that an 
adequate amount oan l>e taken without produciitg nausea and eructations, 
whieh arti the worst features of its one. Naturally when the nervous 
affectioiL ia in asfloeiatiou with aoine such diaeaae of the blood as leuoooy- 
th^mia, phosjiliorus may have a more important therapentie rfMa than 1^ 
here aaaigtied tu it. 

Connjm is a. drug thaL ha.9 beeu nncd extenaively in the treatment of 
spasmodic wry neck, dilferont mauifeiitiond of the tie nouroais, ohrooic 
eborea, and aa an adjuvant to tbe salts of bromme in the treatment oF 
epilepay and tohyoaeyatniia In the treatment of afiiteraaoiaenl eonditions. 
The pre [lara lions most freipeotly used are Ihe fluid ejttraot, giren in five- 
drop dosea and gradually incroased. and the bydrobroiuate o£ coniine. 
given in beginning doaea of one-fiftieth of a grain EUid gradually increased 
to a tenth of a grain. The patient's idiosyneraey to the drug and tho 
reliability of the preparation of the drug must be determined in every 
instance. Many snmplMS cf ouniiun are wholly inert, and it is often- 
times [t«;eKhaiy to try the wares of one chemist after another uubil iuie ii 
found that will produce physiological effects. 

HyoRoyamine and duboisiuBf the former used in the ahapa of the 
hydrobrojnate and hydrochlorate in oue-oue-hundredth-graiu doses, and 
tbe latter in the ahapa of sulphate in one- seventy -fifth of a grain dose. 



pv iaportAut motor wdatir^, Th^ir use is confiiied Iftrgelv to CDiubab' 
|ig«>dlemeiit Jkud motor uareat in acute mania, the Uaia delirio, and 
fuijjns astUiiA. 

SoiDui^ CTgftnie diseasea of tbe nervous aystem are due to f^'piiilifl 
Alt luerciuy and iodide of potaa«iiiiu find a roiuparatiTeTy large field of 
mefalcms. The use o£ the«e drugs ia uot coufined to sypliilitic afTertions 
tloat^. M«rcurj, git^a iusmall dese?, ia an iinportart a^eccj in cootribut- 
LOf tottsCD£TfiCioaof tUe blood in many aoj£!uiic conditic^Ds, and the iodide 
td |oUistum and sodrum are the most reHable alteiiitives m chiviuia de- 
gMcntion of the blood- ver-;^ 1b and pafeiicliyma. Tim mode of admiots- 
tnLioaoE these two dru^haa been couaidered in the pages devoted to tiie 
IieitDKntof syphilis. Here it nifedato be said that not u^fre<^uent]y both 
of t^a are relied upon too exclusively to meet the indications for H-birh 
thry ate gireu. It is unfair to expei't them to do impoasibte things* such 
u to Tegenerate nearal tissue after it has been destroyed by syphilitieexu- 
dueer new growth. In almost every iustauce in wbicih tb^^ise drugs are 
biicated, a general tonic plan of treacmeDt is neceasary in order to get 
iHtir full beuefit. NegJe^^t of this importaat feature is reaponsible for 
xhi many uncored though treated casea of syphilis of the nervous system, 
vidforftomeof the untoward results that ocea&ioiially foMowantjsyphilitie 
BMdicatioD. The tendency of Lhe iodine salts to disorder digestion aud 
iO]|air DutritioD should bo contiuLiallj kept in mind. If tliey are given 
T<i] dilat^ with alkaline water they can nsuatly be taken without uiu^h 
diicomf^Tt unless there beapec*!^ idiosym^raaiea. Ordinarily they are best 
gJTB after meals, but in many cases they are better tolerated if given 
inuiiidiately before mealfi. ('btldreo and some adults are leas diatressed 
bjthem if they are gheu in skimuW milk or awt-et milk. 

It ia unuecesaar}' to devote conaiderable space to the use of tonics and 
sOmulanCd of the circulatory system, or of general alteratives and restora^ 
ttna in the treatment of nen'oua diseases. The priuciple upon which 
Hue drug! Ate given ia such diseaseti is the same as fn the treatment 
<J|enera] diseases, 

Miuy drugs are more or lesa confidently recommended in the treat- 
lantcf nervous diseases which have no se^^ure foundation^ either physio- 
logiPil or empirical. They are recommended by one writer after anotbor 
uulcne i^eneration after another, yet no one is villing to say just how 
or aseleas ttey are. Such are ailvt^r aud aluminam in sclerosis of 
eapiualcord. zinc in hysteria, topper in the tic neurosisj and gold in the 
^eient degenerations of the nervous system. All that caji be said is that 
ibetruie ia founded in empiricism, that they are a part of our inherited 
nptfilQC^ and that Apparently they merit their reputations as remedies. 
The foOowtng table has l>een jjrejiared to t^how the do«<e aud use of 
tl» dmgs ofteneat prescribed ly the neurologist. The niimbers refer to 
Ibe diseases or symptoms tabulated b^Iow. 




AceUnLlld(vitlfGbriD)t gr^ v.-tt. 31. 41», &5, 66, 68. 

Aconite, gr. iH :t. 4, 30, 4&, 60. 


Agfctiin, gr. vili.-x, 39, 76, 

AmmoaLum bromide, gr. v.-zv 28, 36. 

Ammonium valerianate, gr, IL-vili 13, ^J3, 35, 49. 

Amylene hydraiB, jS 39, 

Amyl nitrite inhalation 3, 6, 17, 23, 36, 7:i. 

Auilinemethflblue, gr. iii 31, 4». 

Antipyrin^ gr- Y-uv 13, », 23,^,30,40, 47,56, 66,71. 

Apomorpbine hydrachlorate, gr. i-^ 6, .36. 

Arsenic, Fowler's wl., ni llL^rv 13, 6ft, 71- 

Arsenloufl acLd, gr. Vr-Vt 13> 33, 60^ 

Aaafwtidft, tinc-p 5«.-i 6, 17,34,86- 

Airoplne, gr. tJt-iV* cautlouily 18, SO, 66, 66, 08, Tl 

BelUdomu, alcoholic extract, gr.f^ 6, 10,18,31, 40. 80, 8L 

Belladonaa, flaid extract, m as.-l 14. 17, 23, 26, 48. 

Biamnlh valerianate, fl. ;b«.-1 47, 40, &l, 

fiorax, gr, t--ii- . . . . , ..........--.-. 23. 

Dronuuulde, gr. x,-3ct. ............. 80, 61. 

Butyl chloral, gr. II 31, 00, 7fl. 

Caffeine, gr- 1.-V 16, Bl> 30,67. 

Calcium bromide, gr. u.-lii 23, 86- 

Calomel, gr. J^ii 14, 80. 

Camphor, gr. il-^^x 6. ^7, 31, 32, 40,63. 56, 66,58. 

Camphor monobromate, gr. l.-v.. 13. 10, 31. 

Cannabis indlca, gr, ^^ 6, 13, 17. 10,36,88,40, 72,73. 

Carbon dl sulphide, gr. U.-vt 40,50, 65. 

Charcoal, 3 i--iv 28.81, 

Chloralatnlde, gr. iv.-ilv 39, 

Chloral camphor, gr- TEviii--ii^. .........,.,, 49. 

Chloral hydrate, gr. v.-ixx '2. 6, 13, 17, 18, 19,23, 39,44,72. 

Chloral, methyl, gr. x,-xii ...,..- 4ft. 

Chloralo*e, gr. Itl.-i.-xx 23. 36.39. 

Chloroform, gr. vi.-xn 6, 13, 17.36,48, 72, 7a 

Coca, flnid extract, sl-ii 36, 51. 

Cocaine hydrochlorate, gr- Ba,-ii.. ...,..-..,. 81. 

Codeine, gr. J-l 66. 

Colcbicum.fl. ; 8S--U 6,40. 

ConlLn« hydrobromate, gr. ^-j^. ,......,...-. 17, 19, 

Conium, gr. i-4 13,62. 

Conlum. Huld extract, ni v.^x 10, 75. 

Creasote, gtt. l--ili 80, 81. 

Croton oil, ni l.-ii 10, 43, 49, 

Dubolsine sulphate, gr-^^r-A ^^' **> 00, 76. 

Krgot. fl. extnicl, glL v.-xxx, j extract, gr. lii.-x. 48, 58. 70. 

>:»erlne,gT. Vfl-A ^^*- 

Ether, Jaa.-i *;, 17, 20, 44. 49, 66, 66,6ft 

Kthyl bromide inhalation .....-.--....-...,.- 23. 

Euphorin, gr. v. , - -. . .................... 31, 40. 

Exalgin, gr- il,-^v 13. 31.40, 56. 

GelMmtum, fluid extract, gtt. ll.-xv. 2, 13, 10, 2.S, 31, 32. 

DRUQB. 63 

Gold bninLde> ftt vU\ 3,23. 

Gotf>Dd»dHimchtQrldft,A A A-A 1^*49. 

HoBiiiin'« vLod^DCi H xv.-lx 6« 15« 17, 18, 90, 4Cl 

Hi^ t.-Ii. 2,10,30, &5, 76, 

HydiDbromic Kid, n^ ii.-i . 23. 

Btokuw bjdrobromate, gc. ylr-A 6, 18, 35, 3U, 44 

HjOKTUDtu BoIphAl^ gr. ^^r-A 44,53, 

SyoKjimos. fluid eztnct, gH. t.^x 31, 30^ 5G. 

Hjpttl, gr. IV 80. 

Hypnoue, 3»,-i 3ft. 

Iodine, gr. Hi eilenuUj 41, 40. 

Iim bfomide, gr. v.-z. IS, 13, 31,35. 

jjVQ nkriaute, gr. n.-ll 30, 31. 

LM«ideroil, giL i.-t 31- 

Liiiiozd bromide, gr. v.-x ..,....,.,..„„,., 1, 23- 

Upalin, gr. il-it 2, 10,30- 

Mcnlbol eitemally 0, 31, 49, 55, 6S, Sa 

Mercuric iodide, gr, ^-4 fll. 

)[ettijl*], gr- L-jxi 30, 

MeiiTl chloride, gr, iiL-x2 82. 

MnbjleiH blae, gr. i.-il 08. 

loootoomtte, gr. i.-v 86, 30. 

ioephiDB, gr. 1-4 14,66,80. 

Mi^ Xioctiire, 3**-Jl 16» 17, 23, 40, « 

Min^i«riii, , i, ,ia in pill^ A-A-A 3. 4, «, 15, 17, M. 

Oplma, gr. i-i 6, 30, 34, 36. 

Wmic Kid. gr. .'^-J 23, 63. 

PinWdirde, ; B».-ii 30, 

Phenicrtiii, gr. t.-it 8,23,35,47,49,55. 66,71, 

FtKDocoU hjdrocbloride, gr. x.-xv 40, £6,03. 

Ftio^ifaoric acid, dilute, gr. t^i-A ^^i 35,37, 55, 

fto^oraa, gr. .jifl-^ 37,49. 

Piloarpicie, gr. y^-t ^&' 

PotiBiiuD uvenite liquor, ni t.-iv 13- 

PouBiiUD b^carboiiAte, 3 u— 1 31.41,51. 

Praaimn bromide, gr. t.-tI 3, 17, 10, 23, 35, 37, 63, 72, 80, 81, 

Fouftium cyanide, gr. ^ 40. 

PuiiBinm iodide, gr. t.-Ix 20, 23, 41, 46, 58. 

(^DiiK salpbate, gr. i.-x. - , . 45, 74, 80. 

Qniiiine ™ieri*jiate, gr, «,-iL..., 31, 32. 40. 

Silol,gT. I--XV 23, 25.31,66. 

SalipjTin, gr. iv 31, 66. 

Silophen, gr- I.-XT 1,31,49. 

SilTfrtiliTale, gr. ^1 12, 23,61. 71. 

SiiDDlo 13.23,60, 

ii^iom u«eniate, gr. ^jV^ -'•-' -.--.-. 6, 13- 

rwliuni brain ide, gr- xv.-Jl 13, 10, 23, 61, 72, 81, 

Sodiruo bjpophosphilfl, 80, 

Si]inin,giL X3tx.-lx 6, 2:*. 40, 65, 63, 78. 

ixmiuil, ; 8*4,-1 - -,..,.....-.-..-. S9. 

Mjlphonal. gr. xv.-xsi. SO. 

SoEDbul, gr. x -n 6, 23, tt-l, 36, 89, 

BOrmTiuin brvunide, gr. x.-iix ,...,... S3. 



StrychnlQC, gr. ^-.\ 

1, 7, 8, fl, ^7, M, 58, :a. 

TutronKl* gr, x,-x1. ........ 


TrLotk&l, gr. x.-xl .......... 


:H. 32, 34, a5. 

Zinc bromide, gr^ lli.-x.. . . 

13, a3, 36- 

Zinc chloride, gr. M.-il ,. . . 


Zinc oyanidt', pr- as.-il . . , , 

\n. 23, 4W, 

Zinc indlde, gr. s.-LL 

13, 23, 3B. 

Zinc oiLdc, gr, u^-Li ,.,.,, 

13, 23, 31. 

Zinc phoftphaie, pr, W 

13, 23, -IB. 

Zino vaU'Tian&te, gr. H.-fl . 

20, 2a,3r,.40. 

1. Acrap(u-i«fltbesla. 

41. Lead Poi soul ug. 

2. Alcoholism. 

42. I..ethargy. 

3, AngLim r^toria- 

43. Lumbago. 

4. Apoplexy. 

44. Mania. 

5. AatAflU Abuia- 

46. MenlngltiH. 

6. Asclimn. 

40. Mercurial Tremor. 

7. Angioneurotic (Edeniiu 

47. Mij^lne. 

8. Atrophy, rrogiVAaivc Muscular. 48^ Myelitis. 

9. Atrophy, Ni-mal. 

4U. Neuralgia. 

10. Bladder. Irritable, 

60. Neuralgia, Trlgemiiml. 

]]. Bulbar roHLlyals. 

51. Neurasthenia, 

12. Car'llalgl^ 

&2. Neuritis. 

13, Chorea. 

63. Nynipbouiujla. 

14, Colic, I^acL 

M. <')ptic Nerve, Atrophy ot 

16. CollapHt'. 

55, I'alna, InHainmatorj'. 

10, Coniu. 

53, [>Ains, Tabic. 

17. Convulaioni. 

57. Varalysia. 

IS. TTamp- 

5B. I'aralysls, Infanlllp. 

1ft Delirium Trenienn. 

5U. I^uulysls, Leoil. 

20. niabctVH InnlpiduL 

00. I^arttlysiH Agltana, 

2L DyHtrophy. 

01. l^araplegla, Spastic- 

22. Kiict^phalitiH. 

tyi. Satyriisiri. 

28, KpUep*y. 

m. Sciatica, 

24. Kryihronu'lHJpla. 

f^. Sclerosis, Midliple. 

2>). EnurcBlH. 

35, Sclerosis, ComblriaL 

20- Gangr*n(', Symuieiric»L 

m. Shock. 

27. Graves' dimraiw tsee exophthalmic *I7. Somnolence. 


OS- Spasm, lAtcal. 

2B r>aiitra1gia- 

00. Syncope. 

ay. Gwirodynia. 

70. Syringomyetia, 

BO. Goitre, Exophthalmic- 

71. Tai>es. 

ai. Headache. 

72, Tetanus. 

S2. Heart, PalplULion of. 

73. Tic Donloureni. 

SH. Hydrncephalua. 

74- Tiiniitu*! Aurlum- 

3A- Hypochfindrlaels. 

75. Tortlcolllfi. 

SO. Hysteria. 

73- Tremor. 

Sty llyatero-Epileiwy. 

77- Trirtmua Naacentlum- 

H7. Impotence. 

7H. Uriemla. 

-}8. h^Kanity, 

7D. Urine, Incontinence <if. 

30. limomnin. 

80, Vertigo. 

M, l^ryngismui fSti iduluJi, 

SI. Vouiitiug of I'regnancy. 



RTrKnTSFKAPT, by whicb is gent-rally meant the external applioatinn 
nf «»tet in tbo treaCCDMilof <lL»ea5er h^A been piactiaed since thv Uiuv 
Ite due«3« began. Like other pbysioai ageDciee, it was highly thought 
(d tod mcteh us^ by the anpi^ute, but it fell into disrepute with the 
■dTisit and domiiiancy of Galt-u and his dUciplea and their methods of 
ttntiitg disease bj the use of drugs. The field being thus left free to all, 
pbme^ '^bora doctors" and thoae imbued with bhespistt of charlatanry 
toot it ap to the bettermtrnt of tbeir fortuKa, and it} maiij instanced to 
Ibe pa^petUAtion of their names* Only dnnng the present generation 
hu it come lo be applied aoeording to scientifio principles. When the 
pboGoiena of diseaae bvgau to Ix^ iuterprettii rationally^ according to th« 
Im of pathogcneois, and when phyaiciana benamo poeseesed of comprc 
bnBTe knowiod^ of its cauaationi then caine tbe awakeoment to tbe 
miwity of preventing disease by iQaintaining tbe general vitality, and 
amog it by nstoring the balance of nutrition vhich h^ Wen over- 
thnviL It waa soon recognized that physical measures were quite as 
Aidoiu to aocompliah these, and oftentimes more ao than medicines- 
AntoDjf ite most important of auch physical measor^s is vaier^ At 
ih« pr«£etit day^ the art of applying it m the treatment of disease of the 
teiTCius syfiwm is a neceesary accompliahment of every physician who 
asftji to ireal these diseases. The antipyretic anil antipb^ogij^tk' proper- 
In of cvld water are much uion* widely recognized than its stiuiLilating, 
ttttfpug, and sedative properties, to whicb it owee the reputati^^ that 
il il«5erTpdly holds in jieur<>logic!kl tb^rapeulice. 

Aa Estimate of the Vaine of Hydrotherapy. -The adoption of wal« 
Uktbefapeutic ^^nt baa been much hampered by the intemperate iA- 
fwac^ <rf hydriatists, pbyHiriaua acid lay practitioners, who not only lay 
dum to its usefulness in c^ety diaeaso, but who recommend it as if it 
vfln the only curative agency. Mnny of them, moreover, seem to be 
docoiaatcd by an obsession that the members of tbe medical profession 
bii« covenanted not to use water iherapeutieaUy and to deny its virtues 
ttabealing agency. The fervor and real wbie.h they display in spiesd- 
tac the doctrine of bjdrothorapy may be c^jmpared to that wbirh animates 
lb» eooseientious worker in the Lord's vineyard who feels a touch of 
Maxtj in having beard a special " oall/^ They are continually gosj*!- 
inng the application of water in tbe treatment of all di^ases, and at the 


fiftme time manifesting a f&Datio intolerajit^o uf other methods, eten phjs* 
ical measures which well -baUi toed therapLata knoiv are of quite aa much 
or even greiater value. Attempt to converse with one of these hyilriatistH 
oa any topia» and lie leads bwk to the subject of water as uQerrin^l/ as a 
polanzed needle sxviinis round to poiut to the north. Listen to such a 
person talk of the trQatmeut of dieoofie, and one hcais wat«i apothoosiied. 
Jt is unneceaBary to e^Ly th;it such claims awaken th(4 Buspieion that this 
simple measure with whose qualitios every one is so familiar, and whit^h 
is iji daily use from the momeut cf birth until after death, could not have 
kept so long thd secrets of its marvellovis curative properties from the in- 
quiring human mind. Then, oftentimes, trial of water as acurative meas- 
iird is disa[kpoEUting. So much di^peiLds upon its proper application that 
the inexperisueed are quite aa lialile to get disagreeable as beneficial ef- 
fects from its use. If such an experimsute? has had the auspicion that 
hydrotherapy is not all that has been olalmei for it, he now becomes con- 
vinced of itu uaeleasness. Finally, many hydriatista have tried to croct 
ari elaborate technique which they hold muat be confoimed to lu ordar 
that the best effects may be obtained. Not infrequently they are ani' 
mated by sordid motives iii advancing the luLeresta of some hydriatio in- 

Ruch one-sided a[iv*>caoy and biassed tostimony on the part of hydro- 
therapeutists has done more to rt^tard the uuiverHsU usb of n'ater for the 
therapeutic properties which it un<loubtedly p<isseaaes than the absurd 
claim a of charlatans and quacks. On the other h&ud, ita use bss uot 
become no fully kuowu as it dt^aerves becaune teauhers of medicine ami 
therapeiitii-5 hare been culpably derelict in uot giving epace to it m theii 
teachinge aiid writinga proportionate to that devoted to other therapeutic 

The application of water in the treatment of disease is an a.Tt which 
can be acquired only by experience. Moreover, its haphazard and desul- 
tory uao is just as con train dicated as is the administration of druga in 
a Gimilar way. It is fatuous ti> expe<jt benelicia] results from its iUogioal 
ftnd irrational use. To utih/e it to best advantnge demands ttot only 
Uist one be familiar with the prtiperttes of water applieil under different 
degrees of tempera tiM'o and |iressiire, but that tltero be ileJinite cliiucal 
indications for its use, which in tnru prt^auppose a correct diagnosia. 
As the beoelicial effects of the application of oold water aro co-etiuivalexit 
to the phenomena of reaction and its structural dependencyf it ia neoea- 
aary that ch&He be determined m every iudividual. The ouly way to do 
this is by trial, although experience with tlie same clasa of diseases &nd 
patients scou teaches certalii ^eiieial principles that are applicable in all 
Aftses. Hero an endeavor will be made to outliue the general iuijications 
for the use of water, and to enumerate a few methods of applying it 
which are well within the i-each of the ordinary practitioner. It is often 



^iffiNlt to eonvino* pfayaiciaDS who hare had no eiperieuce with tha 
foff^etl ftppLif^tion of water Chat it does Qot retjuire an elaborate ap> 
|vms. Indeed, one of the most frequent comments which I hear from 
}Ji^cuii3 of cocksiderable ejcptrience, when speaking to them of w&ter 
ia thfi tn«tmeiit of nerrooa diaeaseBt ia that thej eovy the city practi- 
twoer vbo cm avail himself of the advantages of hy driatic inetitatioiiB. 
TIk belief is founded in error. Ablutions, compresae^, wet packs, rijii- 
bvbs, tub-bEbths, lot^al baths, etc., require yeiy tittle a.pparatnB for their 
Hunt BUfCASsful use, even though they be given with greater precision in 
bititutions devoted to the purpose. It ia extremely aaadviaable to com- 
(licite the procedure of using water thorupeuticolly, in other words to 
vnctruct ao elaborate tectmlqner auch as is frequently seen in books on 
Ifdjotherapy. On the i^otrary, every effort should be nia<lft to aimplify 
it >0 thai it may be entirely within reach of the general practitioner. In 
Ftuc&i hydrotherapy in the treatmeat of Derroita diaeaflC oc^cupies a firmer 
^Ik>Q than in aiiy other conntryv and there hydrotherapy is synonj- 
aonswith the use of the douche. Unquestionably the French aeoure just 
Mgmd results from this single procedure as we do from a larger number. 
AX ^e outsel, it is well to state that when certain hydriatio procedures 
■n mentioned aa being of service in the treatmect of this or thjit nervous 
diMO^e, their nse in couneotiou with mediciaal and dietetic treatmeDt, and 
vfteatimea alao iXL oonneotion with other physical methods of treatment, 
ii nlways me«ut- 

The object in applying water tn the treatment of nervoua diseases is to 
cause stimulation or sedation to the entire nervous aystem or to nertain 
puts of it. The nature and intensity of the effect which water nill pro- 
ittoe ilepend upon the temjieratnre at whioh it is need, the part and ex- 
iKiEot the cutsueoiu surface to whieh it is applied^ the degi^e of force 
Tith vhi^h it impinges upon the 8kiii, the duration of its appIicatioD, and 
id aaaociatioB with cerlain mechanical elfei^ts, euch as rubbing and activ- 
jlTOD the part of the patient. More than all these, however, in deter- 
namg the auiouut and kind of tte effec^t, is the ludividuQtity or the 
westitatiooal puCTiliaritiea of the patient. Herein hydrotherapy differs 
ndically from drug therapy. When a doae of morphine, aconite, or 
dllflulis is given* the effects that it will produce may be estimated within 
B*mw limits, except in rare iuatojicea in wbicK individuals have wLat is 
failed dji idiofyncraey- When a hydnatio procodLiro is ordon^d, riothmg 
ft?« trial or esperimenlation can be accepted as a reliable guide. Certain 
tl tB that the application of water in oiip way will cause contmction of the 
blu^-veasels, and in aitother way dilatatioo- Bub here it is uot so much 
li* .nuaediale effects of which we speak as the more remote aud lasting 
nar^ This position I desire to make clear at the outs^^t, for although 
fVmtiDg a kec^n apj^rectatioa of the value of water in th« treatmaot of 
twnwu diseases, I do tiot believe it to be a universal panacea. 


Effects of the Applioatioa of Water at Different Temperature!. — Lov 
t^inpemturi^fl play the most: iinpcirtaut rOle in hyilrotherapy, but high uid 
nieciiitm tPtiiperattires Tipv*»rtheles3 are of great aervice. As the words 
heat and cuiil ui^q ^waya used iu a relative aeuae, il ia wt^ll tii say, in the 
beglniuiigj juat what ia meant by th© wgrda na they ore employed here. 
This 16 Bhovu by the follewijjg table; 

' BxCHMVeoDld from lo (BT. = a3''^I 4fl" R 

Very MLd ,„ « 7' " [Q " =44 " «i " 

Cold " 11 " 16 " =fil •' 6& " 

Cnol t 111 •* 30 " =«) " «S * 

Lukewn "21 " Ifi " = e» *' TT " 

Tepid ■ " «a " ao *' ^78 " Nl •' 

WsJTii '* ai " S5 " ^S7 " W^ •'■ 

Hoi . " 3fi " 40 " =0(1 "^ 104 " 

Vuylwt •* 41 " 60ai]d70'C.=105*Ui \3»-T. 

Ertemal appliaation of water inoreaeoa or deoreasea the eieltabili^ 
of the nervoiis system through the mftliatiou of the enisory oerreg and 
their teriuiuatiuDH by rJrtue of ita luechanical aud thermal propt^rtiea. 
It alao cauaea definite chauKCe ia the lumeu of the blocHl-vesselh, pcrbapa 
alao iu the veseel walla and remotely in the blooi Wurm water and cold 
water produce quite different r^ults upou the muscular ByateTC, the 
former decreasing, th<* latter mi're&aing niuaeuUr force. The remote 
effects of thenpplicatjon of water may h? conditioned through the vieeulu 
ayfiteiUp the glands, excretory aud secreUiry, aod tlierefore through uieCa- 
boliam. Thus it may be made an important agency in contributing to 
tiasue change. Oold apjiUeatious, wher: of short diiratioa, Daueie coutrac- 
tioQ of the cutaTieouB blood- vessel s, Xhi9, in turn, is followed by dila- 
tation, which if aasociat^d witii increaged activity of the huart, as it 
usually is, causes an uci'eaaioii of ineLabolifim, aud this constitutes the 
physiological boeis of reactiou and of permanent tonihcatiou. The lu- 
teiiaity of the et!eet in tlie blood-vessels depends upon the temperature 
o£ the water, upon the force with which it strikes the akin, upon the 
dumtioD of the applioation, and upon the in*ifhtttii'?al stimulation to which 
the skin ia auhjected by friction^ or by the patient liimself in the shape of 
voluntary activity. Water of a very low temperature (below 45° P.j, if 
applied to a large surface of the body for more Uian a fev seconda, 
owuea a more or less pNjlonged contraction of the blood-veaaels, which in 
turn is followed by what may be called paralytic dilatation. At the some 
time the heart's action is reflexly depresseil, causing consequently low* 
ered blood presaure^ not only in the parts of the body to whii'li the watei 
has been OippHed locally, but throughout the entire economy. This ia 
a stato of more or less collapse^ which is known aa incomplete^ or l&ck 
of reaction- It is a condition strenuously to be avoided. Therefore 
one of the moat esaential results to be had from the use of rsAd. water, it 


applied, 13 prompt and suiHrieDt rcuictiou. There 
f&cihtatiui£ aud iiiauring this rea<Tlion, One of the 
K»l important lA to aee iJiat the tcmperaturts &]id force with which th^ 
flier B^pplted kre in etrlot acoordaiiiQe or cuaformity with tLe patient's 
nKililj^ W«iik, aiiKntic patiecta; G^DsitiTe women; p«op[d &t thd ei- 
iRttWof lift-'s si'sm, and those whose vitality has been grea.t]y depreciated 
bj' disease aud sufTerbg, should not be subjected to such exire&jes of tem- 
pfnture and pri^sfitire as peoplo having ahundont or normal vitality* 
Ob the other haad, i£ the cutaaeoiis blocxl'vefiselfi ^I over the body aro 
Kaewhat dilate by the external application of heat, by means of the 
Timi sheet, the dry pack, or the hoT-aip box which la naw very oomm only 
mti in hjdrUtic estabLiaLnienta in tliLi coiiDtry^ the applicaljon of cold 
■Iter to the cutaoeous surface will not cause such profound ccntiaction 
vi the peripheral blood-vesseb with consequent dilatation of the central 
TQU as it doe^ i^'ithout fiut^h preparation- Therefore the vascular 
phMOUtfia forming the basis of reaction, which, as baa already h&en 
Bid. (vnsista of peripheral va^sculat dlldtatioii and aaaoinated increased 
iiLT;Kiui^ power cf th« heart, will more readily occur- Another mcaus of 
^ihtatin^ reaction la to apply Iriction and rubbing of tits parts during 
immediately after the application of water. The mechanical erft^ctfi 
I ichku^y proved by the active ruddiness of the skin and tlie sub- 
reglow and feeling of exhKaration- The same eff net can be produced 
}y patting the patient in warm coveilng, or, better still, \ty aendiug htni 
iUD thA fr«sh air to take active cierciae. The latter is tlie common 
Bsftod by which reaction is facilitated- Lack of reaction is oftenest 
■aaitet in ih« extremities, particularly in the feet, Jn patients of 
vitality this manifestation ia often coanleracted by having the 
cut stand on a warm surface oi iu warm water during tlie active 
liaeuti and by active flagellation or the application of dry heat after 

Tb« effect of the application of cold water will therefore depend very 
If (ipcm the promptness and completeness of reaction. If the object 
lo dilate the anperiicial blood-veasels al! over the body and to increase 
»cii>iint of blood going to the tiaauea* therefore to stimnlate luetabolio 
the effect J3 produced by applying cold water for a very brief 
and then using the means just s;x>keti oE for facilitating reaction. 
Or If tlie Abject la to cause detenninatioii of blood to the periphery in 
ordiprthat the amonnt of blood circulating in a sluggish wnj throngh an 
inlemd Tia<:uei, auch a& the cetitral nervous system, Jiiaj l>e le^^ned ajid 
•I tha same time prompted to greater rapidity of movement, there is no 
nm vay of doing this than by causing the blood to cuipty into the 
iheral v^etsels, and then to give it its proper Telocity b}' atimulatiug 
(^ardio'vaacuJar tnne. In a similar way ia to he explained the 
which the application of cold water has upon accelerating at re- 



larding tbe activity of the glaadular aecretbUi Although perhapa the 
latter doo9 not stond in eatire relatiouHhip Ut the amount of blood m the 
gland and the rapidity with vhich it circulates, these (actors are uever* 
thelieas very im^xirtarit ones, as haa buea Bliown experiiueutalEy. 

Thu tijtcitiiig efi'uctB wliich cold wat«r has are due to eit'itatioii of the 
peripheral nervQB and of their tertaiaatioaa in the actively contractile 
part of the muscular fiubatani^. Upon this depends the lucrease of 
muacular tone to which it gives rise, and liltQwise upon it depends the 
narrowing of the lumen of ihe blood- vessels. Hut as with every other 
foim of atimulatioiiT the motor nerves lose tbeir excitability after a very 
brit^f appIicatJOD, and then the phenomena of relaxation Appear. The 
golden mean in the appheation of cold water is to excite the peripheral 
motor nerves to brief oontrsotiont but nut Uy exhaust thuir contraetibility. 
Then when the rftsction occurs in the shajie of blood-vessel dilatation, 
tlie i>snpUera] motor nerves which are disE^ribuled in the vcAsels and in 
Other parts of the actively contracttle muscular nubatance will etiil be 
rctipousive to the normal physEoIogical stimuli that are continually going 
tc them. 

Cold water applied to the cutaneous surface does not have a nelective 
action upon the jieripheral motor nerves; it. affects as well tlie sensory 
nerves. The effect is ^ atifnu^abing one to the peripheral distribution of 
the sensory nerves, if the application is not bo intense or prolonged as to 
render them functionaUy inaoti^e^ which it may do, thus causing antes- 
theeia. It is quite within the bounds of possibililj that the stimulating 
effects which the mere appHcatiou of cold water exerrisMS U[miu the seu- 
sory nerves might, if i:Brr]ed to an extremei cause a pathological condition 
characterized or attended by exhausted states of the peripheral sensory 
neuronST such as ejtists in some forms of neurasthenia ajid in tabea dor- 
ulii. On the other hand^ the improvement of nutrition which follows 
increased circulation and metabolism around and in the peripheral sen- 
sory nerves more than outweighs Ibis possible objectiou. 

Warm applications, especially if continued for a prolonged timet cause 
a dilatation of the peripheral blood -vcBBels, it^tard the frequency of the 
pulse, and diminish blood prcH^uic, They have a tendency to prevent 
the neuTomuBCulature from being responsive to physiological stimnlatiou, 
and thus the reacLtun which follows their une in a very slow one^ Thin 
Bocounts for the sedation and the subjective feeling of quietude and ex- 
haustion which they produce. This is to be kept in mind when it is 
decided to uae warm applications, for their capacity to mcrease asthenic 
states is very great. Extremely hot applicatii.ins, on the other hand, first 
act as a cardiovascular stimulaut, and if not conhinued for too hmg a time 
may have very much the same effect, though to a lesser degree, as cold 

The hmmogenic effect of oold applications, followed by prompt and 



fifgroos reaction, baa been definitely estAblisheu bj a large □umlit'rof 
(ibKitTAtui&i. Tbeir immediate effect is to increase the number of white 
Hoed wrpuflcles, wbioh is ttflniieBt by the relative increase of leueocytea 
tfDtiasiHl with the number of the red corpofides- Tbei^euiote effect is to 
henwalheDumberof teil blood oorpuMcIeasnd the amount of hemoglobin, 
Isia many nervoofidbea^s there is not only oligocytha^mia, but anseniia^ 
l^ ia an imporf^t pomt to keep in mind. 

Cold watetf by which wo mean water between 40° and <to° F. (iF&ter 
liMnkl never be used at a louver temperature than this^ ezeept for local 
qipltfuicns), may be us^ as a toniu exeitanL in all asthenic nervous dis- 
OMtt except in certain comUtioTuin which it is specially roiitraiudii-ated ; 
varecoQstmctive agency ; as a aedative agency in erethiatic nervi>ns stales ; 
snifsantipT-reticaadautiphlogiatio. A^ an antipyretic it has no very wide 
spplieation mthe treatment of nervous t^isease, for fewof thea<^utemflaiu- 
rastumsof thenpn-ousBystPtn are attended with high temj>erfttare. As an 
satiphlo^^stic it may be used either locally or Ln the sha^ie of cold jtacka 
b tfie early stages of acute inflammatioTis of the coverings of the central 
oflrTous system or of the parenchyma. When it is used in the shape of 
toJd ablutionH or cold paeks the temperature of the water should rarely be 
ktw*r than from G**" to 55'^ F- When ice is employ^ as a local applica* 
iku the effect sbtiuld he v^ry closely wflteh^d, aa intense and iwrBiflt**nt 
Wttialgia may result. 

Ai a tonifying ageaoy^ water haa its field of greatest usefuhiess in the 
tnatment of functional nervous dis^^ases charact^^med by depreciation 
cfmsnta) and physical vigor and loss of tbe capacity to create energy. 
By fw the most important effect to be Btriven for in the use of water aa a 
lomTjing agency is prompt and vigorous reiK^tiou. Tbia follows the 
douche And the prolonged cool full bath or half 1>ath more aurely than 
icj vVher means. The temperature of the boily should be higher after 
tiwir applicatioJk than it was before, and the patieiit should e^cperieoce a 
fnling of warmth and well-Wing. It is this effect of hydrotherapy that 
9UJ be utilized as a most important hygienic agency in tbe prevention 
ofuerroua disease. It serves tbia purpose by cetabhshing and maintain- 
tngtha harmony and equilibrium of all the functions of the organism. 
TUwtioo of cold water as an excitant has already been Bpoken of, and 
tberaoonale of its use ia asthenic, torpid stntes of the nervoiia aystom 
iamuly understood according to this explnnation. 

Kodes of Applying Water in Hervons Di^eaMs.— Water may be ap- 
plied in the ahape of tub batha. nblutions* packs, ram baths, and douches. 
'*rth«se, there are many subdivisions, the moat important of which lu the 
iMitBieat of nervous diseases will be considered very briefly. Ttib baths 
ITS Hjioken of aa the full bath, tbe half batb^ and tbe local batb« such 
u lo the feet, pelvb, or hands- They are also classified according to the 
tenperalure at which ttcy are given. The cold full bath of brief dura- 


tioQ is given at an a7erage of 55" F> It wiU depend largely upon the 
patient^s vitality and upon the evident capacity of the organism to react 
whether or not there shall be any preparatory treatment, and how the 
patient should enter the bath, the time that he should remain there, and 
the treatment to which he should be subjected immediately and remotely 
after coming out of the bath. If there is reason to believe th&t the 
reactive capacity is not very great, the temperature of 4he water should 
not be below 60"^, ^^^^ the patient^s skin should be vigorously frictioned 
both by himself and by an attendant while in the tub. The shock of 
contact with the water may also be lessened by previous splashing of the 
water on the face, neck, and chest before entering and by vigorous volun- 
tary movements whUe in the wattir, particularly by swimming movements 
if the bath is taken in a tank. The time spent in the water should rarely 
exceed ten seconds, and on first trial it should be very much less than 
this, oousistiug merely of immersion and getting out as quickly as pos- 
sible. Reaction is usually very prompt, but it should be facilitated, ex- 
cept in the vigorous who take this bath for its hygienic and tonifying 
effectHf to counteract fatigue and increase the working capaoi^. Even 
these should be impressed with the advisability of vigorous friction 
with a coarse towel, a fleah-brush, or with the open hand, followed 
by active physical exercise for a few minutes, either with the chest 
weights or some other gymnastic exercises, but preferably by exercise in 
the open air. The cold full bath is too severe for the ordinary sufferer 
from nervous disease of any kind, and should rarely be taken unless after 
preliminary treatment by means of cold ablutions, the douche, or the 
prolonged half bath. The contraindications to its use are diseases of tliB 
heart and arteries- 

The prolonged half bath is given with a temperature of water vary- 
ing from 75° to tiO^- The patient after wetting the face and chest 
enters the one-third or one-half full tub and takes a sitting posture. 
The amount of water should be sufficient to cover the legs and the 
pelvis. If the patient is averse to entering water as cold as this, the 
temperature may be lowered after he gets in, either by means of ice 
or by running cold water into it. The attendant throws and splashes 
water of the temperature mentioned above upon the patient and promotes 
reaction either by manual friction or by means of a flesh-brush, while 
the patient may devote similar attention to the legs. The duration of 
the bath should be from one to five minutes. Naturally, the reaction be- 
gins while the patient is stilt iji the bath, but it may be increased and 
prolonged by the usual means after emerging from the tub. It cannot be 
stated in so many words just what the temperature of the wator should be 
for each patient, or Che duration of the bath. This can be determined 
only by experience. He should be removed before the teeth begin to chat- 
ter and any evidences of cyanosis with a weak, thready pulse appear. 


&I ft rait it taty be said tbat the lover tbe temperatare and the more 
HbaliTeUiift patient tJi9 Eh 'i-tereliould be tbe procedure— a rule that holda 
gM iot ill hfdriatic^ applicaticms- On leaving tbe batb the genetAl 
dnKbeorsomeof ita modificaUoiis maj be used, or the patient ma j reueiva 
ftfesmJ AblutiotL with water of fruiu oO'^ to o5~. If the jMittenb eaii tol- 
caietkia, itvill injure a tuti re thorough and prolooged reactiaun Thtr 
Olid ball bath is niut^k hlot^ usefuJ th&Q tbe cold full bath, t^c^use h 
ocmofis lem ihock to the patient aud tlie reaction that foUoVB U pleafi^ 
ortn ifid more laisting. There la littl« danger of the appearance of 
ijttptgmti of depreasioa vhich not infrequently cccur two or three houn 
liter the cold full bath, even in patients who setm to reai:t thoroughly at 
t^e tune. Moreover, it gives alnindant opportunity for the Mse of the 
acchtmcal cS^xs during the bath whit^h contribute not only to tbe occur- 
nacfl oi r^a4.'Cion but to the persistence uf it. The muny modi^eatioiis 
of it whii:h «^lI1 suggt&t themsi-lves to the practitioner to meet the dififer- 
ttl iadicationa in diCFeient patiente and diseases make it an important 
hf(ihati« procedure. Indeed, ne-\t to the douche, it may be enid to be 
tkt &i«t available hydriatio apj-Hanee as a general tonif jlng agency and 
(DQimbat a^^enic states of the nervous system. It has the ^eat ad- 
luiajje that it may be taken at [uime without other aid than a laoEober 
ollhe&milj who has been properly instructed. 

Local eold batba are adininiatered in tbe shape of sitt hatha and foot 
bth«, ecrasionally to other parts of the body> The brief eold eit£ bath 
il gives 8t a temperature of from BO to *iO'^ and from cue bo fire minutes* 
dnndo&i while the prolong^] sit£ liath of from tiO to HH^ ia giveu from 
fitilo twenty minuted' duration. They are used to increue the tone of 
fte pclr;<^ circulation, especially when audi eridencea of slug^ahness and 
piinve hyperjtmia as hemorrhoids and <'Ongested condition of tbe pelvic 
Timrain the female exists as a part of the general neurasthenic »tat«, or 
ttnining in hysteria and hypoehundria. By reflex action they have the 
mfadtyto alter the intracranial blood supply, which actiou iu ofteulimea 
&iaifeai«<l by tbe relief of some of the cerebral symptoms of neuraf- 
Una, particularly the msomnia- The brief sitz bath is indicated ivhen 
ittatMi) J penstalais or an slHux of blood to tbe pelvic organs is desired, 

CoU foot baths are a Tery important hydtiatic proeedure. Tbey are 
pfn wixh water at a temperature of from rt^" to 4if \ and from thirty 
Hcuttdst9 two minutes' duration. They should be given when possible 
vi^nm&ing voter, in preference to plunging the feet directly inio eold 
naeti but when running water is not available, the feet should be kept 
i* active movement. The after-effect, both immediate and remote, of 
lin'rtM !"0t t>ath is to cause dilatation of the blood-vessels, and thia 
bmisbes the clew for its beneBrial use. The cold foot hath is the 
tant important meajmre in the treatment of habitual cold feet, and 
•peciilly when this is a aymploia of one of the functional neuroses, 



euoh as neuroatheaiEt. epilepsy, aud hyetetia. £y causing dilatation of 
the bluod-vesG«ls it allows a detprmination of blood to thetia parta^ which 
in turn causes a lesflened amount of Mood in the oppoaile pole of tbe 
body^, viz., the ce^haliu extreiuitj'; aud on this ac(^}UTit sueh batlia are 
verj BOTviceable in the treattnent of Gravea' diaeaaet and iu overeommg 
the insomnia of the neuraathenic statea, especially when the uifloinnia 
aeeina to tie dependent upon persistent mental activity, the aontmaous 
thoughts nmcdng seemingly in the sameehannel. Cold hand baLhfl may 
be give[i iu exactly the saine way. 

Although warm baths hare comparatively little afpltcabiliby in the 
treatment of nervous diseases, still they are sometimea useful aa sedative 
fancies. We may utilize the eajue kmd of warm baths aa oold baths; 
thus we have the prolonged warm full hath and hot bath; the brief 
warm sitz hath; and the proloiLged liot sitz bath; and the warm and hot 
foot bath. Warm full baths are given of a tomperdtura of tiS^ to 90° F., 
and from hve to twenty minulee* duration. They are administered for 
their quieting ejects upon the sensory and motor nerves, and whenever 
there are indications for a prolonged determination of the blood to the 
amface in order to ptontotp equalization of the circulation op derivation 
of the bluod from central partA. Thus they oftentimes coutribute to 
peaceful, rcfreahing sleep, and particularly when there are symptoma of 
central irritability, such as muscular twitching, Rdgetiness, aud restless- 
seas. If they are followed by some ookl-water proeedurc^ aui'h as simple 
ablutions, the cold half bath, or the general douche, for ihe tonifying 
effecta, this form of bath, given juat before retiring, is oftentimes of great 
advantage. After the bath thfr patleub should be put in a linen sheet and 
wrapped or covered closely with a blanket in order that the peripheral 
dilatation of the blood-vcBaels may be kept up. The covering should not, 
however, be suflieient to oause any couHiderablo pars pi rati on, unices there 
be special indications for thi», becau.^e of the debilitating effect that it 
has njion the patieut. The prolonged hot bath is mrely given, eseept in 
couditiooa of sthenic delinumf especially when occurring in persona 
who are not physically debilitated. In such patienla the prolonged hot 
bath has vi^ry great capacity to produce muBuulEir sedation aud a^^ociate 
mental quietude. The temperature of the bath should be from 100° 
to 114'^, and the duration of from five to twenty-five minutes. The latter 
period is fraught witU danger, partii^tdarly if the latieut is not carefully 
watched. When the temperature of the water gets about 102'', patiente 
have very different tolerance to it. t^ueh a temperature often causea 
symptomg of heart failure, manifested by seneatious of precordial weight 
and onnstnctiouT of distention within the head, dyspncea, feeble pulse, and 
dlzzine^;:. On the other hand, if the patient remains in only a short time 
this bath acts as a powerful cardiac stimulant. When the baths are being 
given to patients who are not iu a mental state to apprise the attendant 



jf t^ich sjmpKiinA, thg prec^vitioa should be taken to wash the face and 
^p«r part of the oeck. with wld wato-, to immerae the bauds once or re- 
^ttttily vx cold water, and t<» ^pplj cold compresGes, an ioe lag, or 
IjUer'a coil to tlie lead. The condition of the palsn and h^^K'? a^^tion 
tkoold IwL-arefvilly watchei], mid when thera are «vidnuce« of luai^kedlj 
lircrtraaed blood prcaauTo the [jatient sLould be removed. lu Bome in- 
fiBtMfi the probngod warm butb (tempei^ature* 9^^'' to 99° F. ; duration, 
tTCntyto avztj iniQutea) ]:j aerrioeable to relieve the rigidity and dunioiBh 
'^« iDt^aai^ of the tremor in paralysis agitanfl- 

Tbe cotitiuuotjs warm bath, T,he wat^r being kept at abuut the body 
irtsporature, is often nectraaary m the trt^atnieut of trophic lt^sit>itB ocicur- 
dafinth destractive changes in the apiual cord from injury or diaeaae, 
TbtwiKt ia brought to the proper temperature before being put m the 
inb^ A abeet ia then put aoroas the tub eictectdicg about half way down 
the JDterioT. SufUcieot water to keep the aores constantly immersed is 
Umd ddded. A mild deodorizer ajid disinfectant, auch aa perm angati ate 
of potusium, ahculd be added la the water- Wheti tbe patient ia iiLCOu- 
iiucot the water must bo renewed very often- A small bed-table and 
properly construc^ted pillows make tlie patient far more eomfortable than 
uj water bed or air bed can do. 

Brief warm sit£ baths are ^ven at a tem[)ertiture of from 9D'^ to 8.V V.j 
ladhomlcn totweaty-fiveiuiEUtca' duration. They are useful principally 
m cLroQiG inSammatory conditions of the pelvic viacera, and h&ve very 
liUJepUmin the treatment of nervous disea^asn Prolonged hot sit^ hatha, 
^TU with a temperature of from itn" to 112", are of use principally to 
ineRuethe quantity of blood in tbe pelvic viscera and to counteract 
jAin in theae parta. Prolon^d hot foot baths, given with the aame 
tuipemtuTea, are aomettmea of strrvi^e in eluding a derivation of blood to 
ibefeet, to relieve symptoms of excessive intraerauial vaacularity- 

The simpl^t and most available hydriatie application is the ablution- 
It bu the great advantage that it can be taken ^ithome witliiiiitattend;ince 
uf apparatus. It is not only of value ua a tonifying agency in the treatment 
df muiy of the neuroses and organic diseases of the nervous a^^stcm, but 
a i£ mv&hiable as a preparatory means, espeoialJy in women, youug chil- 
dren, and aeositive adults, for the use of more tonic and aevere h^driatic 
VMSoras. It oonsiais in the application of water of from 60^ to 50° 
tran the hollow hand of the patient or an attendant^ or by means of a 
taih-glovo or wash-cloth, the entire body being gone over in this way. 
If the patient is verj sensitive, one part of the body niay be splashed, 
dhed, and oovered liefore another ia uncovered. The procedure should 
Mtlut longer than one or two minutes, and it should be followed by 
vl^mcu frietioning with the hand, with a rough towel, or with a fleah- 
broak If reaction is not prompt and vigorous, and especially if the 
patieut is muoh debilitated, this being the initial hydriatio procedure, it 


is advieaLle for bim to havo a hot water bug to tliu fot^t during the aUlu^ 
tion. It 19 reaUiljr 8«en th*t this procedure oaii be made bo mild that 
t-ven lift moHt delina.ta patient eiAn take it- 'For inatautre, with childiexi 
and with \ery fiensitive woineu it ia often Dccesaiiry to beguj. hy having 
tlie ctteodajit dip ber hftods la cold water and rub tbeca rapidlj and vritli 
friction over only a part of the body. Then, day by daj% the surface to 
which they ai'e applitwl la increased until gradually compl&to ablution la 
reach ed- 

AfhiflioDH oonflist in the applicadun of a volume of natf r poured from 
a pituhi3r or pail itpou certain parts, poaaibly the entire body, of the 
eittuig or standing patient hj pouriug the water from a height auy 
desirable mechauieal etTecta from the impingement of the Btream may be 

no. I.— Ta miUTBlfl UiB Jlnillimtlnn or tta OrbmJ PbjtIT ^.TIta Sit«s«^ 

obtained, Tt la the hydriatie procedure that may be used when the donohe 
ia not ATailahle. The trmperHture of the water Ahould lie the same as for 
the douche, tiz,, from 50'* to Cfl^ on aQ average, especially after the pa- 
tient ia aomewhat inurpd to the effects of water. Tho application itself 
should not consume nioro than from five to ton secondaj and the reaction, 
which is very important in these cafles, ehould be facilitated In the ordi- 
nary way. PeraoKallVf I have foitiid afFusicnH very serviceable to com- 
bat the myaathenia of Sydenham ^b chorea^ and in the treatment of certain 
forms of neuraathenia, eBpectally in that variety formerly known aa apinal 
irritation. These two measiireFii the ablution and tho affusion, can be 
safely recommended to the general practitioner who will take tho trouble 
to learn iheir application as important adjnvantfl in the treatment of 
maay fmictionsl and organic nervous diaeasPB for the [uitpose of combat- 
ing the symptoms of attthenia. 

The packa that are used in the treatiuenc of nervous dineoaea are tha 



tj vid w«t gexkeml pack aud the local pack. The techmque of apply- 
luf tbe wet utd drj paek is exactly the eaioe, save that in Uie former 
ce the Jineti sheet ii saturated with «at«T. It is illQetTai«>d by Uje 
panviag illuatrations (Fi^i. 1 and 2)- A narrow litd ajijiroa^h- 
froiD both fiidea is covered with a mbber Bheet if this ia to hand. 
a blanket and a Imen sheet are laid upon the bed ao that ihe bor- 
hang equidiataot on etther side. The patietit hea in the middle of 
b«d and while the arras are held oloae against tha aides, the over- 
g sb«ret is placed smoothlv over hii»; the enda ara bruuffhl; nporer 
bead and the ieet iesp«ctirely, &o that these reoeive a double i^rer- 
]L%, the fac« being left eicpoood- The blanket is then wraj^ped around 
'M |iab«Qt in a eimilar way, the bardera of the blanket being carried 

beieath the patient's back, Clotiia wrung out ttt ice-water or an 
icrbtf should be applied to the head to relieve surging of the blood 
a the head which follows primary con^trictioik of the blood-Teseels of 
the KkiD. 

If the dry pack is ased and it ia desired to get the patient to perspire 
fmljf the sheet may be warm ^vhen the patteikt is put into it. he may 
le fjtea hot drinks such aa hot weak tea or leoioiuwie, or he may be 
ovTVMd with other blankets^ The time that he ^ball be left in the pack 
dtpods entirely upon the effects that it is desired to produt^e. When 
im perspiration occurs the patient must be taken out and some cold- 
iilfrr pro«<dnre used, snirh as ablutions, rain-hath, or doDche:^ unless 
ttwwhe coQtraindicatefl, to <%iRhat the profound dilatation of the per- 
iplKTil blood-veanels. Such measures g-ive tone to the hlood-ressels and 
CUM rigorous reaction. 

Tb» teuperature of the water in which the sheet is plunged for the 



*«t pack depend* ^ntiroJy upon the purposes for wLich it is to be nBeflT 
In the treaticeut of ui^ruoua diaea^ea it is cfiuiinoiily used sta ft quieting 
aud toiiifyjiig agenv^r although ccuabiuo&Uy it is used as an antipyretic 
in the e&xiy sUges of infectious diBeaaes wliich afloct the i-entral nervous 
syatem. VfluaJly water f mm r*^" bO 65'^ F- ia used. It must be borue ia 
mind that, unlike tho douche, nblutiena, etc., there ate no laeobacical 
ftflwta to facilitate reaction in the uae of the paf?k and we must depend 
entirely upon the tempemture of the water Tf the eho«t is wrung out 
of luk<;ivanEi water then the elTeiit ia to uihke the |>atp]ent limp and 

The primary effect of the cold pack la a vasoconatriotiou due to the 
elfeotof the cold un the vu^ncouatrii^tarB, whi(?h in turn is followed by 
vu^^orlilatatitjt! duu tu irrit&tiuu at the \aso<lilatora. This probalily con- 
tinues during the eutire apjklication. The pulao Ijecames soflf r, u£ some- 
what greater volume, and the heart frequency foils. The acnouut of 
intracranial blood becomi^a less when vaaodilatatioa oomea atul oftentliues 
sleep occurs, eveu while the patient i& la the pack. After the paek, oold- 
'Katpv applications may be utiliiwl if it be desired tc counteiaot the vasou- 
Jar diidtatlun. 

The dm^atiou of the cold pack depends upon the purpose tor which it 
is employed. If to reduce tempi^ratnrc, the eheet niuet l-e renewed every 
tea minutes } if to produce rascuisr diJatalton, from oue to two hcure. 
The hot pack is given in very much the sania way aa the eold pack save 
that a sheet is never usfd. If it i^ desirei] to give a hot pack of frum 
105''tf^]Oft°F, the blaukttshoulil he putiijj water i^f from 140^ to 150^ F. 
and then wrung out by two persons who grasp the ends cf the blanket 
with dry Ttirkish towels and twiat in opposite dii'ections. While in the 
hut tlie jiatient may have loe^watei'couipresses to the head to coun- 
teract the phenomena of eongeHtTou , 

The douche offers one of the moat. valiLahle methods for tlie utiliaa- 
tioQ of water aa au excitant and tonifyjng agency. With the douche 
tite mei*hauioa] effects are obtamed tfttm the preeaiira which forces tho 
water thrctugh the nozzle. This prea^inre will vary with the effect that 
it IH desired to pnxiuce, generally fnau one to ciiie and one-half at* 
moBpherea, fiFte<*u to twetity iioUTida to ihtj sriuare inch. The danger 
<K>umet!t(id with the uae of too great pressure shtndd never be forgotten, 
inasmuch as it is oapuhle of cauning not alone coutuslou of the soft parts 
but grave acoidenta to the viscera. The tcujperature of the cold douche 
should never be below 4'.* F. The average tomperatiire that is used for 
a persoji of fair reactiug capacity, wtieu it is denired to give a tonio bath, 
16 from Cty to CO*, and the duraliun from fifteen to thirty accoadfli 
fiegioners and iuexperienced persona are inolmed not only to give the 
douche with too great preasure but to prolong it unnecessarily- The 
duration of the douche should always be in proportion to the reacting 



of each p&tient. For exftiople, the quicker the T^ACtion cau b« 
cl^Md the Bhort4?r ahouJil be the application of the doucLe- 

Xbe patieab ia prepared for tho application of tlie douche bj beiDg 
mofled for a fev minut^a in a hot-air box (Fig. 3) or hot blanket^ 
it It is Applied without prepEiration- He then atacds with the back 
10 tfa4 operator, who allowa fi Btream composed of the outptLt from the 
fijuller tiibaa vilh wbich the noj^^le is supplied to impinge againnt 
ihetfiLk fur two or ihxee Beccmda and then against the calves and the 

no. 3.— HdI Boil. 

f"9t If tbd patient tolerates this then tbe operator retuma to the hnok 
jmd npetia the largeBt (one-meh) tube of the nozzle and with the full 
;nn8iir« that it is deeided to use goes over the ectrre bod^, save the 
bodijtd Deck, completing the application wilhiri thirty or forty seronda. 
IffliepAtit^t is particularly bt;iLsiUve oa certain parta of the bcdj tbe 
iltodiut should be instructed to go over such areas lightly, for there is 
«ilf diaaJvantese from intlicting uspIi^bs Buffering. Tbe procedure is 
nroiUy i«mmated by giving a apray, or fan douche^ vhich is made by 
|Jvmg tlie tip of tbe tingpr i^rmly over the end of the KOiy.le with water 
oadn iLfl aame pressure (of course t]je watei' strikes the body tbcu with 



much leas forre], biit from five to fifttit-n <l<«greea highf>r l^mperatura Id 
nriifi' ta facilititte re&ciiuii. Oirafiiunalty it is i]e(?e8«8ry to Lara tba 
teifiperature of the water used 3U tbe siiraj confliilembly higher than, 
Tbe duratiuu of tho Sojx hafh slu^uld he from five to tea aet'OtLds. 

Thev© are many modiiicfllions of the nn^tbod of doiU'bmg, tLe aioft 
important of whi(;h maybe com |iri»ed under the beadiDj^of th« lonftl 
douche. Tbua ne bave Iwel dovich^A for their effect upon the liver and 
apUeu, tlie pelrio viaoer&; the ei^igiistric doudm for the coiul>ating cf 
anorexia nervosum; the ccphalio aud opiual dout^hea, etc. The luoi^t im- 
portaot of the local douches iu tlie treauueut of tierroua diseafles are the 

VlOi i,— flia tnLaflornraFiil]:r Kqiilpr"^ Hj^lrlallc Itodn, 

Chaicot aud ttie Fleury do^iche aud the Scoltiqh douche. The Charcot 
doacbe ia a jet doiirhethat \» given tbniugb one-aixteenlh-inch tut^s wbicb 
the ordinary uo/.de is supplied with and vuider ap]jropriate preusur^. It 
IB uaualJy appheil to the apine. It ia the legitimate aucceabor to tho 
formerly much-ueod rain bath. It has the all-important; advant^e that 
any deaired niwhanieal effe*'t ean be g<»t by regulating the prf^asure. Tho 
Pleiiry dourbe is a jet doucbft afid Bliower douche cnmbiuei], and it has for 
its object the auuje pur^joHee aa the Clian^oL douche, but it ia more exciting 
to the peripheral blood-veaaela and surer of delerraiuing reaction, The 
Scotoh douche consists of en arrangement by meoim of which alternating 
atreanis of hut aud cold water are directed against the aame part with 
unvarying pressure. Of courae the n>Bult of such proeedure i> that the 
thermal effecta are f^normousTy enhanced. This procedure is therefore 



DlifBUd pari^iculaily when it \& desired to ^l tlie sedaLiou irhU-h follows 
BCEiTucuiAT dilai^tion and L&3t«aiDg of the circuleitioii iii previouAlj* 
dining ringE^B^^ coaditiona, such as m neurolgiD states. It U also an im- 
wttfit a^ncy in stimulating the resorption of inElaiam3.tory exudates and 
Titatf1**'"'C iiasuer«onstrD<rtion. The lix-al douche is alwaja fi>Uowed by 
tt«|«DeTalduui-Ii«!r aa the former is used milelj to obtain the local effecta. 
1W>p(nntaa ia shonn in the accompanjing illuatrattuix and diagram. 

HUMnigh the douche is the prototype ot excitant hydric applicaticDi 
ia «e ift aomewhat limited V> i&fltitiiti one where tL^ te<juisite pi^suie 

IILft'MWnm tn EivMn iTn of Nnn)e Duutl in « Tljitrluir^ rhuulvt. I. frvrnvte niitJlBbor 

^mtm^ttf lT*m S. I 4»; LQ. enU-vslcr bo^e: IL. thennobBm : 1£. pnaiue rcebter Ifr*''?^^ ■ Ui 
^WTjUi* : IC rlci^ ftHdii^ dHutv li nftrmlHl bjr ophlEd^ 1* ^nil HI. at Cto bbaa Uma 4 ■»] a, [b« 
I— 111] 11 fT ■■ niiniaini iiirfuiTff mnninii nf wuw bi noinHi icatporuura- 

bv bu operatioD can l>e obtained, either by steata or comprefised air, and 
blLj^b hcni6C0 in which thd pleasure is furniBhed from a tuik upon the 
mi. In the practioQ of those at a distanee fruQi large citi«9 it must be 
n{ipUnt«dtij abSations and affuBiona orHctme of the other mnre definitely 
lahcated methods. 

There are a number of dericea for the local application of water which 
fll Akdo use of to combat certain ajmptomB occurring with nervona dia- 
mm. Of theM may be mentioned the psychrophoie, which is often ser- 
Tlnalile in the treatment of functional impoteney; Golden berg' a cooling 
undtt, used to DTprcome loca] manifestations of sexual erethism, and 
luap^s nctal irrigator, oft«n of ^eat talne in the tieatm^t of mucoua 
ODteHtu occturiDg A3 a symptom of the neurasthenic state. Xa udac of 


tboj will b« referred 

the chflpl 

these baa geueraJ a^|ilir^&bi 
treatiag of these euhject^^ 

There are an infinite cumber of detaiJa coonected with the therapeatio 
appHcaticii of water, all of which oanLot be passed in review. It must 
suffice la refer to tbe most impot-taiit of them, whioh ore : the temperature 
of the ruout iu which the applicatioji is made - tlie question of g\\mg coli] 
baths ihiriag the perforuiajice of pliysiologloal functions avich aa men- 
BtruutJon and digeatiou^ the ikJviaaliljtjr of making c^old appUcaDioDB ta 
the Tery youDg and the very old, and the sofeness of buch applications ua 
pefBons auffeiing from oanliovasoulnr disease, e3pe<'ial]y arterioBolerostsj 
ppraonal attention of the ph^sioi an; anil butb atl.eDdaiit.H, The temperature 
of the room in which the application of wat^r is made should conJorm 
to tbe hydrie procedure, and therefore be dotcrmmcd by the results that 
ooe wiahea to get from the bath. Cold ablutiona, affusiona, or douchea 
should not be given iu a hot room. Irtitatiou of the peripheral nerves 
with momeniary contraction of the blood-vessels, followed by prolonged 
relaxation of the vessels with increased vs^oular to:. us, are the results that 
are being sti-iven for. An atmospheric temperatute greater thrtn from 70^ 
to 1'^° F. would militate greatly against these. Uu the other handf care 
should be had that the patient ia not exposed to accidental brief depreaaioos 
of temperature and dranglit^ pspecialZy in winter weather. It goes with- 
out aa^ ing that warm baths and hot piickd should nob be given in a cold 
room, because the object of their administration would be defeated by 
the exciting elTf<'ts which cold air biis upon the peripheral blood-vessel*. 

Th« Treatment and the Time of Its Applioatioii.— There is a firm 
and seemingly immovable conviction in the minds of the lai^, enlight- 
ened and iguoranl, that bathti should be disnontiaued or interdicted dur- 
ing the menatruni period. Physicians should continually strive to over- 
come this prejudice, which wna ounoeived and ia nurtured in ignorauce 
of the laws of physiology. There is absolutely no reason why bath' 
ing for hygienic pvirposes Jihould be discontinued during this period, 
and it i§ my own praetiee not to interrupt hydnatio apidityitions during 
this time, save during tbe second day when the flow is at its height, 
and then only for ^sthetio reasons, udIcbs there be apeoial indications 
for contrary procedure. It goes without saying that if there oxiats 
a tendency to menorrhagia any treatment previously employed that temh 
to fttimiilate |ielvic circulation or to inoreaae intrapelvic vaaaular preasun 
ahould be stoppinl daring this time^ On the other band, cold water can 
be made an important agency to stimulate intrapelvic circulation and 
thus to counteract irregular and msuftioieat nienstruation. Tbe wellnigli 
univerBal belief that the contact of cold water to the skin during the men' 
Btrual perioil will cause cessation of menstmation is a relic of bygons 
days, before the principles of reaction after the application of cold water 
were interpreted and understood. 


?7o LjFdriatic treatment ahouid be atlmiuisterfd immediatelj after ft 
jmIh ev^eo though it be a light broakiodt. No more should tuny coujiidei- 
it^ pnx^ura be ^Ten diLring tbe height of Btomachic digestion. On the 
dbtr bud, such measures as afTusions and doiicbes should ttot he givec 
BAte th&n tvo or three hours after flome food has been takeo, on aeeount 
jif Uw lowers Tiiality irhich abeteution from fixid cauaes, Tbo most 
fcTOtable time for the use of water id an hour ot so after a l^bt break- 
bat Of in ibe middle of the afternoon. Cold ablutions and cold rubs may 
begiren b«for« breakfast while the patient ia still warm after arifilng 
fvon bid. It is my almoat inr^anable uu^boin, however, bo rH^ueat suvh 
jBtKDbto take a few ounces of warm milk about a half-hour or au hour 
Mne nceiviug such application. Cold Local baths, such aa sits bath 
ttd Uxft bath, and prolonged w&rm batba are usually giveu immediately 
btCare retiring, on aceount of the effect which they hare to produce aleep. 
Tie age of the patient has very littla to do in deciding for or against 
kjdriaiic treatment, but it has all to do with determining the form of pro- 
eeive* ?iatuialljt one doea not throw ice-water ou weak younglings not 
minfina old mea. but there is a golden mean which makes it ucnecces- 
$txj to exempt any age. Bearing in mind Ukut neither the young nor the 
iddtoWrit^ extremes of temperatui^, and that reaction in such persons 
IftiAeDtu&ea murk more difftcult to obtaio tiian ia ailulta, it will Dot \>e 
Afienllfor the physid&n to decide upoa the tnodificatioDS which shall 
mke faydriatic procedure acceptable to tbe patient according to the age. 
htnots with arteno sclerosis, particularly if it is associated with any 
«»id<«hle degree of cardiopathy, as is invariably the case if the arterial 
dugeaefation has existed for a oousidBrahle time, ahonid be subjected to 
ma the mildest cold-water treatment with tbe greatest caLition and cir- 
cmspcctioiTi- They tolerate eveu the mildest forms of cold-water ap- 
pbntioa, such as ablutions, very poorly, and as a general i-ule it may be 
mi that it is much safer to dispense with tben>. The CDndition of the 
Wrt, both statically c^nd at the time of the admiuistratioit of treatment^ 
Mcds iDvestigatioTif and especially Ihoso cases io which after trial with 
nttdeiaie temperattires reaction does not ae^m to be saliafyiug. Nervous, 
unUt>ic, weak, emaciated persons, with pale skin and cold extremities 
ittftinlly do Dot reeeive the same treatment as full-blooded, robust, 
nm^ikmned individuals, nor ia the prelimloary and after-treatment the 
anewith each patients. In other words and in brief^ the most impor- 
taatficUjr lu the use of water, especially after ita thermal aad luechanical 
propenice have been fully i«cognt£edf in a study of the individual and a 
MHgbition of the needs of individualization in il3 applioatiou. 

Th^qaestioD of personal superviaiou and even administration of the 
bydristjc prooeduras is one that receives conaiderable discussion abroad. 
bume countries, especially in France, It i» customary for the physician 
\aprt the txeatmentt but this would aeem to be entirely unnecessary, as 


llie inodificaLiona of teohinque can be made jiiat as well by the traiaed 
attendaot actiin; miUtar tie orders of the phyaicuui- The latter niuat de- 
cide the advisability of auch change from the study of the phyaical con- 
ditions following the bath, aiid from the atat«ments of the patient. In 
aom6 oountrieB (t is the cUBtom for women to bathe men for hygienic 
prirpoaeSr biit wa wa in thih imly a relie of serfdom luid h retardation of 
social evolutinun It will probably never be tb^ aUBtom ever in (Sweden 
for physicians to bathe ladies^ The niosb tsscittial qualiiications of a bath 
attoQdant are amenfibilitj to auggeetioii and capacity for obedience. 
There are also occasions when od attendant should exercise oommon 
sense, Ihtt. if he is possessed of any beyond this i^ is as well for hun 
to husband it for other [lurpoaes and ocoa^iona. An I hare said on a 
number of prerioua occaaiona, the t<-^chnique of admin istering water is not 
oaly a determinable quantity for c-ach paticut, but it is oni? that must be 

The question of eiercise, drinks^ and diaoipliDS ia one that calls for 
some disouasion. Many ipiock hydristtqts have built up complicated, 
ludicrous, and absurd syatemg of exercise in connection with the ap- 
plication of water. It has been eaid that exercise after the bath is of 
great flervioe in keeping up a proper degree of reaction. It may now be 
said that exerciiie before the application does for the peripheral circnU- 
ticn just what is done by encasenaeut in a hot box, swathing iu hot blankets, 
etc., common procediiren preliminary to the bath. When patients are viu- 
able to walk in the open air immediately after the treatment, the exercise 
may be taken on the pulleys aod chest weights, or by means of paaeive 
exercise and massage. If the patients be kept in the hot-air box for any 
nonsiderable time preparatory to taking the bath they should be given 
frum six to twelve unnoes of water. And as a genera] rule it may be 
said that the taking of a course of hydriatics ia a favorable time to ac- 
custom palieutfl to the disi^ipUne of drinking water^ which most nervous 
patients itand sadly in need of. It also offers a favorable opportunity 
to make more stringeot dietetio conformations, especially in regard to 
the taking of stimulants. 



TaE tbffrafto'Vtio eS&at of electrioity and the indications for its use in 

di9H£« caji be accorded adequate oonsideration without inquiry into the 

ntxuv of the electrical eoergy emplojed. It euHicea our purpose to know 

ihU thia form of euer^j', Ja whatever waj it maj be associated with the 

tihe:, u goncrally conceded to contribute to the raeaas of differential 

diieaovtaeation and to possesa i-emedial properties^ Electricity aj a force 

and oontroUed by appropriate apparatus ie sufid^ieutly familiar 

IicaI praf?ti<!e to juatifj delinite and assured coTLclusiocfl ns to the 

Tvsnhaof its actioa uptru the hum^n orgamnuLS uuder difFereut conditions. 

The majority of phjsiciana believe electricity to be &□ agent of ap- 

ptored Talne in the treatment of nervoua ditieosea. There are, howeTOii 

Dunj phyajcianfl, among them a few lending authontiefl^ who deny that 

dvmricity baa in readLry such virtue. They ascribe the benefidal ef- 

feoa that follow electrical application to the iuduence of the auggeation 

of itacuj&tire actiny. The coses th^t cannot be explained aa thus due 

to purely psychical therapy they attributo to accident. Many of those 

botdiog eueh uibUistic views with respect to the usefolnesH of electricity 

IB the treatment of disease substautiate their contention either by the 

ftMnment of a hare opinion or by the t'ludeat pi/nt hoe ert/o pmjtter ftoc 

TcsfiOTiing. There ait, moreover, some physicians who either because of 

tponuice of the fundamental priikciples of electrotherapy or disinclination 

ii»ii incapacity to acquire the details of its application contend that only 

hufD follows its use- These ara naturally prejudiced against it and often 

pahlish their ill-founded opinion abroad^ even though they scarcely possess 

de qa^it^catioEta to entitle ihem to sit in judgLoent thereon. Finally, uot 

% few phyaiciaus exhibit impatience or chagrin at the absurd and extrava- 

giQt claims of electro- faddists, ill-halanoed therapeutists, and charlatans. 

Th«f lefnae to use electricity as a therapeutic agency or soberly to dis- 

auitu merits and demerits^ claiming that it siuEicks of charlatanry and 

■tpnsaing a preference for oihei- le«is iriysteriouR agencies, the results of 

vbieh are, in their opinion at least, equally aatisfactory- lu consequence 

«f tfaeae unjudifliftl opinions^ the atudent who would form, without pteju- 

&>e,a just e^imate of thc^ value of electricity in the treatment of nerroua 

dfneaie is bewildered by ccn^ioting testimony and contradictory teaching. 

Id this Tnaze of distorted fact and fanciful reasoning, the Ariadne thread 

IbbwiU aafely guide his forming judgment will lead to the golden mean 



between the positii^n takeit by the dectrc^tbcTapeutic sc-o^er ajid tKat of 
him who sees in eleotrotherapj tht^ rejuvenesi^noe of the senik Etnd the 
regeneration of the race. The loquiring studput must lean» to view in 
proper perapeotive the opmioua of those whoae testimon}^ can carry no 
weight in this or any ether di^cusaiou. He must remain uudiatracted bj 
diBputations couoertiing the exact mode of actioa of the eleotric force^ 
whether foe eicamplft it exerts its iniueTice upon the |»**yc'he or the Homa, 
He miiat hulil aieitdfayily 1>efore hiin thi? leal isHue^ wlilch in: '' Uo^s this 
agent alleviate Bymptoms and oomUat diseaaea?" If the phyaiciau will 
lonater tho Bimplo priunplea or olettricity and givo heed to the physio- 
logical and pUyBical otfeote which follow the application of the electria 
current to the difTerant tUsuea of the body, he ean erect for hinuMf n. 
ratiottal liania fcir its use. It ift uii reason ahl 4^ to sup^xjae th^-t ^n agent 
pOHaeBBiug 8Uc1i electro Louie, el»:troiytic, and c-atuphoretic propcrtiefi 
ehould be wholly without eSect upon normal and diaoafied ttaaucs. Th« 
jut^titication for the use of elei^tTicity lb baaed ufx>ii empirical results, and 
the moat convincing argument in its favor is fouud iu the faet that it has 
been serviceably employed an<^ is fltanchly advo^^ated ah a thera[«i]tic 
Agent by oubiaased, trustworthy^ aiid critical uhaerrers, 

tt seema very doubtful that electricity p<)8acsseA a tjitcijic action, at 
leaet as it ia at present applied. Navetthelesa the induence which it everts 
in promoting the return of the liasues to a normal atate cannot be gain- 
saiij. Although the physical, oheinio^l, and minute physiolngieal chaugea 
whinh it causes iu the different tiasitBB^ in the stnictural cells, in hlixd- 
Tessels and nerves may not bo iinderBtood, it has been proven experimen- 
tally that eloclticity atimnlates living tifleue, not only nerve trunks and 
muscle subBtaiu'e, but the primitive constituent of all tisaiie^, the cell. 
The reault of a mild stimulation re^-eak itHflf as AiigineiiteiL mi>talxiliflin. 
Thii in Itself ih aufHcient Ui warrant its use in many, particnlarly func- 
tional uervouB diseases, the causation of which U indicated by nutritional 
change in different parts of ttie nei*ron. The chemical or eleotrclytio 
effects are amply manifoBted ni the destruction of tissue if a current 
strong enough IS applied. The diiuinutiou or increaiie in irritability of 
a nerve, depemlent upon anodii- ami cjithodlc apidniation resijectively, 
furnishes a rational basis for its use in tkie treatment of patliolcgical con- 
ditions of the nerves which may be attended with ]iain, and L>f ita em- 
ployment aa an excitor of normal physiological renchon in nerve and 
muscle wherever muscular contraction is of deticient amount, as the result 
of peripheral or cenrral dLatiaaf-, The electric ctirrent thna perfonus a 
aervii^ similar to that of massage in promoting involuntary exercise and 
its resultant bene6cjal effect upon muscular tissue. In addition, like the 
application of masaaga tiud hydrotherapy, the employment of i^ertam 
forms of electricity is followed hy n diBtinct emd general tonic effect 
This may be due in part to the impreasion that it eKerts on the patient*B 



■infl. This pgychical xefBreoce of the cauee of the b«no5oia] effect of 
CKtncal mpplieaiion onlj contributes to the justlficaiiou of its uae. 

The Fonas of Kectricilj-^EIecnridty la ;teed remedjallj in thefoUow- 
nf forms ^Ij The galTaoJc, voltaic, chemical, coastant, continuous, or 
(rou-interrupted currant; [2) the f&r&dic, induced, toand-fro, or inter- 
ivpUd eombt; and fi) fraokljuic, fri<]tioi]al, eleotro6t&tic, or static 

Tbe force which tends to set electricity in motion of to produce an 

tlcctrio current is called the electroniobive firce. Tho geaeratioii of this 

force 16 one of the couditJona upon which dtpenda 

dteiutence of electricity as a mode of tnottou 

or ■ jihanomBDoii of euergj. It is not itself elec- 

triaiy, but a force capahle of proiliicing the 

ekctrie current under duitabia conditions. Elec- 

tromotiTe force is generated by chemical action, 

■» m a voltaic cell, or mechsuiicaJIy aa in the 

friaioQal machine, or hy indnctlon as in the ui- 

^Dcdon «oil} this force may also be atored In 

cbar^ ttorage tattenes or in secondary cells. 

Tkoe ate olber eourcea of electricity, which, 

kiw»ftr, do not concern us h€re^ euch, for exam- 
pi*, u radiant light and heat ajid the vital energy 

of orginic life. 

Given any wiuroe of electromotive force, foreK- 

tmple ll« cell pictured in the accompanying diagram (Pig' 6), electricity 
vUl le gCQcrated Aiid a flow of the electric current established when a 
MntuiDous circuit :a formed from one to the other element of the ceil, cou- 
itEtndng the internal rireuit, and contlnLied withont the nell as n completed 
ntenal circuit. Thus the cell in the diagram is composed of ane>riting 
otdacttplytic Quid and of a bar uf ^inc and one of carbon placed within the 
Itiiii The electnc current will be generated only when the external circuit 
uiMile or closed. This can bed^ne by merely tipping the carbon and zinc 
tcvanJ cne another until they are in i-ontat.'t j or the external circuit can be 
made mora or lesaeitensiTe by connecting a conducimg wire to the project- 
ingecid of the zinc plaLe, and a aimilaj wite to the end of the carbon, and 
tT bringing into contact theeuda of thotwowirea (n and iin the diagram). 
TliBcufluit is then siud to be closed nnd a current of electricity flows from 
tLeiiDC tlirougb the electrolytic fluid to the carbun and thence along the 
tm mrea back to the ainc again fnstead of bringing the ends of the 
tifS (a and /i t into contact, they may he placed upon the human body 
vA ^circuit l*e thus completed through the body; or, the wirea may bo 
bpfMfht into contact with metal or wood and a circuit or flow eetablifihed 
Omael the substances, if the nature of the anbstance permits. The 
oidiof the wires {a and It) when brought into contact with the body or 

FW. «, 



Other object, &ud thiiB causiug a curreut ot electricity to ^ow through it, 
are c^xUod elei;trodes- T}ie bai'i; wires aie seldom used in this way, but 
are caunecteil whh inatrumenta spofiiallj coutriveU which facilitate the 
paas&ge of the current from tlie eada of the wire to the body. The vari- 
ous aorta cf electrodes in msq for therapeutio work will be considered 
Later. The £iito is epoken of &3 the poeitive element, hut bcoause the 
current flows from the external circuit to the ilnfy, the point of attieh- 
ment of the wire tu the zino irt the uHgatira pole ot the battery; the Bt* 
Laohed vrire ia the negativo wire «iid its terming is the iie^fative t:1ect:odd 
or cathode. Opposite to these in the di&graiQ ntid similari? related are 
the carbun or Dcgative element, the positive pole of the hatter^f the poei' 
tive wire, aiid the positive electrode or aoode. 

All fiiibsiauces oonatitutitig the media tlirough which the electrie cur- 
rent passea oSer resistance to LtH paaaiug. l>tJ!Farent subBtanuea offer 
diflcrCEit dogrcSB of reaiatanoo to tlio pa8Ha|;i> or conduction of the elpctrio 
eurreitt. Thus the nietals offer very tilight reaistance and are called good 
conductors. Silver, copper, iron, and platiiium are the best conduttorH- 
Those Bubfltanr^es that offer eoormouf^ reaistauce Jire calit^d non-conductors 
or insulators. Suck substances are wood, rubber, vegetable and animal 
tiasues, partioularljr in the dry state. So much resistance do these aub- 
stances offer to the electrio current that they may be considered aa oSer- 
iog absolute barriers to the flow of eli^ctricity^ The human bodj offers 
resistance that is considerably greater than that of the metals. This 
resistance varies undhr dilTerent conilitioiis, AltJicmgli water is it^latirftly 
a poor conductor, aud indeed alisolutely pure water is considered it aoa- 
conductor, the smallest amount of foreign aubatance reudera it o. relatively 
^od conduetor. Thus the akin, particularly iu the dry stat^^ offers very 
great rasistaiice to the trsuiHniiBainn of the electric cnrrent, particularly in 
Bucb pp.rtB whern the epidermia is thick and devoid of awes-t glands, such 
as tha palms and soles. If the akin be moistened with water at th^^ point 
of contact of the elcctroUss with the boily, the resistance of the epidcrniu 
to the ourrei^t will be materially reduced. A still greater reduction of 
the resistance will foHo^ the uae of a salt solution to moisten the ele:r- 
trodes. the salt in the water bt-iiig a much better conductor tbnti the 
wat«r itself. It will be readily understood fiom this that the relative 
conductivity of the human body is conditioned by the fluids whioh it con- 
tains. Theae fluida may be considered aa forming n oontinuoua physiciU 
maas constituting the path of conduction of the electric fluid- It will 
therefore not always be determinabie what pathway the current of eleC' 
tricity will take through the humau body. This path will depend upon 
the different r^aiatAUcea otTercd by the difforeut tisaues, the path of least 
resifltance will generally be choaon. It is for this reason that the teaiat- 
ai^ee offered by tlie human body differs so greatly imder different ooudi- 
tiona and in. consequence the laborious determiuatioa of the amount of 


Mutiftoe oS«t«d by the body has UtUe practical eignifioanoo in elMtro- 

The TesUt&nre offered by the cuDdQ<>t;iiig vir^s, th« electrodes, and 
vUb^Ter may hv pl&ctd bel^ween tlie electrodes is (.'allcd the «xt«iiid nt- 
niuace. Th&t offered by the electrolytic fluid and the tvo ekmeuU of 
Ac bBUcry ia called the internal resistance. I& order to meaaure cmd to 
qautify tbe diHeniig r eat stance offered by the i^aiiouB parts of an electric 
luruit a standard unit of resiatanc*^ has been adopted. This unit isaalled 
inotuD, after the physirist who framed the [avc governing the 6oiv of 
ilcfftricity through a circuit. The ohm ia the resistance offered by a 
QOliuaQ of pure mercmy 106^3 cm. in length and 1 sq^mro. in croaa- 
wttioa roaiatained at the temperature of C C. In terms of this tmit 
U« relative resistance of different Bubstancea can be cipreaaed. Thus 
imda- ordinary ctrcumst&ucea and with the skia moist, the body offers 
^aa 2,000 to 10,0^ ohma of resistance, but it may offer as much 
vlOO.OOO bi 200,000 ohma. The inUmal resistance offered by the cell 
or otber el^Otrogenio agent may be considered oonataot and la therefore 
tsttally ignored whpn estimating the r^iatanca o^er«d to the conduction 
of eliDtncal energy. The amoiint of rejji.sUnt^et offered by a particular 
nlBtaiicer by Virtue of ita own physLcal fltructure, ifi called ibi apedfic 
nvitaiice of resistiTity. Resistivity is nmnerically equal to the rvaiat- 
aoe oSered bj a wire of the substance 1 cm. Jong and of 1 
neaof erosa-section. The resistance offeri^i by euch aubstancea as gen- 
«a^ cooaCitute the external circuit ia not only dependent upon the 
iwtJTity of the subatauce used (thus a wire is a better conductor if 
udeof copper than of iron), but the resistiuice oppoa«d to the passage 
of tbe current dcpcnda upon the length and the crooa-section of the 
wilt. Oth^r coiuditious remaiziing conatant, resistance increases directly 
a pTOportioii to the length of the win, and diminishes direotly with the 
udof crcea^ectlon. 

Although the internal rcaisbance is negligible in calculating the amount 
of nrrent that ia at the service of the operator with a given arrangement 
of batteries and circuit, it ia ef consideralile importance in the choice of 
ik butery to be employed. The force that is generated by a battery or 
afibtr elmtrogenic contrivant^e or substance h»a a certain capacity to over- 
nat the tesistanoe oSercd by the eAteiual and intenial circuit This 
ftlratroiDOtive force ia measured in terms of a unit, called the 'volt, after 
Ik Italian physicist Volta, vrho constructed the voltaio cell- The capac- 
vjai )iny electrogenic apparatus to produce a current depends entirely 
Vpnn tTie voltage of the electromotive force, that is upon the current pres- 
suw JPTeloped to overconia resigtance to the conduction of a carrcnt, 
"Tlia the clecLromotive force of a Leclauch^ cell is about one aud one- 
UU ToUfl, and that of a gravity cell about one volt. 

Ihe etureut that passes over any given point of the e^terual aurfaoa 



Will tlierefore have a given vr>Itage which iw tho reaiiltaat vf the two 
factOTB — the electrouiutivo forte gtmeratcd and the I'eaistanr.e offered. 
The ainount of t}ie current that ttis.y he inppoBed to pcLss any gi^eii point 
maj' differ. The unit of the nieaf^ru'e cf the qiianiity of eiirvt^Dt is called 
the (.Miiilomh. A more iiEijjortimt tiieiisure tn that uf ths nmt rat^ tif flow, 
that isi the amount ol current that fiows hj el givQn point in a second of 
time. This unit ia cnlled the ani]>ere, and its deterroination is of conaid- 
etable importance m order to control the iuteosity of the phyaioJtf^cal 
reaction produced by el^tri<*al curpeiita. The arhitrary imita of force, 
resiatpani^, ami current nite at flow are dflfined in t^rna of erne another. 
Thus an elm^trouiotpjve foice of one volt at.'liiig upon a circuit of a reaiBt" 
ance of one ohm will cause a current in that circuit cf one ampere. 
Ohm^a law formukteB the relation of these quantities \u such wiGt< that 
the value of any t^^'0 quantitieQ, bCLug given the third quatitity, r^an be 
readily determined. TheformulH ifl C = § in which C equal? the current 
pipreaacd in aiiiperea, K equals the electromotive force expressed hi volt^ 
and li the resiai^ani^e expreesed in ohxos. 

In the practical employment of electrotherapeutical apparatus, the 
current cuj^aeity of the cell* used will generally be ft known quantity- 
Thus -Sn muriate of ammonia cidls may have a voUageof 1.5 ami a« in- 
ternal reaiatttuce of I'.S ohm edcli. The t^»tdl voltage will ih^refyre be K5 
multiplied by 'M, which eq^iala 45 volta. and the total internal resistance 
of the cella will he 0.8 tnultiplied by 'AO^ which equala 24 ohms, A^eum- 
iug the reeiatanne of the body to bei^fUM) ohm&, and neglecting the reaiat- 
auce of the conductirig wires aud electrodes which ander ordinary oocdi- 
tions ia very eniall, the total resistance offered by tfaecirouit will be.'E.fk24 
ohms. To determine the number of amperea traversing the completed 
circuit and hence passing through the body, the 15 volts of eleotrciuotive 
foroo ia divided bytheS^OLM ohms of resiatanoe, giving a value of 0.0148 
ampere, or aft this is generally written milliamperea. 

By the use of r.he nttiua formula, if the volUge mid amperage of a 
given numher of celk are known, the resiatance of Uje iJssut^a that may be 
interpoaed in the external circuit can Le determined in ohms. These de- 
terminatLoua need very aeldom be made by the phyeieiau himself, bpcauae 
even with the voltage, amperage, and resiatance unknown, the amount of 
current paaaing through a gi vpu eircuit can he determined direttU" by iu- 
ter[x:siug in Lhe circuit pmperly calibrated inatruiuenta that hjtve be**n 
devised for this purpose. With the use of auch ioatrumenta, the elec- 
trodea may be applied to any portiou of the patient's body and the cur* 
rent turned on, and gradually increased until the desired amount of 
amperage ia registered by the recording instrument. The apparatus 
ordnmrily supplied to fiie physician is aluo provided with devices for 
throwing into the circuit variable amounts of resistance, which render 
posflible the graduation of the strength of currents to the needs of tha 



without chottging the cells or nuTDber of oeUo constituti&g the 
roarer of cnpply. 

The dcDsitj of the electric current i» a vHriable feature that tina ah 
QS|Cirtuit bcAting upon the practice applic&tiou of electricity to the 
niv. IE a current passing along a wire <?E & given area o£ croas-section 
imade to pasa aJoog a wire of double this arnv of oroee-aection, the 
dmsit^ of tbe carrent pasaiug alopg any ^ven longitudiual section of this 
fiiflfv^ vill Iw double the denaity of that passing along a sintilar loo}^- 
tnimal section of the second wire, TKts acccunta for the different pbjs- 
UopMl effects of electrodes of larpe and einall area. A current that 
■^pn>diieeno distreasing phyaiologicat effects upon the patient ^vbec 
■ppU«d by an eTeotrode which covers a considerable portiorj of the jAjti 
would he intolerable and perhaps unsafe if it was applied through a 
jinnlelectiode. The acootnpanying tigure represeuts theiu^reut is pass- 

ni f,-QkcTmiti V> amv Dnvftr of ruml rbni ■ Luve And' ■ 8mU Elnctmle 

Dn«d. A B 

offroiD a large electrode through aikd under the epideTmis and finally 
Ikroo^the epidennis agaiD to a smaller electrode. The electric current 
IB ihx figar« is represented by lines. It mil be noticed that befor« the 
nzTCDt passes through the skin to meet tlio emaJler electrode, theee lines 
of *lMtnc eoergy are gathered together or eondensed into a aingle line. 
Any rtrooture, Boch as a nerve, lying directly below tlio smaller electrode 
vcdd oanaequeutly receive a luach more el^ecttvo current than a similar 
ttrqetdiD lying in the same i>ositiou beneath the larger electrode. It is 
^VtO ta importEUit for the ph^siciaa to control the density of the current 
bf thi use of the proper electrodea aa it is to oontrol its voltage and am- 

At least passing mention must be made of the apparatus commouly 
nppiitd to physicians for vlectrotherapeutio purposes. The instruments 
liruab^fi by different tirms vary bo widely that a common desoription 
ipplidble to all iti impossible. Moreover, the Epace at our disposal does 
tM vamnt a detailed aecount of the several portions of this apparatus. 
Tb« l^riBi BDpplylag these instruments provide catAlogaes amply descrip- 



tivo ftad osplarmtory uf tho constructioa and operatim of th&it reapeetivo 
supplier. It r@m^U9 for as to consider merei^ the general featurea of 
the «mj)loymi^nt of aueh inatniin^ats^ these a direct Leariug upon 
the tLerapeutic efficacy of the ekctriu cuiretit aud therefore cannot be 
left entirely to commercial literature. 

The Galranic Current, ^ — Xhegalvauioourreiit, whiohiethe one moat fre- 
quently iiaed in electrotherapy, is furnished by a set ol voltaic or gal^auic 
cf^Ua, called n battery. Batteries vary in the form, size, atLd iiumbbr of 
cells, ranging from the small portable batteries to elaborate cabinet types. 
The individual cells differ in Toltage from less than one volt aach up to two 
or three Tolta. They vary also in the number of amperea of cun-ent that 
they will fiLiuish within a given period of time. Some can be quickly ex- 
haiiated and hence need frequent renewal ; others will supply t!ie needs of 
the physician without attentitjn for a year. The general ooustruetion of 
alt these so-citUed primary celb is the same, A poltaio pair o£ elements, 
one of which it electro- positive as related to the other, is iuimerfled in an 
escititig or electrolytic fluid. The materials chiefly used are ziuc^ silver, 
and platinum for tlie electro-pogitive element, and caibon, copper, or lead 
for tlia el eetro" negative element. The elef^trolyte is usually an acidu- 
lated fluid or a aolutioiL of aal ammoniai;. The electromotive force in 
every form of battery is generated by the chemical action of the exciting 
fluid upon the electro-positive element. In cells using relatively strong 
acid solutions, such as the Grenet or acid battery, which is employed 
because of its high voltage, the elements when the batteiy is not in use 
must be reniored from the electrolyte in order to prevent the rapid de- 
composition of the zinc, the electro-positive elemeub. The greater the 
eatremea between the active and passive conditions of the elements im- 
mersed ID aji electrolyte the greater the voltage. The larger the surface 
of the elements exposed to ehemical action tbe greater ia the volume and 
amperage of the cuTTeni- Zinc and carbon are most frequently employed 
hs the voltaic pair of element!^. The porliun of the zinc l>eluw the sur- 
face of tbe Quid conatitutes the positive element. The electrical energy 
generated by the decomposition of the zino is transmitted through the fluid 
to the pert of the earbon below the surfai-o of the fluid, which repreaents 
the inactive or negative element. The portion of the carbon projecting 
above the surfare of the fluid and from which the current flows through 
the eitanial circuit is the poBitive pole of the battery. The portion of 
the zinc projecting above the aurface of the liquid and to which the cur- 
rent Howfl from the external cireint ia the negative pole. 

The bluestone or gravity cell is tonipOBed of the two metals, line 
and copper, and the exciting liquid, a dense solution of copper sulphate 
whii:h occnpiea the lower part of the cell, A lighter solution of zinc sul- 
phate, which is developed by the action of tbe zinc and copper sulphate* 
floats upon the surface of the copper-sulphate solution. Thia cell is 



IfftA t»U«d a double-fluid rcll, beoauae of its poeaeaamg two exoiting 
Jaidje. The function of the ueootid Huid, ho^ve?er, is to absorb oi: com- 
biDfi with the hyrirogen that is litwrated l>y the action of the electrolyte 
Dpm the decompofiiitg positiva element. In Lha Lecl'inch^ vM the rte^- 
lirc clranent ia composed of a porosis cup containing pulverized rarbon 
ud lau^anese, into which a plate of carbon projecta. The mhn^'aiieae 
pexfonus the functioa of the second fluid of the gravity battery^ that ie, 
itMuabiiiea wiLh the hydtogen liberated and preveuta the polarization of 
il« batterr which noidd render it ^jselesH, The iKJsitive element is a rod 
flf line while tho electrolytic fluid is a saturated solution of chloride of 
luuacmia. The« ara the two forma of batteries most in nse. They are 
ferf eODBt&nt and at the same lima inoxpenflive^ and roqnire very little 
tlttBtiim- The sal ammoniac or Leclanoh^ battery is somewhat to be 
jTrfttred because it will remain active for many mouths without the re- 


MvU of any of its parts. The gravity battery needs to be coufltantly 
■applied with water as evaporation takes place. 

The silver-chloride cuU jiosHest^es an advafitpSge over the Lecl&nch^ 
ud pavity battery in being compact and portable. This cell consists of 
hae and fiilrer elements immersed in a diJute aqneouB solution of aal 
tmmoaiac. The silver element ia a wire of silver snrronnded by a fused 
mtn of silver chloride. This cell gives a very uniform current of 
di^htly smaller voltage than the gravity and Leclanch^ cells. The ob- 
jertioa to the silver chloride cell is that it does not produce a very power- 
ful carreDt^ and lauat not be short-circuited, that is, placed in a circuit 
»iUi a very iowr external reaistanee. If this tateg place, the internal 
•iBftFolytie action^ which converts the silver chloride gradually into 
BPlaliin silver, bei'omes very rapid, and the life of the nell may soou be 
nliaasted. These three standard types of voltaic cell are supplied by 
ill dealers in clectrotherapeutio supplies- There are many variationa in 
lonu ud size. 

A modihcation of the voltaic cell is the stor^ige eell or aeeondary cell, 
to distingnish it from these already described which ara called primary 



cuIU. Tlid strjrnge buttery oiin be rentoreJ or charged after it haa bscioma 
exhaustiid. The a^ivantaye of thia farm of cbU is iouml iu ils high t61- 
ta^e aad relatively long life. It i» serviceable for faniiahiQg electrio cur- 

rnL0.^1\f 11LlHHllK<fiLlV4Illl]Hcrt»i 


reat« when high voltage &nd large amoonte of current are desired. 
not put to very eitenaird use iu electrotherapy. 

A battery of Toltain oelle may be arranged eo aa to gira ciirrente of 
Turying voltage and amount. Different combinations of th4 cella are nec- 
essary to priNliice this result. Thus, to increase the voltage, the ziOD 
plate at one eud of & aeb of aay four eelU^ which represents the negative 
pole of that oell, ia ouaneobed with the carbon of the adjacent cell. The 
tine of the second cell ia then txiuiLectcd with the carbon of a third cellt 
and so on for the entire Bet (Fig. 0). If there are four cells in the bat* 
tery the coruhurting wires wouhl 1>e <]irected tfkthe free cnrbon pole of the 
cell at oiko PUil of the tet luid to tlte free tiiic pule of tli«^ cell at the other 
end of the battery. Tbis mode of joining the cella of a battery producea 
an arrangement of the oella in '^galvanie senee.'' The effect of thie is 
to multiply the voltage by the number o£ oella *' in aeries/' 

If all of the zincB of a set of four oells are coriDected together and all of 
the carbons, and the external oircuit La then conducted from thea« oom- 
bined catljou poles bo the coiubiued zino poles, the arrangement is called 
"ia multiple arc/^ The ciFect of this arranp^'inent is to increase the 
amperage that can be obtained from the battery without inoreoaing the 
voltagen The current is the Hunie that would be produced by a single 
cell of fonv timei4 the size of the cells of the battery. 

CompEexer arrangemejita mEty be used. Thus, in Fig. 10 the positive 
pole of the battery is a combination of the taibon poles of two cells, and 
the negative pole is a. cojobiuation of the zioc poles of the other two 
oella. The remaining caibona and zincs are connected. This arrange- 
ment doubles the voltage and doubles the amperage. By increasing the 
numlier of celU entering into comhinaiion. the remdtaot variations in 
voltage aiid amperage that can be obtained from a batterj of cella of 
oonatant voltage and amperage may be greatly augmented- It ifl fre- 



^ooulj QK^daaATj' to select a bottery aocordin^ to tho kmil of work, that 
j|dmre<i> Thus liviiig Cibbug olfere very great resistance, and the elec- 
iTi* caatery baa very low resistjuioe- A turreut to act u|X)n th« fitet 
tidLOut iujuj^ must have large voltai^H and smuli a.iii parage; while for the 
Imrr BiuaU Toltage with laige uuper^^ la neuesaary. When electricity 
ijput to ft Tarictr ofuHca, a number of difteient batteries will be necea- 
miT, For moet theiapeatic purpoaes, however, a battery of thirty voltaio 
(db of about one-volt capacity will be ample. As DccoBion arUes^ com- 
fcttittoufi nf these cells **in seriea*' and "ta multiple art!'* will give the 
nriannos in Toltage and ampBnige Jesired, Most galvanin cabiiielti con- 
sLTQcwd for electnitberapeutic nae contain coatrivanoea tphal permit of 
the tradv yoking of the voltaic CiOla in suffioient variety oJ ccmbination- 
hdir^ c&binet3 are often more elal^orate than tliey are convenient. If 
1 poitiiile galvanic battery Is desired, care should be exercised ia its selec- 
tion. P^ticuIaTly the i^ella should be easily rt^newe^l with eleotiolytin 
fluid *ithout the necessity of returning them tti the maker. 

Rheostat and Uilliametar. — No electrotherapeutio apparatus is ccm- 
|4E!te ffithout a rheostat and a milltamperemeter or miiliamfiter. The 
Amtai or curre;it controller is always a part of the external circuit. 
T1i« earreot that ia tlowtug through tlie l^idy is at the same tiiim passing 
ihroosih the rheostat. The auiOLint of currt^nt that will flow has been ohovn 
to bf depeudeiit upon the resiatauce offered by the external circuit. Thia 
dtTioe permits the rapid increase and diminution of the reaietaoci! of the 
(ileru&l circuit. The rheostat is an absolutely essential adjunct^ particu- 
Uriy in th*^ poorer type* nf galvanic batteries in which mechanical dcvit^a 
u« Q<n provideil for selecting the uumber and combinations of the oalla. 

ruL let— CoEaplux Giinnia fittriM. 

Ifcb ilwijs a desirable contrivance as it permits of a 6ne and rapid gra' 
dttioa of the reaiatanoe offered by the external circuit, and hence of the 
■nottQt of current that is acting upon the patienf 3 body. One of the best 
A»ortAta is known as the Maesey controller, illuetratfld in Fig. 11. The 
■Dtioaof thia very simple instrument Ib baaed upon the relatively high 



resietftTiPe of graphite* The movement of the control lever over the 
Bickle-tthaped coiidnQtiDg «urfaee Tftri&s the amcHUit at resiatauce oSered, 
because vari&ble areas of the 8urf&rte rubbed with ^aphite are placed in 
successivQ cout&ot with the lever anji, from whit^h the rurrent must ilur 

FID. 11.— nju Mamey Ciimml DudUvIIv, 

to and tliroiigh ih^ graphiui dtirfai^e^ Otter rheontjita tv[UAl)y Hervice- 
abl^T though pethap» not eo ccnveaieat, itit«r|>O0O rumble oiumints of re- 
flistancQ in tho circuit by the use of alloyed wire^ water, or otbf^r auV 
stances oifering great resiBtance to tui electric ciurect- 

Atiother eaaentiiU flttn«hment to the galvario battery h a miUiaiaeter- 
Witb the uouiiiLimly iineil direct-reailing milliatanter, the strength of thd 
current is me^ured regardless of the aize or coxxstituiion of the batteries. 
This enables the pbysiciwi to duplicato exacblj the doaago of the galvanic 
current without giving details with rejipeot to the kind of cell, the aize of 
the elements, capacity and steength of the fluid, eiternal resistaace, and 
BO on. Several foi-ms of milliameter are roEstnicted. The suapenflion 
type of iiistniJLient ounsiHtB easentialjy of a magnet moving freoly above a 
coil of wire through which the current ia permitted to flow. Varying lu- 
tensities of current will causo varying degrees of angular deflection. The 
amount of deJIeotion caused by currents of different intensities has been 
dateruiined empirically, and the instrument calibrated to record accnrstely 
in milliamperes. The only care that ne^ds to be exercised is that re- 
quired to adjust the magnet pointer, so that when this poiuts, oa will any 
magnet, toward tho earth's north pole, it will cotncldewith the lero of the 
Bcal^. The instrumeat must, of eourse, be kept in the horizontal posi- 
tion. A difTerence between the magnetism of the earth's field where the 



Utttnmioit ia c&litmtod and vhore used niKy caase alight inaccuracies to 
flTcpin. Anotber eonroe of falfie readings may arise from a aeighboriDg 
MgD^cic G«ld that may cause deflection of the needle- Milliameters are 
fip^ilifld tttiich are not Eusreptible to theee sourcea of errnr Thecoil 
d thns uistram«atd u routed betreeD the pnles of tixtvi permanent 
bifDcta, Such infltnuDenta areconatruct^d for use in eithe^r the Tcrtical 
orkomonta) position. Fig. lli reprcsettts an iiistrument of this type. 

The co&dnotmg cords BhouJd be of low reeistant^e, thereby insuring 
the grv&iest quantity of current conduction. The best are tuade of a 
liuiiberol strauds of B^iible cepper wires. This cord cari be used with 
ibe galtudc as well as with the faiadic current. The cord that ^uer- 
iBjIonus pan of the eqmpmeat of a faradic apparatus is made of a 
otfUnAl that oSerfl too high r«-eistance for galvanic work. 

It 13 BOmetimeB desirable to change tbe direction of the current in the 
eiti«nul ctTcuiL This could, of course, be eFTected b^ interchanging the 


VUH it their attaebment to the positive and negative poles of tb6 hat- 
tsj. Most elertrotherapeutie contrivances comprise a comnmlator or 
jok ohloger whirh will reverse Hie direction of the current aa it passes 
tbough the bodv by the simple movemeut of a plug, lever, or awitch. 

Tuieties of Electjodea.— Many forma of electrodes are in ubs, Spe- 
^j »M£truoted eleciTodea bave been devised for the application of a 


oorrant to the he^l, ueuk, throat, buckf hajidsj und other parts of the 
body (Tig- 1'^)- All tliese elertrodes diEFer iu si^e, and upou the size will 
defend, aa already stated, t^o current deuaity. Erb^a not-mal electrodea 
furuLah & aeries of electrodes of known area and permit of the caJcuktioa 
of thu deDSLty of tlie curreut UEted. As ordinarily applied, oae of tke tva 
electrodes is regaj-d<td as indifferent, and the other as active. The indif- 
ferent elfictroilo is generally the larj^e ono and is held either in ttiA hand, 
over the epi;faatiiuuL, or pbced beneath the buttocks in the Hittiii^ poaj- 
ticm. The active or so-call^ dilTereiitial electrode ia gc^ueraUj small m 
area. The elmitrode may be held lirmly in position, moved sU^wly or 
"luiokly over aii area, or alternately applied to and removed from the 
part to he ioHiLent^ed. The mode of application may therefore be stabil^ 
labile, or interrupted. The iuterrupled filimulatiun, generally employed 
to produce muacular contractioo, is WO0I conveniently applied by an elec- 
trode with an interrupting device in the handle. The base of tho electrode 
can then be left permanently in contact witli the skin. The eWtrod«e 
or the Bkin Bbould be motDtened, in order to reduce the resistance. Th« 
use of a saline solution is iir>t ailvinable^ 1h4{;auBQ of its corroaiva aetion 
upon the electtoded. Dirt or other foreij^n aubatance upon the electrodes 
diminiehea the rsEtistance and ^ill cauHO variability iu the strength of 
current received by tlie patient. Care must therefore be taken to keep 
the electi'ndf<s clean. 

The Static Current. — The franklinii^ or atatio ourrect is employed 
when elecibricity of high poteutial in deeired. An haa been already seen, 
the gtUvanlc current haa an electro njotivo force of but few volte. The 
etatio machines are devised to give currents of many thousand volte^ 
Theae wachinea were originally devicea for the development of electrteily 
by nieaiLs of frietion. Later the inflneuce and mduetion statie ma^^hincs 
same into use. Btatio electricity ia first developed upon the plates Cff 
the machine by means i>f friction- The involution c^if plates iucreaees the 
original charge by electroatatic induction, and thie electricity is colleoteii 
or coEidensed by the use of Leydcn jar colleotora. The electrodes used 
to apply the static cl<?ctricity are of peculiar type. The indifferent 
electrode is an intmlaled platform upou which the enhject aits or etands. 
Thia platform ia connected with the negative pule by means of a brum 
chain attached to a projecting brass rod. The differential electrodes are 
varwua m formation. They comprise brasa balls and pointe, rollers cf 
metal, aji umbrella-shaped electrode to lit over the head, eta. 

Static electricity may be applied in different ways. By the method 
of insulabioii une pole of the machine Is connected with the eartli, or 
grounded by attaohment to some metal fixture in the room, and the other 
is attached to the putient who is seated or standi npon the insulated 
platform. The effect of this i» not to send a current through the patierjt, 
but to charge him as one might a Leyden jar, with either positive or ne^ 






u" _ . . _ 


H Fi 


rn, UL-thiitnxla tnn/lei tma I^fquar}, 



ativa eleatricity, flBi)endiiig utititi th« jnila uf the uiacliiiis to which he 
may he attached by thtf brasB uhain. The dtrtict-spaik method is more 
freLjucntlj emplpycd. The patient is pW^ed upon the insulated platform 
whioh la oonneu ted with one of tha ootid uetors. The diETerential elM- 
trode is hvJd in the hand of the physician and is corineot«d by n brass 
chain with the other elaotroda. By a|ip]yiii^ tlie el^trcnle lo Llie body 
of the patient a more or leas severe ahoch cmii lie given, depending upon 
the diatauce by which tho rods joining the two oonductiirn are separhted. 
The indirect- 8 par U method is IcM often used. The electrode directed 
toward the patieut^a body ia attached to a nail in the wall, or otherwise 
groimdedp iiietead of being applied to the conductor of the machine. 
The atatio breeze ia produced by using a pointed electtoda iuabead of the 
bulb or ball. It cansea a fau-ahaped or breeze-like curreab to paaa between 
tho piittent and the electrode instead of the sharply delintid apark o£ the 
Other methods just described. The ao-calLed aigrette ia tlio current pro- 
ducad by a rathec blunt piece of wood or metal Itrmnght near eoough to 
the patient to give a form of diacharge intermediate lietween the apsik 
and the breeze. By placing the two Ita^s baUs which form part of the 
negative and positive ironductora of the matrument at varying distaiioea 
a rapidly iutermpted and gradiiateil current U produced^ TheapeciliD 
resistance of the air to the passage of the enrrent between the brass balls 
acta aa a spring interrupter. A spark will pass between Lheae balla 
whenercr the tension of the current e:^ceeda an amount which is propor- 
tional to th(i diatatice which separatee the two balls. 

The Faradlc or Isduosd Cuir«nt>^The farodic, induced, or magneto- 
electric current finds more frequent use in electrotherapy than dots the 
franklinio current just deHcHbed. The faradic apparatus cousints of sev- 
eral celU developing an eleoLro-motive fort:© sufficient to send a current 
of electricity through a coil of wire which oonatitutea the exviting mag- 
netic field. In the primaiy cireiiit ia placed an automatic interrupter 
whiii^h ia generally some form of vibrating device capable of makiug and 
breaking a contact, that is, of olosing and ojj«<ning a primary circuit, sev- 
eral hujidred times a second. A eecund i^nil of wire wrapped on'a larger 
spool, which can gencraJly be slid around the smaller coil of the primary 
circuit, is in oonneotton with the electrodes that are applied to the patient 
when faradic electricity is employed. Through the related propertiea of 
magTietic and electric ourrents, whenever the current of electricity begiDs 
or whaoever ib ceases to flow in the primary circuity a curreiil generally 
of higher voltage is momentarily developed in the secondary or induction 
coil. The strength of the current in the secondary coil is dependent upca 
the number of tiims in the two coils and m]>oq the voJb^ of the primary 
current, as well as upon the rapidity with which the interruption of the 
primary current takt's plat^e. Mora aignificaiil is the alteration in the 
strength of the induced current that caa be efTected by sliding the seooud- 



qrer the prini&ry coil. Tbe greatest inCenaltj of current la pro- 
iifta all of the coila of tte secondary coil are direcdj about thoao 
«f Ike pru&4r7 coiL As thd secood&ry coil is pulled away irom tbo pii- 
BuywiltUiQcurtentgradually diminishes in inteusity. A simtlAT gr&da- 
lioci mwj be effected while the two wiU remain in position one orer th« 
other, by sliding a cylinder of metal between the two coi]g. As t1)e cyl- 
JB^t interoeptt increasing amounts of the two coila the current will di- 
aiauh ih inteoiaity. Yery ingeuioua mstiumonta of conrenient and pott- 

Fi& 1^— Futdir fiBtlcfT. 

ible form h^re been derieed for the ndmiiiistration of the faradic current. 
Obc rf the moet a^rvioeBble fonoe is tbat shown in Fig. 14. The indnc- 
tirmcoil U madenp of sections of wire of different lenglhjf and lAoarseneas 
»iTTULfr«d that the Eectiona may be used aeparately or jointly as a single 
oni cf upwaid of three thousand feet in length. The apparatus contains 
4 tick uid g'ear for the making of fine adjostmeuts of the coil, a rheoatat 
fbr modifying tho strength of the current, a compound switch for the 
•lection of any section of wire, and the neoesBary ftwit^hM for oontrol- 
ling tie circuit. 

The faradic cmretit cannot be measured as can the galvanici although 
tteiDpila have been made to measure it- approximately. The method 
dftpbyed ha* been to keep the initial eurrent passing through the pri- 
uiiy toil at a eoostant quantity by employing variable resistance in tlie 
drcQiL The voltage of the indjoed current can be computed from the 



voltage of the primary current if the niraber of tnriiH of wire Ja Lhe pri* 
mary coil and the iiiiiuheT at turiia in the iiidunel coil are known. Other 
methods have been devised for the empirical detenaiikatioQ of the etreogtli 
o£ the faradia current as it may be practically apptieU to the tiasue^. 
But theae devices a« for the most part too complicated for the ser^'ice of 
tlie electratherapiat, and these evact dPterminatioiiB are moreover not 
requisite for the safe aud eMcieiit applii^ation of tliiR form of electricity. 

A coavDnient source of electncal euergy at tho disposal of the phyai- 
oian would aoem to be the etreet current aa wdiQarily fumtshed for elec- 
tric lighting. A tap has iteeu devised which may be cotineoted to an 
ordinary lamp and attached to acurreut controller and mi Ilia meter. The 
rheuHtat will reduce the itii-audesceiit current, to a range of fmm ieri> to 
five hundretl milliamperea. This current may oUo bo connected with the 
primary coil of a faradic battery. The safety of tappiuj; the street cur 
r^nt for medical purposes in stiLl a debatable question, although it ia uti- 
lized and highly recommended by many leading el ec troth erapiatS- 

ElectiotODTLi, Eleotrolyaia, and Zleetrounetla Before the electrie ciir- 

i^ub can be applied judiciuuFtly in Uie cure of disease it is demanded of the 
elcctrotherapisl thnt he fully appreciate the oftentimes port^utoue elec- 
trical and chemical jtheuomena to which it may give rise in the tmaueB. 
The most imponajit of these are hnown aa eleetrotonus. electrolyBis, and 
eIectroBmOBi.4. The animal l:K>dy ia itself a source of electricity aud the 
pathway of natural electric eurrenta. Tlie application of a current to a 
portion of a nerve at ones oauseH a atat« of altered excitability — the con- 
dition of olectrotonuB. There is an iucreascd mechanicalf ther&ml, and 
eieotrioal excitability at the cathoiie pole, to which the rtauie cateloctrot' 
nuns ia given, and a diminished excitability at the negative pole, known 
aa analectrotfpnus. This state of electrotoniis exists nnt alone in the seg- 
ment of the nerve includsd between the tvnt electio<les, \mi in the nei-ve 
beyond the clcctrodaa, and the stronger the current the great«r the arCA 
of its influence. This altered condition of eiaitability in the nervo is 
moflt marked near the poles; between the t^vo polee there is a point at 
which it does nab exifit, known as the indifferent point. Thia point Is not 
equidiatant from the two poles, nor is it at the same place in the pBHsage 
of currents of different intensity. With a weak current it lies nearer the 
anode, while with a strong current it lies nearer the cathode. Tu other 
words, a weak current ircroasee the section over which the negative pole 
pre™ls, while a strong current increaaea that over which the poaitive 
pole prevails. A nerva ia stimulated at the moment that eleotrotonua 
ooours and when it diaappearsi that is, at the opening and closing of &e 
current* At the opening of the current gtimulalion occurs at the anode, 
while at the closing tif the current it occurfi at the cjithode, and the oath- 
oiiai response ia normally greater than the anodal. Tha reversal of this 
relatioQ of stimnlation to the occurrence of cstelectrototius and analec- 



nviawu, which tftk^B plac« in oerres tb&t hsxe beou 8tibject«<l to degeu- 
ffi£iT« pattological processes, constitutes one part of the foriuLiU of reac- 
ODdof degcmeratioii- The laws of coniracticn vary vith feeltle, medium, 
tad rtroog curtail ts^ 

CtaaioiJ de<M>mpa3itioii effected by rueans of eleotricity U known as 
«i4CCrolj8i£> Eloctrioity is ftoiuetimea employed in lUo treatment of dis- 
M«e for iu destructive eleoltolytic *ffwt upon tissues, bat Dever in the 
ifcanptnrirn of nervous diaeaAeB. It is mentioned here only to warn 
t^ DO aaraoit can pan through the liuioan body without elTectijig elcc- 
tnJytic decompontion. The aniount of elei^tric decomposition will de- 
ftuA qpoa the quantity of oLectridty which passes, and upon Uie nature 
cf the aubotance that it decomposes. Rapidly altercating eurients pro- 
ihKeetwcrolytir effects not oiiiy in the medium immeiliately surrouDdiug 
the piilefl oi electrodes, but also in the intrapolar area, l^riig continued 
miUcatioD of a SCrong but not necessarily severe current may cause bain;- 
fol ricctivlytic decoroposition of the tiaaues affected without causing any 
titr erident physiological or struotura) phenoujeDa. 

k dtrreut of eleotricily sent tbrciugh two liquids separated by ft |tor- 
on diaphragm or septum will trnnsporb bodily a portion of the fluid 
ihnngh the septuio in the direction of the current, th&t ia, from the 
mode to the cathode. This phenomenon ia called electrosmosis or cata- 
phnsia^ The human skin, and other tissues that permit organic csmo 
lii, c^ffrr similar septa for the production of the phfnomena of eatapbore- 
lii. It is therefore possible to carry into the body by means of the 
piTaak current almost any medicament that is capable of solution. An 
tlrdrode thoroughly moistened with the solution is placed aga)i:iBt the 
itift irlb^te it is desired to inject tbe substance and i^onnec led with the 
positive pol« of the battery, while Uie negative pole is placed over some 
lELdiffprent part of the body. Tt has been proposed tointrodnce the alka- 
ioidxl sub^uuit^s, rocaine, niorphint^, quinine, Htrycbnine, etc., in this 
vajr. Although the method Laa the advantage of permitting a local 
spptication to the parte that it ia desired to induence, all of these sub- 
itKKes, >are cocaine, exercise their thera^ientio induence through a^bsorp- 
OOB iaio the general system. Therefore It hns nothing to recommend it 
OTTT hypodermatic injection, and, as a matter of fact, except as a method 
d employing cjxaine for the relief of local yaiu, it ban never come into 
ettcnl a»e. The electrolytic and cataphoretic action of a eurrent in any 
pBttiaa of the intemodal pathway through the body may cause a decom- 
leijtioti and transportation of the cbemieal constituents of the tissues and 
ihifi famish the material for subsejjuent ret'onstruction. Little is known, 
iurever, of these complex chsmical reactions, aud they are at least uot 
II fft controlled to the purposea of eWtric medication^ 

The Therapeotic Application of Electricity- — No definite rule:; can be 
Uid down for the guidance of the physician in the appli<?adon of electric- 



4tj for eaoh case. As In tlie use of all other therapeutic measures, espe- 
cially nua-medicina! ouea, iudividualizatiou ifl of Uie greatest i m portanc*^ 
The mode of ftpplicattoD varies alao with the diaeue that it ifi deaireid to 
iufluenoe. This fiubject will receive detailed coli si deration in the ohapteca 
devoted to special cliseasee. Wlien electricity is used id the tieatmeDt of 
a peripheral uerve paralysiB, such as the facial or the musculoapiral, the 
curreut ib applied directly tu the nerve, as well as Ui the Dku^icles of its 
dLstributiou. As a rule, the current to which the neuromuscular appara- 
tus is most rcapooaivo is the oa« decided upoii. If the inflammatory or 
degeiierative cEiauge in the uerve is eonaiderable, the faradio eurraat is to 
be rety>mmended. On the other band, when the current is used to iu- 
flUAuce diKeave of au orgnti which is fur removed from the periphery^ 
such as the braiu aud spiual ooid, one must decide whether it is advisable 
to apply the curreitt directly over the aiTected paits or over remote parts; 
in the latter eveut, the distant organs or tiaau^a may bo intiueuc^d rc- 
flexly, or through the conduction of impulse* through the rentri}>etal 
neurons. As a rule, to whioh there are few eiceptionaj it may ba said 
that, the iudii'atious in this respect jK'inl to the locn* uee of the ourrent, 
that iS| to tlie applicatic^n of a current of certain strength aud lutenaity, 
directly to or over the parte \vhioh it is desired to influence. For in- 
staDue, in tabea doi'satiu the indications are for the applttration of the 
galvanic current directly over the apiiie aud the jMisterior ganglia, and 
not to the geueral cutaneous surface with the expectation of causing the 
ourreut to pass along the centripetal neurons to the spinal cord. This 
local application of the current t^> the seat of the diseese presupposes an 
exact diagnoats. 

Another feature which calls for the eiercjse of good jiidgmeut in 
6V&ry ease is tlie amjierage, or atrengtb, of the currents As a general 
rule it may be said that the current should not be so strong as to cauaa 
pain, nori on the other band^ so weah that it cannot be felt by the pa- 
tient' The reeistanee of the human body under di^erent circumstances 
is so variable that the amperage required in the treatment of different 
diaeases can scan-^ly he approximated in tigures. Many writers, how- 
ever^ publish the average figures of numerous tests. These are disap- 
pointing as a safe guide, and I do not believe it neceasiiry to refer to 
them. TIte tenii^-ncy fjf hoginners in the use of ekcti-otherapy is to 
Qfle Coo strong eurrenU^ particularly in the treatment of muscle inao- 
tivity sequential to inflamed or deganernteLl nerves and disease of the 
muscle spindle. It should oever l>e forgotten that electricity is not 
only capable of causing very disagi'eeable symptoma, auch as fiashes of 
light, vertigo, pain> and syncope, but it may also initiate profound 
Btrnclural changes in the tisauea. To ovoid the former the greatest care 
mnat be exerc^ised in applying electricity about^he head and neck* 
The galvanic current should always be graflnated by means of the rheo- 



fWt lUid tha C3iUTfiDt should never h& iacreas^ or decreased except hj 

tktowiiig ilk or t&klog oat the resUl^ice hy means of this contioller. If 

t!ui pwcautiao to diminisli the current by gradual withdrawal of the 

rheoaiAt pUtoQ he neglected aad a atroug current of electricity be aud- 

4enlj cut ofl \ty remoTing the plug socket from the switchboard of the 

phvuc ctuteut the patii^Dt may experiecice very dieagreeabie eeneatiOQB. 

Thne methodg cf application of the differential electrode — the sta- 

Ue, labile^ and iaterrupt^d riiethoda^ — have beeci mentioned. In tnoat 

WMBt it inattAn very little whether the labile or the stabile method 

is tnplojed' Natar&Uj the application of the current for the relief 

of f«ia demands as little interruption ae posaildo without the exagger- 

tfM] efler^tc of continued stimulation of the same part; hence thu Jabila 

tBithnd is to be preferred. On the other hand, if the stiintilatiog effect 

of ihe elertnc current on the muscles is desired, the iutt^rrupted method 

ahoold be used. The electrode may be either intermittently touched bo 

Hio fATt and removed or an electrode with an interrupting handle niaj 

be ffia ployed. 

It also follows from the relatively greater reaction produced hy the 
athode uver that produced by the anode that the positive i)ole of a gal- 
lanic battery should be applied to a part that ueeda quieting as in neu- 
nlgia. and the negative pole when stimulation or oomitet irritation ia de- 
md. I'poD experience with the diverse effac^ts of auixie and cathode 
hii been founded the " polar principle " of galt^anic application. 

Tbf frequency and duration nf the electrica.1 treatment accorded a 
particiilai case demand the careful attention of the peraon who eaaaya bo 
veifc, A disease or disorder that calls for electrical treatment at all 
de&kfida daily application to obtain the liest efFecta. Very rarely ia it 
i4viabLe or neceasai}' to give two applications a day even in a case, such 
a facial paralysis, ivhen for aesthetic or other reasons the patient is par- 
tiruUrly argent that no trace of the deformity shall be left and in witling 
to jubait to an excessive expeuditurc of time and money. Beginners are 
iljowith iliHicalty xeatnuned from unduly prolonging tha sitting. In 
QWQW of eldotricity for the restoration of function of the neuromnscular 
ippifilus the current shoulil never be applied for longer than fire mi n- 
aie% ktid. as a rule, one'half that tiuie ia lietter fiir it8 ap])licHtiLrD to an 
isdtTijLj^ nerve. When the current is applied to one of the viscera 
meh as ttie stomach, or to the spinal cord, from live to ten minutes ia 
qiuie &uffictQnL In using electricity to combat the progress of the dys- 
iwpbiea, a few minutes should be spent in applying the current in labile 
Wiloa over the l»elly of the muscle, and then the muscles should be atim- 
olatwi t4i mild contraction a fpw times, not more tiian eight or ten. For 
piifTil firadization twenty to thirty minntes are required. 

The t£rm general electrization or general faradiMtion will occasionally 
Uufi in future chapters. The indieaiions for its use Bifl usiially a low- 




ered condition of Dtitritioii and. vitality, as Id DeuraetheELi& ajid ceuralgiA 
of can»t1tutioiin1 origin. It is applied by having the patient suiad or sit 
upcEi an elei^brode connected witli the catLode pule, while the poaitavv 
electrode is mbbed over the different parts of the body suco.easi-felj id 
methodical faahiou- When the faradic current ia uaed, the patient maj 
plaoe the feet m a tiasin of warm water in which the negative pole la 
placed* while the physician holds the electrode of the othet pole in one 
haud and applies the electricity to the different parts of tlir patieot^s 
body vith the other hand* the current thus traversing his body belore it 
reaohea the patients Thifl method of iippljiiig the <]urrent ]£ often vety 
grateful to the patient and ia used with effect by charlataaB. It ia to be 
recommended in. applying the rurrenl to a very sensitive part of the body, 
while the eittrmuitie^i Eiiay be nihbed with the ordinary apctn^ electrode 
or with the roller electrode. The touio elTecta o! general eleutrizatioti are 
both immediate and i-emote* The patient CKpcnences a feeling of well- 
being and of lenened atrength after a edanee, which may^ of course, be 
due to a payohjcal inOuence. Usually after a series of appiicationa more 
remote Iteneficial efTecta appear, auch as incieaae of appetite and im- 
proved digestion, less easily induct.d fatii^ue, refreishiug sleeps diminution 
of pain and local crampSi and greater L^apacitj for mental and physicaJ 

General galvanization does not appear to be aa serviceable as general 
faradization, although it may he uaed in the same manner and to meet 
the sanitt indications, ft^-ard dtihcrilted h form of central galvanization 
which is not infrequently recommended in the treatment o£ hyateria, 
neuniathenia, hypochondria, t^hon^a, and other neurosis. The procedure 
consists in placing a large Hat eleotroile connected with the cathode over 
the epigastrium, whileaaniall el ectr^ide connected with the anotle is placed 
over the middle of the forehead, then over the parietal region^ then be- 
tween tho ears, remaining in each place for one to two minutes, while a 
weak currenb is allowed to paes. At the end of the sitting the anode is 
applied in labile fashion over the vagua and sympathetic nervea on each 
side of the neck for from two to five minates and then over the spinal 
column for about the fjatne time. Personal experience of its application 
in these conditions does ool warrant its recommendation with any con- 
siderable aaaurance- 

The electric bath ia one of the moat satiafactory methods of general 
electrization, as it brings all parts of the body aimultaneoualy under the 
influence of the current, It had a general stiimdatiug and tonifyhig 
effect upon the patient, which ananifesta itself in increaaed appetite, feel- 
ing of vigor and vitality, and refreshing sleep, partit^ularly iu neuraa- 
theuic and myaathenic conditions. Any bathtub well filled with water 
may aerve to give the eleotric bath. The current should be turned on 
after the patient baa entered the water, otherwise the shock will be dia* 



if!«Mble, Both electrotlea may terminate ia wtLiet at opposite ends of 

tiw mih, or one ma^ be attached to some part of ti)e patienl'fi body. 
TV UUer method is very serviceftble in the use of the local batb to 
kf^y the ccrreot to the exlfemitiee, ia c&Bt^ of poliomyelitis- It is 
ileD fiot Dece«5arj oompleielj to diarobe th« patient, &ad the hydro- 
tlM^iie bath mny be given in tiie phyaici&a's office or at digpensaTiea. 
The temperalore of ihe waU^r is a matter of iridiffeien<r« so Icing Ji» it ii 
oaaloTtable. It is not advisable to Add a^t to the vater, b^'auatr of the 
eoROSiTe action on the electrodes. The ititensity of the current and the 
Itntioti of th« bath mast be decided by the circum stances Ln each case. 
A bath of short duration And slight ourrctit Intensity is refteshing aud 
«Mfptii]g, vhUe one of long dntatpion and considerable CDrrent intenai^ 
edn* lod induces rest and sleep* 

Stttic or franklinic electricity is of less serrica to the eloctrotherapiat 
Aa is either the faradic or galvanic. Given in the iorm of so-called 
•IsetKStaiic air baths, the head douche, the sparks, or by contact wtth 
iW clothed body by means of the roller electrode, it may asaist in com- 
\aXxag eocae of the neurasthenic tnajiifestations, such as ht^ad pressure* 
[Anfitbeaioc in various parts of the body, and myasthenia. Because 
of thaimpressioQ that it makes u^n the mind of the patient, it is soma- 
imH UMful ill dispelling hypochondriacal ideas and feelings- Xhe 

^arkfl administered vigorously often cut short hysterical symptoms, snch 

tf Tijrsteric&I aniesthesia and analgesia. Tbey are also employed to cause 

cmnaotion of mu&cles functiooally disabled through [emote lesiou^t as in 

teaiplegia of cerebral apoplexy, 

Th« diseases of the Tiervoas system in which electnaitj can be em- 

ployB4 »ilh more or less prospect of relief are comparatively few, de- 

i|jit« xhv fart that at one time or am^ther its use has be^ci recoLiinezided 

in tlffloat every disease of this important systein of the body. For pur- 

p«m of conveiucnce these diseases caci be classified as foUowa: 

L DiMasea of the nerves t {o) Functional (neuralgia and spasm); 

^} orgaaic (infiauLmationa and degenerations), 

E- Tibea and tlhe sequela? of inflammation of the ventral gray matter 

•f ^ central nervous system (poliomyelitis spinalis, poliomyelitis bulbi, 


3. Xouroaes, especially those dependent npon or associated with pro- 

fotmd pervertioD cf the sympathetic nervous system; neurasthenia, ei> 

ojitthAltitic goitre^ acroparicsthegia, and hysteria. 

*. I>ystrophiea and inactive states of the muscles due to local or 

^iAsnt keioris, as in hysteria, hemiplegia, and Biation atrophy, loo&l 

mmp9 and exhausttoD. 

Tt* application of electricity to each of these oonditions will be con- 

■idared jo future chapters. 



SfjLHflAnR, the art of applyiog pressure and streaa to th« eoft tiSHUei, 
1g a thnrftpeutio prooeiliLTe thjit baa graflually wrought its w&y to tbe fore 
as one of the valuable aids of modem Acientific reaource. The UM of,g« to oveTcomo fatigue, bo promote recovery after injury, and to 
cura difioose antedates the history of uiedioiue, la the days of Hippoc- 
riktes and of Galeo a high degree of perfection was reached iq the caan- 
ner of ita applicatiuu, aud the reaults it seems nere curre^pondin^^ly satia- 
fiidtory. Durint^ mediaeval Lituea it full iulo Uiau^e axid disrepute. It is 
only dLiriug the last quarter of a century that it h^B been allotted a place 
as a Icjfitimate therapeutic ageuj^y, Evod now its use is largely (u the 
hands of [lersDDB whose lueutal endowment and truiniug allow tliem to 
make clflima for it* usefiilnesa which to eveu a tjro iu physiology and 
patLiology are absiu'd, aiLd vbt^ae coneeption of pathological proce«a ia 
fto sterile that they puhltsh cures tyhlrh euTpnaB human understanding 
and approach the supernatural. The ciaima of such individuala not only 
prejudioa many of the faoulty against its use, but makes them loath to 
accept the atatempnta and claims of others, more worthy of being liateoed 
to, concerning lU ef^i^acy In the treatmeut of disease. Originally founded 
in empirtoisiii, and for many centuries basing itd claims for aixeptatiou 
a:3 a therapeutic ageot upon experieni^e and tradition, massago has latterly 
come to stand upon a Aolid foundation of eiperinientalismT bo that to-day 
its use aa a curative »gency is aa legitimate as anything can jKissibly be. 

Hitiniation of lT,a Worth in the Treatment of Nervous Diseases. —Mas- 
eage does not occupy a very imjwrtaut place in ihe therapcutit-a uf nervous 
diseases, rior does it have, needless to say, any specific attioa in counter- 
ftCtliig puthologioal states of thLS Bystem. In attempting to estimate lis 
value in the treatment of nervous diseasofl, it may be aaid that ita um- 
fulness iri restriirted to qiiinketiiiig the lympli aud blood circnlation and to 
atintulating tissue metamor^ihoeis. secretions and excretionsiT thus helping 
to maintain nutrition and to restore it when disordered. In like manner, 
it promotes the absorption of pathological prod outs mainly, if not entirely, 
through iti effect upon the interstitial circulation. Aoting directly upon 
the terminals of the sensory nerves, asedativeor excitinginflueocemayi^- 
vult. Tt is within the bounds of seientific poeaikiility that such impulses 
may, on boicg conducted centripetally, have au iiitiueuce upon the central 
neurnl apparatus. 



III usafiltiieBS in nen'oUH dispaies mej^ thereforet b« coDsider^ under 
tkcihn^? (1> As a general tonifying agf^ncyj (2) as a stimulant or ex- 
cianl of mudcul&r tissue ; And {S) aa & uedftbive. The fir^t of these 19 li/ 
fir tJi« moat important, for vo hav^ other agencioa lliat are more availnllQ 
•Oil jaore reliable for the otht^r two pur[>o&fl3. In nervons difiead(?3 inas- 
«^e u used as a tonifyuig agency to rdplat^e exercise when the latter is 
m|icssiMe or inadvisable. Thus, it is used in loromotor ataxia, nenras- 
iheaiif hjsLeria, aud hemiple^a, to atininlate tlie vaAcular and lyinpliatic 
Ctm&ts, to Euraiah gentle rasomotDr aud trophio excitation and thns 
ai4 phy«iological metamorphoeisi to maintain suppteoeea bj preventing 
«bug«« in joints vhich lead to their immobUizatioii, and to stretch newly 
Eorved coanaetiTe tissue. The most satia Factory raethod of massage to 
SDcnlI^liiah such aims is that which v^ll he described later aa general 
oMttagt* Ua^sagO is used to etiniolate or excite muscle tissue; to ovei' 
MDie njasthenio states of the abdominal viscera, fiarticuiarty the large 
bovdi to tonify relaxed Tolimtary muscles, as in neurasthenia and 
tjiteria^ to stimulate mnsole fibres imdergoing atrophy from enforced 
iDSftirity, aod to sta/ the coitrse of iahfrent pathological i^h^n^es in the 
KLudM, such ars take place in tht^ dystrophies. The prooeduie that beet 
loopipiifihes the end in such conditions is that of striking, chopping, or 

ta s sedative, massage ia used to induce sleep, either through lallu- 
raring the intracranial circulation by means of throat stHrkiDg^ or by in- 
iamg a d^ree of relaxaiion and weU-L>eiLg that will bo conducive to 
nposc by SQcaxka of general caaasagei As a pain reliever, it ia uaed in 
lie sbape of rhythmical boating or peroussimi to the nerves that supply 
th« area in which f«in is manifest, and by stroking and kneading to re- 
liifTerenoua erjgorgenjent and counteract rnflainnjatory coDditicms. The 
fofaieris of service in neuralgic conditions. The recurring taps or petcus- 
tiaos of eqoal intensity tend to produce an anjeathetic state of the uerve 
to whifh tliey are applied. Tbe various tneobanical perou^sors that have 
bsiD devised are based upon this principle. Stroking and kneading are 
QBcfQl particularly m overcoming pain of luctalized neuritis and ^teriueurttis 
which IS often the morbid anatomy of sciatica. The therapeutic worth of 
tauM$^ depends entirely upon ita fulfilling the above outlined ii^dications. 
Ibit tt can do ao every one who hn^ had sutHeient expcTieuce to entitle 
tdm to sn opinion will admit. This will not prevent him from the admis- 
BQB. cm the other baud, that the phjrdcian may avail bimeelf L^f otlier 
OCUfs whLch excel maasii^e in lueeting one t;r another o£ these in dica- 
tODk Therefore maaaago i» a remedial agency that should seldom be 
dipc&ded upon exclusively to bring about a cure. At bcstf it ehould be 
nwidervd an auxiliary of other n on- medicinal therapeutic agencies, Huch 
ubydriaties, eleotncity and dietetics, and uf medicines. The fact that 
U requii^HS no apparatus or parapherualia for ila use and that any intetli- 



gent person Tiiay Hoon acquiif^ thn rlextral |iroScieiii;y Deueusary to apply 
it, proviitiiig he Iiaa the atr^Dgtb, in one of ils leading recomnieDdfitiotifl. 
AcoUier is that the results of its uao in certain conditiona liave been 
sbowTi to be satiafaclory by numerous trUBtworthy obaerTeran 

Th« Mode of Applying Muaa^. — Maaaoge Bva.y be given either by the 
hands or by somp mprhanioal devica. Aside from those ronstituting th? 
merhaniAnis of vibratory therapeutius, the latter may well be coiiaidered 
under medicftl gymuaatica. Manual niaaeage couBists in the uae of atrnk- 
ing, rubbing, kneading, pouitdjng, striking and slapping, to which the 
Fivnch lerme of (1) effleurage (stroking); (2) friotions (rubbing) ; 0) 
Petrissage ^aqueeziug or kii«a4ling); and (4) tapotement (striktag, tap- 
piDg, pounding), are conunoniy applied, espeiually by professional niaa- 
eeurs. These deeignatiotia are likewise coinmoaly used in special mono- 
grapha oa the tnbjoct. Feeling as I do that Juiiaaago is tending tovard 
formilism, aiid to its great disadvantage, and c?cnvinned that it ia in re&litj 
the simplest form of inefihanlcal ptocednre, no further reference to these 
Frui b de^if^iatioDS vill 1« uiadi4. 

6v 'vJ-ig is one of the most tisefvil manipulations of the operator. Its 
benf J elfoct depends upon its oapaaity to quiekeD the circulatory ttuidst 
and tner *fore indirectly t{) etimulate the prucefieeB underlying nutrition. 
Stroking conaisla of just what the name indicates — of appiying thepalma, 
the approximated tlienar and hypotlienar eiiiitiem^es, the volar surface of 
the thumb, the tips of the three Jirab lingers, or the ulnar border of the 
hand to the part that it is deaired to inlluenre, and stroking it in the 
direotion of the venous onrtent with greater op leas proasuro, according 
to the amount of vascular change that it is desired to bring about. It tm 
to l>e remembered that the movement ja always cptitrL^vtalT no pressure 
heiug given in the return movement. Delicacy of touch rather than 
strength is essentials One or both handn may be uaed, depending upon 
the Bi^o of the parts that it la desired to massege. Aa a rule^ it may be 
said that it is preferable to use one hand, la nervous diseases, stroking 
is useful to overcome the myasthenia and easily induced fatigue of the 
neurasthenic; to increase the nutrition in inactive parts, whether they 
bo the seat of local disease such as dystrophy, or whether the inactivity 
be the consequence of disease in the spinal cord such as in£anuuation or 
degeneration of the ventral gray matter; and to absorb indammatory 
exudate in the sheaths of the nerves, or in their more remote environ- 
ment, the muscles- Stroking is an important integral part of the ma- 
nijeurres known aa general mass^e. 

Rubbing, or superficial friotiou^ ia a method of applying masaage that 
is of comparative inaignificanoe in the treatment of nervous diseases. Its 
only real nae is in facilitating the absorption of exudate in the sheaths of 
the nerves, and in hical luyusitia. The procedure oonaist sin pressing with 
the tip of the thuiub or the tips of the Grst three fjugers, with a circular 


^nStBt. The fibe of the circle de|«Dd0 upon the area th&t it is cle- 
HhI to miBBmge. If theobjeot U to iuflueoce deep structures, very great 
pugQW is Deoeaiaf^, and there is no procedure that taxea tlie strength 
rf tbeopenior t-o a greater degree. The massage should be given firut 
viA OM thojiib aad tUea with Another. Some gperatcra ure able to use 
tkv tlieuM eminence for the some purpose and with equally good results* 
If titeohject of ruhbing or friction is to facilitate the ;kbftorption of the 
superficial eiudate, th^ pressure ia naturaU^' of less severity. First the 
•kin is usoTed iDdepeiideutiy over the area, aijd then the skin &nd auper- 
ficiil liaaueB are moved fliiuntt^jieoualy' 

Squeezing and kneailiug of the tisftuea is one of the most important 
fwbirM of geaeraJ m^aage, and therefore one of tlie most useful varietiea 
of nUiMAgifr movementB, The ti^uea are grasped with one band or both 
Ih&^ depending npon the part; and its volnme, aud auhjected to kneading, 
iqassdcig movemeuta done in rhythmical fashion, llere again it depends 
hrftif npoti tha tissues that one wiahea to inEueuce how mauh pressure 
Bhalt be appli^. The object aa a rule is to increase tissDO^ nietamor- 
phoflLt, ftud so lo iixflneuue not oiAy the local hut the generaV'ii'iiTition- 
ltiafrei|uentlf uecesaUT^ to use quite aa much fori^e as the str«L ih of 
theeperalor will permit- Tho patient uftentimes otijecta strenMoufily to 
thiafratnre of the treatment. Tbia moveiuent is an important agency 
ID R^tteicLg exercise during the rest cure iu iieutMthc-nia ; in prcreutiug 
Lbs eiceeeive deposition of adipoee tiaaue in many Jithaemio patients, 
4(«dally while taking a rest and dietetic cnre; and in innreasmg the 
iLnngth of the ainloiiiinal aiusclea> Tt alao 1:4 one of the principal 
fraCiuts in abdominal mnsaage, 

Striking ot porcueaion of the skin and musclca with the flat hand, the 
ulnar bivder, or the tips of the fingers, 1^ an important procedure of mae- 
ogF. owing to its capacity to stimulate muscular contractlou and to in- 
cieue the mechanical irritability of tlis nerves. It la often dune in 
ZukAa iaatitutes, and mechaaiL':C>- therapeutical inatitutesi by means of 
n\^\te hammtis or mallets, operated by machinery- The advantage of 
tififl is that the intensity of the blow may be carefully graduated, while 
lie rhythm is cf mathematical regularity. But this is outweighed by 
oanul beating of the skin, in which the results of each blow can he at 
DMA ncQi. Muscle heating i» of aervice iu overcoming the myaathenic 
ftate in many of the ueuroaeSt and when done with care it should be triad 
latke pfogreseive dystrophiea of alow (course, it is likewise on available 
of cotinteracting inactivity muscular atrophy. 
The general indicationa ftir each of the above procedures have been 
ij considered. Their application uiuat vary not only with the 
for which they are to be uaed but with the iudividnal. Many 
vmm patienta are so erethiatic and irritable that they will not tolerate 
k^Midiog or muscle beating of any conaiderahle severity. On the other 



hand, there ai-e mdividuala of phlegmatLC dlapoaitioD, auSeruig from lose 
of neurorauaciilar energy, who ju-e Hoothed and rested by such appliaationt. 
One uiuflt Le guided largely by tha geueral iudicatiuaa and bjtlie outiMime 
of ti'i&L All of tbe above-mentioned proceJutea are oftea con^biited, u 
in general miLasage, which ia a variable proc<^dure, depending: upon the 
operator. It luayconaist of itrokiag of first ouo foot, followed bj knead- 
ing and a few filiarp stmke» wiih the ulnar border of the hajiil, eadtng 
with a lutniber of passive iiJuvianieiitB of the joLiita- and lliea aeimilar 
treatmeut of tlio other foot* or one entire extremit; luay be Rjiiahed before 
passing; to the oth^r. It matters not which plan is foUowod, the detaiU 
lire practioally the same. After the lower extremitres are tiDishedi the 
Upper extreniitiei Bte tvcated in fiimilar fashion. Then the trunk is 
Htrokr<d, kuf^aded, and tapjied, Ix^^inniri^ with the dornal surface, followed 
by maatfageof the tht^rax, and tlieu aWuij)iual ina^aagf, the atanne eading 
with etroking of the throat and the sidea of the neck, eepecially if it is 
desired to Ipfluence the patient to repoaa and aleep. If the object ia to 
BtimiLlatd the patient, and to have the treatment aot aa an inimediate 
tonic, the Branca shonld terminate with vigorous general Ktrikirg of the 
trunk aud eitreniities with the palms or the uJuar borders of the hands. 

Abdominal maaaago is ofteu very efBcacioita in overcomiTig the relaxed 
condition of the abdominal vall, Emd conatipation due to aluggiabnew 
of the niuGoular coat of the large ijitesttnes atLd deficiency of intestinal 
seoretioDs^ The patient lies on the >>ack, with the thighs semiflexed tnd 
the alKloiniiml walla relaxed. The operator applies rubbing or friction 
in the way a\tor& described, taking up the different part3 of the ab*lotnen 
iu auccessicDi bvit making particular efforti to apply aevere preaaure over 
the three dirisions of the colon. This is followed by aiiaceKing and 
kiieading movements applied gently to the luperflcial parts, and with 
alKJut all of the form posaibla to the deep^^r parts, then by vigorous t\y 
dominal beating. The a^atice lasts i;t least one-half hour. The method 
of procedure in throat niaesage has already been si^oicntly doseribed. 

The Seanoo- — The mode of applying massage is not oINnipottanti 
although nHturally there is a right way and a wrong way. The profee- 
aional masseur^ who, after stripping his patient, walks about him and 
takes a general survey, at tlie same timt? liberating some of the informa- 
tion which comes to him through his critical eye and which f-eeminglj 
astonishes him or ooufiruia him in a previous belief, oi who iimita his 
comments to a repeated " Ah, yea," " I aee," etc., et^, wliile at the same 
time he makes ready to begin by indulging in several passes through the 
air, huTrieilly putting a joint thrcmgh a few tiinia, or raising an •^trem- 
ity and letting it drop, apparently to see with what force it will fall, 
should bo dismissed at oucq. He may lie a good masseur, but he is far 
too superior a personage fur the ordinary patient, and if not eliminated 
early from the ease ia likely to have a demoralizing effect upon the pa- 


ithatwUl Tuore than counteraot any benefit that iDigbtbe derived from 

tiefttQU!St, Judging from my own eKpetience, especially vith miUe 

of whom fliis country would now seem to have more than a 

ttilnftbte nutnb^r, esj^ecially tluAe viih diplomus anil (.■(.■nLti<.-at^4 of pro- 

UtiMj from unkuownanduDheaidof Scmidinaviaii inatitutioQST the study 

Kid prVtic« of nmsAagfi hj those ignorant of tha simplest principles of 

ikjBokrgj' Aeenie to be very conducive to the development of manneriams 

vd OTOTMning ^elf-impoTtance. There is acarcely an oci^upation to 

vkicfa SQch ancillra &re not more benoming. In this conntry, it is not the 

flivtom far the physiciftii to give luaHsage treatment himaelf, although 

ihert is uo reaaon fihj tie aliocili not do ao except a lack oE time. He 

Acnld, bowever, have au?h theoretical b&owledge of tbo aubjeet and 

of th« ends in viev as to be capcible of tlireotiDg tlie procediixe. It 

«i>tld h& an adTantage if he were possessed of the manual ski)] necea- 

nry to give it a^ well, ^taaaage oj^eratora, unlike poets, are made, not 

bonL There are no special requisites to fit odq for such an occupation, 

»Tc X fair endowment oE strength and undefonncd hands of fairly good 

BBL If these sue associated with a moderate amount of intelligence, 

putifiilarlj in the line of amenability to instructions and obedience, to 

orifni^ tho operator is complete. 

Tbc patient should bo prepared for general massage by being a tripped, 
mpped in a co'^eting in keeping with the atmospheric temperature, and 
pnlui a fontfortabte position, preferably oa a resistant surface. Mediate 
mmiET, that is massage through the clothing, is recommended by some 
uflxritative speaki^rs on this Htibject, huE; it dues not seem to me a 
nlioDal procedure for manual luaaaage. In the application of luechanical 
oasnge it appareutJy matters not at all whether tlie skin is lightly 
wnred oi not^ The members ore exposed in Buo^ession, and covered aa 
^fj ue hnished. If the massaged part is of considerable enrface, and 
fSitiimlirly if nibbiTig and kneading are to be employed, it is very eesen- 
tiil that a small amount of lubrii:arit, such as lanolin, be used. The 
pvitirjQ taken by different writers on matis^ige about the use of lubricant 
ttootbing leAS than ridiculous. One author states that fre^^h hog's lard 
v the beat, another that it is the worst ; one writer maintains that vase- 
liM ii the ideal lubricant, another that he can scarcely imagine the 
pnvan that would ctiuipel him to use it. As a matter of fact, the beflt 
bbaont is the one closest to hand, providing that it ia neither icatbeti- 
nJljEiorcutaneoinily offensive. Care must be takeu not to use the lubricant 
nwarively, for then the band will glide over the part and the operator 
bvunable to massage it with siifBcient stress. Another precaution that 
ibmld not bo neglected is to ehave tLe part if there is considerable 
tasotwieBi or if the applitiation of massage causes paid by dragging upon 
lifl fcir bsiia of a given area. In this way one will avoid not only caus' 
lag the patient pain ajid soquential erethism, but there wiU bd no danger 


of tho st^^LQOQ being fuUawed by iaflaiiiuiatioa in the buir follicles. In* 
diiriilual porta shuuld rarelj bti tnaiiSHged longer tL&ii fifLeeu minutpeii, and 
often one-third or ono half of thia period ia sufficient. General masst^ 
should last at Jcflst one-half hour. It depends entirely upon th 9 individual 
and the conditioii that ihh operator is striving to overconie, ho^ severe 
the treatment shall be. Ma.sfiage operators very often mabe the rnistahe 
of giviug the treatment with entirely too greab sorfirtty, esp^^ially in 
thd beginningp A general rule applicable to sU forms of niecha.Dic&l 
therapy is that loleroiioe is acquired slowly. Therefore, the firat few 
treatiuente aliould be mainly to prepare the way, and not to frighten the 
patient or to mak^ him ho unoinfortalle that he dreads a Becoud visita- 
tion or receives it agBinst bis will. In the application of massage for Uia 
treatment of nerrous disease the operator ahould never leave any fiigns of 
hia visitation. 

Tha individual applioability of massage and the indioatioDs for ita um 
will be apoken of in detail in discnsaiug the treatment of the individual 
diseases. Hf^re it may Le anid that it is of serrioe particularly in snob 
neuroses as ueurasthenia and hysteria; in such organ in spinal oord dis- 
eases as infantile paralysis and tabes, in single or multiple disease of th« 
peripheral nerves, parti<'ularly if the inflammation is of low grade and 
of Blf>w developmentr and in the various immobllities due to eni^roachment 
upon or interruption of the motor heiiroDs. Fhially, it is of service sa a 
gOTkeral tonifyiiig and sleep-producing agency in a number of conditious- 

Kedioal OymuaatioflH^-Tteatment by moTement or medi<'a] gymnaatics 
ia frequently UBcd in oonnection witli massage to supplement the effect 
of the latter. The benelit of such movemcDts is due to their action upon 
the circulation, the digontion, the renpiration, the absorption, the aecre- 
tioiiH and excretions, in brief to their effect on metaUiliam and conBtnio- 
tive tuetautorphosis. They are performed in ooe or the other gymnastb 
poaturca^ standing, sitting, or lying, which are further subdivided accord- 
ing to the particular form of exorciae^ 

Medioal gymnastics are divided into passiva and active movements, 
both of which are performed upon all of the different Joints, 

Passive movementB aro used in immediate connection with masaago, 
usually being given as a part of the s^ee. For instance, after a part, 
eueh as au arm, has received massage by means of stroking^ rubbing, tap- 
ping, as the ease may bo, the treatment is concluded by passive move- 
ments applied to the joints of the fingers, wriaL% elbnw^ and shoiUder- 
These are of course doue by the operator independently of any effort or 
will on the part of the patient- Similar treatment is applied to all of the 
other joints in tum^ or to any one of them aa occasion demands, the dif- 
ferent iDOvemeute used being adapted to the different jointfi and to the 
individual need of tlie patient. The passive movements to which the 
various joints are aubjected are referred to as extensions, flexions, rota- 



tiCQi, EDpinations, nnd pronations, u^ed aocordmg to the nature of tbe 

]>b1 inrcdTed and s> varied aa to get tLe partioulai kind or d^ree of 

«EtdM desired. Ta udditioD to ifieir ordinary uso aa eKerciae, such 

■prtffiCDts aro of particular sorvioe in cert&iit c^&cs of sttffQOSS of joiote 

Iftd of »eai^€afl following prolonged ioactivity, by gradualiy adding aup- 

flfflisa and atrength, thufi prHiraring them fur iitore active exercise. The 

norrmmta vary greatlj iu Etrengtii and rapidiLy^ usually being applied 

caotioaaly at fii^ ai^d increased ^aduallj according to thd attength and 

codiatBce of the patient. Active movementa ooneiat of Binglo and dupli- 

(■led or rcsiBtauce movements. The former are done bytho patient alone 

mi t^ latter by tb^ operator while the patient Tesists, duplicated ecoen- 

Izie itoTmientfif or hy the patient tfliilo the operator lesista, duplicated 

amcojLnc movements. These bring into plaj the Bauie joints a^ tJie paa- 

ttoTemcnta, but oflei gn^ater variety iind force of octiou. Tho great- 

'- wi^rantage, however, to the patient who ib able to perform Ihem, lies 

. '.he fact that, being voluntary ai?tion, tb^ require an effort of will on 

'. r-art- By means of fiexinn^ estei^eioo, abducliou, adduclinn, rotation, 

tinrumdnction peiformeil singly or in combination, and vith or wltL- 

\ rtfiftCance, an indefinite variety of movementa is obtained which can 

b* tftaptcd to the different joints and to their individual needs and 

btklditioD to these exercises for the joints^ there is another set of 
■etire movemen ts intended eayeciallj' iu aid rea|iLration. The^e are per- 
taaatd by ^^ I'i^^ ^^^ include lifting and expanding the ct^st, Qezion 
nd dtenaion of the arms wi^ reaistanoef eitenaion and fiexion of the 
^dnl ootaiDn with resistance, ete. 

Ibeiystem of Swedish movements invented by Ling is one of the 
QMBt popular in viae for the purpose of medical gymnastice. It includes 
aD of the priDciiml movements which are of service in bhi« conneotion 
«4 tdinita ci a wide range in the matter of the variety and intensity of 
l^etenise. It is divided into two forma of movement, those done with 
ud these without apparatus, the latter admitting two postures^ standing 
ttdnqenuon- These movemeuta are in reality much more simple and 
iwy of compreheaaion and applicati&o than th a detailed deaeriptione of 
tUtj in the manoala on the subject would suggest. The appairatus em- 
[^td la also of comparative simplicity, 

la the Zander system we have another method of applying medical 
I^BtuMics which requLT«8miich more complicated apparatus for ilaexecu- 
tioD, The outfit consists of anch mechanical devices as rowing^ bicycling, 
ndin^ mirhlnee, and the like, run by atcam to which the patient oSers re- 
ivtujce^ also of other similar maohiues by which theputicut rt^ceivea pas- 
m it«ieise. Properly applied, these movements are often of considem- 
bfeMTfioe in thd treatment of nervous diseases, especially the functional 
MQMn They not only give the requisite eiercisej but the formality of 


tlie appliance and the intrioaoj of the maobinerj are oalculated to impreM 
the moie forcibly the mind of the patient acd therefore the better to elicit 
his intereat and will power. When, however, a properly equipped inati* 
tnUon ia not at hand, it ia necaesaij to hare reoourae to one of the more 
readily available methods. 



TffSKC ore f«v factors tbab&re moTc conspicaoaa in th« oaOfi^tiOD oC 

fwflfl tlun neglect of exercUe. In olden timea, ei^rclae of thd body 

IMoTtt^I itself into oomparativelj Bimple considerations. The itearer man 

1M to ft itAte of nature, tlie simpler &iid mure EpoaUneou-j were bb ei- 

ocisa^ tast«s, uid habitfl ; theief ore tbe mote conducive to the aouadnesa 

rfbaahL The diildiiood of the race, like the childhood of the indi' 

ntatdf ftmnd life a eimple, not a oomplex ptobleEo and therefore more 

«nlf mulcKd sa far as ita own needs were oonc^med. But aa the 

diildTnui adruiced it became neceasaij, in order to meet the increased 

ioDuda put cpoa bim, to cultivate intellect and wit in proportion aa he 

liT«d more bj these EUid leaa by brawn. The results ehow that it was 

Dftn dooe at the expense of the body. Insufficient and improper exei- 

iM b one of the commonest causes of disorder of nutrition. Since exer- 

» is kDC«n to be so neoesaarj to the maintenance of health and ainoe it 

ii fuch a eimplo m«aanr« within the reach of all, neglect of it is the more 

rapriiing. However, habit and expediency are two of the strongest iu- 

iilMDeN IB shaping the hfe of the average individual, and unfortunately 

^tibira, therd are laacy situations in life in which neither the one nor 

tte otbcr favor expenditure of time and energy in what appears to be an 

Dnpni£tahle way. The immediate and remote effects of methodical ex- 

ftciit upon the body is well known. It malcea the muAcles firm and 

liforxu, it tones the eircnlation, deepena respiraticna, and insures the 

pnper funetioning of the tisaues of the body. The want of it leads to 

iieadity and debility of the muscles, stifTne^s of the jotitta, atuggisltDesH 

aftnslhia^ aodf in brief, depreaaion of all the vital functions. 

Tbe importance of open-air exercise in the development of the youth 
smivenallj admitted. The majority of th^ so-called leisure classes in- 
jaJ|v in some form of athletia sport or physical recreation. Of late years 
ihse bis bien a gratifying revival of athletics, particularly in connection 
vilh ths education of ycnith, and we may expivrt to witness even more con- 
i]iax>iu beneficial effects in tlie succeeding geueraLion than in the present 
«u 6ct it b in the gieat m^La^s, the brain workers, men overtaxed 
tith bosinesa cares and women with domestic duties, that the need ts 
iKit pressing and the results cf lack of exercise most startling. It ia so 
<B7 Is let the hour's fresh air and exercise be crowded out by the things 
*^h they feel bound to do for the sake of themselvea and others. lu 




their endeavurs to meet the coiuplex ileiuauds ot modem civil Iz&tioii, they 
often forgtt tLe simple riilee of right living. The truth is that, owing 
to the eoiuplexity of their oireiuBstauceB, occupations, ortd envirOELment, 
tha application of these rulee^ simple as they are, is not bo easy aa is tb4 
recogaition of them. The average hu^y m&n or woman i\nds all «iercis«, 
ojtcept a little desultory driving or walking, an far removed from his cr 
hor ordinary mode of Liie and its exigencies as ate the luxuries of the 
rich or the sporta of childhood- Instead of heing n neccQaity of one's 
daily life, exorcise is resorted to Only when the vigor of the body has be- 
oonio wasted and when illnesa supplaula health. 

It is unnecesBHry to consider in detail the manner in which exercifla 
acta to maintain & state of outrition inimicd U) diaeaae, aod to facilitate 
the restoration of nutrition which conatitiitea the cure of diaeaae, for 
this IB a matter of physiology that is well known. Briefly, exercise 
promotes eouBtructlTe metabolism, by causing increased activity in the 
procesflen at combustion mid a demand for the comljnHtiblr>S; and also by 
ridding the system of effete products the retentiou of which, cYtm in 
flm&ll quantities, might become otiemely injuriuua. All physical exer- 
oieo causes the oonaumptiou of fuel — food-stuffs that have become an in- 
tegral part of the organism after absorption — which constitutes the tisane 
change forming the b^sis of metabolism. This consumption causes a 
pro|MirtionBte Xn&i of weight whicih in turn creates a demand for material 
to replace it, iu other words, for food. To aid in remuviug the waite 
products is an important element. It is very easy to see that the inoro 
readily the old particles are destroyed and removed and tha fiiel renewed, 
the more vigorous will be the process of metabolism. The physiological 
activity and constitutional vigor of every cell are in direot relation to the 
activity of metabolic nhaiige that goes on within tt. If the pro<.^SH is 
exoeasive, nutrition will be imperf^b liccauae wast« will then exceed 
repair. On the other haadf if the proceaa be innafflcicnt, the waste prod- 
ucts will fail to ba removed and not only will tbe metabolic fimcttons 
become clogged to the exuLusion of new and wholesome fuel, but there 
will be au accumulation of material whose presence is detriuiental to the 
economy* Iu this state, the food, it matters not the amount or quality, 
fails to nounsh the body and to ^i?e tone to the musolea and nervee. 
Indeed, it often adds to the accumulation of waste products. The result 
is that profound disturbance of circulation and nutrition which is at the 
bottom of SD many nervous diseases, 

fiporti and Oymnastica. — J'hyaical exercises may be divided into two 
kinds: first, those in which the genera] plan and the tinal object to bo 
attained are definitely indicated, the movements themselves being left Lo 
the choice of the in.dividual-, and second, thuse in which the movements 
are accui-abely planned, their force, duration, frequence, and form being 
determ^ined by strict technique and rarried^out systemati^-Edly^ In other 



vordAi it maj be coaaidtred uader eports and gjicnastica. There arc, 
ttf ooane. many occnpatioaa that Bifard much pcpoaeful and healthful 
mmiifli. bet as these require that thought aud effort be directed toward, 
tk* md JLod little toward the manner of th^ir execution^ th^ may for 
fnytlual purposes be included in the fii'st division. 

la <irdtT that eierciae be effectual it must call into activity the mind 
M Till 03 tte muscles, and it must be so selected otid arranged aa to bo 
■dipted to the p^oliar mental and physical condition of the individu&L 
Itbeuy to understand that the kind of exercise which will interest and 
teaefit one person of certaio age and position m life will be BDtii^lj on- 
BUied to another under di^erent conditions. Id a similar wnj* the same 
fitfm ud degree of exercise is not recommended for him who is suffering 
Cram Ilia resnlta cf exceBsive mental application and for him whose cod- 
dibon ii ihe result of aonte diBease. Henoe the BUperiority of what may 
te «Jled spoutaneoiiB exercise well directed orer merely perfunjrtory 
■liking or driving for health, and gymuaBtica done iu routine fiiahioii 
TiEb no particiilar meaning or method aa to their execution. Ideal exer- 
ei^ ifi that form in whioh the gt^'atcst general play of muscles ia obtained 
with the least studied effort. For this reason the different sports ard 
iDDSUorably preferable to systematic gymnastics. They afford that 
fmnof eKereise which approaches most nearly to the natural and spon- 
tOHjaa and to the exercises of childhood. Their virtue lies not only in 
the nereiae of the body hut in the appeal which they make to the mind 
lAd tkdr power of maintaining intereet and eliciting the dii-ection of will 
■itb the least conscious effort. Aa a rale, they also bring into simul- 
lueous action a number of ditferent muscles, thus generalizing the exer- 
ax uid its boneBcial effects. 

Dotcrmii^tioQ of the kind of sport that will be most expedient and 
beoe&dat in & given case will depend upon temperament^ statiOD^ habits, 
dcgn* of physical attength, and nature of the iudividaal's infirmity. At 
deprvsent time the tield of active apcrta and athletic esterciseH cover so 
vidsi range it would seem that some suitable form muflt be quite within 
ihfttvaeh of the aveiage person. Walking, the most natural of all eser- 
AM, knd long-respected remedy for many ills, is rather an exercise of the 
vdl man Uian of one who is ill. To be of considerable service, walking 
nut b« brisk, active^ trnd prolonged, and there are many reasons why tho 
(VBKribed walk of the nervous invalid, taken in the aame spirit as a 
laqMNHiful of Ul^Oavored medicine, will scarcely be of any n&s. A fairly 
aib mle to follow ia that so long a^ walking is spontaneous aiiU refresh- 
iii{[ it is benefieiAl \ carried beyond this, especially if it i9 irkaome to tho 
pactnit, little or no good can be p^pected- 

BicycJing has come to be reputed as une of the most valuable exercises 
in die prevention and cure of disease. Its ^cateet merit lies in tbc fact 
tUt it appeals equally to the sexes, and to all a.geB and conditions. 



Moderation in its Lodulgenco and a properly adapted &iid well-fittitig 
saddle are tlie twa things that; the phyaictAn shimld insist npon, and 
tfspe^^ially for wGrnon. Carried to the point of eKhauation, it is decidedlj 
injurious. It must ba recommended with ^eat c&atioii to those who have 
Oiguiio disease of the rasaiUar ajatcm. 

Of aJl the gai]]es that lend themaelirfiB to tho iteuropath, golf i» the 
Tnoat favored. It haa a larger field of uBefulnp-na iu th« treatTnent of 
uerroua dieeaae tban Any other fiiriii of atliletic sport. It cornea within 
the phjflit^al reach of a iuyicIi larger number of people than any other game 
and it baa the aignaL adrai^tage of affording pleasant activity to tho mind 
OS well aa to tho body. Moreover, there is aoaroely any dan^r of orer- 
exertiou as there ta in ao ms.ay other fomia of exercise. Unfortunately 
there are iimtkj' soiditl acid fiiiaueial reslrictioiks around the game in this 
country ho that (comparatively outy a few can avail themselves of ite 
advantages. Tennis affordB splendid oiereiae for the well peraon, and it 
can bQ iudulged in most piotitahly by many Buffarera from fuDotioaal 
nervous disease, especially those m which the mental element is coa- 

Of the milder forms of exerouw, rowing U one that can ofteji be recom- 
mended with safety, evcL to the veiy fiaiL The movements are rery 
genera), bringiDg into aotivity a large nnmbcr of muBcles and nob putting 
iodividuat imisi^Ies or gioups of muscles under special strain. In fact, 
almost all tha aquutie recreations may be taken Into favorable ooDsiden- 
tion in the treatment of many fuuotional and organic nervous diseases. 
Even tiahing, if it be suffiriently absorbing to bold the attention of the 
individual, may be recommended. For much the same reason, mountain 
oUmbiiig and dcnkeyriding, when there is eome special object or destina' 
tlon in viE>w euch as a search for wild tlowera and hirdn, or whef) thd person 
is a stifTlciently entluitiiaatic admirt^r of natureto find pleaKure in the mere 
Oontemplaticm of her wontlerSf are also beueficial. ShootiDgi bunting, and 
the many other epoita which the country a tfords need no special mention. 
It IB usually in consequence of the limitations of city life that the greatest 
difficulty is found in hitting upon the particular variety of exercise which 
is suited for a iiarticular caAe, hut the walk, the drive, the ride, the bicycle^ 
the deliberate opeu-air lireathing-sjiell on the front platform of a street 
car, some one or all of these is within the means and opportunities of every 
busy worker, male and female. Feneing fur thosa who have the strength 
to indulge it, is an important exercise Ijecauas of tlie bodily and mental 
diseipline which it affords^ The same may 1>b said of a much milder ex- 
BTOise — hand-hall. Riding and driving belong in the list of Bo-ealled 
pasaive exercises. This is particuiarly true of the latter, but both of tbem 
bavo their uses. But here it may be said that latterly it has become the 
oufltom to deeiy tiding as oxoeosTvely violent and injurious for women. 
Like bicycling, it can undoubtedly be mads so if oarried to excess, but 



vfaoi akoi moderately and umlerstaitdiiigly by a parson vho enjoys it, 
l^gJ9 ia scarcely any e^ercLse ivhicL Las ■ more exhilarating aitd at tL« 
m>«tUDe soothing effect oq both the body and the mmd. Those who 
«BB»plaia of gresX fatkgtie following & moderate vide ahould aubmLt to care- 
fat tuDUSation and instruction before making further testa of their eu- 
teiDOP- When wrongly done tba effects may be detfidedly injariooa. 

Grnmaatiis. — Ttje rdlo of gj'mnastics m the treatment of nervon^ dis- 
MfletSEomewhatdiifereat from that of aportSr and aa neither one can ol- 
tG(etber feplace the other, tbey afe often leoommended simultAneoualy. 
SpoTtitend to the production of geneml effeets, nhile gymnastice, on the 
Mber hud, have pnmarily a local action on particular groups of mos- 
dea, ■llhoogh Lbe general fijatem may benefit indEr^tl^\ Tliey require 
for their perfortaanco concentratvon of the attention upon tbem and are 
cMtti^uttiUjr of ten ixkoomo. As the different movements are arrunged on 
t«rifi]tilio baeia lo meet certain indicationB, and aa they ate aeually carried 
vt DAder the directiou of scime one who understarids their proper applica- 
nno, it » a comparatively easy matter to fiud the ones best auited to the 
sfcdsof each casC' The important elem^.nt is the localisation of e^ect 
10 one set of niusclca at a time. Thig in then ehifted to another, and in 
Ifcu wiy all porta of the body, or aa many as may be desired, receive m 
BUB tb« particular hind and amount of exercise tliat haa been decided 
Tpoi. This method of localization secures to g^mnastic^ prupt-r the ad- 
mli^ of mor« mteose muoontar effort than do mora Bpontane<iuft erer- 
Qfts. Buch an end is often of great necessity in certain diseafiee in which 
itMd«BinbIe to obtain coasiderablc activity in certain parts of the body, 
vitk'Ut causing general disturbanoe wbich it may be advisable to avoid. 

All aiovements eoming under the bead of gynmafltica can be divided 
!Bta|iuHive and active movemenbe. They are dune with or without ap' 
{uratoj, but tbe latter have the decided odvaatage of aEordinj; a greater 
irenityef scope aod a tangible form in the nature of a *^cnre/' on 
»fciflli the mind of Uie patient can readily fii itself. The appeal which 
bibaa directly mfiJfes to him ia of much importance. Tbe varietiefi of 
irmnuCipa vary in form and intensity from tbnae whii;h require the least 
pMible output of caiefully guaided sbrpngth to the moat violent forms 
tf V£9roiAes, such as leaping, vaulting, and ninning. However, the latter 
Sfrd tiot be further mentioned in this connection, as their indulgence 
dtmudA a degree of vigor which is not eompalible with considerable dis- 
own of tbe nervous system. The syi^tem of gymnaatica most favored in 
^a tr^tnient of nervous dineoaes is that kuown as the Swedish. Here 
Ijip EDoremetita are eo mUd that they &re applicable to nearly all ca^ee in 
»tii<h the object is to aid restoration of nutrition and to relieve the 
mmm of overstrained nerves by atTording gentle activity to the weak- 
oM ncMles and engrossing occupations of the mind, 

Iti considfiring the use of gymoafities in the treatment of nervoos dis- 



BAsea, the quefitinn n^LtumJIy arises to what extent are b^nefii^ial reBulU 
that follow ludulgiQg in tliem due to tha physiological effect of exercifle^ 
&iid to what exteat to tha psjchioal uiflueDces exerted b; tbem upou the 
auggoatible mind of tho patient. It would bo a difficult mfiittcr indeed to 
draw an oxaut lino of dilTereutiation. Of the definite physiolo^csJ eSeotfl 
And of the boneEit that accrue tlierefrom tberd can bd no doubt As tbe 
p!4yrhi(;al effect, howover, we have to deal with a subject which is much 
more diffii-iilttri explain, altlicnigh its re^uUa are apparent to every oue. To 
m&uy pati«nt3 it is one of the means of introducing tha leaven of energy of 
whiuh thoy Gtand Boraly in needy iind it m&y fill Eio important uictie in a 
deapfiLrmg lifa of unrelentin(( invalidtsm. Thia payehiral inHuence ia an 
integral part of alt thers-peuUc agendea and one that cannct be neglected. 
Rett iZL the Treatment of Diieaae. — Unlike the hygiene of uierciser 
th&t of rsBt, except in its mcJit natural and priiuitive seuse, in of com- 
paratively modern applicatioci in tho treatment of diseaao. True, the 
•aying that ** sleep is b<?ttop than medicine'' has been omrent in all timea^ 
bat as the necessity of sleep in the maintenance a* in the recovery of 
health ifl Aelf-evident, it trail aoarcely l>e oonaidered from the jioint of 
vi^w of aoience. Enforced rest, in conneotioQ with relative isolation, b 
now generally conceded to bo one of the most essential measurea in the 
treatment of neura^thdni^ aad hysteria, and of very groat service in n:iany 
of tha functional aiici organic nervous di.seases. The systeumtic plan cf 
treatment that baa been devised for carrying it out is Icoown aa the Weir 
Mitchell rest eure, after its distiuguished originiLtor. It consists esscsn-' 
tiallj in forced feeding, reat in bed and isolation- for a period of time last- 
ing from one to two months, and in the utilization of physical and medi- 
cinal measures that contribute to improvement of nutrition and TeGtoration 
of mental equilibrium. The nit^ntal influence of the isolation is unques- 
tionahly tho uiost ini|»ortant faiii-orof the rnst cure, Tt is ciiGtoinary to 
apeak of a complete aiLd a partial n^st cure, hi tha formrr the patient 
is put to bed in a properly ai^le<:ted room mid required to take absolute 
rest- Writing, reading, and all diversions are forbidden. The patient 
is, however, not left to tha eoutemplation of his or her own miseries. On 
the other hand, the tima is carefully allotted with a view to the 
Avoidance of aiich thoughts. The schedule consists in frequent and reg- 
ular feedmg, the use of water, massage, exercise, and cloctricity- The 
jemauider of the time is spent in sleep and being talked or read to by 
the uurse. The complete rest plan is required in a relatively small 
proportion of all cases cf naurastlienia and hysteria. In the leas se- 
Tare forms, particularly if they have not been already subjected to cao' 
fliderable treatment, other measures and a [>artial rest cure suffice. Un- 
der uo conditions should it bo decided upon until tho physician is rea- 
sonably certain of the ability, both on hia own part and on that of thft 
patient, to carry it ont with thfi conformation to minute detail which is 



aft«f t^ essential eleraents of its Buccesa, The method of the Ueat- 

ppt m iMued upcjQ tLe idea gf ayateiu, and thxs iundtuaeaX^ piiuciple 
MUOt be rguured to &ay degree vctbout materi^lj farfeiting the r.haaces 
df nDP«s- Tlira point caoQOt be too strongly urged in the use of ©very 
plu of traitiDCTjt for the relief of any (^lirtinic aervoua di&euse in vhich 
tlia idection oC the mode of tr^atmeiit Diust ba determined to a gre&t 
tttcfit by lh& ludiT^dunlity of tiie patient, but iu wbich tbe mode of ap- 
■ftattntm^ onca determined, admite of no compioiniae. In tbe ful&lmeut 
tiUmt Ivo canditiona li^ the severest test of the phj^sician^s power to 
K^viththe disease^ It presupposes tlte capacity of iud^vida^izatioa 
fatbefiucst eenee, for it by no meana Buffices that he poase^ies the ability 
bpotntOQt the beet mode of treatment adapted to a give-u disease or 
ptbeatiuiiess this kuowlcdgo be aupplemented by the capacity to carry 
ft ML The application of the rest cura alieald not be decided upon until 
tbvjatifiLt understands and a^^cedes to tbe conditions whifh it imposes- 
All jotLeata Jitarb out with the cucvictitfn that tbe treaUndut is u^ttulapted 
ttUienu To b few it is injuiioua. To the many it is beneficial. The 
twtfaJ pbysiciao will separate the one from the other. When it is once 
bidertaken it is to be carrLed out without any considerable omission of 
dfiul, bat of course yrvh modifioationa to meet the meatal statua partic- 
iJv{jrcf the individual casq. 

Tbe indications for the use of the reet-plan of treatment are difficult 
to )xj down categoricaiiy, but it may be aaid thAt the mfijoiity of the 
«Na which are benefited by u are neurE^the&ic and emaciated patientn 
vbo hare been brought to this state by neuropathic dUpositlon and mani- 
fold mjnrious mduences acting upon their general nutrition and the 
■nnvsof their nervous energy. 

The more complete and extenaire the peyeho-pabhological manifesta- 
Otmj af d\^ii30 arci that i3] tb« more conspicuous are hypochondria, anx- 
v^r and depressioEi, tbe more ui:icetlaui are the bene&cial eSacts of the 
tKilment. It is far more suecessfnl in the treatment of acquired neuras- 
lIcDua than whet may be catleil ronstitutional neurasthenics. Every one 
vbo kaa had much expeneuco in the use of the reat-plan eoon Icame to 
b0«btiy in prontiaing complete cure or even permanent amelioratioD to 
ibvcbwiof patients. Moreover, it is early impressed upon su<^h a patient 
Att improvement in the body does not alvays ga haud-in-hand with 
Mufit to the mind- 

The object of the rest-plan of treatment is bo improve nutrition and 
fire mi^tal oud bodily rest. The enforced rest prevents eitpeuditure of 
fMrgj while the proper use of food and physical meaaures^ such aa maa- 
og?, piaaive gymnastics, hydriatics, electricity, bring about the improve- 
amt of nutntioTi necessary to recoYery. The value of these phjaicaJ 
GMUun» in tbe rest cure varies witb tbe individnaL No two casea 
Mcepl just the came form of treatmeDt. Tbe importance of the part 


playefi by moseaKe uan bo overoatimated if we altonipt to lay down 
any flpMLtic rulea^ If absolute rest iii bed is preBPribed^ mas^fagQ in 
some form to aid Cfmstructive metaboliflm is necesaary. Maar^age pre- 
renta tLe euforced rest from haviDg Jiijurioua u^msequeuces upon the 
muBolea themaelroa, by iacreaaiag tlio geDCTal and luterBtitial circula- 
tio&T thug favoring ttsguo metmuurphosia. It increases the tonus of 
thd gaBtro-inteatiual tract, and thua coatTibutea greatly to the increase 
of uutritioQ find indirectly to the excretion of inoomplat^ly digested 
and ab9ort>e(l proilucts^ By many it is aupnc^eed to bave an inflaenoe 
apart from these conditions. Binswanger, for inatanca, ia of the be- 
lief that a certain anioutib of uniform mauipulatioa of tbo ekin ov^r a 
large autfaoe of the body causes stimuli to be B«Dt to the cortex of the 
brain which hare a direct sedative infiuence. Stnw, uniform, moderately 
di'm rubbing L»f tJje entire outanauuR Hurfane, without pArtitnilur pressure 
or kneadii^ij of tUe muscles, has a peculiarly aootliiug eHect upon many 
patients. When it is found advisable to viars general massage, the pinch- 
ing and kneading o£ the muscles, followed by masaagi? of the skiu, ia moat 
advantageous. Maasage is applied to oil parts except to the head, wLich 
is generally L«Ht left untouched, tiuless there are special indicatioDfi for 
its appUcatton. ITauolly it is advisable in the beginning to have it ap- 
plied only to the lower estremiiieai then, later, to the l*^dy and the arms. 
The a<Saaoe, when tho whole body is massaged, should last from forty to 
aii.ty minutes. Tbe beet time to apply it le in the afternoon or evening. 
If it excitea tbe patient, makes him restleaa, sleepless, and diacontented, 
the iuteuaity and duration of the massage must ha carefully looked into 
to see if some modificatiou of it oannot be brought about iii lieu of ita 
oomplete ei is pens ion h 

Tbe external use of water itt even of greater importauoe than maa- 
■age aa a factor in the rest cure. Any of the variona ways of appljring 
water foi- itn trniic e£Tecta emunerat^ in th» chapter on hyibotherapy may 
be utilised. The selection of the procedure will depend entirely upon the 
patient's capacity for reaction. Water in the shape of hot and cold packsj 
dripping aheet, prolonged warm baths iB used extenaively for its sedative 
el^octa to combat sleeplessness and manifestations of phyaical and mental 
erethism, oeaurriug with tbe diseases in whiHi tbe rest cure la appropri- 
ately employed. Electricity in the shape of general faradisation and 
galvanisation of individual muscles and groups of miisc1e& is not so fre- 
quently employed aa a component of the rest cuve as it was formerly, 
although it does not deserve to be neglected. It fulEls to a degree tbe 
aame indicstiana as massage and in addition makes a stronger imprefision 
Upon the mind of tbe patient, 

Aa isolation is always imposed, the patient is thua left to the constant 
and exclusive companionehip of the nurse. The selection of this indi- 
ridital is therefore a matter of the greatest unportanoe. Here again we 




oecnDtoTthG diiBcuIt subject o£ mdiTiduaJizatiooi so that it 15 impoflsiblo 
Ip by dovQ rigid mlea ior guidance in ey&ry case> The softest puide is 
^ oburration Qt the effect wlucb tte nnrBe hhs upon the patieut. It is 
«ften Dec«fiaary to cbange nurses nii^iiply because of unreaaoualle pr«ju' 
toon the part of ttie patieut. As a g^oeral iLde it iti uafe U> s&j that, 
Of^ty IQ the ordLnary senae of the word being included^ tb^t nurse ia 
btflGttdJto desl with uervoi^B patieat^ who poBsesses the greatost amoimt 
of wbaC iS called rteerve forco^ ^^^ ^h ^^ <^^ ^^'^ ^ most suie of tlK 
pOTCT tA manage the patient and least auxjoua to display it. Add to this 
fBiliif a fair amount of intelijeencer a muoh greater amount of tact and 
Bsdcimce, a pcrsisteotlf optimiatio dispotiition aj^d bearing, and u& abid' 
iji| hith in the physician in atteodanoeT and we have the ideal nurse tot 
t^p reat cure. Sympathy in the oommon sense cf the word, partacularlj 
dlle emotional variety, has been nmoh overrated. In truth, it is rather 
to be provided against tlian cultivated iu dealing with audi patients. 

TIw administration of medicines with the rest cure depends upon the 
^ptomatic and constitutional indications^ To bring the rest cure to a 
BDeoMefdl ifsue one must have constantly iu micd that it is the combined 
ue of ftll th& meaaores that have been spoteo of and not the one or the 
atberthat is necessary. 

The plan of treataient ia of greatest importance, 

Tho two following schedules, one for the full reat cure as giren by 
Dt, J. K. MitcJiell, and the other for the partial test cure aa ^iven by 
Dr Weir Mitchell, niay be taten to ludieate approjiimately the disposi- 
tioD of time and the utilization of the various measuree. 


7 i.H* Cacao, followed by a cool sponge bath, with a rough rub and 
Ibfllcilet for the day. 

S j.«. Btcrakfast, with milk. Rest an hour after. 

10 A-M, Eight ounces of peptonized miJk, or ita equivalent. 

11 A, M. Massage. 

12 X. Eight oimces of milk or soup, after which the patient can be 
md to by the nurse. 

1:30 p-M, Dinner, followed by rest for an hour. 

3;^ r.u. Eight oujjcea of milk, sjid a half-hour later the application 
d Electricity. 

C:50 P.M. Supper, with milk, followed by roat for an hour, after 
tlwh Uie patient may be read to for a half-honr or longer if it does not 
fttigoe her, 

S'30 P.M. AdininistrHtiou of malt extract^ with aperient if necoBsary, 
orlhe otihiation of aome measures to induce sleep, such q& the drip'sheet 
cv 1ii9 administration of hypnotics. 




A.U' On vakiDg, a trup of (TAj^ao. Take bath. SpeciiSed tern perature. 
Lie (lowD OR lounge wLila using drying towels; or, beLtet, he npociged and 
dried hy an attendant. In this proceaa, the surface ia to be tubbed renl, 
or, in drying ouq'b self, use flesh-brush. Bed or lounge agamn Di-eak- 
fmt Before eaoh njeol lake lliree oun^^ea of malt extract j sip^riejit at 
need in malt. Tonio after eich meal. Detail aa ta breakfast diet. U 
ejRH me gixid, ma/ then rtutd Heatfd iiL 1>ed. At 10 to 11 A-u., one bourns 
maasiige. Rest one hour, may be read to, ot if eyes are ^ood, knit. At 
this ttme, 11 a.m., four ounces of beef eoup or eight ounoea of milk. At 
noon may rise, dvess slowly, resting once or twice & few tninutea vhil* 
dtesaiug, and remain up until 3 p.ii. See children; attend to houBshold 
buamesB; eee one visitorj if desirable- t to 1:30 p.h,, malt, etc., and 
loQoL. Detail as to diet. At first, as a rule, let this meal fepresent 
dinner. Tonic, and after it to rest on a loungo, occupied aa above, read- 
lag or being read to. If poaalble, drive out or use tramway, so as to get 
air Walk aa little as poBBible. On returning from drive rep«at milk or 
soup. About 5 P.M. clf'C'tricitj, if used at all. Rest until aeven. Sup- 
per at 7 p.M- Detail as to meal. Malt aa before, wither without aperi- 
eot, as oocaaioQ demands. Tonic. To apcnd evening with the familyj 
u usual. Beat not to uac eyca at night for near view. Bed at ll~^ r.sf, 
'So letters to b« wHtt«n for two months, when moat of these details hare 
to be revised. 

The Art of Relaxation. — Aside from the radical application of the 
reat cure in certain dLsoaaea, the woaderful power of simple relaKBtion is 
yet very far from beiug understood or appreciated, not oi\\y relaxation of 
the body but relajration of the niind is meant. As a people we are so 
accustomed to belag spoken of as restless and nervous that we have eome 
bo look upon the iinpittation with national pride instead of regarding it 
aa one of our moat serious weakDesses. If there is one thing more Uiau 
another that prevents us from securing adequate relaxation it is mul- 
tiplicity of interests, many of them unnecessary, ^nd social dissipation, 
Excessive absorption iu vocation is a close second. By multiplicity of 
iiktereala is nut meant bLisinees intereats excluHively. Tt embraeea fam- 
ily, esthetic, epirituol, social, intellectual, and political iDleresb^, which 
every one hae, or should have, and should inddge in proper proportion. 
An ex<?etia of time devoted to some one or all of these robs from that 
which mifiEht profitably be girea to the pursuit of some hobby tli^t bringa 
relaxation which every man and woman ought to have. The American 
habit of intemi»pralf n<^wj<paper reading, newsjfcajierd with their weird and 
never-ending details of crime, their pages uF foulish a^icial gossip^ their 
columns of made-to-arder atoriaa, and their leetbetic' warping pictures 



iMff nunUl atonjr and disaipfkks time th^t might othenriae be profita- 
Uj VJaphfeA ill seciuitig rest and relaxation- The aaiud uiaj be «fiid of 
iaesttoij reading, or bettaraaid, wading through the tomes of so-called 
Hiwiliiif Uuit one feels compelled to read in ntiler to find real entertain- 
■tttanJ isIf-oblivioQ as w«U aa Kelf-ijii]irov«>[ne[iL Judioiousl}' liEiutBc] 
K*Vpapcr ai^d '* gcceial " reading will do much toward finding the time 
EnitliUtioiL which every oilg needs and which so few properly socure* 

EEeeesive absorption in vocation la really tlia bane of the AjnoHcan 
tmiD«u tufln'a life and to a leaser degree of the po]itici£Ji's life, Aa a 
uboa w» are yet Um yonng to bave tearaeil to proviile ade*juitely for 
^ locial Bidfi cjf viiz uatuie. We are yeL apt to go to one or the other 
ettreme; toeapoase the priiaitiveijaaa and barrenness which characterized 
ti« social iniereoorse of a N«w England town a generation or two ago — 
tt ilunent of the euviKLment largely responsible for that important 
firtDr in many neuroseB and psychoses, the K«w KngEand eonaC]ence< — or 
ffl illoT uuiseUcs to bo sucked np into Uia vottet of social diasipalioti 
iQtil it pmvea a verital>lo Juggernaut to health* It may be advan- 
UfMMia at times to be oa aloof as the Mikado or na retiring as a hermit, 
baL, u a general rule, It may be said that temperate indnlgeuce of one'a 
VDciil Bide is one of the surest preventives of dying in harness, and the 
EEL^st natural way of securing relaxation. 

Growth and repair bear a direct relation to physiological rest, local 
BLd generali It is essential for every normal healthy life that exorcise 
led test be properly alternated, tlie timo devoted to the tatter being that 
tbicb oatnre takes To repair the loss tx} those powers that are exhausted, 
ind Co restore vigor to the body and mind. If the human inachiDery has 
\o hm too muok attain or bha time and facilities for repair are inade- 
quatf^ It* work will bo done siightingiy aJid it will he only a question of 
tnw vben there will bo perceptible dimmution of power and imperfee- 
tim in the machine. Nor does the want of rest in the ordinary sense 
of Ihfl word cover tlie whole ground of tliia defiineni'y. The need wbich 
s oeut to be Loiplied is better cjipre&sed by lelajLatiou which io the 
imltaf chi^ngfi Ixi one's occupation or moilc of life, and that which will 
gin complete rest to those faculties thai have become futigued from 
muEtoia&d use, by giving exercise to others which are usually held in 
iFWe. This explains why physical exercise is often more restful to a 
Boawho is overtaxed by mental work than idleneaa. The principle of 
idoition ia the same. Wheu all the faculties ese suffered to undergo 
AitniD, either from overeKettion or from want of proper nourishment, 
it i> evident that general rest is necessary, 

Occapation a Therapeutic Agency.— Occupation as a therapeutic agent 
hu u[»t rect-ifed rhe con r^ idem ti on that it deserves- Maiiy patients with 
nald hypochondria, neuraathenia, hysteria, and melancholia obtain more 
iDUDodiabe coiofort and permanent bene£t from participation in properly 


selected manual labor than from any other treatmeot. Tbe mental elo- 
inent is pruimneut in all tbese cases aad many of tlie patients date their 
infirmitiBa from pcnoda of enfoTced idJeness due to lack of opportimitj, 
inability to t^e this initiative^ ot to convictioQ Uiat occupation is iojijrt- 
otiH. The therupeat:o value of engroB^ing mental occupation in sonio 
neuruaes is referred Co in the chapter on psychotherapy, while the Tjecefl- 
eity of iittiiig o4;cupation for epileptics is spoken of in the chapter en 

Some oppoaitiou must naturally be expei;ted when a mode of lifeeo 
rndicnlly different and perhaps tbeoretu^ELlJj lepu^ant as manual labor ^ 
is propo*4ed, bill this can easily he overcome, eapeeially after a short 
trial when the benetita of it begin to be inunifeflt Some ot the tmploj- 
menta that the neuropnth may avail himself of are fanning, gardenings 
forestry, uLrpentry, modelhng, and caiviug. There ia mxich to be said 
in favor of aottve life on & farm for city-bred individuals- It takes ths 
patient away from the Boe^eB of his misfortunes and suffering; his lat'k 
of mental energy is comuienaurate with mui'h of tLe work to he doiie^ 
and aasociabion with the stolidity and reticence as well aa the energy anl 
fortitude of men and women which auch environment engenders is icitni- 
oal to self'Concernment and exploitation of small ailments, Th^t the 
patient should cot have to conform to the dietary of the average farmer 
goes without sa^'ing. He should participate ia the benefits of farm life 
without tlm hardahipH, 

If the patient caii be got to take an iiitereat in forestry or gardening, 
these are ocou[Kitions that oaji bo indulged in to much advantage, as thej 
make strong appeal to the mental, physioal, and *eHthetie spheres. Th« 
ailvantagtia of carj^entry, modelling, and i-arving are that the results are 
Lmmediate and the produi^t^a bometiiuea useful. The buoyant eatiafaction 
of doing auccessful work aftet repeated efFprta have resulted m failure 
may prove the bit of loaven that the deapalfing mind nee<ls. To indulge 
in these requires ixmiparatively slight spai'e and ezpenae^ while the mus- 
elei brought into action are often those that stand In greatest need of 
development^ Huch as those of the thorax and abdomen. Moreover* these 
occupations make the patieut much leas suacepbible to sounds nnd noises, 
while they cause a mild degree o£ fatigue contributory to sleep. ThoMi 
who have been surrounded with lujiuHes and indulgent la extravagance*' 
soon iiod that suHi occupation offers a refreshing wbolesnmeneRs in marked l 
contrast with their previous mudes of life. For the mentally overworked-' 
and thoae harassed and burdened by afTaira and cares it not only facili- ■ 
tfttes restoration of nutrition and Btrongtb, but it is opposed to irregu-' 
Larities in eating and sleeping} and the exoeesive use of aloohoUca and. 



Tek faJU!tioQal and orgauic diseases of the uervous Ayst^m are often 
oBitd bv gi AA&ociated with profouiid disturbance of nutritioL. £ape- 
liillj- la this true of certain disewee such as neuroathenia, hysteriEi, epilep- 
ijf, tad tli« arute ps^choses^ In the treatment oi many of these neurosea 
ttMTHl^eof m^diome IB not to be compared with tliat of proper riiet and 
tike ose of pbystca] hieasures of reconstniotiuo. Therefore it Wiinjld seem 
lololkra nahir^y that ankOQg the m«asareB for orercomiiig this disorder 
oftutritioa the aeJeotiou of appropriate food and its udmini strati on in 
idtqoate qoautitieE, in aliort, the prmeiplee of luodero dietetics^ would 
bi of first impOFtance. It is a faot, however, that do Bnbject in the 
fnotjcal applii^tion of our art is more DPgle<-ted, One of the i-on- 
*T"**"— of Uiis is tbiit patients ttiemselves do Lot place the reliEuice 
tp<m dietary in the cure of their disease that they do upon many other 
BifuiiTea which we k^icw are of cumparattve iastgiitliciuice^ 

Xdeqaate and appropriate uutriment do^a not^ of t;oDrse, always mean 
i luf^er qamntity than is ordinarily taken. On the contrary, in many 
iailuii:«& fiuch as iii neiuastheniA or migraioe dependent ii^od or asso- 
tiiUtd with the uric-acid diathesia, it may he of signal importance to 
djmmiflh the quantity of food and to elimiuate largely certain kindsi 
rwh as the red meats. It may, however, be stated at a general rule 
tlittbe neuroses are more frequently the result of insiifHcient and inap- 
pntpriate food than of overfeeding. 

The proper noorishment for a particular eaae must consider not only 
\ia quality find quantity of food, but the frequency and regularity of feed' 
af, the amount to be taken at one time, and Idtewiae the adaptability of 
tkt diet to the needs and peculiarities of the iadividuah For this reason 
it«Dti]d be nianifeatly impoutibla to give rules whii:U would apply to 
l^ivtivitJi the differs at forms of nervous diaeasen It is particularly in 
4M in which auto- in toxical ion plays an importaut role, either in thoeau- 
otian or m^inteuanoe of the diaeast^ such aa in epilepsy, that rules of this 
^ioduight apply in more or less routine faabion^ An effort will be made 
tOQuwider this as^reet of Lbe subject in the ebapters devoted to the Ireat- 
DCDl of the individual diseases, 

Thfi object of food in dis«aBQ is the maintenaut^a of vitality Bsd the 
n-««tablishment of iiutritioo, and thereby the restoration of tone to the 


various HysLrtiun of Uih hitdy ttiat tliey tuny resimio their cuHtooiary func- 
bioua. The diet that will bodt meet ih^if requireiiieDts ia tbe diet beet 
suited to eai'li vase. In other worda, tbere ia tio food known vhioh h&a 
special properties to nourish the Letvous sjstem. For a Icng time ther9 
was a popular belief that fatty fcxxla poBsessed such virtue^ and it is yet 
generally believed by the laity^ and by aume membeis of tbe prufeasiun 
as nell, that fata oiid fiiLbatauct'a "which contain a couapicuoits amouDb of 
phoaphorus, auc^h as aoote uf the cerealSf have peoiOiar heneScial proper- 
ties in exhausted atates of tha nervous syatem. It ie generally ooneeded, 
however, by physiological ohemiBta^ that this is nut ao. Fats are force 
produoeps because of the oxidation which i« tiecessarj for their diaposal, 
but they do not, herauae of thia^ have sigual effect upon the Dutiition. 
All that can be expected of any food ia that it shall contribute to g^neni 

Whatever niay be aaid of the relative importance of the ptoteida, ani- 
mal or vegetable, or of the hydrooartMins, a mixed diet la the only one 
tliat meets all the requireiueNta iiJv the uiaiiiteuance of health. It may 
be btated ua a gt^neral rule that a alight prepoader&nce tf the nitrogenou 
floods is most appropriate for poisuua of the neuiopathie diathesisp It ii 
estimated that the amount of carbon and nitrogen required by the normal 
{>erson is in the r^tio of 16 to 1, it matters not vhat his palititrs may be. 
Therefore, an exehisivety lueat diet would provide far toogreat an amount 
of nitrogen for the earbon lliat it would briug into the aystem, while on 
the other hand the Qtarchefij iu order to supply sufHcient nitrogen, woold 
give twice aa muclt carbon as the system requires. Thia is one of the 
fatal mistakes of an exclusively vegetable diet^ Several times the amoont 
of atareh muat be taken that th^^ reqtiiitlte amount of nitrogen heohtainedj 
and naturally the system rel>elH against tliis abuse (as it doea against 
moat othora). 

Milk ia the most nearly perfect of all foods, as it coutaina the neces' 
sary aubataneea, proteids, fats, starches, water, aitd inorgaoir aults tn a 
proportion appi-oximating that whieh the system requires. It is prao- 
tieally the only substance u|)ou whic.h a person can maintain perfect health 
for a long time, A s^rioua objection to milk as a sole article of diet ia 
tlmt it containe too large a proportion of nitrogen to carbon to constitute 
the exclusive diet for a pernon in health. In diaeajje, however, it may 
be juat the food that i-^ needed, particularly if the o^idifing eapaoities of 
the patient need atimuhticig. 

Milk or some preparation of it should enter largely into the dietary 
of uervoue patients. An cxoluaive milk diet for a time ia often neeesaary 
in the treatment of certain diseasea such as epilepsy and neurasthenia, 
[t is an important element of the rest cure, and tn many diathetio condi- 
tiona the greatest raliam^e ia p1at<ed upon it to induenue the disease if the 
patieut ia able and i^an h*3 induced to take it. There arerarioua methnda 



d^tffurmg milk for patients in whom it ca^uses unpleasant effeota when 
A^ iQ tbp raw state. Slamming and boiling make it more digestible, 
ud^ilaliiLg it witb plam or aerated alk&line water often urerc^mea any 
leoiJVQcy which it maj have to produce pyrosia, dizzineas, confltipatioD, 
fU. iVben it tends to cause those symptoms commoulv tolled ^^ bilioufl- 
Mtt" they can often be prevented by the addition of small amounts of 
flWBKU Bale, biiTarbonate of sorla, phosphate of soda, or milk of magnesia. 
Hdnpite aiirh modiliiatioii oradditinri milk r-^uDot be taken without dia- 
Iptc^Jo reaults attempt should theu be made to gire it in tlie form of 
firtuJlT' digested or fermented milk^ such aa i^eptonized and paii<-reatui- 
tffd miJk, whey, kumyes, matzoon or zoolak. Many patients who cannot 
Vilenta milk in a natural state or modiSed in any of tbe ways mentioned 
i-iibletJitakeit in ^-ombiuatinn villi other Hiibftlaiues undi aa rii-f, wheat- 
roi, Ahreddcd wheat, cocoa, and fruit, Otherj» rau take it iu eouididerahle 
qouiitics if mixed with a small amount of tea or '^otFee. 

Water is a ^^fj necessary part of the diet of neuropaths, altbougb 
QofortanitAly it is not partaken of by the vast majority of people in fiuffi- 
viait quuititio>- Many peiAOna go fur weeks and months without taking 
«tcr excepting oa it is contained in their foixl and suchdrinka as tea and 
coffee^ This is especially true of women who, from fear of becoming fat 
or from laok of thii'st, due to insufficient dxerci^e, rarely take water in its 
Ditiml state. It is not improbable that this is ooe of the causes of COD- 
icpauoo cou^mon in womeu, and which physicians know to be reaponsi- 
Ue lor aiany of the minor ailments of women. Water should be taken 
inimillqnantitieaj not more than four lo a Ix ounces, at meal-timoa, and as 
fmJjas desired botweeu meals, unless there is a tendency toward obesity 
wbeat^ amount which the person can couBume must be curtailed^ unJese 
bear she ia williug to take aetive exercise. The raking of a glass of 
ntet Just before retiring, and immediately on arUiug, unless it ia the 
mtoiD to breakfast at once, should be eopotiragcd. Oftentimes the olka- 
liu vaiers may be uacd to better advantage than p\&m watera, particu- 
llriju they are taken with more relish and therefore in larger quantities. 
Thf carbonated waters should i>e used with eaution as thpy may induce 
flitd«nce and distention of the stoms^h attended with distressing symp- 
ttnL In special oonditiona, such aa the uiic-acid and rheumatic diathesifl, 
in tb« tf^Qtment of many diseosoe fiuf.'h as nouraigior ueurusthenio, and 
ubes, and m combating certain teudeociea auch as obesity and anemia, 
^imDeral waters are of much service. The mineral water that one 
d«U t> administer will depend entirely upon the condition tliat it is de- 
Uffd to orercomfl. In the uric-acid diathesis the Vichy water of France, 
niTdllaa the nativeandartiGcial Vichiea, areof ten of great service; while 
in the treatment of onxmia there are many chalybeate waters that are far 
note serviwable than the administration of an etiual amount of iron in 
ayotlter form. The great advantage that tlia waters have as a veliicle 



for a medicinal aubatAnce ia that thej etiondato the emuuctories of t\u 
body to renewed aetivityi ^hkh id itself is very beiie6<.nal, 

In regard to the pamc>ula.r value of tbe difTetent olasaes of loodatufb, 
the fflts and starches are the Tiit>at JQJ5>orUint aa lieat prCHlucerSf and th« 
proteid^ as fleali jirodurers and tissue builders. Itshuuld uot be targets 
tQD that the animal fats aud tbe aiiiinal probeids are mote eaaily digested 
than tlie vegetable fats and the vegetable proteidfl. An important feature 
of the vegetable foods^ liowever, is that Chey ooniaiu, besides the elemeatl 
tliat are eaaeutial as beat producers and flfsh producers, ininerBl utiLstilu- 
enta, b\\v\i as Aulphur^ phoephomsT BOtliuiu, poUusiuni, aud the like, which 
are essential to tho ec^>nomy, aiid a very large proportion of wator^ Tbc 
vegetables that gi'ov above the ground, peaa, beans, and Jetitile, and tbe 
edible fungi^ are the moat importrant substitutes for meat, Mushrfioms, | 
however, are not, as has frequently b<^ii asseited, a substitute for tneatJ 
and fihould not, be tlie principal part of the meaL In the email ainoual 
of ptoteid tli«y f^oataia they reserablo rather the fntita sai'h aa apples, i 
pears, pcaehos, tmd molouti, aud outidQ[|ueiitly eouaot take the plaice of b 
concentrated food. Fruits are pot very nutritiouSr butthey are importani 
noDFititneiita of the dietary because of the water aud the vegetable aeids 
that they ceabam, The latter buve u uiosL aalutaiy eSciit upon tbe ly&teu. 
uid in Bomo bjDmio diaea^ee are strictly curative. The laxative effects 
which luoflt fruita have is also advanta^eoue to nervous patieats- 

VVheiL determining the kinds of food and the amount which are Indi- 
cated in any special case, it should always be hept in mind that the aai- 
laal fiiods are the most nourishing and should i?onstitute a I'oiiapicuoua 
part of the diet of persouH who aie makine demauds upon their vital 
forces. This is especially true of amemic patients and those who are run 
down from overwork or exhausting eiperieooea. These subetances, in- 
eluding milk, egga, meat, liah^ gelatiu, and fats, fontain the nutriment in 
a L-uuE<eutmtei1 fonii Jind in approxiuiately the same ehemirjil combination 
BA the body. Moats, especially red n!eats, are fi-e^iueutly taken too often 
and in too lar^ quantities, especially by thosd who have the urio-acid or 
rheumatie dratheais. Jt is often atJvisable to limit their consumption to 
once a day, and to supply their place by ti^h, white meats, and vegetables 
rich in proteids. The best meata for the average nervous person are fowl, 
beef, mutton, aud pork, the latter preferably in the form of Ijacon, The 
remainder of the diet should ooasist largely of miik, vegetables, lUkd fata, 
the latter taken in the shape of olive oil and cream- Vegetable fats abould 
betaken, particularly by thin, anaemic pa. lents, inaa large ijuantitiee as can 
|je consumed without disturbing digestion^ If the digestive eapacities 
EU'e not much impaired, the animal fats should likewise be administered. 
Of the vegetables, those which are eoat'se aud gieen are of as{>ecial value, 
partieuiarly if a tendenry to conatipation eiists^ As to the matter of 
beverages and drinks^ cotTeef tea, and (?aeao, if taken in moderation, ara 



iwuUr huraltiss to the adull, but thcQr aboulJ oerer be giTen to chiLdroi 
of lie ueoropaUiic diatliesU. Neither should they be token vith aug&r 
bv tliQae who bare the uho-acid or fheumatic diathesis. AI«ohol m just 
umtich & focMl OS &ny of the substances compoaed of the elements, Tbe 
6ivbBU:;ks to it as a food are \list it coTitaics therse i^lem^nta in too great 
WMOtntioii, or wiLhout hulk as it were, and the great liahility to ite 
ocoKiTe use^ Neither of these conc-erns ua here. Alcohol aa an article 
<f dirt 13 best taken in tbe shape of light nines and unadiUterated 
vLiak^^ Comparatively few persons afTef middle lile <^aii take TaaLt 
l^ucn Adrajitageouslj. The numerous malt eTtracta now upon tbe 
muket, and reputed to be of great Bervti^e a» agencies of recoDstmutioii, 
ilcsffTe very little support from the physioian. They poasesa no peculiar 
^perties that can Lie utilized to advantage. If tbe pntieut has been in 
tba babit of nsing alcohol as a beverage or otherwt^ef he may be permitted 
tocODtinne its use in fitiict Jroderatioii, partimlarly if it assists digestion 
md pranM)tes aliaorptiun, ^ it not infrequently does. It will ofteu be 
bOMaaty, however, to insist that the patient reduce the amount of alcohol 
QBaaaMd, for, nuleas taken at iceal'tinie aad well diluted, it ie an easy 
mttr to overdo. When the disease hs.a aiiy causal relationship to aU 
Mbot, or when the phenomeDa of the disease eeem to be exaggerated by 

r||tikiag of alcohol, tlien alcohol should be absolutely interdicted. To 
^role there are few exceptiona. The oidy oite worth meutiouiug is the 
^icaUueut of delLrium tremens, iu which it \A aometimes necea^ai? to keep 
Epfpta time a degree of alcoholic stimxUation. 

The time when food should be taken :s an important matter for tbe 
ladtTidofll suffering from nervous disease to Gooaider. Although regu- 
Uhlyin eating is very desirable, surh a. |>er30Ti should take food wben- 
ercr there ia i^al inclination for it- Neurasthenics particularly ore often 
Deacfited both temporarily ond tiermanently by taking small quantities 
d as]ly digeated food vrhcn they ha^'o what they call sinking feehnga- 
Vbrtheror not food should be taken at bedtime depends upon the indi- 
ndfotand upon the internal between t}je evontng meal and tlie hour of 
ntinac&t. Most peraoca of tbe neuropatliic condtitution. as weH ae most 
iilsttn from nervous disease, are usually benefited by taking a small 
fualtty of some simple food, such as a glass of loilk and a biscuit, on 
Minng, porticulaply if more than two hours have elapsed since the last 
aaL Of quite as much imporULn<-e as the i|uantity and qu^tlity of tbe 
(acd in the treatment of some nervous diseases ia tbe method in which 
llistAken, Neuropathic peraona almost invariably eat loo rapidly. They 
oftta masticate sniHcicntly, but the sum total ia pat into the stomach iu 
uoitort a tirae. On the othei- hand, epileptics are notorions for bolting 
liwir food and for eating ravenously. The vipiouanesa of such custom 
QfiFii Koaicely be pointed out^ 

There axe few dietary fashions that are mire pernicious to the nen- 



ropath than the order of the modern dinner. Li^soally tboae Bubetac 
which a.i& cot digeat^d m the etomach, starches and bw^^Fs, are put in at 
the end of the dinner, oonstituting oft^ntiinea tiiure than tvo courwa. 
Thej are retained in the stomach for a protraited tint^T a]jd atsircbj 
formeatatiuD with ita ectailiiienb ia ttie Teaiilt It ia etiU the cuj^tom of 
many to eat fruit at the etid of a full incal and for the individuai with 
unimpaired digoatire capacity it may be quite iimtioiious. It majr^ how- 
ever, he kxiked upon aa an evidence c^f progreas iii civiliyatioii to b«^n, 
rather th&n euU the lueal with fruit. 

The question will alao arise^ Should food be given between ineala, and 
if eOj what kind and how much? Here the pliyflician must cxereist 
i?are and judgiuent. Aa a general rule the interval of time that ihould 
eltip^e Letweeii meals or before the further Jxigestion of any food ia 
three and a half huiirs. This, honever, will vary vith the kind and 
quantity of food. In lowstatea of the nerTDu>t eyatem It ia usually uecM- 
Bary to auppty the syetem with nourishment at frequent iatervaiit. It ib 
in thla matter that mauy phyau'ians are in error. Milh, the food moit 
generally given in aiich raaes, re<|uir<fl fully two hours for iia digestion 
and therefore must not be given at ahoiter intervala, or the farmation of 
probeoaa and of peptone wiU be withheld. Far preferable i» it to give 
a larger quantity at one tiiue, keeping always iu mind that the average 
capacity of the humau adult stomach is two litr^s^ ' 

Brief refi^retioe luuat be made to artificially prepared and coneentrated 
fooda^ Healthy mdividuala livlug uuder normal aud customary oondj- 
tions ehould ar^*id them. Tliere ia a tetidern'y at the present tirueto foed 
mankind with eubatan^ea of very slight bulk which may be taken without , 
expenditure of time or energy, From an ewjuomic staodpoinl this may 
be all right, hut I axn i-onviuoeJ that from a dietary standpoint it: la all 
wrciig. The various nut ttrnda arnl arlifirially treated cerealH whi<:h are 
now on tho iiiarket in great abuudauRi) fall far short of uit^eting the re- 
quiroEiaeiita of au adequate diet, even thoU|^h their capacity to produce en- , 
ergy and their conatitnente may be attested by ever no mn.ny i^hemvsls, 

Th» artitldally preparfd or partially digeaCped fomla shouTd never be 
taken by persons iii health, af such indulgence tends to create diaurder of 
the digestive and a.uimilative funotionfi, in the eame way as every func- 
tion bei^omea perverted when it lacks suitable initiation and Btimulatioo. 
Even during disease thi>y ehould not he used eontinuoiisly or, save in rare 
i&fitanoes, to the complete extdueion of other foods. As a rule, the pa- 
tient who can digest any of the diiTerent beef h.xtractai^an digest the juice 
expretiaed from raw or slightly cooked beef. It is a very common mistake 
in certain nerroua diseases associated with digefitive disorder to give too 
large n part of tho food in the form uf liquids and predigested prepaiB- 
tions. Th€ result ia to weaken the stomach and thus increase the du* 
ordar by giving that organ too little to do. 



Of iL&oftt if not quite as much importanrH as the kiutl (if food is 
itqufitity that c^jox bo taken witli advaiiUge. la f^w ut^rvoua diaeaaea 
■ ji DccTflsary to plaice rigid restrictioiia upon th« quoutity of food to be 
nfeen. S^ra chese u^araathenic^s, uarvous patieiita are litcely to eat far 
W tiuJe- C»u&l]y thdr digestive aiid asiiiiiLUative ciipaiities are im- 
pund- For this rea^son audi patieots roust he feil at frequent IntervaJs, 
ihuDtallof th^Di req airing food At least Gve times iu tbe tweotyfoui 

>'ot ui.{ri;qaeiitly the error is made of laying too much etreaa upon the 
diftof (it^r^oufi patients. Particularly is this true incases of neurasthenia 
imUDfaDied hj considerable mentnl deprenaiou, morbid feara, and aniie- 
ivt. Detailed attention to wliat ihey sh&li eat tends to author the DuDd 
VtLeir iniirmities and to exaggerate the importanre of them. In such 
nao, proTidLDg there bo no considerable disturbance of either stomaohio 
Bll£t«stinal digestion, recovery is facilitated by diverting the patient's 
ttind from contemplation of his symptoms, of which slight dyspepsia is 
fifEPD a conspicuous ooe; and this ran sunietinies be done more efBcacious- 
)j \ij letting the patient eat what he ^ilL providing th^tt he eats enough. 
ki has been said, the reflation of the diet Aril] di'pend largely upon 
tli« Ludindaal and the various factors which contribute to bis in^mlty. 
mee teaches that not the If'^^st important of these complieaUona is 
iflFect of the mind on the diETerent functions of the body, the digestive 
a|>ii3 not excepted. It is by no means nnoommon to see persons fiuf- 
bmtg from some comparatively slight nervous disorder attended by incon- 
■aquential disturbanoe of digestion, put upon such restricted diet that 
u t M«alt they undergo a prooesa of slov starvation, Tliis of itself 
ut^the greatest obstacle to re^^uvsry, while it auj^cnts the symptomSf 
erai apart from the morbid coni^tion of the mind wliiub is an itivariable 
actcnpudiQent. The thing to her kept in laind in t]io dietary tteatment 
d tier?ons diseaAes, as in the utdization of i^very kiud of treatiuent, is 
^i mterdependence of mind and h<idy; the wonderftil, inexplicable in- 
bare of the one upon the other. And the object should ba the simnl- 
tueoustteautieiit of botlj. 




PflToaoTUEitAPV owes ita poaitiQn of chief impoitanoe among the 
general therapeutic agea<^ii4s u\ the troatment of the di9ea!4i's of the ner- 
vous systejii to thendvanues of phjiiiologifial pay^chology, the exploilA^on 
of the pbcDomeua of hypnotism, aud the bettei- comprebenaioc on the 
part of the physioiiin of tlie influeuce which he b able to exert upon the 
miadfi of his patients, aud through that upon th«ir boiiiiy processes. A 
consistent treaties on tlie treatmeat of nervous disease nmat of neeesBity 
enter with eonje degree of falaess and detail upou a conaideration of 
tho^te iniluencea which affe<^t directly tlm patient^s mental condition and 
attitude. These psychical inflneQcea or stimuli may form a part either 
of the natural environment of the patten b or the artihoial enfiroiuaent 
prescribi'd by the physician. 

Muoh of the mystery surrounding the reitponse of the body to montat 
stimuli has been dune away with. Although we are far from being abls 
to give a aatiafactory scientific esplanatiuu o( the manner in which mental 
atiiaaJi exert through the cerebral cortex their effects upon the rest of the 
nervoua eyetem aud upon the eiUire body, yet these effects have beeu 
definitely aacerlaiiied and the phyaieian can now av-ail himself of such 
fitimuli with tlie oniifrdent eMpectatioii that the results which he desires 
and anticipates will be attained with some measure of fulQhueut, 

The mere afBtmntiou of the close reiationahip hetveen the bodj and 
the mind ia trite indecil. Every physician is well aware that disordered 
digestion, functional inactivity of the liver, or deticient eieretioo through 
any of tlie emunctoriee will produce states of mental drpressioti. He is 
even assured that aoiuu deSnite form of lueiitat ejuotion may accompany 
6peci£c bodily disorder, aa for example the euphoria in terminal flt^es of 
puLmouai-y tuberuuloats, the peeaiuiiiim attending even the early stages of 
diseaae of the liver, and the depressi^^a attending organic diseases of the 
intestine. The pbysiciun is in general suFQciently acquainted "with tbe 
influence of menial coiiditiona on lnjilily proresse^ whether or not these 
form part of the symptom complax of adiaease. Such are tUe disturbance 
and retardation of dlgi^stion produced by anxiety and fear; tbe secretion 
and voiding of large quantities of urine, and the occurrence of diarrhosa 
as tbe result of intense joyful or d&presaed emotions. 

That the significani^e of this reciproi-al interaction of Iwdy and mind 
ia far from being underato(»d and given the oousideration that it demands 



StheptftOtiftiDg pbyflidaii and ueurological Bpectaliet, is veil atteeted by 
ttvnr (ictS- Cue Uluatratiou will suffice to make ihis clear. It is cua- 
mtvyfor maii^ physiciajis to specie cC & paia or of oLiier ayuiptoma 
Ifbeiagfiouietiiiics " imaginary." Frequeutlj a "mental" paia ia spoken 

|( Gi it is referred to ui hjsterical. What the physician iuteuda to 
iqgeAt by the use of th«8o terms is tho absence of a discoverable cause of 
l^^ptoma. Aji hysterical patient maj have pa-in localized, sa}', in the 
liOoUer, whiuh is increased by ph^alcal exercise^ causing distress of body 
lad mind. StiU, it is absolutely dcuioat^brable tliut there is no organic 
Lir fiujctioDal conditions of the ehoulder to account for it. Siich pain is 
M :f4l as if it were the resultant of ordinary physical causes and should 
vfltus oar best efforts for its rebef- Tho inappropriate designation 
Mr frequently implies That there is also no physical basis vbatfiver 
wiTthei* in the body. The only purely imaginary symptom without 
f^i«in] basis is cue tbat a patient describes whca be is uob telling 
iht troth. If a patieut thinks bo has a symptom and describes it in 
nvh a Ttty that one iB com[>El|ed to betitive that be poaseescs it &q a 
nvstil oontent, there is at least in the processes of the cerebral cortex 
vmedefinita pbyaic&l basis and location. That ancb basis may not be 
hiown Dor its locaticm sssignahlo luatters not. It cau be accepted with- 
nit lay reservation whatsoever that tbere is no mental content, whether 
it beu idea, a tbought, reason, memory, sensation, or volition, without 
■n us^erijing physiological process connected with tho ccllutar entiCiee 
of the eortex of the cerebral hemisphere. The capacity to produ«i^ 
modificatioDS or symptoms elsewhere in the nervous 3yBtt!m or in even 
jmuM portionB cf tbo butly will depend entirely upon tho capacity of the 
|0ftiDa of the cerebral cortex involved to produce, through ita aoatomical 
ud }tliysiolo^cal connections moditicAtione in other assoutated tissues^ 

Eecccit physiological and payi?bologi[;at investigations tend to empha- 
■ua cbe unitary aspect of tho entire organism. That is to say, every 
MunJua, no matter what its point of origination, Gucb for example as a 
iouary stimulns directed to one of tho special aenso organa or applied 
itifhere to the surface of the body, or an intracorporeaL etimulus 
Ippliad to the vpinal cord or to any part of the cerebral cortex, will tend 
Q be deflec^ted or spread cut through the entire organism, as a wave dif- 
biei itself orertha surfane of water whert a Ktfiiie is dropiied into it. 
SamotiwueSr owing to ciiiser phyaiologioal or anatomical connections with 
t^ cerebral cortex, will bo more affccti^'d thiui others. Special inTCstiga- 
LoaalijQe can determine JKtst wh^it the direct channels of diffuse stimula- 
liooniaybe- Inasmuc^h as physiological process may modify structure, 
tatrther words, functional use and disuse may produce organic modifica- 
tiDQs, diere may be expecttnl t^ be peculiarly favoring conditions of ex- 
ataticm of the cerebral cortex that will effect not only physiological proc- 
*tHt in remote portions of the body, but determine as well permanent 



orgaiiio chaii^es. Tlie cortical cjtcitaiiou, no matter how it may he 
awakened, even though its moat deCaite maiiife station be only an idea or 
an emotiotkj may thersforo be as&dmed to be ciLpable of producing both 
fuDctioiial and organic disi^axe of tho iiorvous ajst^m, nod in l^as d^gred 
of all other tisfluea of thfl body. It i^ not my purpoae to g\v& ^ven a 
aummary of reaulta of recent inysBtigationa fiointing to tlie inBueued of 
mental conditions and their n^aociated rorticn] proceBSea upon functional 
and structural moditications throughout the organism. It io prop06ed 
merely to call to t&Lnd certain facta of almost common knowledge that 
will trdiriite the possibility tif snoh interrMatior. 

The moat common maiiifestatLon of menial inHuen<;e upon the body 
IB that vrhich is foiind to bo exetted ujiou the voluntary muscular Hystem. 
Liideedi eo common is this thnt ita BigniiicoiK'e ia often orc-rlooked. If it 
is wished to pmdui-'F the compleic c<o<ordi»Lit]ons npusssary iii picking up a 
fltoua nnd throwing it 8t a ninikf th» only practii^l wny of causing thU 
bodily ai^tLun is to point Ui the dtone and the lOiuk, and lo ti^Il tlie ]?erson 
what is desired of bim. A domiucn description/ though ib is not an ex- 
planation of tlie rt^eiult, ia that the snbjei^t wills the action wliich he per- 
forma. The act of willing a voliiiun takes pLi^e only under certain 
dettnite conditionH, He muqt Bee the Btone and the murk snd bnar th* 
wonls; tildt is, the sensory Htiniuli must act upon bis cerebral cortex and 
there awaken procesaos which gi'vo riso to certain dfiBnite ideas- OuQ of 
the most important ideas involred in the proceaa of voliuon ia the idea 
of the movement or tliekma'sthptio memoiy idea of the contraction of the 
muacles- Voliiionseenisto rasolvoitaelf primarily in(*ian a*^tof eiolnaive 
attention; that is to eay^ an t^xdnsiva co n scion sness of the idea of th« 
movement to bo |H*rfornied or of sfiiiio iih-a closely a:s»i>riati"d with it. 
When th** idcu of the movement is presented vividly m cunHi*iousuess to 
tha exclusion of other ideas i\i\ii nmy be contradmtory to or inhibitory of 
it, the movement will of iiei'*?ssity follow. This kind of noliviCy hiu 
liHpn <ialled ideii-moLor af.tioti, a term tliat I'mphasires the essential, in- 
stantaneoiLB, and almost aulomatio eequonce of the moTement thought of 
npon the idea of tho movctacnt. If the idea of the movemeht eaa be iji- 
tenaified, or if eoiitradjctopy and inhibitory movemenia ean be excluded 
to a greater degree than normal, a movement of more eousiderablo inten- 
sity nmy resntt. This is well shown wbi-n we give jl inan a dynamometer 
aad nsk him to squei^^e it as hard as pos.^iUe, and then follow with cer- 
tain encouraging worda whi^h causa the serinid trial to lie considerably 
more effective than the ficftt. Different persons will bo acted upon by 
the same Btimidus in different ways. A eotirf^e of great danger, snob as 
a fire^ may hriiig onl powers of motor activity in one man, and reduce 
anotlier to a state of hopeless inefliciericy. All training, whether it Ite 
for physical effort aa in a footrane, or for intelleetual effort aa in a 
atmgjj-le for professional eiiatenoe, will reaolve itself into a strife for 



Bplvtii uo«nd9ULOT of itleas Httest to |>rt>tuG« activities over others tliat 
■ Lttil^tarid perhaps negatikrjr. The comjilejter co-ordinationa of the 
■pLU] heihQ can be brought about onlj by thia idecruiotor activitj cf 
la consciousness. For that rea«oa their mantfeatation iu coDnectioii 
Hh %ny orgftniam ta tAken to indiG^te tho presence of otrme conactouaDeas. 
^G^er electrical etimulaticjn cf muaolea, nervee, or brain contrea, nor 
■tkolo^oal eTCitation of the cortex, is capabla cf producing the per- 
ptonl and complex co-ordi nation a of every -day life. 

That this influence of ideaa upoa tlie uiusclea la not merely tie inaui- 
ftftttaoQof soma myatetioua power uf rolitJoa, is evidenced by the fact 
liaL It eit«Ld» tilso to the mvolmitary inus«uiar oystem. A dangerous 
abjrtt aroosmg fear, or even a. thought avrak^nuig the emotion of fear, 
ci^nufe re1:t:EatioD of the apbinctera. It will proJure disturbance of 
Tipiffttion aud modify the heart'baal. Aa rdea of some nauseating anb- 
£ifiCe vill fltimulate invohuitary <^L>Dtractions of tha muselea of the 
lollet tnd diaphragm and may ev^a lead to the act of voiaitiog itself- 
TU Tificxdap gyatem ehowa Jts ail^ctability by UiG bluah of shame, the 
irjihof in^er, and the p^dlor of fright- The Hocretory system responds 
iliia watering; of the mouth uu the tljuuglit of a aavory tidbit, with the 
frafaae perspiration that atteuda the realization of great danger, or with 

^r-static and seminal secretions that follow natural sexual stimula- 
of ev^n laactvioua thoughts, 

Tfiereadme^sof bodily action B to follow upon mental oonditiona varies 
(TOth in difTert-ut subj»*cts. Tii all Mime mt-sisure of response lo these 
mrntil mcitements will be manifeat, aitd in many the reaction mar bo 
AmsdenUj e?LA^gerated by an appropriate conjuDCtion of circumstancea. 
Iboie kida to tho exaggeration of the nornml response of pcripherul proe- 
tts to vuch meut^ stimulation have been rather crudely Hiuotnamed 
undt^rtbe caption of Suggestion. It ia well to diatlugnishthe intentioual 
ar aifiilPaUl employment of stimulating thoughts, senBatiuiiai and emo- 
tumy from thd ^mplantfhtion in the muid c>f the patient of some definite 
Of indefinite idea which it ia expected will be followed by remedial r^ou' 
iiqiiftciws directly relatingto the idea thus implaated. Acheery bedsidd 
HDitteraoonsisteEit position of Htal wait encouragement may act directly 
upua tJie patient to develop a nifntat well-Mng ?hich of ilaelf Las a 
huefieial effect upon the physical organism. It ia not the cheerfalneas 
'■hih tlie es^ntial factor, for its place may be taJten by auGterity, by 
ftWtlncity, by systematic brow-beating» and these are sometimes em- 
fiffftd purposely or naturally by the physician as a part of the 'Mjad- 
ude" manner The natural or asanmed manner of the jihysician may thus 
uoitse m the patient feelings and ideas whuh we have shown to be capa- 
ble 4>F bringing about changea in the different aystetna of the body, par- 
tienliily the vegetative syatem, that contribute to the restoration of the 
•qntlihriBm of nutrition. The mere presence and manner of the physi- 



cian dy iiot a«t <>tljorwiso tlian would otlier fficiora prediaposicg the pa- 
tient iQ favoring jDental attitudes. Other otiuiLU; gf iho enviroiuaoDt 
act in tJto aftjiie vay and may be oflt^utimeB profitably employed. Thus, 
muaio or devotion to any art, j^liy^ical c^KHrcise^ mental work, pTPoooitpa- 
titm ill a. {nvtitMe kve affa-ir, may all nliki) couditpiou reute<Ei]d abitea of 
Donsciousuefis, The physioiaii ebould aot DonBtder btoiaelf above u»iiig 
theso uormal aidn to the reatoraticii of healtb. If they bave no other in- 
tliieaoe u\Kia the patient, they at least dtvert hitii from iiitroapectioa and 
poaslble hypoclioudna. 

Upon the other band, the phyi^jciaii's l^earing and worda may giTe 
the patie[iC a duett euggeatioa in tlia d]iei:tioii of physical well-bein^. 
Thia auggeatioEL ntny bd either a general one, as when ha inspirea the 
patient with oonhdentTe in hia ability and with the thought of speadj 
cyiTt*j or it may be speoifit', ay when he gives atimulating connaal^ de&nitalj 
related to the anieliontion of particular aymptoiua and atitrdy perntatent 
etR'ouragRmeiit bai^t^d on exhaustive phyaiual «\a:ui nation a ai^d conaiateni 
reasoning. Tbe employmeut of spe<iilic euggeatiou is mure frequently 
called fur in nervous diaeaaeaf pEvticularly in neurafltlieuia, byateria, and 
"haliit difieasea," than in the treatment of ether diaeaaeg. 

In luany functional diseases, such aa nt-tu-asth^iiia and hysteria, it u 
often neueaaary to make tbe au^geationa in a very forcible vay ; the patient 
may Lre informed that ho will show marked eigne of iin provfiment within 
a certain numbf^r of days, or he may bo threatened that if he doea not ini- 
}irove he will be sent away or placed hi tbe hospital, (.-aaualsuggeationg 
are often more effai^tive than bitenlioual ones. An Apparently unstudied 
remark to tha niirae or a byatander that tlie patient ahowa aigns of im- 
proveuietit vrill often bi i:ig about a desired betteriug of tbe patient's con- 
ditiou, or tiie patient may bo ]jermitled to overbtai a (conversation ad- 
dressed to laeinbera of the family. The physLciau may have tn indulge 
or cajole, lie may need to threateo or to promiao^ and al] of these agenciaa, 
although thfiy may h^ue little elTe<'t upon tlu^ patient's diaeoae, will yet at 
Least cauae hijii to take tlie preacTiljed dmga regulaily, to submit to physi- 
cal treatmantf or to follow a strict regimen in diet. 

The aume methoda will not ba offeoti^'e with all persona. It is often 
more neoeaaary to treat the patient than to treat tbe diseaae. To be all 
thinga to all men ia aa much demanded of tlie phyaician aa it ix of the 
cociuette tbir sting for extensive conquest. It \rill l^e necessary and de- 
sirable to take into consideration the patient^a temperament, hia manuer 
of life, hia culture, bis social scale, his personal and family history, h\i 
specifie beliefs, bis Hkea and dislikes. If he is religious, prayer may 
help; if supeistltious, a horse chestnut, on image of a saint, an amulet, 
or any fetich. Eaeh phyeii'iau will have to judge for himself lijw far bw 
ia willing to come down to the belief and principles of these whom ho ia 
treating. lb will be fortunate for both him and hia putient if the latter 


Biatbaitft of all credence and sLisceijUbility to readj acceptation of wha^t 
■EtIMed ^nth ait nir of autUority aitd conviction- The must recjdcitrant 
itff«r«r from Ekerroaa disorder is tbe patient wbo lias loat bia cfcildlika 
iijib ia the teligioiia beliela of hia father, and who has Jed a worJdJj life 
m vhich amhition and mdividaal forr^e of character have superseded 
pnmiLie iatuitional moral prmuiples and bland aDceptanca oE social 
idol^ karing I im without conHdence in auj person or any action^ 

It most ever be borne in mind that it is one thing to cure a patteot 
t&d another to faara him atay eured. Auto-suggestioa is exceedingly 
cfleotiTd in producing dii^ease but seTdom works its curf . Through auto- 
flmitinin th« ntfuraatlieuLc or li^ Bt^ric ahowa a woelul tendency to bac-k- 
liii» ialo his previous conditioc, Maay of Hit cures of one physician 
pMoref into the hands of others "with all the work lo be done over again, 
bat tbft able firat physician keenly reoogciata that it 13 not alone his dnty 
tBCTue a patient Imt to leave him better able t(j be vAired again. Sug- 
frmns arft thus particularly effective when they are new. This applies 
UfLlLho«6ftgeDCies that depend in part or entirely upon siLggeation, 

General and speci£e au^gesti^ma are not limited in their applicability 
Utd QMfuZnesa to th& functional diaeasea of thd nervoua system aJone. 
VtfE^Ls Buffering from organic dtaeasa often shoiv mark«d improvement 
Mtha result «if advice which can have uo dire^.t physical in6iiei«ce oit tbe 
mMj itAelf. The general prai^titioner andncmvtogiat can meet no caae 
n which they are cot required to lake a position that looka BinRly to 
l^p«tieQt*a happijiesa arid comfort. It is for the physician to infuse 
lopAintebiB patient, promise help, and call attention to the favorable 
n^vhirh tha latter in his despair often fails to see. Even in IneuraMa 
diMMHB, it is very seldom tha physician's dtity in tbe premisea to iii^ 
famtbe patient of the abaolLite hopeleBSncsa of hia disease. It maj be 
Vtssffing to the phyaician^s despondent frame of mind to say that the 
BOtlmoie and orthodox treatment of the organic cervous diseases is 
cfia VOTB0 than useless. It may be a triumph of conciseness a]]d f rank- 
DBS to terminate a di»i?arsive consideration of disseminated insular acle- 
nnaorof Friedieich^a disease with the words "all treatment is useless," 
Balthe endeavor to force either of these states of mind U]>on tbe victim 
«f larh diseaao will lesult in more serious consequences than a reduction 
aitia physician's clientele. Ethical obligatioua compel the physician to 
pnJoof hiB patient*a life and Ut keep biin fi'om suffBriug. To gain these 
ends tlie diaoascs of tlio nervous system which are generally considered 
lUOEirable most be treated as carefully and persistently aa if there were 
Itttnubte ehajice o£ overcoming Uiern. This, it seems to nic, ia a fun- 
duBOital principle in the treatment of nervous diseases and one which 
BOft b« admitted by all who aspire to bBCome aiircessful therapists. 
When the surgeon encounters a wellnigh hopeless oporatiou hft does not 
forthwith forego all treatraent and suggest that the patient only etand 



and await death. No umto ehoald the neurolugist in tlio pTcaetii-o of a 
caa« of bulbar parblj-sifl npure sjxy etfort m utilisLlng meaauree tliat liave 
been Hhown to ba of avpn the slightflst lianellt or in ex jvn rim tenting with 
eubstojicea IhdL may possibly be fouad useful, dometimea it may he 
neoesj^aiy to tell the patiect tbab liia disease is inciirablsi but tliia should 
be followed by the asaurance that it mny not luateriallj aborteu hiB life. 
It is, of coursflj very d^uj^eroua to D.Uvise that & phyaiciaa etep beyond tbe 
bounds of truth in thd atat&menU that bo luak.^ to bis patients. If bft 
continually iafoniisbis patient that liia disease \s not & serious one s.nd 
tbAtheia making rapid improveujent, it will lessen tbe patient* s confidence 
in bim> It ia therefore often better to be frank with the patient, and in- 
form him that biscomplniut is really serious. It ia tha appearance of 
franknG^s that is more demajided than ita actuality, and it should be the 
physioian'a tjrst aim to gain tha entire conljdence and implicit obedience 
of the patienL It is for these raasnna that phynieal measoreti are often to 
be recommended, even when they can have but little thorflpontic value. 
Tbcj strcugtben tbe patiently faith in bis physician and they constitute a 
material basis upon which the physician cEin build bis ALiggcstiona. For 
a aim liar reason, frequent exam in Jit ion of tha blood and urine may provide 
eviiienct^a of ifrjproverlmetaboli^imarjd be comforting to tbe patient> The 
mental effect of tbe physical agent upon the patieut 13 ample warrant for 
faith in euch the rtipeu tics. This is i^ot intended to imply that all drugs 
and phyeicaL lueasurea have tliQ aame tbotapeutic value. It is incumbent 
upon tha physi<<iftu to be aa akilled and discrimitinting iu the employment 
of tho pbysii-al ageiils as he is tai^tfid in developing n healthful mantal 
tone aud lu.Mpunai veneris to treatment. lie may learn tbat he obtains 
many successes from drugs that are useless. A rabbit^s foot and a livelj 
faith in ita healing properties are more efficacious than medioamenta that 
are often reoomuiend^Hl even to-cUy, 

Tbe history of therajieutirg teaches na that many druga have been em- 
ployed with large measvjre of sm^cess, whose activity baa been ascribed 
to properties which they have eubseqnently been fuund not to possess. 
It is not necessary for us to deny to sympathetic cures, to botneopathy, 
osteopathy, to faith cureSi Christian Scieuuej to magnetism and met^- 
iBoij all posBihilitiea of success. When such an authority as Moebius 
aagerta that four-liftba of all electrical cures have been effeoted in cases 
irbereiu e!<?ctricity coLdd nut have been of the slightest avail, it may be 
Been tbat the mental factor has a large scope for its influence. Certain 
phyaioal agents, moreover, aueh fis warm and cold baths, have a direct 
influence in Htimiilating the will. The self-respecting physician will 
bave much hesitancy in Jookmg with any favor upon methods which 
Beem in hia mind to be asr^ociabed only with fakedom aud <^itackery ; but 
it reats upon him, to distinguish tbe mental factor from the physical 
agenaies in the measurea to whi?h he has recourse. He must develop 


w fci e at ability and knowledge to distiugvish between tlic lemtrdul 
AMgh m£ge9fc;Td vaiae of drugs and other pbjeical meaaurea, Aud tht; 
kftkw credulity iuTolved in euch pro<^edare3 as mind «ur«fl through 
thMgfat trvi^ferecce, or tba telepathic octioa of drugs. 

HrpoEftiiiiL — T have already called iitl«ntioii to tli« fai:t that momenis 
d ET^t kitMOD luaj lift tho iudiyidual to a stage of euperuormalitj, or at 
Imt^onoaiity- States of ezzdtedemolion, auchforoxaiDpIe as those ao 
itn x^Ifttcd in tha historj of martyrs and aainta, and even of r&Ugtouiata 
lioifo uor« apt to ba caUed cranks A.t the present day, show those fiub- 
jpOai to Uietu to be posses^^ed of sujieriioruial rapaUilitif^s, unusual €od' 
ffd pier Uxlily prEK^easea, and great fiuace^tibilit/ tu auggei^tiou. Hjp- 
Doni a a ^t^to of exalted euggeatibiiity, capable of artiticial production m 
tlsoi^tAlI |>ef2uus in which the subject affected is more than c^rdinarily 
sKfpCiblfttO the ccattol aud stimulation of the oue ^vho baa thrown him 
iBia tbe h jpnotio state. There ia do more mysteriou^nesa about it than 
ibne 15 about uther modes of beneticent intlueaua that every physician 
act 10 daily practice and which hare previously been discussed. It is 
hcC tuy mtentioQ to describe tbe methods of faypuotiam nor the details 
dl^ephencmenaappv^ingin the state of hypnosis. 8uffij;:eit to say that 
Ijjiioaia is a sle^p-Jike couditiou in whu-h certain parts of tlie brain seeiu 
tobetbronn out of fuuctioQ. This is particularly true o£ the aflsocia- 
titt^i] labihittons ttiat pUy such an important part m every consciousness 
n th« noraial atat«. The mind is thus bereft of many of its acquired 
fc«stfa:oa9, aud attentioo is focus^ed to a limited number of processes. 
Tht degree to which hypnosia can be produced differs greatly in different 
fuvtna. Some can ba thrown only Into light somnambulism, but even 
lloBUiof aasistanoe tonerroua patieuts, a« it puts the subject into a state 
afcatfflsubmianTenesa and strict attention. The deeper stages of leth- 
ttgy ind catalepsy ore difficult of production &ud of little or no then- 
piutiis Tslue when produced. Unfortunately, those pattenta who not 
iBtejiCiMe to ordinary suggestion arfl generally refrat*tory under hyp- 
HfEifi iodueute, altliough a very nnsuggestible person may sometimes 
be thrown into deep hypnosis by mechanical meaaii The moral ef- 
tKlTcli be to make him more subservient to the wishes of the phy- 
Bfhh, and apeeifie suggestions will sometimes then be effective- In gen- 
*nl, profonnd hypnotic suscpplibility is ari inLiication of the neuropathic 
^uifatois. It is impur^sible to give de£^nite rules as to when hypnotism 
kippUc&Uo and when it may be seryiceahly employed. This must be left 
tatbf divcretion of the physician, who will need to measure his own powers 
Bid to «Otuider the character of his patients 8omd ph3-sicians wilt per* 
lu^ never need lo have recourse to hypnotism; others will employ it 
tith a fair measure of success. Tn general, hypuotism should not be re- 
nrtedto unless the indicatioca are that suggestions in the normal state, 
nnbiDod with adequate physical measures, will be totally inetfeotiTe. 




Hypnotiam baa been employed suoceaefully, if «e may give ' 
Teportfl, Id the treatment of youthful perversity, mental and znoi 
certain partial fonne of mental maladies, bucIi as fiiced ideas, ai 
dominating habits, hypochondria and indecision, what may 
present be termed hypnotic suggestion is often usafuL Alct 
morphinism, insomnia, and aeJtual perretHion have also been ai 
to this mode of treatment. Hysteria and paraJytio manifestatioi 
such as hysterical aphonia, cramps of the involuntary muscles, hj 
anorexia, stammering, and hysterical disturbances of sensibilit 
oooasionally to hypnotic suggestion. In mental disorders in the 
sense, in epilepsy, chorea^ and paralysis agitans, the function of suj 
is to produce emotional calm, and in this manner it may be of s 
even in o^anic diseases such as tabes and multiple sclerosis. Ir 
hypnotism as a therapeutic entity has a very insignificant poaitiot 
therapeutic measures of considerable value and wide appHoatioii. 





WpEN the unqu^fied term meaingitls is used, infiammation of the 
pa, or Ifptomeniiigitds, is unrTersUJOi]. The Uura may al8i:> Ije the seat of 
inflaiumatioa, ftJthoagh on account t>f its predoniiiiautly £broua struature 
afid iui^ificaikt r&sculanty it is much less liable to auch diabase than the 
ytM. Jnflammatioii of the dura ia kt;owit as pschynieningitiB. 

Lkitomkn' inu-iti a. 

Lcptomenisgitia is aubdirided into; 1. lafectioua or true mecingitia ; 
iLC'I. psr^ ado- meningitis or meningitis serosa- 

M«tLoua meningitia may be tlie result of different bacteria, but the 
rvt majority of c^aes are dtie to one of the four following: the pneu- 
(HCMous^ th« stapti^lix'oi'Ciis, the diplooocuMs iDtnu-tflliilarii^, and the 
bidJluH tubprculosia. Very rarely ia it due to streptococci, gonot-occi, 
tfc*f«i!oii bwilloa, ot the bacilli of itiflneii^a and eryaipelaa. The patho- 
It^-Kra] i>roilupt of memngitifl excited by one cr other of theae organismB, 
i more or less variable, but it always coittains [)ii3 in greater or leaser 
IBntJtiffi. The ruexiBtiDg BeruuSj filirinoua, and suniuus cxutlate will 
dtfcnd luf ely u[ian ttie mitrrobic nature aud intensity of the infection, 

Etiologically and clinicaUyi three diatinct Tatieties of true infef^ions 
nKiiQgitis may be couBidered. These are; 1* Ordinary purulent monin- 
pEit dae to infection by either the pnenmeeoce oa or the etaphyloooceue^ 
tftaooe of the leas common bacteria above mentioned; 2- Meningitia 
liiietolhe dijilococcus iDtracellulariB, and known nliiiically aa Fipldemie 
tVtbrupinal meningitis^ or cerebrospinal ferer, and 3, Meningitis due 
tothebBcillns t'lbcTculoais, aud knovn aa tuberoiiloua meningitis. The 
ftiOlogy and treatmerit of eaah of these conditioDa will be consider^ 

Srm-infectious metiingitis, meningitis serttsa, or pneudo-meningitia is 
1 lixopsical ooDditkOD of ttie pia» which urcura under two rather diatinet 
■MpiceBn Iq chronic alcoholics, in which it constitutes the condition 



knavD ftfl wet braii:; and in infftota and adulta «s itn exprwieion of a 
diatheBifl, nuth an rliochitia and other depraved etatea, and after iojur}'. 

LLke evf^ry other disesise of the seroua me nib runes, leptomeningitis 
may pa^a into a more or leas chronic condition, but this is alw^iys ser- 
oudary tu an aoute pro^^eaa, uulefiS the change in the meninges bo & dt:- 
geoeratis'a one. Tho typical form of L-hronio lepbomeningitia is the 7&ri- 
etj dno to syphilid. Jt la somewhat qneationable whether thia form of 
meningitia ahuuld be daaaitied among tha inHammatory varieties. It Ia 
not a tnm in£ammatit>n^ iinleBs one admitH that the o'(Tvin'eiice uf HKuda< 
tion coiintitiites indammation, Sypjiilitio infection may produce diaewo 
of the ineningoB in two wa^e— drat, hy causing a degeneration of the pia, 
ths morbid conditionfi being mediated through the vascular eupply; and 
second, by inttuencing the pia so that it becomes prone to the a<*tion of 
th* faciorfl whu»h cause tnie inHammation. 

Etioio^. — -The causatiuu of meuin^tia may be couKidered under two 
heads; 1. The conditions which precede the attack with mich frequency 
that tbcy may be propody consideNid predisposing cauaesj and '2. The 
exciting oauaes. Ab the latter are now known to b« certain variotiea of 
bacteria, mere enumeration of them is snfflrient, but somewhat: eTtendfid 
oouflideration of Ibe predibjxiaijig causes seems necessary. 

The prediapotiing causes are A variable quantity iu each caaa- 

Leptomeningitia is more common in early adult life than at either ex- 
treme, despite the fact that there is art iofectioua meningitis of the new- 
born. It ooours more often in males than iu females, the predileotion of 
the former being clue t*J tln^irgrejiter liability t« einfiHses and e5|>erienoftSj 
AUL'h a^ alcohol and injurit-H, vrliich ai'e t'oulributory factors lo the dia- 
ease* TiOptouioningitis is moro common iu eveiy form, so-called idio- 
pathic^ sporadic, or epidemic, in the spnng and wmter, not aloue beoause 
of certain oJimatip couditions which eiciflt at thesa times that are favor- 
able to bacterial development, but because the Infectious diseasea occur 
more comEuuiily during theece Beasous^ Of the habits^ bj which mankind 
ia addicted^ the moat potent in producing meningitis in esceBsire indnl' 
gence in alcohob This ia easily understood when it is keyit in mind that 
a disordered eundition o£ the circulatioa of the brain and pia is a physio- 
logical effect of aloohoL 

All the conditions that predisiiose to ai-ute itifiammatory dtseaaot, 
aach fts exposure to wet and f^oM, particularly if the ritali^ of the pa^ 
tient is in a lowered state from overwork; worry and anxiety^ prerioiu 
disease^ prolonged and exhauating applioaCion of the mind; exposure tn 
extremes of temperature or to the direct rays of the suOj atrntiBpherea 
that are noxious and enervating ; slight and repeated injury of the head ; 
jmd the coejdstenc^e uf l)odi1y disease predi^poHe tf> m^'ningjttH, Borne 
Waiters believe that neuropathic constitution preclispuses to meningitis, 
but it does not seem to the writer that there are adequate reasons for 



«dL ft Ti«w. in a certain number of ca^a of mecic^itis, the moat diU- 
fEBfiseftrcii CalLa to reveal any causation save trauma^ which may have 
\tm to iBBigiiifieant thatone ia louth to attach serious import to it^ The 
nutia acte, in all probalnlity, in bo depreciating the vitality or resist- 
mMof tke meninge-s that the actively exciting cause via.y berjjiiie oper&- 
izn. A mueli larger uiimher of caaes, but still small irLeu nompated 
ritfa ihe outiro ^roup, are those that follow severe iajory to the head, in- 
jsry that not only wounia the epicranial coveringB but the alcull as wgU, 
Jlnif^itifi developing aft^r a «nrgical operation is, in these days of 
vrptic aiirg^ry, couijiaratively rare. Tlie wounila that are most apt to 
heojme <:oaiplicateil with JueaiDgitla aro the penetrating aiid cruahing 
Tcnm^^ the tirst because thef clear the vay to the meningea, and this 
JltUitatafi the work of infet-tiou earriei^; SDil, sefoud, because of the re- 
figtttie« that they oftet to cleanliaess. Penetrating wounds of the eye- 
bdlf TiLh or without cyditiSf are very ]iroiie to excite nieiiingitlfi. 

OiMof the TDfBt iiDportaiit fac^tpors in the cauaation of infectious men' 
iiigtla« is the exteosion of inflammation f rum pjo^nio diaeaso of adjacent 
imtnrea and cavitiee, such oa the mastoid process and middle ear, the 
ttittiaof iheDOse&nd antrum of Highmore, tha sphenoidal and ethmoidal 
umsn, and the sinuses of the frontal liCTie, the o&iU of the ethmoid an6 
die sphenoidal fossa, septic diaeaae of tha orbit or its oontectH, cranial 
nttaDfdttiSt and oeptiG difieaaes of the epicraniiim aEid surrounding aoft 
liinM^ Of the latter may be meutioued in the ordcrr of their impor- 
Qace^ erysipelatous infiammation of the deeply seated structures at the 
Jnciionof tbejaws, tbeskuU and the neclc; anthrax, carbuncle, furuncle, 
tnppontiTe parotiditis, septic tonatllitis, angina Lmlovici, and, in short, 
til condJtioas ejtcited in the soft or hard parta by speci^c bacteria. Of 
tiw csisea included in the second category, those attributable to the 
tuatoid processes and middle ear are most important, A purulent otitis 
ludia that has existed without special symptoms, with periods of ejcaeet- 
bvknand aii}>ftrent intermission for many years, may suddenly^ under 
raie unacouun table iuQuence, light up an attack of meningitis, with or 
Tithont septic einuB thrombosis. On the other hand, meningitis may 
follav burrowing of the purulent matter which leads to rupture of the 
tognun tympflni, in connection with or supplementary to extradural 
ihMA. Leptompningitis may follow operation on the middle ear, such 
u fat the retnoval of poljjn from the tyrnpanio cavity, especially if the 
maanX be attempted through the eitemal ear, for it is next to impossi- 
Id* to render the tympanic cavity and antrum completely aseptic, even 
vbm they are approached from behind the ear. It may be secondary to 
pholpRteatomfttous ntiddle-ear disease, Next in causative importance to 
di»aj*e of thft middle ear and to pyogenic proceaa in the petrous portion, 
come mastoiditis, fnruncle and carbunclej and diaeaeca of the external 



Leplomeoiiigitia may rsaulL iliriwtly from phlegmoaouB iiLfl^rumatioD 
of the nose, tho vftms of the uaaal cavity- beuig the pathway of mfDctioo. 
AS they ate in thoao cases in wliich meningitis follows operation on the 
D096 for the removal of polypi and for the cure of hypertrophic rhinitis. 
When ineningitis foUowa punilect disease of the ethmoid ceUs, the infec- 
tion CKHiLirs through the laniJna cnbrosrL Infection of the spheiioiilut 
losea is most oft&n complicated by thrombosis of the caveriit>us ainus. 
Next in frequency la a baaal meningitis which eventually extends to the 
convexity. In theee c^aes it ie prohable that the infection eometimea 
tnke^ place in the bone dlplo^. Furaleot disease of the frontal fiinusea 
predisposes to brain absceBs more than to meningitis- In fact, tTie latt^er 
is a» extremely rare com plication. 

The existence of the iiifectiotia diseases predispoaoa to the occurrence 
of merungitis, inasmuch astbe bacterial causes of this disease ha<^eGeoured 
& foothold and base of protluctioti aiid operation in the syatem- The most 
important of fheye distaeps are pneumonia, typhoid fever, cholera, dysen- 
teiy, iiillutiiiza, malaria, gonoiThij^a, and fieptica^mia. Meningiti.f occurs 
sequenbially to acarlatiua, to meaalea, to variola, and varicella, but in 
these ciBes it is probaUle that the ujeoingitifl is preceded by purulent 
middle-ear disease, the direct eoneeqnenoe of infection, or that the disease 
was associated with pneumonia- 

By far the njoat iiiiportaitt infeotiouB agency in the prodaction of 
purulecib meuiugitla ie tlm bacterium known as the pneumococcus. Latter 
years havo showa that this diplocof^cus is quite as autivo in the causation 
of mcaia^tis as in the causation of pneittuonia, so that it has been pro- 
posed to call it the meningococcus. A& it is not the only bacterium that 
causes pneumonia, so it is not the only one that eauaes inenlngitis, Tt U 
merely tha most coiumon one- As we become more fariLiliar w^ith this 
diplococcuH, we recognize hon widt^ly distributed throui£bout the body 
it ofton is. Ill the majority of cases the noi^e and mouth are probably 
the avcnuea of entrance for these eooci in the production of meningitis. 
The next most frequent are the maxillazy and tympanic cavities and 
the crihriforTn latiyrinth, on aeoonnt of their vas^'iilar and lymphai^lc 
intrarrouial communications. It is bai^ely possible tliat when pneumonia 
exists the cocci may pass from the lunga through tlio loose connective 
tissue of the modiaatmum, between the n^sopliagns, the cervKal vertebr^E, 
trachea and carotid, ajid so to the pia, Meniogitis duo to this bacterium 
occurs ranch more frequently independent of pneumonia than 9S a com- 
plication of this disease. Naturally, it often o<rura coiiicidently with or 
follows diplococc^uB pneuniOJiia* In pneumonia, as w^ll as in every other 
diHoaae due to this diplococcus, the cocci are widely distributed through- 
out the body, and it depends upon the reeiatance of individual parts that 
are known to be prone to infeetion whether or not they will escape. 

The capacity of the bacrlllua of T^^lierth to cause meningitis is generally 



but the association of meningitis with typhoid fever ia«xtrem«ty 
lUn. The I'olon bax^illus is likewiaa the actively eici ting agency 

A study of the mortuarj lists of the gre&t oi^ea in this country during 
tfter thvepidemicjof lutluenza which prevailed here in 1S91 and sinG« 
ijiowfl n marked iocreese at this time in the number of deaths al- 
to tneningitis; and it ia not unjustifiable tit presuuie that the 
sdlus of luiiueiiTA is capable of eiccrurig luetEingeal iiifiajjiuiaUon. 
LeplomeoiagiUs of a purulent nature may be due to the gonococcaa, 
ttd a Dumber of coses have be«u recorded in which this aeemwi to be the 
cKltiDg onse. 

la addition to all these there are cases at iiieningitis tbat areproduoed 
streptwxx^ri and Btaphylococti. JuAt as in a certain number of caaes 
|iOfitanonia the only organisms to be found are the two juat mentioned, 
lit is in If ptom^ningltis. It is bj tbe direct ai'tioci of these cocci that 
leumgitis ansea in such conditions as nleei-ative endocarditis and 
OLfoervl leptic conditions, such Bs puerperal aeptic^miaj and often in 
spptic coadii.ions, surh tm purulent, otitis media. 
In meningitis of the new-bcm, which is now happily & rare condition, 
Knott of iufectioa is usually through the umbilicus, although cUier 
itoufiB cannot be denied. It must be recognized that genuine meningi- 
CillDty OMruT in tbe very young infant fnuu alnmst any of the difFerent 
ctUKi t^iat we have enumerated. 

Hioh^y of Epidemic Cerebrospinal Heningiti&^This form of njenln' 
^tifl hu been <iju5iiiered in the past, aiid is yet by some, to be a disease 
ipart from acute leptomeningitis^ in oo mitoh as it is caused by a specific 
and has aclinie-al history and course which are rather dislino- 
But if tt-e were to consider all the forms of meniugitia Eeparately 
of their individual bacterial cauai^s, it A^onld be an etioniious acid 
'ICSB(Thatpro£Uess task.. Tbe real cause of epideniio cerebrospinal men- 
mgiua is the diplucoccus iutraeellularis, which was originally described 
hj Weichsel bania in l-^^7. American bacteriologists have had much 
do in firmly establishing the sole causation of epidemic cerebrospinal 
pdfl by this coccus, Sporadiv. caaea of the di&ease primary cere - 
linal fever aie often caused by tlm pneumococcus. The disease in 
Ltly becoming more prevalent, especially in this country, for 
ictnely ft year goes by without a report of one or more serious epi- 
Jeaiet, The greater prevateoce of the disease may, however, be due to 
ia mere general' reeognttion and differentiation. 

Jostaa pneumonia maj prevail epidemically, just as it may seem for 
jma lo Lave certain centres or foci of occurrence, so inay cerebrospinal 
B«ingitia- Like other infectious diaeases^ its place in the mortuary iist 
^ great citiei is never Tacaut. Unlike them, it ia liable occasionally to 
d*Tastftlfl Heetions of the country under the influence of certain antihy- 




gianic couditious, [lorticul&rly those of defective BanitAtion &nd impropw 
Wiiter supply. 

In a g«uer&1 vaiy, the etiological conditions that are true for aciit» 

putoiletit ]e|)toiQe&iiigiti8 hold as well for the epidemic foriu, except that 
in tim latter oliildrui fall ea»y victimv to th« disease. The pathway of 
infactioD in the ^tect majority of caA«a is through the nasal and buccal 
oavitlea, Kut the intracellular diplococoi may reach the meniageB througfa 
tha lymph channels. 

Etiology of Tnberonloui MeniagltiL — ^Tha BHsoniis] oaiisa of menin- 
geal tubetuuloais is the Lubetdo bocillua- WlUioub this the disease docs 
nob oiciir. TLe etiology may tiien ho coDoidCTCil undtr tho followiaj^ 
heads: (1) The conditiona th^it favor or allow tho dt^veloptiicnt of tub^nJi* 
bacilli In any pait of tho body^ (2) Tho Bourees of the batilli and the 
avenues by whii-h thi^y gain nrceas tn tho meninges; aaid (-1) Tho eondi- 
lion of the meningea which allows the bBt^illi t;>take up their abode there- 
in find to excite a typiriU reat:tion. 

The t^onditions that favor tiiborculous infection of the ineningcji do 
not difFor very materially from thoBii tlLat prpdtsposa tr> tiiberuulous in- 
fection of othi^r aeroua iiiembranefi, sui:b aa the pleura, peritoneum, and 
serous envelopes of joint cavitioH, eEi;cpt that the pia is more resistant to 
such infprtioii than are any of tliese membranes. The age is perhaps the 
most important indirect fai^toi-, as the diaea&e oi'curs almost exclusively 
between early childhood and adolescence; the majori^ of cases o(*curring 
between lh« first and Iifth year. The disease is cumpuratively rare be- 
fore the end uf tfiH firHt year and after puberty, allhinjgh naturally cases 
oocur even at the toudt'rest age and after matLiril^. It is more common 
in artificially fed children thjin in chiMren unrsed by healthy mothers, 

Tho disease ia somewhat mora freqnon. in thomulo than in the female 
seXj as are all forms of tnl^erculoaifl. It ifl much moro common in the 
winter and spring and in tempprnte climates, on account of the facilities 
olferoil for the dcvelopuieuband pru[ja^'»Ltiun uf the bai-illi, by the enfurced 
houaing which euchcUniato and season entail, and on account of the prera- 
lenoe at that time of diseases which tuborculous meningitia often follows, 
such as munjps, wbooping-uough, lueaslea, and more ruroly scarlet foTsr. 

The disease may occtir in families in which there ifl no tuborculoua 
history; but luoi'o often there ia a hLatcry of Lulierculosift in some of the 
immediate ancestors or relatives. Almost evf^iy writer has remarked tin 
frequency of the disease in children wlio inherit tho so-called st^rofulous 
diathesiB. All conditions that tend to lower the patient's vitality pre- 
dispose to tuberculous meningitis by leaaaning the resistance uhich the 
getn^ral system, as well as the meninges themaplveSj ofTpTS to the infection. 
Study, proloaged mental activity, particularly when under couditionn thst 
entad physical exhaustion, such as ]a<:k of exernse in the open air, de- 
fective sanitary surroundingSi neglect of hyirienic principles, improper 



■ml insufficient food, buoh a^ tbo lailk of an iiapovcriabetl mother, or, m 
iildtr ptiddrcQ, food lacking ui fats, are powetful predispoaing factors. 
Filb mad Uons on thti bi>ad, aud surreal operations Aeem ii: many Cftsei ^ 
B» be proTocatire of an attack. Many children who develop tubercu- 
Uk3 meoing;lis show before their illuess nturked prwocuruMiietts, and 
da mergy expended in maintainiug this ^efnia to facilitate tL;l>ercu- 
I«3 iafectioQ of the meninges, patliciilarly -fph^n Uio child's eagcmeu 
tovtadr 13 fostereti by parents and teacheran It is more frequent in the 
milir^n of foi-eign-l)ora population and those in the lowi?r walka of lif« 
thtD in the naiive born and well-tO'do, It forTns a far greater proper* 
tk» of deatha in the niDrtuury lista of large citif-B than in ihose of small, 
«ul jt u relatively more frequent in urban than iuauburbati cummunities. 
The Jisettao u prediapoeed to by the acute infeetioufl diseased, ha veil tia 
hjtlte ftcfite catarrhal and inHammator^ infections of the gaatro-intestinal 
tivCi^eouditioiia ^'hieh make sudden and profound impreasion upon thtt 
putritton of young cliildrfn. 

The Botirces of the baeilli are in the vast majority of eases tuberculous 
io£«tion or foci iti other parte of the bo<ly, the lunga and pleura, 
jomtsand boue, perituneiua^ and glands, eueh as the testicles and lymph 
|luds- Of theeef the pulmonary organs are by far the most com- 
DbU sourees. The iuleotion of thtt meninges i^ hy no mi^anji alwaysi SAt*- 
ovdvy to the oecurrence of tuherdfi in other paits of the body^ although 
la jooagchildren it is soaa a rule- luadults, on the other hand, primary 
jnf«ctioiiof themeningi'a rntely occurs. The avenues by ivhioh the bacilli 
^vatraoceto the pia are pnncipailj' the Lymph and blood currents. 
Uhm the source of infection is some tuberouloHS focus of the cephalic 
'•od of the liody, Eu<rh as of the eyts, ear?, no3i«, or ihroat^ that is, from 
pifti irbirh are m ounne^^tion i^itber diiecUy or through aimsLomoaiH with 
die lymphatic aystem, the* current of lymph is the infection carrier to the 
iMEUiiged. When, hovo^-or, the tuberculous focus is in a dista[it part of 
lb« bod^, such aa tha inteutine or the lungR, the blood itself carries the 
pwrant agency. Tulierpuloue iJifection of the mptiinges, like that of the 
lungs aad of the glands, is probably sonietiuies trannmittepd from the 
BOtLer to the child before iiirth. When infection of the meningea is 
pcioify, lUe bacilli usually reach the lueninjjea through a v^ound of some 
putof the head which has direct eounection with them, rertain it is 
ihatrhe infection of the mpiittigea from tubercle bacilli taken in from 
I lliawteide world, witliout £rst causing tuberctilosis in Eume other part of 
^^4» body, ift of great rarity except in very youug children, 
^^fe Thatobercle bacillus ia very slightly saprophytic and consequently 
^^U DO particular development outside the human body. The bacilli may 
takenp their abode in one part of the body like the lungs or the lymphatlo 
^■Gm of the risoeraT and without producing lesions attBtided with symp- 
Ums will he the aouree fnim which meningeal infei.'rtiou arises. 


AiHong t[ie CL»nditiuu3 ot the meiiJngee wUith uiake tliwn eusceptiWo 
lo the pei'iiiain'iit viKitalion of the tubei-ola baeilU may bts mentioned th« 
differerit factors whirh have a capnoity to diaor*ier or to deprave the in- 
t]'Bcrai)iaI rirculaLiuo, whether thej arise witbm tha brdiiiT s,6 pby^linznl, 
or wltliOLitT buch 84 tbe cffrcU of traumai alcobol, or exc^si^jve ]i«£Lt. Thn 
neuropathic conatitution or diathesis may also come under thia heading. 
Blo^TK aiu] injuries to the bead may t^^^'t up & Eatetii: tuberculosis. 

Noii-Infe«tiou« MeniCLffitli ; Pseudo-MeiLingitlB ; Meningitis 6«ToiS- — 
This is a form of tiieniiigeal affi-i^ticu which is not of barterial origiii^ ami 
not associated vith the presence of bacteria- It is Dot a tnt^ inEaui' 
matorj proce4s> Clinically and etiolo^ically, two fouoa may l>e consid- 
ered: (1) Due to the prolonged taking of alcfjhol of siime such drug an 
morphine, cocaine^ or chloial, which we may therefure call the l<iiic 
variety, and which is nothing elne than acute toxemia of the brain with 
serouB elfusion , and (2) Due to iujury and acute di»caEie in wbich the 
actoua effusion ia the result of impain^d inneivation of the moningeaJ 
blood'veasolo, or of vaaeulac depravity. The etiology of the alcoholic 
variety needs little further conBideratioii, The immediate ooi'urreoc^ of 
the symjitoms uf " wet. brain " may be precetJed by an atr4ack of delirium 
tremens, or they may occur duriitg a prolonged dehaut^h- The disease 
may oorur with coesiating disease in other par1-» of the body, aui-h as 
pneun^onia* In many of thd 'naes of wet brain that conie to aubopay 
there is found a true purulent meningitLe, but in these eaaea the infection 
has Iteen superadded, and Us soiik«s are quite tlie eame as in the ordi- 
nary purulent form. 

Tho comuiou attributable vausea of serous meULngitia in rbildren aie 
Bome amh injury art a faU^ n blow ou the head, which in theuiaelvefl do 
not fieem to be of auy rouaiderable gravity, and the occurrence of gaatro- 
intestlual diHeanes, The diae&se is particularly likely to oceur il f^hildren 
in whirh there are evrid^nree of the rhnrhitii: diatfaesiH. It results in acute 

SymptoniEi of Infectious MeiiinKitia.^Thesymptomsof all forms of acute 
meningtlia are somewhat SLiniEur. They vary in individual cases and ac- 
cording to the bacteria that prcdur^e them. The prodromal symptoms differ 
very much in thedifftirenl; varieties. In ordinary infections meningitis they 
conflict oC the usual pceiuouitiOry symptoms of infection, with pi^onouncod 
headache, vertigo, and mental irritability. TheproLuiuentsyniptuiiisof the 
early stages of the disease are beadai.'lie of agonising severity, agi^ra^'ated 
by all varieties of mental and pliyai4-al exi'itation; rigidity of the neek; 
nausea and vomiting; retraction of the abdomen; cutaneous hypeneathe- 
ma; bx^ali/ed twitching or jjcneral cooviilaions; vacillating or persistent 
strabismus^ irregular or contracted pupila, and lusumuLa wbich leads to 
flightines? and deliriimiH This last, with the continuance of the symp- 
toma already enumerated, characterises the second stage. The amountof 



IVTBT viU depend l&rgel/ upo4L the c-^u^e o£ t\i& meDin^itia, Tbeordiuaiy 

^■iimni nriiin xncniugitia ia rarely aooompouied by a temperature above 

■K8* F- Ifr bowerer, the disuse is profouudJy aaeptK', it ma.j re&ch 

!<•* or 106' F.J and Iw more or 1pm roiitinuoiis. Durhig this stage the 

pthe is npid, teUHe^ and reaistant. The skin \a ^^le» and if ths Snger 

Mil be drftira ai^r>3s it, U Itieves a reddish- while iiue with purplish-red 

su^DA, known tis the taL-he cer^brale. Gradually tlie Ueadache beoomea 

kfli severe, and the p&bieut's iLt«Uei-tuaI fai'ulties bei-ouie submerged, 

1^ twitch in ga, spasms, and oontraotures bet^ooe lessened, the evideoces 

of ruomutor Bjiaam are repla^rd by vaBCimuti.]r i^areais^ the pulse Joses its 

Eiptdiiy, and the blood pressure falls. The delirinm takes on a more 

lobdued totnplexion, aitd the patient passes into the st^e of. depreasion, 

ladiridual palaiea of thorraaial nervoe may loplaoe previous apa^ms} tho 

wck btfrvmea Ipss rigid; th^ patient objen'ta less to handlings the abdo' 

mm loAM ita i«trai.^tei] ap^iearante and may become distended; the pulse 

bKouicaiDore lupidand ft^ble, the pupila me widely dilated, and respira- 

tmbc'.viiies irregular in rhythm, i>erhaps of tlje Cheyue-Stokes variety. 

jAthoQoma deepens, alt the funotiuus of the body become profoundly 

teia^vd, and the general fyicptoms are those of eollapse. 

The symptoiua vary very defiiiedly with the WaUiy of the menicgea] 
iaAsmmation and exudation. If it is at the liase of the brain, e.arly and 
preltMnil syiaptoms will be those referable to tlie domain of the oranial 
anTfOf and rigidity of the neck; while if the hemispheres have been 
UTolTi>«if pymptomB uf mot/>nal and ^^nfiorial irritation, Kith early ap- 
pMnnte of deltrmm &nd coma, are mo^t eonspit^uous. The diseaHe i« 
ciinmelj grave and it is rery questionable that any cases of true puru- 
Ittt moniiigitis ever recover unless the pus is removed artiliuially. 

SrnptflKt of Epidemic Cerebro»puiaL Peter.— The aymptoraa of epi- 
deaia cen^brospinal meningitis are of two dlatinet typeSf the mild and 
ibe Kvera. The symptoms eharaot»?ristic of the severe form are the 
luddm oQMt and great seventy of the irritation symptoms. These may 
or not Ije pn^oeded by a profound chill, wliich if it orcnrH is followed 
)j proupt, a!iarp ri^e of temperature, intense aiid agonii^ing headache 
nd hsduchf, a^so^iated with rigidity of the neck and back, palsy of 
tmt of the ocular muaolea, violent delirium^ and rapidly deepeniEg 
mm*. Death may ooenr wUhin tweriTy-four hours. In the leas vio- 
kiLsod castomary form there are malaisCi rij^rs, dizziness, vertigo, hy- 
tovasitiveness to lights noise, aud all forma of excitement, and great 
natal depression. The vertigo, backache, aud headache iucreaser the 
toperature ranges fr<>m 11*0° to irM^ F., tlie pnlae is accelerated and 
often irregular ; and the respirations are shallow and frequent. The skin 
u ilraost always the sf'at of some eruption, erythentatous, urticarial or 
pMKhiali therefore the disease was formerly called spotted fever- The 
are involved early iu tbecourae of the disease. Somctim(^3 the 



disea-se begins witU ejuiptoius of i^roat aeverityt vrliich eoon laitigato or 
oe&ae, aiid to this variety tho namo uboitivo is often givoo- Thd mdi' 
vidual irritatioQ aud pai'aljtia sj^mptonig which thd diasosa caxiMft uid 
iU sequel !i^ depend largely ujiod the Hegmeutof tho central D^rvoua sjftteni 
which bears the hriint of the irritiLtive nr destniotive prooess caased hj 
the meuijjgeaJ iudiimuLaLioiL and eKudation. Oiift of the moat oonslAut 
phenoineoft of epidemic ctfrebroapixial fever mo thuse to which tho desig- 
ikatiun Kerntg^a Bign, after the Husaiaii who first ]winted otit ita diEkgnoB' 
tic aigiutiaiiu(>e, la giveu. If the patient is put in a Bitting pi«tiire in bed 
and at) attempt made to extend the If^g on the thigh them ia contraction 
of Uie tiexors wlui^h dc.i«>i uatnltow thelt^gnto Iw straight«ii«il. This lain 
marked contrast to tho ease with which the leg can be straightened whe& 
the fiatieiit ia in tlio recitmbcnt posture. Thin aign is not pathogDomonic 
of epidemic uerebroapiual iiieniugitifi. It is pve^^nt in all forms of men- 
ingitis when the spinal in^i^iitgea nre involved. 

The gent^ral symptoms and aocompaniinenta of epidpniio cerebroapinal 
iD^uiingilis are einiilar to tho^fi of other acnte infections diseasea. 

SjrznptomB of Tuberculoaa Meningitis. — The symptoms of tuborcoloiM' 
meningitis do not diSer very ijiatt^rially from those of infeoLious menin- 
gitia, except in the oocurrenoe of amuewhai charaot^ristto prodromal 
symptoms and in the prolonged <!onrHe of thr diiieii^e which is liable to 
exacerbations and. rduiiasiousH In other vords, auide from the prodro- 
mal symptoms, the difference is one of degree aud not cf kind. The 
prodromal period may be of long duration, bnt the disease may hav& 
all the characteristics at the oiihet of an acnitd infection. The customarjr 
prodromal symptoms are ehangQ in the patient's disposition and demea* 
nor, gradnnl iuipaimient of initi-ition, and jiaroxysmal anil inttriisely 
seveie headaches or (darling pains m the head which go and come with- 
out obTioUB Oftuse. After a variable period, the headache bocoinea mors 
cr less constant and of an ii]crea»in^ severity, and its occurrences is asso- 
ciated with seeming involuntary shrieks kcoivn as the hydrocephalic <jryi 
vomiting without nausea, projectile in chnvartar, of frequent re|>etition, 
and not followed by prostrittion; constipation of the most obstinnlne char- 
acter, asHDciatod with retractiop of the abdominal wallSf giving the abdo- 
men the shape of the intemr of a boat, and lixedneas in the retraction 
of the head and stiffness of the nek. All of these i^ymptoma may miti- 
gate and the t^hild be apparently progressing toward recovery, when a re- 
ruri'ence of them carries the patient intoapitralytioand comatose condition 
which are the forerunners of diBSolution, The disease often nuis a moat 
irregular course, and nob infi'oqueiitly a chronic one when the symptoms 
of hydrocephahia will be the most canapicvioua features. 

Symptom! of Beroai Merdngitii; Hon-Infcotions Meaingltu.— The 
symptiima <jf alcuholic [nenJngitis, or wet brain, usually come on after a 
few days of delirium tremens, and are characterized by change in the 

w- hKntnuitth 


of the delinuiQ nnA a graxiuoi ainkkig into a condition of neuii- 
eoua, vbich deepens day Lj day uutil death occurs fit the ouil of from 
«M to twG wcwks. TlL«rfl are usually rapid pulse, aJight elevation of 
mnpnatuT^^ fit-mi -riguHty of the neck und of the eKtremitiea. Tha 
pftbent cmn generally be partially aroused, eitLer by sjjeaking to Jiim or 
br pKteing opon the peripheral nerves which dx& almost always sensitive. 
TbefcseTAl condition is that of a modLlied typhoid state. The outcome 
ift bot ttf^cenaj-Uy faUil, alitiougli it is usuaUy 8C, 

Tb« wrons meningitis of childrea and adults which follows injurieB tft 
ihe bead and nociufectioiia ejJiauHtLng disoariea U very variabld lu its 
tyo^itoaiA ftnd iitteusity' Usually they do noE^ develop %rith tlie abrupt-* 
:ie» uid wveritj cf ordinary leptomeningitis, nor are any of the symp- 
Mii^ tare those of increased intracrautat pressure which depends upon 
iKl iBCteaBe of extra- and intraventricular fiuid, soioieuae. The symptoms 
d^rflap T«rj insidiootdy, espAcially in the tf-a#es following trauma. They 
Muiit of headaobe, rigidity vf the neck, some vomitiug, and irregular 
COttootioQ or dilatation of the pupila. In the severe ^aaes there Eire oft^n 
fitreme dilatation of the pupilsp in addition to the other eymptoma, and 
optic Deuritis, delirium and cioma, without the developmeut of a tempera- 
ture above 302^ or lo:*"* F. After the cweurrence of these aymptoma, in- 
: Kuing size of the head, if the disease occurs in patienta befcre the 
fouUMllea have closed and sutures ossified, or signs of iotracranJal press- 
ure, if after this period, are the symptonia that follow. This form of 
PuoiELgitiB can generally be easily recognized, but many do nut diiTcron< 
tiiH^ diagnosncato it from the infectious forms. The majority of casei 
of meningitiB thit go on to recovery probably belong to this category. 
Oa itie oUuir hand, uot a f«w of the caaes go into a state of chrouic 

Tlteftttaeat of Infectiona Meningitii. — The prophylactic treatment of 
UTite infectious meningitis is of thegteateat importance, in view of the fact 
itiltheoutcoaie of these cases ia nearly always death, despite the moat 
■pioDved treatment. Considering the relatiouship which the bacteria of 
[jnfDmgma. influenza, and other infectious diseases have to the occurrence 
ot mfuingiiifi, it is apparent to everyone that menBures should be taken to 
Unpitp the bodily tone, and that eiccesaive fatigue and all hygienic errors 
^4 avoided wh«n the mortuary lists of cities or the experience of phy<<i- 
riius in the country show that these diseases are rife. Considering 
llio important l^le played by wounds of the head in the causation of men- 
ngitn^ it ie scarcely neoessary to emphasize the fact that such wounds 
Aodd be treated according to the principles of asaptie sui^ery- No 
UN is it nec^aary to dilate upon the fact that the danger of secondary 
BHungitic infection from bacterial inflammation of adjacent carities and 
plHiyeB b lessened in proporticn ae auch conditions are early i^cognized 
ad flTen approved treatment. 



The uext iimst im^Hfrtout feature in Uie treatment of nieuiiigitU is the 
early disuivcry auii vi){Qrou3 Lreutmeut cf all thoiv tx)udLtion» to wliich it 
is aaooadary. Early dm^nueis is an extremely impartaot factor ui the 
treatment af the dideaae, and to tUis end the withdrawal of fiuid from the 
lumbar ar^liiioid spaoe ia very necessary — not that I b«liev& aspiration 
of fluid from the Aubaiafhnoid ^piu^e can \ieoi ^artiirular serTicc in ajnelL- 
oratJD^ the disease. If the diagnoeb i-aii be made e&rlj, theu the disease 
can btf trtrated in a rational mantiei- Luctbur puncture of the »ul>£U'ach' 
noid apace is a procedure bated upon knowledge of the faot that the aiib- 
arachnoid spaces of the brsin and spifisJ cord are in direct communica' 
tion, and that Imth may lie injured or injprted at the inferiot end of this 
space iu the lumbjir region. The tritling operatiou ronsjalfi in pmsaing a 
needle into this apaue between Uie third and fourth, or between the fourth 
and fifth lumbar vertebiti^ tlje former level iu adults, the latter in chil- 
dreu, and about one centimetre to one Bide of the median line- It is need- 
less to sny that all antiseptic precautioTia are ti> be taken. The size of the 
needle varies arcnrding to ttie H^f of the patmnL In young childreo a 
needle of the diameter of on otdiuary hypodermic needle and from four 
to six eentimetrea in length uuswcrs the purpose, uhile for adulte the 
needle should be at least eight ot^ntLinetrca long and one anJ ono-balf milli- 
metrea m dtanjetei, A mistake most frequently made m first attempts 
to apply this proiWm'e is that the nei'dle is not i-arried to a sufficieni 
depth. A ueedle with a stylet la to be preferreil for a^lulta. It seema to 
he the unatiimoua opinion of tlioeo ivhti have entployed this method that 
an aspirator should nut bo iiHcd. Thu operation is most eaady performed 
in fhildren when the patient lies on the alidomen across the knees of a 
nurse, the back Ving thus forcilily convened in the limibar region. In 
adults the patient should he on the aiiie, with the kneea drawn up and 
with the uppermostp shoulder so depressed as to present the spinal colomu 
to the operator, particularly if an annsthetic is used, whu-h hy the way 
is often advisable, or in the sitting posture with the spinal column flexed 
on the pelviB if narcosis is considered unuecesaary. Ab soon aa ths 
needle enters the subaiachnmd 1i\^Ae**^ the dutd begins lo HoWi drop hy 
drop! nulesfi the lumen has become occluded by a pieue of tissue or hy 
coagulated blood. The fluid is remred in to a sterile test tube, and cover- 
slip smears aitd eultures on I^JcHler blood scrum are made, The fluid is 
also stained for the Luberele bacilli. E Kami nation of its physical and 
chemical composition is of considerable importance in differentiatlDg in- 
fiammatory couditiona from intracranial growth. That lumbar puncture 
may some day be the avenue through which medicaments intended to 
reduce the potency of the inflammation or destroy its excitant can be 
introdneed, as has been hinted by bome, seems to me beyond the pale of 

When the diannosiB has been made, or when the presence of the 



Biw IS fltroQ^ljr suapet^ted, tho patient should be jiEaced m & liu^, 
vcU^Tmtilated^ dark, abaolutely ^uiet room. The h^ad sbould b« sliiLved 
■od it vitk iLe neck and forehead surrouuded with Ice-tAgs. If the 
|Bti«Bt 13 lobuat, and pai'licuUrly if the ineiiiugitifl is not s^ondarj to 
Mne disCMe that has exhausted him, topical veneaectiou b^' vet^cupa 
tt) Hkt back of the neck, or geaeraJ vdoesectiOTi is earnestly ro^oniiueudeii 
L^bKncting severa] ouncef^ of blood from the body robs the system of 
^^^kanmulLle organiBms^ while it does not materially lower the vitality of 
-Jic {i«ti«iit, because it call easily he aubatitubed by the subcutaueuufl iu- 
jfCttonof Bormal salt solutiOD», Th&s^ t^enerol measures are the most 
pek&tfactora in reheviug pam next l^ the hypodermatic injeotiou of 
■Mlpbine; a^d as the pam must lie mrti^ted, it is mvte advjsahW to itse 
thraiifld such iniiooijous drugs as antipyno rather than morphine^ whi^h 
«lny« increases iutracranial coi^ge^tioiu 

Asid^ frum Uiese measarca. the treatment is purely aymptomatic, on- 
lettiCbe decldc<l to op«ti theakull. If the temperature tises aod remains 
aoal i02* F., the fuli-bathof 80^ Y. of twenty mmates' duratiuo, repeated 
r%eTj three hours i% advised, oold applieatlons to the head being kept up 
uioaiffliUe. If the infection i.s sevi^rt? and the temperature higher, a 
cd^vr bath can be given profitably, and, on the other hand, a lukowarjii 
toth if the teiu|ierature is not so high. Prolonged lukewarm hatha are 
«rrieeabie in combating the general hypem^sthesia which is to distress' 
Off in the earlier stages of th^ disease, 

ill forms of irritant applications to the haolc of the head, neek, and 
liilhiT tuasti^id pn^teases are earnestly deplored^ The slight amount of 
|DIh1 which they may possibly do is more than counteracted by the pain 
Tkickthey, in commcm with all forms of stimulatiort, cauee the patiejLt. 
In the begiiining^ endeavor should be made to get free action of the 
teviik, and this ean he done most speedily hy giving drop dosea of 
oolou oil, by mooth if the intervals Ijetkveen tlie artfl of vomiting per- 
lut QtherwiAi^ by tectum. Stimulative foot-batlis and ainapiema to the 
hd may be nseii in oider to cau^e derivation of blood from the head, 
puticiilarly if they do not seem to cause any irrUation. 

The admtnisTTattou of large quantities of iodide of potassium, even up 
» in ounce a day, as has frequently been refomineuded by writers, ia 
Anmgly deprecated as beiug at variance with all that we know of the ac- 
tioaef that drug and its i-eol therapeubio uses. In not a few coses 1 hive 
Bpen disastrous results from its use m eases of serous meningitis and 
m tubevGulous meningitis of loug duration, ^mall dosea of one of the 
branice salts, from fifteen to thirty grains for an adults given in the be- 
immng of the disease, is oft^ii of servif^e in quieting the pain and in 
ffiitigating the severity of the motor symptoms. In the begiuniDg of the 
diauM, after the pain has been somewhat alleviated by local or generaJ 
'tettiDgr the administration of sleep producing agents, such as phen- 



acettn, antipyrin^ or morphme, can do do harm, Ste>e;> not alone leaaeas 
the Bgouy of the patient tiut iaoraases his rcBistacii-e to tba disease- 
In uuM iu whicL it has boeu tl^termmed ly tumbu puncture and hy 
the course of the diaoaae that the meubgitU is profouDdly septio or 
purulent, the questioD of operation will come upn It is difficult to make 
any general statementa^ which will neitlier be iniwofistrued nor misuiider- 
atood, LTk refermioe tio th hso ctL^ea, It may be Aaiil thnt operarioii is acl- 
visabla in every c&he iu which local suppur&tiveoouditiou of the meniD^rea 
can be made out, This» unfortunately, ib rai-e. In cases in which pyo- 
genio iuf^ction can be traced direcUyi ns from ito internal otitis media 
or an infectious wovind, the bLeuH should be trephined as near the point 
of infeotion aa is feasible, and tJie greatest paius taken to cleanse and 
remove the purulent product, particularly if there be aeptic foci whick 
are cauaJEif preaeuTe- The rapidity with which purulent meningitis 
Btartlii^ at the convexity of the brain extends to the base and even to tbo 
cord, should be borne in mind Jn deciding ujion the advisability of opera- 
tion and in estimating the benetit to be derived from it. The dieaatrous 
outcome of these coaes when left Uj themeelvea sliould, however, be taken 
into oonaidoration, The cnJy chance that the patient can posaibly have 
is from operation, and some surgeons are warmly advocating it. It moat 
also be borne in miud that abaceaa is liable to follow operation uitder- 
taken for the relief of aiieli meningitis, and likewise septic pneumonia, 
but a suftitient niimber of recoveries following njteratien have been re- 
corded to mtike the procedure justi6ab]e. 

Treatm&nt of Xpidemi« Cerebrospinal Hsniti^tis,— Although the out- 
look for recovery is nothing like eo grave m epidemic cerebrospinal men' 
iogiUa as it ia in ordinary infectious jjieningitis, there is no specific remedy 
for the disease, and no effectual method of treatment is known. The 
ex penmen ta spoken of above for lessening the temperature and mitigating 
the pain and <?ontribating to the comfort ^f the patient may all bo used. 
The moat iuipoi'tant feature is the early adoption of mcafiures to maintain 
the patients vitality, especially in those oaaes in which the infection Sa a 
profound one. Stimulants and supporting measures are inrHoat.eii from 
the begiimin^ of the disease- Aside frum the^e aud froru core expended 
ID treating the complications and sequelfe of the disease, particularly 
those that affect thG eyes and ears, the g^^neml indications for treatment 
are the aamu us in every other variety of meningitis- 

Treatmsnt of Tuberculous Heningltls. — There ate some who still be- 
lieve tbaL meningeal tubercLklusLs ia uniformly a fatal disease. The un- 
biaased observer must, however, admit that a sufficient number of un- 
doubted cases of tubercvilona meningitis eliding in recovery have been 
recorded to entirely negative this belief. The treatment of the disease 
is, however, most unsatisfactory. Innumerable plans, medical and sur- 
gical, have been adopted, but to-day after they have all had a fair trial, 



\^ pb^nioiui stauUa in the presence of tuberculous meuingitia ^ith tlie 

lAMe fecli&g of iuabiiity U> stay its progress as did his predocesaor of u 

gtopcAtwa %gQ. Meoingeat t^iberoulosig ia almost always a a^t^oodary 

MMIflit and propbrUf^tie trpatm«Dt, 1.her4>fore, is jncnt iitiportanF;. The 

4lttiitaof suL'h prtiphyliLxis L'uJndde entirely mitli tliosi* for the preveu- 

tioa of tuberctjjoua iufaction of any other part of the body. The bafiia 

«f thfu ipplicatioa may bo smuinari^ed in a line. When the nutrition 

«i & c^ll or of a ttBGoe ia ntaintained at a phydiologioal statef it is an- 

tfttluc to tb« tiib«rc1e bsrlUaft. It U all the more neceaaary to strire 

totQUiitain suuh a degree of nutritioQ in tliose who iohent or aojjiiir^ a 

Vod^q Lo tuUBiculuttia; ^kile in tLose whose bodies have alr«»dy giTen 

nnptinty to tho tubercle bacilli the grcatoat care ahotild be taken to 

ptffeat SMondary infection of the meningefi. 

Thegenvral direetiona given for theeareof infectious meningitis apply 
u w*i\ to the tuborculoua fonni4» save in the latter no debiliCatiDg treat- 
iiQitiudi iva Teneseetiou ahuuldevrr Ire thou^cht ot. The e^entml point 
ol diflvTVuce in the treatment of this variety ia that iodide of potafisium 
ntkto^ uniformly recommended by n^iters. The reason for thiB, oon- 
iid«riiLgth« outcome of the diaeas^, 19 ditficutt to discover, unless it be 
LhiE llie <nuTse of the disease is lengthened hy its application- Whether 
;h» a a deairable feature or uot, especially in infants and young chiKiren, 
fschune mnat decide for himself lb has al^o been re<;ommei]ded that 
aeraorr bo nibbed iDt<J the neck and behind the ears, but thia, aa well ad 
t|] fonns of euuu ter-irntationf has never been shown to have the altghtest 
Tirtiif. Conl^ciporaneoua with the appearance of almost every one of 
duroal-tar produets, substancea vhirh not only relieve pain hnt reduce 
louperatiire, has beeu the report of their service in the treatment of 
iJibcRTilous menittgitia; but aside from their symptomatic use they arc of 
M valae. It ia known tliat iodoform in solution when injected into the 
ptntoaeom has caused a cure of peritoneal tuberculoais, and thia has led 
laths Ufie of iodr>forni in tuberculous meuingitis. A nucilierof physi- 
ciuEd hire reeorded results of its use ; but judicial weighing of the testi- 
mmy and the eridenco forces one to the belief tbat it must be claesified 
Tith the uaelese ageneiea. Naturally, during the laet few years numeroua 
•ip?j-inienta have been mad© in the treatment of this disease with tuber- 
(Tilm and guaiacol as well aa with other medicnmenta which have acquired 
ilnjisient or more or less peruianeub reputation in the treatment of 
tnbercuiofttt of other parts of the body, especially of the lung. The 
fltolts Bato not been at all gratifying, 

Ifae operative prooedures that have been suggested for the cure of 
tJibemiloufl meningitis and aeute hydrocephalus, of which it is the com- 
DQDcflt rause, are also numerous, and although in latter times a few cases 
kT« been reported which entirely justify such procedure, at the present 
iiritiag ^e treatment has not materially iuhueneed the mortality of 



tulrarculoua lu^nijit^itis. TUb cbjftct of ofieratioii may \j« pAlliative or 
curative, the Qrat to reduce piessiire, the secoucl to facilitate ibo ccadi' 
tioQB which will bring about fibruue t:haiigea in the tul>erclco and inaotir' 
ity of the bauilli. The operation* that Jiave been rerommendecl AM 
Bimp]« trepftuiting, and tapplug tbe ventricles, or tapping Lbe veQtn4il«i 
tliruugh a foutatidle if it be 01)6116(1, atid trepkniiln^ anil drnitiing the 
veutricles and aubaracbnoiii space thiougb an opening in the vertebral 
column. The firat plan hus been extennively tried, imt has never been 
peruiiinontly BUccoaafuL K^eov^py has been recorded in a caae in which 
the subR.raphnoiJ sp:Lc<^ v/rs opened in the ferviral region, anil in a Cfl-se 
in whioh tb^ liuid wan withdrawn by Inmbar piinoture, Tb« ajierative 
tieatiiieDt will be diaouaaed at greater len^h nnder the truatnient of 
hydrocephalus, but here it may be ^aid that practically the only procedure 
justiciable for the relief of tuhertintoua meningitia is lumbar pnn<'ture, 
AH that can be promised from this is that it vlU ameliorate the pressure 

The general managemtiut of all CB«eB uF meningltta is the same, it 
matters not what thu pathological form may be. and it itt of the greateat 
importance that the details of uuch management bo attended to. The 
pulBe, temperature, and bliuUler should bv odrefnUy watched, and when 
devlationa from normal which predict death appt'iir urgent, tneaauree 
fihould be adopted fur their relief. Fi^uently the proper use of digi- 
talis, and of other cardiac stimulant!', such aa strychnine, or of the cold 
bath, or of the ratheter, will tide the patient over nome critioaJ periled 
until the recuperativL* power gains the asoendenoy* The pOBeibility of 
bulbar aymptouifi, particularly diHiculty in swallowing, Bhould be kept in 
mind and proper measures taken to prevent or relieve them- When 
there is uiaiked dysphagia, nutrient eueuiata should be reported to. More 
is to be gained by attending to the patient's rest and comfort and by 
combating symptoms aa they arise than by any stereotyped plan of treat- 

Xrcatment ef Serous Henlngitii. — In the treatment of Himple aerons 
nieningitis, Qiiiit^her who has had much to do with establishing this form 
as a recogui^able elmieal entity, baa warmly recommended the adminia- 
tration of meroury internally or by meana of inunctions, carried up to the 
point of slight mercurial izatioUf especially in aonte cases. Many cf these 
cases go on to recovery if only the general syiaptoniatic indications be 
met. The iiae of salicylate of aodium in from ten to twenty groin doses 
seeuiB to exercise a very gratifying infliienrM tii some caaes- If the men- 
ingitis is secondary and directly attributable to au injury or dieeaae, 
measures that have for their object the combating of such oauaative 
factors should be adopted early and pushed LrigoronHly, 

In treating eanea of alcoholic serous meningitiii, it ahoidd not be for- 
gotten that the diaeaae ta i* toxaemia with seeondary exudative conditions. 


It about h^ a patbolo^rjil and asthfiiirc (\oDilition of the (^irf^ulfttioD, 

BSDidAted with profounU generEd weuknesa- M^esBurea to combat 

ifthoald be adopted e^Iy&nd pushed Yigoroual;, The patient should 

U pet upon a Liberal, vaailj digested diet of hot milk, ptam or peptonized; 

coftMBttzated meat extraots, b^f juice, peptonized gmeb, and nouri^L- 

iBg broths. The patient's alimentary traot usually demands special 

iMntica, ajid the treatment sliould in all c^fs b*^ liegun hy giving an 

AetiTC putative, »uch as calomel followed bj salines. In almoat evef j 

itflvice it will be neccsAurj to give some cardio-vawular etimuJant, but 

if poBuUe, it is urgAutl J advised to avoid aloohoh 'the diffusible stimu- 

Isitii n^h as caffeine, muaole Btimulants aucJi as stiyolmme and Btrophs^- 

tbutvill usually meet the indic^tious. The general treatment of ordinary 

Bttiiigitja as to the use of syuiptomatie measures that contribate to the 

reakn of the patient must be applied here aa well, and an important 

point ta beai in mind is that &ueh patienta are extremely intolerant cf 

Jf pigling measures. 

Tlie Treatment of Hydrocephalus.-- Hjdropephahis, or water on the 
bnim i» a pathuloipcal increadd of tho inlrai^raujal Huid, whicli may be 
athcc in the ventneles in vLIch the fluid is found naturally in largest 
^untitiee, cr between the parietal and Tiseeral layers of the pia, in a 
(|ac« which it makes for itself, 

Giaically, the condition, or symptom as it really isi ooeura in an acute 
aDdefanmio form. The acute varielit^ are represented by the hydro<;epha- 
ktt of tuberculous meningitis, and oE gerous meuingitifl- I'athogenetacally, 
tnebj^oceph^uaisof two kinds, congenital and acquired. The acquired 
Inn id almost always secondary and ayuiptomatic. Anatomically, hy- 
dxtnphalua may be divided into internal when the CQllecticn of fluid is 
pndccninaniiy within the veutncleSr and pjtternal when it i& exciusively 
IB tLs intenneningeal space. The latter ia ao Tery i-are that it scarcely 
BMiritB rousi deration. In the acquired form there is always an increase 
bf Quid within the yentricles. In other words, the acquired form may 
U iceoinpaaied by an intrameningeal ooUectiou of fluid^ but acquired 
fnamal hydrocephalus ouly occurs syiuptomjitically. The most common 
koudiate causea are closxue cf the foramen of Mageudie fi-om inflaiuniA- 
krj ot degenerati^^e processes, ndhestoua of the tonsils of the cerebellnsi 
b«afh other acd to the sides of the fr^urth ventrielo, and tumors of Uie 
bnin that encroach upon the Tentricular flyatem. Symptomatic hydro- 
n*fih&lua may be present with congenital condttiona, sucli aa porencephaly, 
bat nnh hydrocephalus is uot consirlered eong^enitalf although it may be 
^fBptOfuatic of a congenital condition. Acute hydrocephalus is always 
fcBjmptoruof aome disease, congenital hydrocephalus is always chronio. 
GoDgenit&l hydrocephalus may manifest ttself at any time after the 
fiftk ttranth of prenatal life, or during the drat months of poat-uterine 
Hh. Very little ia actually bnowri of its cauaation. Faotora that have 


bMrn fcfnnd U* precede it »0 freqaentlj that they ue itfiiitillifi tt» Mnd 
ia «tiCfI'jgiraJ relAU'^nahip an weul tnnsgnwiaia of the par^^ nek v 
tlfxJiolivifjT MrxTul exceu, Aiid LrperfTfUiloQ, a:id voch pln-sicil diMUB 
and tiigiAata ^ fijphllis, carLeiiA, uid somatic evidaiMS of degCBcra- 
tioD. Hjer^ is no dearth of evidence to ahoT thai oansanfiuimtj aod 
fuDilian- fAtiUjn etiXfti into the etiologr. tfrntal aboek and pbjaical in- 
jury of the m'Ahfrr seetu sometimea to stand in cansaDra i datkwi a h ip- 
The i^xnmunts of iDferrtious dbeaae during ptefnaiicj wvf alao eootrib- 
uta to ita development- It u sometimes seen in infanta vbo ahov other 
•omati': d'?feeta, such as harelip, cleft palate, spina bifida, and the tike. 
Caa^ hare been recorded occorring with sjringomrelia, but it it likely 
that thene caaes «ere examples of mjelobrdHiaia, Uie expansioD of the 
central cauai being secoDdair to overdistention of the renlriclea. The 
a^wjuired fonns have already been sufficiently considered. A woid might 
}jc iiaid Ktiwt'.miug the Mo-called Gptirioafl bydrDcephalos, ft ooodition that 
woufN in rha'^Jiitic children, especially after exhansting diaeaaes, such as 
choJera infaiitiim and the infectious diseases. As a matter of lift, itu 
ijfA a HpuHifiJH bydrriCi?phalua at all, but a genuine accumtOation of fluid 
witljjji the ventricles, and to some extent in the intermeningeal Space, 
whir:h riisajfj/ears whi^u the nutrition of the blood and the conditicn of 
the a.]ni'/r\itsu\H lre<''j|jie completely rehabilitated. 

The treatijient of t^jugf^nital hydrocephalus mayor may not be the 
saifie Hs that applicable to acquired hydrocephalus. When congenital 
hydr^f-'rjjhaluH is c^riNj^eiiHatory for some defect of development of the 
brain ariHiug during intra- uterine or early post-uterine life, no treatment 
khoijld ]rti instituUti], not alorje l^ecause no treatment has been suggested 
Ujat is of th»3 nlighf -Ht avail, but because it ia not desirable to endeavor 
tooviircrtnifsa WMjijK'Tiflat^*ry cwjdition here, any more than it would be de- 
Htrabld to oVftrcoiriM a cojniicnsatory cardiac hypertrophy. On the other 
hand, thn treatjni^Tit ot symptomatic hydrocephalus presents a number of 
proitliims, altliougli none of thein is of greater importance perhaps than 
the gftttiug rid of tha fliiid aiid tlie prevention of its production. For it 
matt«m not whi?thor it Ije due to tul>erculou9 meningitis, syphilitic basal 
meningitis, librrms duHure of the forameji Ma^endie, or adhesion of the 
tonjiilrt of tlie cereljelluin to ca<^h other and to the sides of the fourth ven- 
tricle, if the (luid in not got rid of it will eventually cause preasnre upon 
the <^rebral cortex that is tantamount to its destruction. 

Aside from the causiil tr<-:itnient of hydrocephalus which must be deter- 
mined in every cane, the treatment consists in performing some operation 
to get rid of a part of tlie fluid and to prevent its production- for the 
former I have no hEfHitan<;y in recommending the procedure of lumbar punc- 
ture which has previously been described. In many cases, however, it 
ia imposHible to draw off very much of the fluid in this way on account 
(if the fact that there is a closure of a portion of the channel through 



tlM fluid of the UierrJ veiilriol«4 must paaa tu T-f&ch the atibaracli- 
9F«G« outride the forfUD^n M&gecdJe, add ia such ciLBe« it would 
tbAi the methoil of intracroniai drainage recentiy described by 
texWlOQd and Cheyne, and which they have ntiliied effectively in two 
ttta oi chronic hydrt>ce[>h&Iii», is tlie moat fi^aaible. They believe that 
t pBrmAiictit opeuiug lihould be [ii&de through the cortex into the laUir&l 
Totride. The method of procedure ia to tre|jhin« tbc ekulJ, open the 
^DEi, ud fon^e & catgut drain thiough the oort«x luto the veutride. The 
doja ift then sutured over the brain^ and finally the scalp ia flutored. Such 
Dosires as simple erariia) pimeture, tapping ths ventrieles, and the intro- 
dnctitjQ of saljae solutioue, or a water solution, mixed with iodiue^ Uave 
^ Abundantly proven to be of no senice. It is UDuecesaary to mention 
the use of cathArlica, diuretica^ and diapbo^eti(^s, ^^'hich were foT-meTly 
idmiiustetcd with the mistaken id«a that thejr contribute to tbe removal 
(f the fluid, except to warn againat theJi- use. The treatment of hydro- 
(V^khilua, aside from what may l>e called symptomatic, such as the admiQ- 
btniioa of mercury to children whose parents have had syphilis, or of 
mil i]o«es of iodide of potaasium to those in whom there are marked ante- 
cedat diathetic conditions, tonaista in the adoption of measures that con- 
tnbotetoabetteriDgof the child's nutrition. It is imnecessary toenumer- 
■U specifically thei^e measures here. Children who have had a mcMleTate 
depre of hydxocephalua and in whom the condition has come to a stand- 
iRiH, hire often been known to make encouraeiJig mentftl and physical 
ffDgrvsswhen tjihen from parenta, placed in new euvironment, and aub- 
jMted to wholesome discipline and an intelligent dietary. The education 
d nch children should be carried out along the lines now adopted for the 
itt&raetioa of defective children by the advanced school of pedologists. 




By the term eucdplmlitifl, inflamin&tioii of the brain Bubataooe U 

meant- It ia ftlso sometimea spoken of ^a cerebritis. The former term 
iB to be preferred, aa the inflammatory process need not by any means be 
limited to the cerebrum. Much confusion has arisen in the oomenclatiire 
of brain diseases from failure on the part of clinicians and pathologists 
to concede that the same pathological processes may go on in the braii^ 
tiBsues as in any other tissue or organ of the body. I shall apeak of th4» 
treatment of eueephalitis under three headings: (1) Acute hemorrbagifj 
Don-purulent eu cephalitis ; (2) Purulent enoephalitiSf or brain abeoess^ 
(3) Chionio interstitial encephalitiB. 


Acute nou-puruleiit encephalitis is in the majority of cases undoubtedly 
hemorrhagic, and it therefore merits this additional descriptiTe term. It 
is commonly described as acute primary hemorrhagic encephalitis inordei 
to emphasize the fact that previous changes have nob existed in the blood- 
vessels. That acute encephalitis may occurs however, without hemor- 
rhagic eitravaaatious goes without saying. Indeed, it is not unlikely that 
many of the cases which end in complete recovery are of this nature. It 
is undoubtedly true that inany cases which were descrihed by the older 
writers as cases of meningitis and bretn fever were true cases of encepha- 
litis. It would seem no less a fact that not a few of the cases described by 
modem writers under the name of men ingo-en cephalitis are cases of the 
latter disease, especially of the hemorrhagic form. It is fallacious to 
contend that cases of inflammation of the brain substance, even of the 
cortical substance, do not exist without coincident inflammaticm of the 
meninges- Such a position cannot be held to-day, in view of the many 
authentic observations which prove that inflammation of the cortex ha9 
occurred without such acoooipaninient. Encephftlitis may and does occur 
secondary to the various forms of meningitis, be they traumatic, septic, 
tuberculous, or post-infectious; but such varieties will not be oonsidered 
apart, as the indications for treatment are in no way at variance with the 
indications in either of these conditions occurring alone* 

Stiology. — Acute hemorrhagic ent^ephalitis occurs most frequently iiL 

cbkUrcn up to the aj^e of pub^^rty^ although it may ooinir at gjxv age. This 

|ndil«ctioo for ear] J life is te' be explaioed vu the basis that it aometimee 

^aiiffwtihe acaw infectious diae&BeB, which Afd nioro liable to occur at 

tkiAtimv. females a.Tts iiffentecl luora often fphan iiialea. The diaeAse u 

dtptudent ill the majority of caaea upon some infectious piocesBr altbougb 

taomft ia th€ oDly eticlogicul fat^bor that can be elloited iu a nujnboT of 

tkecutt. The two most potent organianis in thi» causation cf this variety 

dne^philitis 3u« the piicuiuoco4?cua and the int^u^ uza ba^illua. Although 

lb* Drgauifims aro not alvays found afi«r death, there an? uov Ucklng 

ana it; which they ha\e been found. Whc-ther aiich encephalitis is due 

IB iJte absorption of toxina which ave the result of bacterial a^^tivily io 

iaiD« distant crgati, euoh n^ ih*t lungs and the uaso-phnrynx. or whether 

lE u d^p^od^Dl uixiTi loc-al action of the bacillus^ caunot he aaid. Aout^ 

tfiscFrjiikgic eiiicejthalitis ocfura in conn»?tion with othpr infectious dis- 

«Mi^ particularly epidewio cerebrospinal lueuingitis, typhoid ajid typhua 

Itrtn- In a number of co^ea it ocrura sequentially to ulcerative en- 

dtcvditis. It occurs al^o iu conjuncticu with the puerperal statei nl- 

tbaqfh it is not improbalile that some of the Oiises that are deacrihed 

rnider this caption are in reality cbkas of aepttc embi]li. I have seen 

iwolypical cases of the disease occur after heat pi-ostration. It may 

onr coeKiftteoUy with intlatnmatioii of the hiain covering and with 

IhntabiMis of the sinuses. Acute abscess of the brain is often sur- 

iDiuide*! by &n area of acute hetnonhagLe oucephaJitLS. 

STmptonu.— The syajptf-^ms are variable and depend upon the intena- 
i^. l<r*LHiu, and e*tfut of tlie patbologieat priKieat;, UsuBlly the,pre- 
iratiitory symptoms are those of genera] iiifectiui:- headache, laasitude, 
BWital imtahility, and vomiting- Theae precede the development of fever, 
^htih may reach I^)5'' or 10!> ■ F. Evident'ea of irjitation, impairment, or 
abolkkn of function of the parts of the brain that are involved then 
mear. Tliese phenomena are predominantly F)arB]ytirf although oci^- 
maaXlj they are ronvulaive. Tliu paralysis may consbt of ujouoplet^iai 
<r hemiplegia, partial or complete. Some variety of aphasia or hemiaa- 
<^ianiaT ocrur and bespeak invol^'emont of a correapoudiuj? specialized 
flvticAl ar^a. Tha mental faculties are ol^ftcured^ even up to complete 
<DiDL The general symptoms are those of an acute infections disease. 
3ja|jtomaof meningeal irritation* Hurh as stiFFness of the neck, pin-point 
popiU, and h^TK-rsEsthesia, are not usually preaent. If tlie seat of the 
bemorrhigic inflauimatory condition is in the j>onSf the oblongata» or the 
ecfsbdliun, focal symptoms more or lees characteristic of diffo^ lesion 
of ikrae parts, in addition to ihoac already de^enlted, or aj^art from them, 
tin be present. The i-ourse of the disertse in the majority £»f cases is not 
■aiorcaly progreaaive. It is characterized by periods of exAcerbations 
ud retbiasions. In thia way the duration of the disease may extend over 
Ljieriod of from many weeks to several months. The average duration 



is about BUteei) days. AhbougL lli« progLOsis ta jpay**, it is probable 
that ftt leant one-half of the rases emi in recover}'. Very abnipt onset, 
high tempprrjiture, and luteuse focal »>mptoma are signs of (Un^«r. 

Treatment. — ^The treatment conaista in BiicurJngahaolute rest and free- 
dom from all aimoyingand disturbing t; laments. This can best be obtainod 
by putting the patient iti a large, well- I'sntila ted, darkened toooi. Tbe 
head shonld l>e env^eloped in ice-bags, whili^ derivati^^ tri>atm^nt in tha 
shape of a promptly actiug cathartic, aui-h ar) c^mtoti oil or t^alomel, fal- 
lowed by a brisk aaline purge, can nob be given tooqiiinkly- Tho endeavor 
shovild he made to siimiLlato the funi.'liuiis of ther^km and kidney e, in order 
to fa(*ilitate the reuiuval of waet^ prodviGts> If the patient is ri^orooB and 
robnat, utd not an ^cffiot, local bleeding by the application of wet-eupc 
or lH;c'htii4 Nboiild 1h^ employed, Hut if the patient's physieal eoTidition 
has been weakened by previoua a/rut^ disease, such as indnen^a, thesA 
severe measures should nob be used. The diet should be of the blandest 
and most assimilable kind. The intense headache and elevation of tem- 
perature are be8t combated by the aduLinistTatiou of pheuooetin, salol, 
and antipyrin Quinine may also he given, but in small dos^s, aa ill 
phy^iolo^iral cLcliun IH to cause liypcru^mia of the brain and verti^. 1/ 
the patient is rfstlesJi, e^uited, and delirious, one of the hromiKe aatbs, in 
from ten- to thirty-grain doses, depending upon the age of the patient, 
should be given oecasicnally. When the symptonis are of an astbeaic 
eharaoter, the most reliable stiinulant is stryohiiine. The reader is cau- 
tioned agntnst thi) une uf aU-oho) and ruifeine, which are both contTain- 
dicaied. High teia^^emture should be controlled by cold ahbitinns or 
cold packs* Foi^al symptoms are not amenable to treatment. The in^ 
terual administration of men'ury and iodide of potassium && antiphlo^' 
i\c3 can bo of only very slight use. If the disease pasaea into a subacute 
or mora or less chronic pondition, counter- irritation of the skull over such 
parts of the brain an Ui« symptoms indicate tu tie the seat of the disf'Ase, 
aad the internal administration of iodide of potassium aro recommended. 
8equclw of the disease, 8uch as pai^sia of an extreiuit^, with or without 
coutraoturej should be treated bj gyjimaKtirs, resistance eKereiaes, re- 
eduoation, and by the applieation of orthc^iedtc applianres, while mental 
dflfeuls arid aphasia reijuire the intelligent co-operation of the physician 
an'l |>edagi»gue. The previous ejiistence of aJJ area of hemorrhai^ic en- 
oephahtis prcdispoties the brain t^o other infections and diseases, a fact 
that Hhnuld not be forgotten bj the physician. When such diseases as 
sinns thTomboste and brain abscesa develop siuiultaueoasly or seoondanly, 
they shoidd be treattnl in the usual way, surgicallT. 




Chiotiic «flcephaljtis U scarcely recognized ss a clinical condition, 
DO particular cous^deratioti cif it will be given here. Patho- 
\j it maj be said tu i^ct^ui in ouu tif Ltkree foraia ^ I. Syphilitic en- 
if COQsistitJg of the occurrcaca of diEuae gammatous foriuutiocs 
[Uie gray and white matter of the cerebral hemispherea, particularly in 
ft« pay, iQore rarely in other parts of ih© brain, and eutirely divorL-ed 
booD meningitts and meningo-eijeephfllitia. The starting- poijit of the 
narfbnnatioa which consists of a round-call inliltratioQ with jrrolifer- 
ilJUB of coDnec live- tia sue cello with nevr vascularization, ia the tela 
ekroidea and tlLa-blood-vcssels^ il. Hypcrttophic nodular gliosis of 
lie brun, cotiaisting of a hyperplasia^ of the neuroglia cells and 6bres 
tNdiug to gradual atrophy of the nenrouBj associated with perivascular 
duD^^ of imknowa cauiiatiuii And d«ve1opmeu(.- Trim tuberous gliuBLs 
V not an iudammatory dbease. Conditions siuiulnting it oocnr from 
^berited syphilis &i:Ld insular sclerosia. 111. Diffuse sclerosia of the 
irziiit, which occurs uuder two couditions: (n) as a tcruiinal stage uf 
«har condJtioufi^ such as inherited syphilia, around aongenital and ae- 
^Dtnd defects, such as porencephaly and spots of softening; and (/>) aa 
^modary to acute, nun-pundeut eucepb^itis. WhL'bher or uoL difFuae 
nlerDua of the brain occurs as a jitimary affection is very debatable. 

The rules for the treattuent of syphilitic eucephalitia are embodied in 
lie renarlcs on Uie treatment of eyphilis of the nervous system (p[i. ;^0- 
3$|. Hypertrophic nodular scUroaia is practically an undiagnostio able con- 
Ajtitti. It may be suspeoted to exist in yuung children who are epileptic 
ud idiatic, particularly if there are any anomaliaB of derelopmout or con- 
^ital tumors. It is esaej^tiaUy a gLiomatoais and entirely uaamenable 
to my fcrrm of treatment. Tho treatment of dilTuBO BoleroBis of the brain 
i^is oal J be spoken of when this condition ia sequential to acute encepha- 
lida. In other t'onditions the diagn(jKis cnunot he made with any degree 
tf t^rtoinLy during life. When diffuse acleroaia is suspected the treat- 
cnrat that ia indicated is the administration of remedies that have a rcpu- 
tttLon of being inimical to neur^Iia and con nective-t issue proliferation, 
■odi is silver and arsenic^ the removal of all L^onditioas that cause UH' 
ntreaiary eaipenditure of bodily and mental energy; and the adoption of 
OBuaies to increase tlie palient*a nutrition. 

Bbativ ABdCEsrt. rtrnuLENt Bncrpgalitis. 

?aniknt encephalitis results from the activity of pyogenic organisms 

ifaratn BubBC&noe. When the inflaniinator; prcjceas is cir<^um scribed, 

the pus mora or leaa couhned to a distinct area, it is vailed brain 



absc^Bfl. When it ia not liioited or fiTminacnbeJ it U called brftiit 
absoefls too, aithoiigh it should be called diffuee purulent iniUtration. 
But as theae two oonclitionH are not clinicalJy separable, it ia of no im- 
})OrtaDce to luake anatomioal disiiTimi nation - 

Of nW the dineatiiir'M to wliirti tl^»i brain ia litibler abaccstt oC the brain in 
hy far the most important from a therapeutic standpoint. Ita cajisatiuti 
XB reasonably well known; ita j>athology i:i cLoarly undoTatooid; and it& 
treatmi-nt calla fur but one meoBure- Loft aJoikc, it le^a to death from 
sepsis and ajchauation, from rupture into the ventriclea or on to the aub- 
etaiire of the bruin, cr from n^ute hydrocrphaUis and iiicj-eaavdincrafi^nial 
preaaure. lustaui^H h^ive been recorded in whii;h abaoeaaes of the btain 
hare terminntoi apontaueoualy in recovery, either evacuating themselves 
through some abnormal o(>ening in tho Bhull, the lesult of injui^y or 
caries of the bone, or through one of the natural openinga, euoh aa the 
Eustachian tube and naaal pasaagi^R, the pathway into them iM^ing formed 
through eariea of the bone. A. sfeond nLanuer in which abfit^ei^jtes are 
said to have terminated in recovery ii by the eneapaulatinn of their con- 
tents and the gradual shrinkage of the absiiesa wnll. If this really ot- 
cura, it ia very rare. It may theiefove be truthfully said that the ter- 
mination of absctss of the brain, if unJnf^rfered with, is In death. This 
knowledf^e makes it iut^umbent u|>on t)je jihy^^idan to ^[larti no lime or 
care that the diaguoaia may Lie made, in order that the one measure in ito, 
treatmenti viz., surgical interference* may have a fair opportunity to 
proT© ita eflicacy. As the moat important factor by far ia the diag- 
noais of brain abaceas ia its etiology, it behoovea ua in disonasing the 
treatment of this diaeaae to give the csimative factors careful atteDtion. 
Until a few years ago alMoerta of the brain waa considered one of the rari- 
tjea of an individual'-H experience. The last decade of the nineteenth 
century baa shown that next to meniagitio it ia the commoneat intia- 
otanial dis^aae^ Hand>in-hand with the wider recognition of the diseaae 
has developpfl the capacity to cope with it. A few years ago the hojie- 
leaaneaa tif cases of brain abwesa waa appalling. To-day, if properly 
diagnosed and skilfully haudled, sut^ical tteatmeut gives far greater 
prospect of relief in this than in anyother intraoraniol leeiou, 

AbGcess of the bram ia [?linically and anatomii^aHy either acute or 
ohronic. Clinically the a*^ute abscesa la cbaraf^terJzed by tbe cardinal 
symptoms of increased iiitraerauial pressure to which are added the symp' 
toms of an acute BCplic inHaiumaticn. Anatomically it ia (character- 
ised by the abafuco of a (.apauJc or limiting raembrancj which separates 
it from the surrounding non-inHained brQiii tiaavie, . The intiammalori' 
process in acute abseesa of the brain ia one of transition from the centre 
of the niiw'esK, wherein the indanimatory products are wholly punileot. 
toward tho peripheiy» which is aurroundc^l by an area of hemorrhagio en- 
cephalitia. This circumferential hemorrhagic encephalitis may in turn 1m 



SQapdiDii by a zone of scroua infiltr^tian. Cbtonic abscesses are ch&rac^ 

Mnd olioioaUj by their protracted courae> and hy the absence of febrile 

fbttomena^ albeit the remammg symptoms of abacess of the braiti exiat. 

iaatomieaJlj they are distinguialied liy a capsule or limiting TuemhTaner 

«kkh isparabes them U-oin tho iiurrouciiHiig tissue. This u^etitbraue may 

\bbq delicatft that it la scarcely diBCsniible, or it may be thick and re- 

laUut the t«sult of organization. I'attkologioally it is an expreasioTi o£ 

alumuatory reaction in the normaJ tiseueB, and it is to be looked upon 

win effort OD the part of BBtura to limit the extant of the destructive 

pffflS- Nature's elTurt is abortive, however, iii almost every iuatance, 

brclhiis been proven iLat aucIi eucapBuIated ahiscesAes almost invariably 

mtfunlly increoae in size at the expense of tho suirounding tissue, and 

l»t relieved by sitrgioaJ interference, end in death. It has been ape- 

OODflly oootended that this encapEulatiou of the abBcesa makes it danger- 

Ibu, and obviates the na^essity of evaoaatioa. Such teachings are rnost 


Stiolo^^ — The causes of ahsceas of the brain are direct and indirect. 
Tie dinct causes ore the pyogfcio ci-^aai5ioBf of which the moat impor- 
tui ue ataphylocoeci and strpptocucci. The le^s important ones, buc 
B*^'eTtb?IeM the direct i*xi?icnius of purulent inflammalion of the brain in 
ajffis iasiauc^a are the (gonococctis^ the diplococcus pneumonia:, t,he tuber- 
cle btcillua, the colon bacillua, the bacillu-sof typhoid fever, and the acti' 
tufujcefi' ^Occasionally the parasite oidium albicans is the ditect attrib- 
M^ Can^e' The staphylococci and etreptooocci are by far the most 
iBportuit. When they are present in a certain degree of iuteneity, 
lutrolsiiy if tlia nntritien of the brain is lowered and the resistant 
ftfTCa of the tissues are weal\eneii, tht^y invariably cause brain abscess. 

He indirect causes of braia abscess or the apparent causes are the 
mmi Linpartant, because if they did not exist, the direct esoiting causes 
vt butertal causes would not exist. In other words, the indirect causes 
ni ilxr^^s of the brain are tho^e froru which the pyogenic organisms set 
mi fv tlie brahi, or tbey are the couditious that allow the entrance of 
&p^£eujc organisms into th« brain. These indirect causes may be 
littiiadaa follows: 

1- Tmama, Injury to thecephalic extremity, 

Z Suppurativa process in any of the cavities of the skull, {^tij Otitic 
ujfjJuntiTO disease of the middle ear; (A) Rhinitic suppurative disease 
^tbeaaul aud accessary pas^agtiH. 

^. Hetaatatic abscess. Suppurative process in the lunga and ulcera- 

1 Tuberculous abscess. Retrograde and pyoge no us change in solitary 
U^ cxrnglanierate tiihei-cle. 
S^ ^bscrss depending upou the oidi^un albicans- 
InjtLTy to the head is numerically one of the most important causes of 



brain abs(r«S£. It is VHrbiiHly RNtiJimt-e^l by fliffei-entwritHerHat from fift««n 
to fifty per i-eot of &I1 the cu^es. Il> i^ probable that from one-fourtli to 
Olio-third of all cuaed of brjiiu abscess are of this origin. Trauma to tho 
copbtdio extremity may contribute to the ocrurrGnce of ab3oe>ia Id two 
Wfiya : first, by prodnoing an op^n wound, exposing the outer table of 
the Hkull, vhieh gives the pyogenic organinmH coming from mtbout & 
direct patUvay to tliu brain. Brain abscess tliu:4 conditioned usually 
develops wibhtn a short time after injury, oftentimes befoje the euj^r' 
ficial wound is completely healed, and it m mediated by extradural m- 
flamjuation, whicli may or may not he purulent. Snch abfit^^Bsea ate 
commonly of the aiip«rticies uf the ^rjrtex, oftt^n immediately beneath tbe 
leat cf injury, and are but a part of tL gaiieral circumacribpd puralect 
liifiaEumatiuu, involvujg the pia as well- Thin in the common vay in 
which trauma caused absrcsd of tho brain. Second, occasionally in- 
jury to the akwll, which do«B or does not oause an open wound, may 
CiUfle disordered va«<»ularity of the brnin or certain parts of it, whicli 
bIZou's pyogenic organiams which mny have had a focus in nome ooe of tite 
adjaceDb skull cavities, to caitsa purulent uiflammatiou, which would have 
been rc&iated were not the parts made vulocraUo by the antecedent 
trauma. It id in thi^i latter way in aEl probability that anuient trauma is 
operati\'e to tau^e biain abscefiB. It hua L>e€ii proven beyood question 
that Hii^h trauma ntay antedate tha otvnrrence of abscess, i>r iit le^^Gt t^ 
manifestations of absi^esx. fcjr many years. \:i some of these the rf-mote 
trauma has no part in the r-ausation of the absceas^ but in otliers ita 
pathogenetie rMo (and in the way above indicated} cannot be doubted* 
The varieties of injury most likely to cauae brain abacc^sa ore those ia 
whit^h the injured tiasuea are lacerated by something whioh carries tiie 
iiifective Mub^tallpe wiih it^ thiiH penetrating wounds i)f the orbital €&%' 
ity^ punctured wuunda of the epicrauium, which penetiate tie Sikul]-ca|iy 
ajkd compound fracture of the skull £TC attended with greater liability 
to thia aomplication than are wounds produced by the surgeon. 

The importance of purulent disease of the middl« ear iind of purulent 
profieflB in thf^ tfutjural bone in caitsiog brain ahs{!?!44 is universally rec- 
ognized. This class of abHceHses^ indeed, form sui.'h a conspicuous part 
that they are known as otitic brain abscesses. The frequency with which 
abacesa of the brain follows chronit: suppurative disease of the middle ear 
has been variously estimateil. The consensus of opinion, however, of neu- 
rologists and onoToglsts is that about thirty-five per cent ef all cases an 
trainable to this affectiou. Coiiaideriiig tlie curahility of chronic otilia 
media, this is either a redection on the skill of the aurist or an indication 
of failure on the part of the general practitioner to point out the danger 
of ijuoh auT^l eonditionj^ to par4>nts. When we considpr that suppurative 
phlebitis occurs sequentially to puruleat middle-ear diseasea about as 
ftvipiently as does brain abaness, and that purulent leptom^nirigitis fel- 


Vw It &bout one-half aa oflea, il is rectiiily s^^ii how serimm this iu iUelf 
omparfttiTely slight affectiun u\ay beionie. At'utfi puruleot diaeaee of 
IbA middle eat hi>Ids a more importaut ciiusative relatlouahip to brain 
tktOMB than was formt^rly su]>|>OBed, Recent elatiatioe show that this 
Itfttt cooditiOD ia responsibie for al'out twenty per c^nt of otitic brain 
ttvMWH. Usually tlj« aural iMnidiLior) is uiie of aevaral years' statiding 
inii Elf but trifliog annoyance to th« patient- In fnrt, in some casea in 
iluch btain abscess baa been tlio rC9L]]t of this dbcasn, the AuJT<;rer has 
othtf completely forgotten the euutence of a pamlent discharge, or 
doiied that former ^At trouble had existed, evpii after exan^iuatJon pre- 
noti ta or folloviug the operation hud shown u]iinisl.akable symptoms 
of ptch dUea^e. Brain abficea^ OependeDt upon ear diaeaHG Lfccurs almost 
ilwAp in infancy and early ad;tlt life, whi<?h la in keeping with the fact 
thitU»ai^ut« infectious diaoases of whii?h suppurativ'Miiiddle-ear disease 
II oMottnnatcly a common sequel, ocour nio^ frequently at this time, 
Tha middle-ear disease may or tuay nut be associated with iianes uf the 
hoflT at uctiiie ill which the miildle ear i^ situated; but a» a rule when 
^t aU&ceflfl occurs seqtientially to chronic middle-ear disease, caries of 
ilic b>De coexists, Hnc of the most dangerous v.arieticB of purulent 
middle-ear disease is that asaoclatad vith eholesteaUmiatcus deposits in 
tM xmt of the tympanic cavity. Otitic braiik abscess may be secondary 
^ conBtoid involvtment a»*l to septic iu Bammation of Lhu lateral sinus. 
Tlvy are of more common uivurreiii^e on the right ^iirle than en the left, 
tIi^ i» due to the fa^t that the bony walla ixio thinner on thia side, duo 
b>th« greater depth aod eise of the mastoid fossa. 

Rhiaitii: braio ab<;ce$ses are, compared with those occurring from 
poialent mHammatum in the middle ear and its accessory eAvities, of 
cooipar&tively lUK-oinuioii ixri'urreufe. In the casea of ttiin origin the 
Iiurdent focus is commonly in tbe upper nasal {>aAsages or the fi ontal, 
tttiowidal, and aphcuo-maxjll&ry siiuieeB- OocaGionnlly, tb*j origin uf tha 
poritleat process is sequ^tttial to some operation which in itself is looked 
npon u ftomewhat trivial, such as the removal of polypoid growths fporo 
thi nisal passages, and scraping uf one of the sinuses. In a few i]i- 
itlOCfS it has followed extraction of oue of the molars, the pyo|^enio 
^mcFU cvtonding to the antrum^ of Highmore, and thence to the otbitai 
ntitiM, snd so, by tbe production of a septic phlebitis iu the orbital 
fom, to the brain. In a similar waj^ phlegmonous pio^e.^s iit the orbit 
Einua abuc^B of tbe frontal lobe by an extension of the periostitis along 
the inner aod upper border of the wall of the ethmoid to the OlaBerian 

Hetastatie brain abscesses constitute about one-fourth of the entire 
Dtiiaber. Septic nietastaaia is so common from the thoracic organs that 
kun abscesses of this origin are frequently spoken of aa pulmonary brain 
iWMHeH, Tt hsfl bei^n (<ont«rjded by some writers that tho brain la tho 



eidiiHive R^ii^ of m^LasUtio furiuatiou frouj puniknt lurigB, and that xhtt 
[ueta^taLiD kmi wludi iteult ni€ iki^'txyn multipk. This, however, hsa 
hoen coiii'lusirely dia(>rDvciL hy tbo iDVostig&tioEia of Martins, nho found 
that ia t^'eoty-tn'o o&sea in which pLimletjt disease of the brain occurred 
seooudarlly to pulniouury dise^i^Pr La six. there vsls uietafitaBis in other 
orj^nSf and in nine instancpa solitary al^scess of the brain waa Eoirnd. 
ThiH ia entirely in keeping with my owu expeneni;e liuil with that of 
mofll I'fcent vrriterBn i.lcv^oaioti&lly brain &b«cea3 results hy juelaataai^ , 
from other organs of the body, snch as the iutestiuee or Jiver, very rarely 
from osttKiniyelitia of the lon^ l>one. The diseuae^with which it htiA b^eii 
demoTistraCed tliat brain abscess is ai^aoci&teJ most frequently ure puru- 
lent brDUEibitis and briMichiectasid, gaiigraoe of Ui« hingH, purulent pleu- 
risy, and uloerJLtiv^e enducarditis. In BOme of the so^i^alled pulmonary 
brain absoe^acft lung pigment and el^tLti libreti hare been foiukd in the 
brain, . * 

TubercuJoTja ahsc^ydea of the brain oonatitut* fiom five to twi pepcwit 
of the entire number. Formerly theae abscesa^R were clanaified sa idio- 
patbiis brain ab^cejises. They are the result of caseation and liquefactioiL 
i>f solitary tubercles or tuben.'uloua conglomerations which experienoo 
superadded pyogenic visitationt eitlier from tuberi^le bacilli or from aom^ 
more potent purulent excitants. Formerly it waa thought that tuberclo 
bAoilli were not jtyogenio organisms, but this view ia no longer held by 
Pathol :>gi^t^. Among the infections that have been followed by brain 
ab3L-d»3 njdiy be iL^entioned thoae of the inSueu^a IjacilluR* the cocoub of 
arysipeEas, and thi; diplococcua intraccliulftri»> 

The caefe associated with aphthm, in which the oidium albicaos was 
found in great numb^ra in the contents of the abecesa, have already been 
mentioned. A peHaiii number of caaea of abacess of the brain occurs in 
which none of the causes enumerated can be found. It la to these that 
the Ujime idiopathic htis bi'eu givon^ This class is cx^nstmLtly growing 
leas, as bacterioEogiBtu are demonstratnjg tlie pyogenic propertzen of 
orgauifims that were formerly considered to be lacking this paruieiouH 
quality. Naturally, geuuiue Idiopiithic brain abst^es^^es do not eiiat. 
The use of the Cerm nierely siguitiea that occostoually ab^tcesH of the brain 
o£ unknown causation occurs. 

The &eflt of Brain Absoeii. — The location of bmin absooas etanda in 
deEiiiLte relationship to Ihe origin of Its cs-usative faotora. One of the 
moat encouraging featui'ea of the therapeutics of brain abseeas is, that de- 
spite the absence of acourabe Fi>cal or localizing brain aymptoma, we may 
eatim.ate the seat of the abscess with considerable accuracy from a careful 
oonaideration of its origin. In a general way it may be aaid that the right 
side of the brain is more frequently affected than the left- This i& espe- 
■dally true of otitic brain abaoeasea, the reason therafur having alr^^dy been 
mentioned. Ahsi:eases due to disease of the middle ear are almost always 


FiK tkkat: 


fllmtdd on the simie eide as the purultint prtx^esa from which tihcy origi- 

nte. Their location ta either in the teTnporaJ loktea of th? same side or 

ta the oerebeUutn, about thre« times ofterier in Uie former than in the 

Utter. This predilection of thn teiiipoial lobes adiI rertfl>el]um to abscesr^ 

Tfauliiag fiooi luiddlu-ear di^ea^e ia de^JcnUeut ou a utimber of caiiBeHf 

de stost ptoiaiaent of whi<;h aro the thinaeea of the tympaoic roof and 

tb«grMer liabilitj to implication of the dura ov^r the antf!nor surface 

d ihe bone ihan that over th« posterior wa31 cf tlie middle ear. It has 

Imh dafinitrij proven that when the prlnjary disease is in the sup^rinr 

tiQ of the middle ttij^ the reHuItiiig braiu abace^a is in the temporal 

Ijbf i while vhta the posterior auiface of the petrous portion or the inner 

bcrdtr of the maatcid prooeas is primat-iiy involved the abscess ia likely 

'^>b« m the r«r«bel]am of the same Bide, This apparent elei?tiveuess is 

ikj^udent u]inn the diSert^ut distributions of the veins sJid lymphatics 

fnB the various parl.Ji of tlie middle ear and its imni^diate bony envi- 

louEttt The dura and bram subatauco between the primarj diaeaae 

ol lJ)« eu and the abscess aie frequently thcmaelves tho seat of the dis- 

rite, and oftentimeit the dura, the pia, and the purulent collection in the 

ron*! are matted together with pnrukrt matter, forming one continuous 

vma9. In thiise cases in which there ia healthy brain tissne between 

ikibacess of the temporal lobe and tho petrous portion of the temixjral 

btQ» it \a probable thnt infection iikkea plixoe tJirough the veins that enter 

nito die superior petrosal sinus, or through the perivascular lymphatics. 

JiilnnJly, brain abacessea of otitic origin are sometimes found in other 

pvt9 of the cerebrum, such as the occipital lobe, frontal litbe^ pons, nud 

iwbral peduncle, but compared with the frequeuej of oi^urrence in 

ibeloHtious lueulioned, they are yery uncommoa, Iv the cases of ab- 

loeMSfrom ear disease io which the dura and brain bu balance between the 

Bppi^r bony eovenug of the tjmpanio membrane and the sbscess are not 

dMWd, there will ba found In some eases s. tbrcnibosU of the veins and 

(be nrrits^ which establishrs a direct coinrnunieatLon between the original 

ii«lioa and the al.4H.<esHr or there riiay be found a purulent infiltration in 

Ibe iheatha of the seventh and eighth pairft of u'^rrcs. 

Absceasea due to carious prorei^gee in the sphenoid and ethmoid bonra 
icd tbosfl resulting from purulent inflainmatioD of adjacent r^.avities, 
riknilio brain abai^esse^^ ar^ almost always of the frontal lobe. Twenty 
mt§ analyzed by Dreyfus ahowed that nineteen were in the frontal lobes 
uioae waa of the temporal lobe^. 

Rrftin abscess due to trauma may ocour on ttie aide of the iLrain wbioh 
ba been the seat of the original injury, or it may occur on the opposite 
lidp- Although no such clo^e connection exists lietween ewrtain parts of 
llje brain and the liability to abscesu therein following trauma, as exists 
in «r diseaiea, it may be said that, as a rule, abaoess of the brain fol- 
Iwag open wound of the epioranium and cranium is I'ery likely to de- 


velop dire<?tly bent^atli tlie 8i?at of the womid or its imniediale eoW- 
roomenl. Moreovf^r, sirnh aijBcrases are usually IwRted in the uortex cf 
the brain, Ibe puruleut piuteAs belu^ umre or lean coutinuous witli that 
extendiitg h-om thti wound. On the other hftud, abscess of tho brain 
reaultiitg from trauuia and delayed in its de re lopmenb until after complete 
repair of tha wovind, ptirh^ps utonths and even years after, is apt 1o bo 
more deeply situated and as liable to be found in tlie poles of the brain 
as any where elae. 

Uetftstatic btam abaceases are much more couunon in the left henai' 
sphere than itt the right. Their OBual location is in the dietributioD of 
the artery of Sylvlue. Those abBceaaes being of euiboiio origin, they 
ofy.'ur on the left side of the brain for the same reason that ordinary 
<rt<rebra] emboltHiii duf^e. For the eaine rflAHon likewine th^ae abscesaeft 
are more liable to be found m thii ceuLral ganglia ai^d mid-braiu thaa aro 
abscesses of other ori^. Tuberoulous abaeesses have no apecial loca^ 
tioQ, except that they are almost invariably deep-seated, situated between 
the gray matter aiii the while. 

Abeiie.Hses I'unHecutive to uli^eration of any uf the rranial bones sjid to 
oranial oateouiyelitia are usually situated immediately beneath the origi- 
aal pro<^es9 aud aaaociatcd witli, cir coneeeutive to, epidural abscess 
and aeptie periphlebitis. 

AbB<~'ess of the brain not of inetaatalie origin Is usually single, and 
varies from the Bixe of tha end of a finger to that of a fist and larger. 
Mt^taat^tio abacesaeEt are not infrequently multiple and of very diifereiit 
ai^e, the fooi of anppuration having no communication. Von Bersmann 
baa reported a case secondary to gezieral pyi^mia ia whic^h more than 
a himdied fooi of suppuratinn were present. The color of the pus, 
the odor, the specitic gravity, and other phyaioat rharflcteri sties depend 
ia these easea, as they do in all other forms of purulent formations, 
upon the cauaatiivQ fartora. Wlieu the deatructive prouess has been very 
rapid, the color of the pus ia reddish -yi?llow. This is due to the presence 
of ooasiderablo disintegrated tissue. ' In some eaees a disagreeable odor 
ia very pronounced, usually due to a special banillus, the bacillus pyO' 
genes fetidus. Wlreu the pus is groBnish-yellow, the bacillus pyoeya* 
neus is responsible. 

It has before been said that it depends largely upon the ra]>idity with 
which the piTmlent proeess develops whether or not the absi-'esfl will have 
a limiting membriine, that ia^ be encapsulated. If the process has devel- 
oped rapidly, and if of moderately short duration^ there will be no abscess 
wall. The pr<jc:eBs of infltratioji will ta|>er off from the centre of the 
abscess cavity where the pus is entirely purulent toward the periphery, 
through various grades of iuflammalory rpe<*tion, Such alwcaaea ar© 
eomoion in the cortical gray matter and are often associated with diffoao 
purulent meningitia. In cases that have been of moderately etow deveN 



iCand of considerable duratiuu, pua 'pvill le surrounded bf a capBult* 

Of less difficult tQ penetrate. >'o doubt Burlj abBceaae-s often temaiu 

Lt for proki&ged periods, giviEig riae to no eipressioa of their exiet- 

but Ih^Tfl BTP graduiilly gcifig on a prix^'fa of attrition in tKo rapaulB 

th« it»3cess and a slight inrrtffisti of tlt« &iMC.esB carity s.t tliv I'xpt^Tian 

tbe suETOundLDg ti^soes, which eventually cauae its rupture iikU> one 

the 1^ttHtie3 of the bram or on the Biirfucef which provea fatal- Thin 

ij go OQ fio slovty that^ the patieut has no cogniimncc of illneas, I du 

not mttn to dan^r that tbe Umiting memhrai^e which eucapaulatas the 

ibves is nnt somftiuien rapsible of hringinjf the activity of tho jiLinilent 

Mces to A temporary t^HHsaLiuji, and that during such tini«a the pua 

brvosa more or lesa sterilSf perhaps completely bo; I merely wiah to 

iKDphuise the danger of looking iipoo such an abseess aa a benign and 

iufl[erte9s conditioa, 

SjIBplemt. — The symptoms fif bmin alfBcesn are briefly: 1, Those due 
lo ihe iafetli[>us i '2, Those of iutiacrajiial preasure ; and 3, Fotal eyn^p- 

ktuifl(. The first symptoms ate present only in the acute abaceeses, and 
nuistof ri^ra or chills, with irregular fever, malaise, meotai irritabil- 
ity, and physical depression. Those due to increased intracraaiai press- 
DM ttfcnr bi»lh in the aeuto and chronic forms^ more conspiGiionsly in 
Ihe fiinner^ are headache of varying severity, usually profound and deep- 
mtHl, vertigo, vomiting, alovr pulae, and in about one-third of tbe cases 
optic neuritis. Focal syujptoma which occur alike in the acute and 
oltraiic brain abacus 8 deiTend entirely upon the part of the brain that 
if mvolT«d- Abscess of the frontal lol>e3 may or mny not be ae^yimpanied 
h^t degree of mental obscuration. Abscess of the motor areas will be 
itteuCed by corresponding paralytic manifestations. Abscess in aoy part 
of tl^ zone of Languago will be attended by eymptoms which benpeak en- 
PHiutLnieDt upon the various specialized ai'5as o£ which thia zone i^ made 
Ei}>. AbH^^ss of Che ei>r^belluin is often attended by such profound mani' 
feaULioas of veHigo aud iiU!>>-ordiTi;iUon that they are instantly snstiected, 
hit often, unfortunately, tbe geueml profound lueutal and pJiyslcal 
utbfliiia preventfl tbe patient from maldng complaint of these, and tbe 
pt^nnan from making tests to ras^eal their existence. The two most 
nnportaat symptoms aside from the focal symptoms are headache and 
lapraaaing apathy. N**it to these is the diasociation between the pulse 
ud temperature rate in acute abscess and Uje subnormal temperature in 
(boaic absce^. The moat important elements in Its diagnosis are con- 
tidnation of its cause and its bearing on the location of the abscess, due 

(iitftfptetation of foeal aymptoms, and recognition of the symptoms of 
iTitrtcnnial pressure. 
Tnatment..^ — The preventive treatment of brain abscess is so impor* 
taltbat itcannot be easily overeatimated. If it is kept in mind that 
ttluBt one-third of all cases of brain abscess are due to a disease, otitis 




m«lia piji-ulenta, which is ordmarily not looked upon as one dajtgerous 
to life* and which in extremely anmnable to treatment if handled at tlm 
prop«r time, that ia m the bt^^itJiiLag, it is readily aeea that this ccndi- 
tbn is the one whioh demands urgent and careful attention from the 
phyBician- Lrnfortunately, acute purulent otitis in a very oonimon con- 
dJtinii, aud familiarity with it has bred eontempt on the part of phyai- 
ciaaa and parents, bo thar* it frHijuently {laAaes into Aohrmjic conditioii 
merely from liiuk of attention to rest, clean tiDeBSf iiiid local appli (nations, 
euch as heat or cold, to combat the infiammation, and paraeent^aia to 
allots free ili^chor^e and draiuage. More unfortunuto yet la thdfaf't ihttX 
when the chronie stage has arrived with itH frequent accnmpaniiiienta of 
cholesteatomatoiis deposits and condensing oHrfiitia in tha attio of thfl 
t>uip&j]Lim and in the mastoid cells, the getteral {jractibiimer is ■.^oiitent 
to temporise witli trrigatione, inau{Hation of drying powders and tlie 
applicationa of astringenta. Just bo loni; at this conditiDU of affajn 
remains aad the tadionl operation, aa deviaed by Staelfd and modified liy 
Sflhvvanze — in other words, the Stack e-Schwartae rodieal operation for 
tho cure of chronic Buppurativo frho^esteatomaloiis middle-ftar diflease, 
which haa r*^coived tlie approbation of the otological faculty — is not 
itiaistod upon in these cases, jn^t ao long wdl brain absoesj^e^ continue to 
occur as the sequelm of this tiorulttion. 

The prophylactic treatment of brain abseess due to trauma of the 
epplialic extremity and oi^teomy^litis of the cranial bones lias made ^eat 
progress since the introduution of antiseptics or modern surgery. Jlrain 
abscesses eeqaentiol to these conditions are gradually beconaiug less f re- 
qiiontT as it is reco^iEsd bow importaat it m to keep wounds of the scalp 
Hod cranLum in an aseptic condition and that wounds of the dura ehonld 
bo freely opene<l, drained, and renilered aseptic. No precautionary meaa- 
ures wdl previ-nt metaataaia from a gjtngrenona lung or an ulceiated endo- 
cardium, nor due [I treatment seem toicbinHu^nj^aand the specific bacterial 
diseases of theif oocaaional malignity in causing thia dlaease- It may be 
aasumed, boa^ever, that measuroa that oonteibiite to the maintenanoe of 
bodily vitality tend to prevent all fomplications, brain abscess among the 
TRSt. The same may be said of inainteuance uf (be circulation in children 
with patency of the foramen ovale in the propbylaxb of brain ab&oa»s 
occurring in "blue babies." 

Brain absnesaes will coatinue to oceur despite the most rigorout 
prophylactic treatment. To ovOTtome them there 19 only one meaflnre r to 
enter the skull, evaluate the aliHcess, ele.an8e it thoroughly, and drain it 
At the present day, when the relationship between the sources of rnfee- 
tLon and the location of the resultiug abscess is fairly well known , when 
the localization of the abseesa can be made with considerable exactitude, 
even though striking focal symptoms are not present^ and when the 
lec^bnios of cranial surgery hare reached a fairly s.itisfartory degree of 




perfection to deUy openitjg tlie shiill^ not with a flinall trephinp, as 
nnfortnmately ia ofteo done, but with a large generous bono Hap tbat will 
expose the aurfaod of the brain hb Jaige as the palm of tJie baud, if needs 
be, is ona of the must glairing farme of malpractice. More than thifli it 
nastters not whether a dia^oaia of the ex^at looation of the abs^^ess oan 
be made, the neceBHity of eatering the skull cavity when one is reason- 
ably certain that brain abscess exi^U, and followtiig the patLways of 
infection until it is found, is a duty that the physician cwos to bis patient. 
When focal and general eymptoms bespeak ccitain involvement, the 
earlier that portion of the brain is laid opep the greater will be the 
chances iif repnverji for if the physician procsrastinatps bw^iiise of an 
indefinite feeling that the diagnosis ia ill-foundei], or of an iU'dAflned 
sentiency that something miracuJoua will happen to clear up the symp- 
toms, the disease will have time to make such inToads on the vitality of 
the patient, both hy increasing intracianinl preaaure and by causing de- 
struction of essential parts of the brain, that the shock alone will be suf- 
floient to sever the patietit^a hold on life. 

Conftidering the frequency vith which two localities of the brain, th« 
temporal lobea and the cerebellnm, are the seat of the otitic abscess, and 
the convinf^ingneaa with which it has been shown that primary disease of 
'certain parU of the tympiUiic cavity has lelationahip to the oocurrenee of 
pnniZent disease of one or other of these parts, it would seem the rational 
plan of procedure, when tLe B^niptoma of otitic brain abscess are lacking 
in localising accompaninien ta, to lay bare the »kuU over one or both of 
tbeee areas, eleciting for the lirat operation the aide indinabed, perbnps 
indefinitely, by certain symptoms. For instance, i£ to the usual complex 
of symptoms going to make up the history of a patient vith brain ahsoosa 
Uiere areo[itio neuritis and persi.stetil vertigo, involvement of the cere- 
bellum would be more probable than that of the temporal lohea, although 
the latter might be the aeat of suppuration and cituae these two symptoms 
m addition to the others. The first opening should therefore be to ex< 
poae the cerebellum. If after opening the skull, freely inoigmg the dura 
and exploring the brain snbstancej not only with a probe, but by free 
incision into the brain matter, no pus is found, very little danger to the 
patient^e life haa been contributed , no mote than any one would lisk if in 
ft condition to give an opmion^ considering the absolutely fatal outcome of 
this diaeaae when left to itaelf- On the other hand, in view of the fre- 
quency with wtich Thinitio abacessea are found In the frontal lobes, no 
reason can 1« offered why these areas slioiild not be fairly exposed if tl:8 
etiLilogy of the abscess has been proven. A similar argument holds good 
for the absccases following trauma capitis. Naturally, the hesitancy in 
teeoiting to surgicnl procedure wiU come througli uncertainty of diagnosis ; 
then the question to decide la, whether exploration ib not justifiable in 
the search after light- I am of the opinion that it is, providing other 



coadibiifoa eimulatiDg the aymptoiu cumplcx of brftiii Dbscossea, "nhich do 
not call for surgical treatrDent, can be excluded. But aa a taatter cf 
fiiCt, the conditions that parallelize symptomatically those of brain 
absoaaa are the verj unes lliat demand surgical treatmeDt for thetr cure: 
purulent meuLQeHis, septic throiuboaisT and btaiu tuiuot. AH Uio greater 
reason, tlierefore, for deciding upon explor&torj opening of the ekuU. 
A fuct that has been LinpreEsed upf>n me at the autcipey table is that it 
is puerile after we hare decided to open the akull cavity to be content 
with cutting a small button of bond out uf the slcull and th^n passing 
a probe or a trocar in dilTeient directions througli the brain, perhaps 
making only & alight tilit in tlie dunu More than ouce I hare seen 
on poBt-mottein examinfttion & largo bone flap, mode in tho ar«a of trephi- 
nation and thrown boJdly back with free inciaion of the durii, reveal an 
ab3cess cavity but an inch away from the plapa ta which it had been 
localized, and whit'h had eluded the searching probe. The moral of this 
is that when the mind haa been made up to aeek for the brain abiiceast iL 
should be sought for with the same determination aa ft couqucring arnij 
ferrets out bands of ambushed gnerdlasH Bram surgery has nut fulfilled 
the ptomiae In any cranial disease which it held out a few yeaia ago, except 
in muus tlu-oiiibogia aiid the disease under conaideratiun ; but here it ha^ 
more than equalled even aanguine expectationa. AH such operative pro- 
cedviroa for the treatment of brain abaceaaea aa opcciBg the mastoid and 
the like, unleaa there aro special indicatione for their performance^ are to 
be deprecated. If, on account of the abeenoe of focal symptoms and an 
inability to trace the causal location of the abscess^ the point for election 
of operation is not indicated, theo tlie general rules for upeiting of the 
skull given in any modern ti-eatiao on suigery should be followed More 
spoaitio rulee are to be foimd in &ny uodarn treatise or surgery. 

The process that goes on lu the absoess cavity after evacuation of the 
pus is similar- to that in abscess of any other pH^rt of the body. In acute 
abscess m which the process of development liae been very rapid, eveu 
before & semblance of the limiting membrane has formed, eacape of tbe 
pu3 ifl quickly followed by obliteration of the cavity from expansion of 
the brain about it. In elowlj developing and in chronic abeccesee, in- 
cn?ased intracranial tension does not facilitate emptying of the abscess 
cavity, and as the remaiEiug pua, as well as that gradually produced from 
the limiting membrane disappeais through draining, the abscess walla fall 
together and the gap heals by tlic formation of granulation tissue. As 
these granulations develop from tlie bottom, when the reparative process 
reaches the surface it unices and anchors the pia to the cortical cicatrix. 
Macewen has shown that the physical after-effects of this is akui In its 
pathological results to a blow applied to the crauinm^ It is apt to cause 
unconsciouaness* generally of brief duration, which may, however, recur, 
and be accompanied by the development of more or less surrounding en- 


CdphaHtiis. Hd thinks alao that this cerebral irritation might lead to 
epileptio fits, although no inatancea following operation for ccrehral aV 
BCess are recorded so far as I can determine* If, howerer, such a condi- 
tion of affairs should arisen a secondary operation for removal of the 
cortical acar would be indicated. 

The general treatment ia the same aa for non-pnralent encephalitia. 
Every care must be taken to husband the patient's strength and vitality. 
Pain and insomnia should particularly be combated. Not infrequently 
convalescence after operation for brun abaceaa ia a alow one, and measurea 
tloat contribute to the improvement of the patient's general nutrition most 
be pushed vigorously. 



Inb-anfilb narebral painj is the nlinic&l deBigDation of AdUtioct 
of oaacj} cliHTaeteti^ed hy the uocuireuce of sumo degree of paralysis in 
or all uf Uia ^xbreuiitbs, ocnirriiig in yoong cJtiMreu. An&U>mioally and 
pathologicaliy, the elioical picture ia dependent upcm videly ditferootcoa- 
ditione. Any hemorrhagic, degeaerB-tive, or itiA&nimAtory (.'ondition (with 
the exchiaion of the InSimiinationfl caused by pytjgenio organiaiaH), pra- 
datal, naULl, or post-natal in oocarrt^nce, up tu the time of eecoud denti- 
tion furnishes the aoatomical b&sia of tho iufantilo cerebral palaie*. Thua 
many diffeient pathological conditions, Bttended by more cr leas clearly 
defined clinical entities, ard considered here. It includes teratological and 
defective protal conditions, states of arrested deTelopment, disease of the 
braiu caused by deleteriaui4 factcrs mediated through t}ie mother to th» 
child in utero, s.s well tia tho niiany traumatic, inflammatory^ and degen- 
erative Btatea of the brain which may cccur during the first years of life. 

Infantile cerebral palsies muy he ctosaified aaeurding to the timo when 
the leaion ocrnrs; that is, the disc,i*e may be of the primary constit- 
uents dC the iutraorruiiAl cunl^ent^, of the fi^-tal brain, or of the braiu ati 
or after birth. They may alfto be claasified according Ut the Icsiun upon 
which tb«y are dependeiit. The somatia baaeaof the infantile oerebral 
palsies sometimes originato oontemporaticously with the deTelopnient of 
the primary constituents of the fcetua, and such developmental defects 
are often the indirect result of pathological herita^. The morbid condi- 
tions that are operative on the diikl during its prenatal life may re^t 
through tho vascular supply of the brain andoonaiatof inflnmmatioo, 
Boftening, disintegration, and atrophy, all of which may follow rupture 
or occlusion of the blood-vessels. The infactioua fevers which may 
attack the fretus Bt any period of its existence cause some of the congenita! 
birth paLiiita by producing emhoHym and thrombosis of the bIoL>d-vez^seIg 
of the brain, while ayphiiia by cauaing thromboals and rupture aeema to 
be the accountable factor iu from five to ten per cent of all the oaaea. 
The most importaut etiological factors acting through tlie mother aro 
direct and indirect trauma^ including under the latter the injuries that may 
result to the fi^itus from injury of auy origin to the mothan Accidental 
and purposeful injury auch as blows on the mother's abdomen during 
the later months of the child's intra-uterino life are sometimes sufflcient 
to cause cerebral palsie^n Maternal fripht^ anxiety, worry, grief, and th« 


» do not havo Jhaj reUtionahip to the occurreoce of infuitiJe cerebral 
IBM, BETO A« they c&obc impairment of tho mother^s DUtpTitioc, whidi 
^■QflCt uofavoTaUy upoQ thd ;]t@riad eoBteat 

The causes tliat are operatiTQ at Uie time of birth and a.fter tirth aro 

UMantrafalj^ more importaiLt than those juj^t mentioned. It is iinnec«s- 

try to eDUmerate all the cauBoa that maj be contributoij to the eucepKa- 

>pttthie£ of natality. They may be eummariaed in a wurd^dystooia. 

Iw lubility to injory of the brain at the time of birth ig in direct pro- 

iiriiun to the duration of labor. The dyatoria ouusen asphyxia, whk'b is 

cvoDupaoieil by a retardation of the circiilation, the injunoua action of 

rluolk is swa manifest to the brain, which is not well supplied with col- 

lAttnl circulation. The coneequencos are that one or more \ease1e be- 

^bpltii^«d or Tupturedr PoatnaUl birth polsies uiay h& due to causes 

ipEitiTe: 0) on the blood-vesaeTs to produf^e hemorrhage, emboliam, or 

llmmbosiar C^ ^^ ^^ blood'vesselH and tiasueH of the brain to produce 

CDOt^tblliCis; and (2) on themeningeaof the brain to produce inflammation 

mi bemorrha^. The acute infectiong diaeaecs, influenza, diphtberiat 

^pboid fe'rer, scarlet fever, and the like, may produce infantile palay m 

dtbtfrf the two ways first mentioned, B3owh on the head, pyogenic dis 

aia of adjacent aku]l eavitiefi, and acute infections diaeaaea may be th« 

ttbeceieut fftctota of meningeal hemorrhage, einus thiomboais, and men- 

ioptiA, upoo which tlie heuionhaga lUelf la dependent. 

The symptoms of infantile cerebral pnley uiay be divided into motor, 
ENpUc, sensory, and psychical fiymptomi, the frst and last bein^ by far 
diB BiDit important. Tlie irc)t^>r syiiLptoma conjitst in some degree of 
pnlyKS, almost iuvariahlj spastic, contracture, convuIaianR, athetofiis, 
ijm^us, and conjpuUory associated or choreiform moTementsp The 
ffljebical symptome consist of limitations of mental derelopmenb and in- 
VIlKtaai exprBBsion, varying from the slightest sluggishnese in reaction 
U tiis «iiTironin«nt up to complete idiocy. The trophic symptoms con- 
sit principally of retarded development ot the paralyzed extremities. 
The paiolysia may assume the form of diplegia, of hemiplegia, of para- 
plegi^ and posaihiy oE monoplegioi diplegia being the commonest form of 
fratatal cerebral palsy, and hemiplegia of the natal and post-natal varie- 
tHL The symptoms of post-nntal cerebral palsies are in reality the 
ijmptDinB of the accidenE; or disease wVich cjiuses them, anrl are not to 
bt enji^itiered here- It ia easily seen that in one coaa such aymptoma 
ittf b« thoee of acnte en<:Qphaliti9, in another those of meningeal hemor- 
rbge, ind ia a third those of rupture of a oerebral blood-TSBsel or cere- 
bnl tofteaiog. 

Uttle'l Di*ea*e,- — The designation Little's disease, congenital spaBtie 
ligidity, or apa.^modic tabes ia oftentiojes given to a variety of infantile 
Mnbro] palsies characterized clinically by spastic rigidity, with slight or 
Da paralysis, of all the ex-tremttiesT including the bead and face, but n<o3t 



marked iu tlie lower extremity and usually but not invariably ftooom- 
pani^d wiLh some degree of meutal sborbcommg. This coaditioa was first 
described by an English Hiir^eoo, Little, wbo obaerred it id children 
boru in premature, difficult, and complicated labor. Some European 
writera b a ve endeavored to aeparate lliia ictia of miantila cerebral polsiea 
iiom tbo lar^ gt-oup aboro deeeTibed, and to consider it a diatinct etio- 
logical aud morbid entity. Van Gehaeht^n particularly has striveQ to 
show Ih^t the riijidity^ aitd in fact all the 3yTiLjit4.}Jri4 are deiie.tid^nt 
upon incomplete development of certain tracts in the brain, pLtrticularlj 
the projections of the Bolandio area. These chddien, he coutenda, are 
born prematurely, btfore the fibres of the pyramidal projection are com- 
pEetely mature, and the gradual aEiieJioration of the rigidity which usually 
occurs with the increasing age of the child is aynehronoua with the devel- 
lopment of medullary sheaths to the fibres of the pyramidal projection 
which reodera them functional, Theie ia much to be said iu favorcf this 
contention, and it is nob unlikely that somd cases of infantile cerehras 
palsy are to bo explained in thia way, Tbo outlook in these cases ia 
more hopeful than in c^^&s of infau tie cerebral palsies dependent upon m- 
flflmmatory, vascular, and degenerative conditions occurring after birth. 
ludeed ii few cases make grutjfymg recovery. 

Treatment, — The treatment of the infantile cerebral palsies is still moat 
unsatisfactory. The physician can accomplish aa little bete by the admin- 
istration of dTUga and the utilization of other therapeutic procedures aa in 
any other disease which he ia called upon to treat. Farenta appreciate the 
hopelessness of these tiases, and anxiously seek the trial of any experi- 
ment or procedure whii^h holda out thd elightest prospect of relief, Bo 
faif DO plan of tireatnient has been devised save the adoption of measures 
For the prerention of the accidental and uuavoidable occurrences upon 
which the symptom comples is dependent, the subjugation of theae acci- 
dents and diseRsea at; the time of their oricurrencef and the mitigation of 
symptoms and emelioration of deformities which are cunaequent upon the 
intracFEinial lesion. 

Cases of cerebral palsy of infanta ore rarely recognizod uutiV some 
considerable tiine after the ocetiirenoe of the morbid process upon which 
they depend. At least this la absolutely true iu the experience of the 
neurologist. They are seen by the general prartitiuuer and by the ob- 
btetriciau moro frequently at this time, IjLit are often not given proper 
interpretation. The true diagnoaia is usually first made when the palsy, 
the contracture, the choreic or athetoid moTsmenta, or the epilepsy and 
idiocy begin to dominate the eiistence of the child. This being eo, the 
opportunity of using preventive measures has ceased to eiist. The 
colossal r6lo that dystocia plays in the causation of infantile cerebral 
piOlfly is by no meana soffiQiently recognised. The dangers of dystocia 
are usually considered relative to the life nf the cbild, but the urgency is 



itv^greai that tlieybe coDfiidered relative to the ooi^uireiico of lufan- 

ttocerebral pa1»4y. The injiinousnesa of forcfps delivery i» slighl; when 

I nmpar^ vilh the far-ieaoliiDg eFTc^cta of tedious labor, Tlio eeverity or 

[ bplvaaDesa of mnnf casea of infantile cerehrjvl palaj couUl ho r^ry mu^h 

I siti^ted if cas^s depcndeot upon aouto intlammation of th^ gray njatter 

I gfttebnuD vera recogDized aad treated at th? b^ginaiag of ttie drse&se. 

I tbitr#Atment of arute enct^pbaliti^, of meni^gitiB, or of any foim of ceie- 

I bilipoplfTKy, is the saiiio when the^ifl coiiJiLioiis occur in eariit-^t ehild^ 

I MiS wheu thej occur during later life, aud tbeiefote do not call for 

I ^lal eQumerattOT; hero further than to say that the tr^nttueot ahould be 

I offiedout with thoeame cure and urgency that aie given to ctmilar di^^aaea 

I WBtting in later childhood and adult life. The cocvulsive pheoonieQa 

F ifcid be cotnhated by the adiiiiiii»tratioii of tho hroinidea or the iirhala- 

I DilA of chloroform, while thd febrile pheiionieua are overconio by the ad- 

auuiAtration of one of the modem antipyretics in appropriate doses and 

br tLe external application of cold. But, aa haa been Gaid, usually the 

ttva lor the applii^ation of such treatment haa long gone by when tbe 

pitkiit eomp-a uuder tteatmont for the iufantila cerebral palay aa a dis- 

«Ase. The treatment then conaisL^ (1 ) in the utilization of iueasur(!B to 

couatfract the deformity, including the paralysis, the contracture, athe- 

tocifli and choreiform morementfl; (2) treatment of tho epilepsy ^ aud (3) 

treatment of tbe idiot^y. Miich may be done to cvaroome tbe deformities 

TAoltiDg from the paralysis acd contracture by the use cf modern or- 

tliDpsdie ajipliaTioes, particularly if the progress of the deforraity and 

cnitncturo is at the same time opposed by the use of uiaBgagei and by 

li*niterTontion of operative surgery. The hopelessness of the deformi- 

b« in these leases should urge the surgeon to the performance of subcu 

luftiia or open tenotomy, or other surgical opMalions whenever ii is 

pnibable that the slightest benefit will follow them. 

Very little can be done by eithf r Thedicatum vt appliances to counter- 
*^t the athetosis, and rery much lerfS can be dooe to overcome the choreic 
AL>v^me[it9^ although m individual oases carefully eonstracted models in 
f^Ua percha from casta of the arm, and aptinta have been used with s6t 
^Wss in contributing to the patient's comfort, OccasioDally permanent 
efit follows sneh application. Cases have been reported in which 
ible stretching of the nervt^s exposed by the surgeon and prolonged 
^^XifpcinHion bave mitigated somewhat the severity of the choreiform 
'V^ovement. In fiome cases of atheto&is the cr>ntinnal movements have 
a«ai BO aggravated and diatreasing that amputation of the parts has been 
'^iffopcBed and resorted to. In others the eTcision of the eortex corre^ 
&]vmding to tht^ ppripheral j>art that inaiiifesta the movement has been 
^ocie with amelioration of this symptom, 

Treatment of the epileptic attacks whioh occur, in a majority of the 
viut at least, id alflo very nnsatiafactory. The flustom&ry dietetio and 




bromide treatment so beneScial in tbe majority of cases oF idiopitthlo 
epilepsy wjiintH for little here. If the jkatient t* brought thoroughly 
under tbe laHueace of the bromide and if the digeatire tracb and avejiuw 
of elimmQtion are carefully looked txit&Ty the number of epileptic attacks 
may be diminished and tbeir severity mitigated. But nothing real u 
gained bysueh treatment except that the existence of the unfortunata 
one ie made mora tolerable. Yet this ia the treatment which the major- 
ity of casea must receive. When such a plaa of treatment ia net aiicc«s9' 
fuL lu lessenujg the number of attacksi the opium -bromide pl&u should 
be tried. It oonaiatB ia the administration of opium from three to six 
grains daily, according to the age of the child, continued for a period of 
BIX veekSr then stopped abruptlj^ aiid one of the salts of bromme givfu 
in mildty ti>xic dohes until the paLieiit ia thoroughly under the influence 
of the latter drug. The dose is then diminished until evidences of ita 
toxicity diaappeaTi and the patient is kept on this minimum quantity 
until the fit^ again begin to be frequent B^d severe, when the opium 
may be repeated- 
Cranial surgery has a narrower field of uflefnlnefla in the brain palaiea 
of infancy than in any other disease for tho relief of which it has ever 
been auggeated. Dunng the last few yeara, especially since Horsley 
:^owed the skull oould be opened with considerable impanity and smoo 
Lanuelongue olajmed a considerable degree of efficaciousness for craai' 
ectomy in mierocaphalio idiooy, this operation haa been extensively 
employed, more in America than auywhera eltie^ for th& relief of 
epilepsy de7elopmg with the cerebral palsiea of childhood. The resulta 
have been carefully oatimated, and are found to be woefully disappoint 
lng>. Surgical interference la useleaa in cafiea cauaed by dystocia, for 
the very apparent reason that the pliyaiclan has no conception what 
the intracranial lesion may be in such a aaae Tha only cases in 
which tha surgeon should he advised to operate are thoso in which 
a diagnosis of a focal cortical lesion can be made and those ia which 
Bymptonifl denote the dcpeudence o£ the symptom cotnplcK upon men- 
ingeal hemorrhage or cicatrix. In auch cases the surgeon should be 
urged to operate, for nothing is to ba lost by procedure. Every case 
of epilepsy, it matters not what its origin may be^ is temporarily bene- 
fited by operation en the skull, and in some cases it may be uot only 
fitting but very advisable to resort to operation for such modicum of 
grateful relief, particularly aa there is Eflwaya a chance that aome condi- 
tion susceptible to partial or complete removal may be found. My own 
enperieuce with operation for epilepsy associated with the cerebral palsiei 
of childhood leads me to coincide with the opinion of Dana . in the vast 
majority of cases it exercises merely a pedagogic intiuence. The opera- 
tion itself and its cntaUment of confinement to bed for a prolonged time, 
cflreful nutsingf regulation of diet, enforcement of obedience, all tend to 



tnflueuoe these imfortunate patients for the better, but thia infiuencG is 
rarely permaneiit A degree of peiinanent relief from operation should 
be iiDtLcipa,te<l or promised only in crises in Tthicli the Hympboma are mdic 
ative of foL^al lesinD whioL can be eipoaed by the HurgeoD^ Whea such 
conditions eiist the aid of the eurgeou ahould be e7oked> lb c&d then 
be determiced whether or not the lesion ib partly or eompletely an eradi- 
cable one- 
Something can be done to lessen the severity of the trophic tronbtes, 
porticularJy by the utili^tiou of friction, prnlooged warm baths, luaasage, 
and dry beat to the paralysed eitremity. If the paralysis is not attended 
with oouBiderabio spastioityT a weak gaivanio curreut to the entreniitiea 
may have a beneliGial influence in facditating the ciroulation of the parte. 
The measures that ara appropriate to counteraot the trophic iafiuenees do 
not dilTer materially from those applicable to combat like eoTiditioQ4 
occurrmg with anterior poliomyelitis. 

Pedagogical treatment ia after all the most important for thie unfor- 
tonate daas of patients^ The physician can aooomplish more bj gLving 
this sida of the treatment hia carefn] attention while the orthopiedic sur- 
geon looks out for deforming contractnres than by the pursuit of any 
other plan. The vietims of infantile cerebral paJsiea aJkd their SHqnets 
of mental defects and epilepsy are the pariahs of our public schools, and» 
as & result, any latent capacity for intellectiml nwakenment and cnltiva- 
tiou that they may possess is lost. Parents should be urged to place 
aoph chitdren in ouo o£ the many private, semi-publie, and public inetitu- 
tiona whmh have been founded in many parts of tha ccuntry for the 
educatiDn of thia class of defective cUildreu, where meittal uud physical 
diaciplme heat adapted to them is administered according to the most 
approved methods There they are taught at least the rudiments of per- 
sonal cleanliae^s and bygiene, while mental icstrnctton goes hand-in- 
hand wUh the acquisition of manual dexterity which is sometimes ac- 
quired to such a degree that the patient becomes skilled in name variety 
of handicraft which makes him partially op completely self-supporting. 
Such methods of teaching and diacipline ate supenor, m almost erery 
case« to ludividual treatnient by s. physiGum or teacher even in cusea in 
which the financial side of the question needs no consideration, iiuleaa 
the tea^^her has had large eiperienee with mioh patients In truth, the 
TictimH of infantile cerebral palsy constitute an impoiiant pro]iortjou of 
our defective population, and they should be as carefully and fully pro- 
vided for by the state aa the epileptio and the insane Physicians should 
use Iheir inflnenoe t^ bring about such an expansion of o>u pedagogical 
and provident syatems. 



MthjTifle scileroaiB, inaular corebroapinai sderoaia, disacmiuAted scldro 
8iSf imiltilocular sderoaiB^ ^/•/croso en jififpmSf }/'<rd9ktcroi*:^ polyiieBK^ 
BcteroBis, Cbarcct a diseaae, etc , is cue of Ibe commonest degeneratiTe 
diaeasea of iha nervous system For inauy years after it was first reooj 
niztid it was eijuaidered to be odq of the rajest. It cousiats fuiatomioallj 
in the formation of laJeU of scit^ioais or counectiro tissue througli whicli 
nonrascna pa^a without loamg Iheir protopJaaintc continuity, in different 
parts of the ceTebrospmoJ axi5, but especialty the spinal cord and oblou< 
gata Clinically, it varies witli tbe location and extensiveness oE the ecle- 
TOtiCr areas, 

£liolog7 -^Multiple scleroaia la a diBeaao cf oajly life. It usually de- 
Telopa before tho n^e of complete udoleaconce^ rarely, if ever, after the 
thiTty-tifth year. Many cn-sea oeourriug in very early childliood have been 
reported. It affliets males and femaleB about equally. Although it is 
imptobabte chat it is either an hereditary or family disease^ a fi?v mstancea 
have been reported iii winch it would seem that heredity was a i^nxoi. In 
BOitie of these caaea> however^ hereditaiy cterebellar ataxia hud not he«ii 
excluded eonvincingly That a marked inherited neuropathic diapoaitiou 
exiata m many patienta who develop this disease is beyond doubt- 

The attributed causes o£ multiple selorosis are tiutuerous. Named 
in the order of their importance and frequeucy they are 1 Infectious 
diaeasea, auch as pueiimonia, influenza, at'arlatina, meaales, typhoid 
foTfl]:, dysentery, malaria, the puerperal statCi variola, and diphtheria, 
2. Slow poisoning by some of the metals, euch as lead, copper, mer- 
cury, zmCj and phoaphoruaj thua indirectly traceable to occupation, 3. 
Esposure to cold, rafngeratiou, pariicniarty if associated with hardship 
and inclement weather; 4. Psychical shuck, strain, fright, grief^ and 
social reveroGB and axcesacs, sm^h as make a profound impreaaion on the 
mind and Borve centtes; 5. Trauma, 6, Inherited or ar^uircd ayphi- 
li3, which plays a very uniicjportnnt rSle, if any ct all The part played 
by infection in tbe causation of multiple sclerosis is in many casea so 
conHpiouous that it must be accorded greatest pathogen olio capacity 
How infectious agenciea, diverse as they are, operate to cauHo destruction 
of tissue in remote areas which have do particular inteTdcpeudeuc;, with 
the simultaneous development of degeneiativo tissue and the procosses 
that mediate these states, is a nddidj and any explanation which la 



offered must be theory baaed on analogy. W© have gone no further with 
blood patlitilogy than to be able to any that U is probable that the prod 
acts of lovf formti of vegetable life, on well aa certain organic subatanccB, 
taken in front witliout and forming compouDila with aonic of tho ct>]iat]tu- 
onts of the bloodi ure oft€n mmiicol to the preservation of the natntive 
bfltaiice of vnnous parta and conatitiieiiCa of the nervous e^'stem. Partic- 
nlarly ts this true if the latter haa been endtived wnh defi[!ient anatomi- 
cal and entrgi£iiig pottrntialit^ What i^eteiminds the doslruvtion of ouo 
part after one toxio condition of the blood, or the occurrence of an in - 
fijimmatory procsda in one instance and a purely degeneiative ouo in 
another follon'iug a Biaiilar infection, we are quite unable 1o Bay. That 
the preaen^^Q oE diveta speoilio organisina in the bloo<l aa the reenJt of 
dtvera speciHr: dineiVHen may facilitatd the activity of a vulgar pathogenetic 
mLCroba and bhab thua a uombmed uifecUun cavme» t:!;^dutiively multiple 
inanlar adero^is aa sviggeated by P. Marie, is fanciful to a degtee 

Proloiigtid exposure to eome of the metallic poiBona nmntioned uude; 
niunbet twOt preceding th^ ocmcncnce of multiple flclerosis^ would se«in 
to be of mere common oocnrrence In Germany than in this country 
Only two caaea of Ih'ia kind have come under my own obaervation. 

Recorda of caaea which show the ralationohip of esposure, fright, 
and trauma aro numc^rous, but in eevonteen cosea which 1 have had re- 
cently under personal obaervatioo, in three only has there been auch a 
history. It does not aeem to me praLseworthy to take too aenoualy thoae 
caac8 in which it haa been reported th^it the disease was traceable to 
a fit of auger. Certain it la that the ajiupLoma may ahow themaelTcs 
first after an exhibition of temper, but to admit aitch coincidence aa en 
denco or even testunony would be to[erat*?d m no other apience thou 
raedioine. Expoaure, ediauatmg experienceSr and the like are often the 
immediate auspices under which the symptoms of multiple BRlerosla occur, 
but how far they can l>e ciriisidered atrictly causative it is difficult to eay 
No fai;t ia better eatabliahed m neurology than that theaa occurrences 
debilitate the nervoua aystem and thua facilitate nutritive ohanges which 
word! disease. The causal relationahip of physical injury to multiple 
flcleroaia la thoroughly aubatantiated. But wo are more in the dark aa to 
how It operates than we are in otfering a rational explaaation of hnw 
trauma operates to produce tabes dorsalis. From time to time the im- 
portance of inherited or acquired ayphUia in the etiology of thia disease 
is urged by aome writers. Personal experience and e^iamuiation of the 
literature lead me to deny any particular relationahip between either 
inherited or acquired syphdia and tho occurrence nf multiple scloroBiB. 
despite the fact that it is possible bo get a history of syphiiis in a very 
amali percentage of the caaee. 

Multiple scleroaia occura ofteneat at on age before euervating hahits 
or injunouB eKcesses are arquired or indulged lo, and thua these fnctora 



do not enter materially into the etiology of the disease, as thay do in tHe 
caoaatioQ of Bome oCher degenerative diasaaea of ihe nerroua system. 
Neverihele8H, sexnal excesses bav« be«a DOled by a number of tnToati* 
gatora. Al present it aeoms to be ratber uuiformly admitted that tho 
mnat peruicioua factors are the infectioua diaeaaea. OccaBionally multi- 
ple sclerosis follows m tbe wake of ftcute myelitie, and on the other 
band, acute myelitis now and then oceurs m a patient who hai multiple 

The predisposing causes of multiple eclerosis are undoubtedly impor- 
tant factors. It IS difficult to say wWein this predia position conaista, 
eacept to postulate that some slight defect m the original development of 
the central nervous system tenders it liable to decay on encountering 
factors that would be inadei^aate to overthrow the vitality of normally 
developed tissue. The endogenous and conjfemtal origin of multiple 
sclerosis has recently been pub forward wilK considerable Itkelinefis by 
StrUmpell, but no positive proof of such origin has been offeredn 

Symploni** — When we consider that the islets of ecleroaiB may de- 
velop in any or lu alJ of the Beginenis of the oerebrospinal nervous sys- 
tem, or in the different levela of any of its Begments, it is not at all sur- 
prlaiug that the symptoms will vary in nearly every case. There are, 
however, certain cardinal syTuptoms which are sure to develop at some 
time during the course of every typical case. The most important of 
these are: 1. liitentLOu tremor^ or ataKio tremor, which shows itaelf oti 
purpoBpfiil or reSei movement, eapecially of the upper ettremities, rarely 
of the cephalic or lower eitremitea. The rate of tremor is from three to 
five per aecoud, the oseillations rather regular and subject to eiACeirbationa 
by mental and bodily eicitatJon. 2. Muscle rigidity and spasticity of all 
the voluntary musolea of the body ; ooourring in the emotional muscles, it 
gii^ee rise to a peouliar Bpastio expression of the faoej in the e^tremitieait 
causes siiaUc BpaatieUy. 3, Exaggeration of the deep refleyes, partiou- 
larly the knee and ankle jerka. 4. Nystagmus, occof^iimal diplopia, aud 
ooular palsies. 5. 61ow, scanning speech, with rhythmical articuletioo* 
6. Some degree of optionerre atrophy, partioalarlj bitemporal paleness, 
m about fifty per oent of the oaaea. 7. Sensory disturbances when the 
aenory neuron u encroafihed ti[ion at any level by islets of scleroeia. S. 
Vertiginous^ apoplectiform, and epileptiform attacks, after which the pa- 
tient js usually worse. 9. Soixie degree of mental abf^ormality, varying 
from slight exaltation or depression with a tendency to mental vacillation 
to a considerable degree of dementia^ 10. The course of the disease is 
eharaoterued by periods of more or less brief exacerbations and more of 
leas prolonged remisainns. 

Atypical forma of the disease which simulate s^mptomatically the 
QGcnrrence of chronic disease in some part of the spinal cord or brain are 
not uncommon. 



Treatmeat — The treatment of xQultipIo sclecosta may be' sum[aanied 
in two vorJa: rest and nutntion. After the dise^LSO ha? devQloped tbero 
ifl DO medicameat that haa the slightest eS^t m iqAucdcjo^ the ooiirsa 
or in thwarting the progress of the disease Nfeastirea directed toward 
improving tha patient's Diitvitlon, ajtd as educIj rest as i^ i^imi^idLieDt with 
bodily Leakh, r&r?]j f^il to Juake the patieut more comiortabie and niorQ 
tolerant of hia inSrmity^ No one vho aeea much of hospital patients 
can fail to recognize the truth of this. Such patienta by very reaaoii of 
their fitay in the hospital with ita i^gima and didiiipiiue are mote eomfort - 
ahle, and their di^^ase makes stuwer progress than does that of patients 
under different ALiBpii-.&'i, 

At different times certain medicinal snbsbauces ha^~e been advocated 
in the treatment of niultiple eclerosis, but none of them haa stood the test 
of experience. It la probable that in those inetanc-es in which a certain 
drng^ snch as solanme^ ba.s been highly praised that the disease for which 
It has sef^tited so henetit^ial b»a nat been multiple eclerosia at all, but 
hysteria. If medicines njust be given in this disease it would se? m most 
justifiable to givQ those eiil^stancca which have attained some remedial 
reputation in the degenerative diBeasea of the Ci?utral nervous system, 
such as arsenic aiid nitrate of silver. Indeed, the former is recommended 
by Eulenburg, and that hypodermically. There can be no doubt that in 
maiiy instances dniga have secured a reputaliou undeservingly iii this 
disease, beoause their administration coincided with or preceded a f^eriod 
of lemtssion or temporary cessation of the syipptoms which were a part 
of the course of the diJ^ease* Like in all other orgatiic diseases of tbe 
centtal nervous system, electricity hng at one time or another been advo. 
, Sited Id the treatment of multiple sclerosis. I have never seen the slight- 
^mt benefit follow its musb determined use. Nor is massage ur hydrotter' 
apy of any service save as they may have aome effect to improve the 
pattcnt^s nutrition- Patients who are at home lu northern climates are 
much more comfortable in eumiuer than m winter- it follows^ therefore, 
that a more balmy climate should be thetr winter residence. 

It ia impossible to spi'ak of the preventive and caiis^ treatment of 
multiple sclerosis- The endogenous element which consists in improper 
dereJopment of certain components of the cerebrospinal nervous system 
<iaiiuot be coped with. Nor is there apparently any treatment of the 
infectious diseases that will deprive them of their oci^asiooal potsatiahty 
to cause multiple scleroeis. Furthermore, its occurrence is not so closely 
related to occupations that anything can be said oo that score. As 
fright, ei[)OSUFe to wet and refrigerEttion, are conditions that are practi- 
cally ODp re rentable, prophylactic treatment conaot be applied. 



Thh brain and tbe tiafluea sarroundrng it offer su^oeptibili^ to new 
growths aa do all other tissuea cif the body. In adtlition, the brain ftir- 
Diahea tbe point of origin or HOil^ lu coinmou with tlia enLire nervous system, 
for a unique growth, viz , the ghoma. Th^ term brain tujijor is used to 
cover all new formatto&3 w^tlim the akuU. Thus it includca cyat3 and an- 
euTiaman Althoiigh auch new fonaatioaa as the two lasb mentioned do not 
suggest the growths m&ant by the word tuiuor in the conventional aens«, 
they nevertheless^ by encroachment upon E.nd destruction of tiasncs in 
whidi Lliey develop, cauaa symptoms ideiiticiLl with tliuaa of a solid growth. 
Therefore they are coDsidered, from a serueio logical and tLerapeatio point 
of view, with the solid tumora. 

la no departtoeut of neiurology has ths advant'e that has been made in 
the reoogoitioE), interpretation^ and treatment of malignant disease been 
more conspicuous than in the tre;itri[ieat of tumor of the brain. This ad- 
vance has kept pace with the growth of our knowledge coucamiug brain 
localization and with aaeptic aurgcry. Formerly tumor of the brain was 
recognized olinicallyf and its recognition was practically tantamount to 
a varuio^ of speedy death ; for medical treatment then, even mora than 
now, was powerless to halt or delay the progress of the diseaGe, save 
in tumora of syptiilitie nature- Unfortunately, vre are unable oven at 
the present time* ^hen localization of function to the cortex of tha brain 
IS comprehenaively known and when the physiology of the encephalon is 
satiafactorily nnderstood, to take a very saugniQO view of the tteatmont 
of tumora of the bram. This is dne pi-incipilly to the fact that the vast 
majority of theiu are inoperable pither because of their location or of 
their sizB and luBltrating nature. Operative surgery has not fulfilled 
the promise, in the treatment of these conditions, which many of the 
present generation seemed to thmk that it held out when it waa shown 
that the cranial cavity oould be opened with at least a degree of impunity, 
Kxpenence has shown, however, that it^ failure to do ro 19 dependent in 
a large measure uixm the inability of the physician accurately to !uca1i7« 
the lesion. Despite the wouderful precit^ion with which lesions are often 
localized there are still comparatively vast areas of the biaio which toler- 
ate the encroachment cf tumor formation, especially if it occurs in an insid- 
ious way, without tho production of sympl-Dma that in any way indicate 
its exact location 



An exuninaticn of tbe tecoids of oi^eratioua for bram tumor dar- 
ing the last few yeara sho^rs, wih otie striking ejcceptiori, that the 
roseate view which waa taken by maoy of the Burg^oal and neurologieal 
autboritiea of tha world a ckcade i^o has beeu r^'placed by one of thera- 
peutic gloom aril] despondency. This may be loterpreted as reai^tioDory 
to an nowarraotatily saDgaine attitade assumed witbout aufHcLcat e&- 
perieucQ. lb will bo pointed out when dtscuasiog tbe treatment ^F 
brain tumova that tbe p^Esimi&tio views which maay neurologists oE 
exp«riQDee now hold in regard to operations for brain tumor are dud 
more largely to the fact that the procedure has been applied or utilized 
without tbe same amount of diacrimination thfi.t m uaed wbeu operation 
13 advLsed for growths or diacaae of comparable malignancy in other parts 
of tbe body. Heni;e to-day it may be Euid that if in tho treatment of 
tumors of tbe brain eurgioal interference is adviflod and undertaken with 
the same acknowledgment of its limitations as in that of treatment of 
malignant growths in other parts of tbe body, it will be found &9 satis- 
factory Telativ^ely in tho treatineot of tumors of the brain aa in that of 
6uoh aforesaid disoases- 

The tumora to which the brain is most liable, named in tbe order of 
their frwinency, &re tho infecCioi»Ji granultimata, anch as tabernidoma 
and syphiloma; the ombryonal and parasitic granulomata, such oa gliomar 
sarcomaj carcmomat aud Cjsts due to the presence of echmooocci^ new 
growths referable to congenital anomaUGS of development^ such aa tera- 
toma, ongioma, and dermoid formations; and fioallyf tumors due to dia- 
ease of the walls and distention of large biood-veaaeU, aneuriGms. 

Etiology. — The causation of tumors of tho brain is, with few exoep- 
tions, still eiiBbrouded in dense obqennty^ Naturally, the etiology of tho 
infectious gtanulomata, surh as tuberruloma aud syphiloma, is fairly well 
uuderstood. Tbe Siune fatilora that predispose to the occutrenoo of tuber- 
oulous and syphilitic disease in other parts of the body are operative in 
causing these diseasps of the brain. The essential TGquiiementa are the 
t>acilli cif these diseases, tbe life histnty of the former Iwing very well 
known, the existence of tbe latter not yet having beco satisfactonly 
proven. The same may be said of the occuTieuoe of paratiitko tumora, 
and of aneurismal dilatation, Un the other band^ very little is known 
of tbe af'tnol causation of glioma, sarcoma, cholesteatoma, fibroma, and 
carcinoma, although it may bo said that the occurrence of these diseases 
xa ibe brain is dtip«ndeLit upon tbe same factors that cause their occur- 
reaco m other tissues of the body. 

Tumor of the brain is comparatively a very rare conditiOE. Atthovgh 
some surgeons and neviTologista encounter such a number of cases that 
one might be l«d to think it somewhat common, still the fa«t that many 
general practitioners do not see a case in tbe course of tbeir entire 
experience ia iinpottaut testimony to the infrequency of the condition^ 



it hflfl been vanousLy eatimaled that from one-half to two per cent of 
all Deurolo^tral oai^s aro tumors of th^ braio. In my own exp«<ri6ii04 
they conHtitutG 1 'A |»er rent. Mulea are nUlit^ted much more frei^uentlj 
than females, the proportion being about tv^ to one. No aalififactorj 
re&iMin can be given for thia greatot liability of tho male, unksa it mij 
be ai^GOUoted for by bis bomg more exposed to physical injviry and to the 
inff^ctionB. Briun tumor may ocour at any age, bat it is extremely r&re 
before the end of the first year and during attniUty. The largest niun- 
bor of iia^es occur between Lbe ages of fifteen and thirty yearti, while the 
dftoade after this shows the neit largest number ; and the jeara of child- 
hood Atond third in the order of frequency- Children aro particularly 
liable to the development of tuberouloma, indeed tbis neoplasm coneti- 
tutes the majority of casea of brain tumor whii^h Of^cur Tn ohildren- 
Naturallyf thft children of the lower walks living under unhygienic con- 
ditions, and those irho are deprived of fresh air and suitable food, are 
mote liable to the occurreQce of this condition- The aame factors predia- 
pose to paras 1 tie neoptaems. 

The relationship of trauma to the occurrence of tumor of the brain ii 
universally admitted. Juat how injuries to the head which are or are 
not bulHcient to produce tangible results contribute to the development ol 
'brain tumoi is didicult to explain* It seems safe to infer that the disor- 
der of nutrition ^hich sur-h an injury may cause or the still profonnder 
disturbance of vascular equilibrium, amounting even to rupture of minute 
blood-vessels, may be sufficient to give the infectious agency that la di- 
rectly responsible fi^r the eiietence of the neoplasm a mdus wherein t4> 
develop. On the other hand, the injury may be tbe stimulus that eicitea 
embryonal remaina or terato logical defects to developmental activity, an^j 
thus causes the growth of tumor. The liability of children to t)ie occur- 
rence of tumor of tbe cerebellum has been explained on the gmuud that 
they are very much more subjw^t lo falls, striking the back of the haiul 
It ia not at all beyoud tbe pale of posaibility that such trauma migbt 
excite a gliomatous proliferation in tissue which contams the remains of 
defective germinal evolution- If the trauma la svifhcient to cause a 
woundj then the scar that results may form the atarting-place for the 
development of the tiimor^ it being abundantly proven that scar tissue \% 
often tbe seat of such gcowlha. 

Although it 13 thought that tumors of the brain are more liable to de- 
velop in those of a neuropathic constitution^ all that can be said is that 
It hiia been noted that nervous disease is often found m other members of 
the family. 

Tumor of the brain is very rarely aeoondary to tumor of other parta 
of the bodji although carcinoma, one of the uncommoner forms of brain 
tumor, is not infrequently metastatiCt 

The etiology of intracranial aneurism U the same as the etiology of 



orism in tuy citber part of the Ik>i]j, the ital uid predinpoaing canaea 

tt-&U tboao faritirs Uiat are capable of iiauaing degeiieratioa of the 

K^efiseh, such &^ the diatheses, the infections, syphilis, a,iij trauma. 

BieeKcitiiLg caiisQ being uujthing that iQcrensea mtravuscvilar preaaure 

Eb<in to destroy the support of the iLtmcraniaL blood -veaaelfl. 

Bjmptaau, — The Bymptoma of brajD tomor are the geaerai symptoms 

■lik^ ■!« due to inortMLte of intranraniai pri'saure, and the fuiHl ^yuip- 

%BU which aro due to the ej^altatJuji or depreH^um of iLe fuoctioiia of 

spoeuU^ parta of the brain cauaed by eticroaohmeut upon or deatractiDti 

of Biit^h ^rt9k by the new gro^vth. 

The geuer&l symptoms of brain tumor which occuj- with more or iaiifl 
fOQlttnry in every c^so are 1. Headache. This has nc charactenstio 
lettunorlocaliEHy, although it ts by all means the most cooalaut symp 
IBD. It i» usually of abrupt uQseti more or lead contmuoua, liable bo 
napitiD&blo exnceibations of thG most violent kmd» sonietiniea of a 
dolt, ben ombing character, in otb«T cas^s sharp and lanciitating. At 
Ulc height of an e>:)oefbaticri tha patient may be dehnoua and hallu- 
EMlorr. Although aunietiniea locaUzed to tlia forehead, the (X!oiput, 
oiiljendeof the head, the area of ita greateat intensity do^a not point 
Ik JoL-aUon of the tumor, Oi\ the contraryj tJie tumor may be m & 
put of the braiiL most ri^mote from the point vfhereiu the headache 
[i Itifaliied by the patient 2- Optic neviritis, elevation of the papill®, 
Mad diac- This ocoura in from seventy to eighty p^r cent of all the 
mu, i]iove frequently uheii the tumor U of the cerebellum and at the 
bwof iho braiu than ^vhen of tbo anterior polea of the hemispheres. 
T^ EDoat essential point for the phyaicmn to bear iii mind is that vision 
H Bot impaired commensurately with the degree of neuritis, and espe- 
mUj dnhug the early staj^s of ib* e.\lsteiioe. 3. VerLigo, or aubjeetive 
MuaLions of insecurity and dizzmess^ liable to paroxysmal exaeerbatioDa, 
jarlwularly keeping pace with the headache. This symptom is more 
eniiaat and of greater aeTenty when the tumor is of the cerebellum or 
tiMpoos and baEsal ganglia. It 13 also often the raost diatreasing aymp- 
tmwhen there is palsy of one or mere of the onular muscles. 4. Vom- 
i^g, with or without oauaea, and often apart from the subjectLve and 
(ib]«cLive prostration which one is accustomed to a&BDciate with thia 
Ijttptom when it m very severe. AtC;Lck3 of vomiting are most liable to 
4ceu in the morning, and they are severest when parosyeina ot headache 
indT^rtigo are at their height. 5. Psychical disturbances of variable 
dararler and de^n^, dejXiuding somewbnt ujwn llie loeauon of the tu- 
■01, but more upuu the rapidity of development and intensity of iutra< 
oiiual pieaaure, Wbsii intracranial pressure derelopa rapidly and la of 
piofatrnd intensity^ there is almoat always a marked degree of lethargy, 
EnipoT, aad progresaive dementia, 6. Slowness of tha pulse. 7 At- 
bi^of syncope of variable duration^ and sometimes periods of prolonged 


OIL percuaaioQ. 

These general symptoms are present with more or l^a uavjujmgciesa 
iu every case, and they hav^ b«en enuiaerated in tbo order of tbeir iinpor- 
tanoe and couatani-'y, Ufiiially some one or all of ttiem precede the 00- 
cuETcnoo of fotal Byaiptoni^, althou^U in ttome CQses one or utore focal 
aymptoma may be the initijil ruan ifeatatvoD. 

Focal ayiu]jto][i3 may be outircly vjLDtiiig' It depends upon the part 
of the bruQ in whit^b the tumor ie situated vhethor or not aooh a/Esp- 
toms will develop. The areas of the brain to whioh are Bllo^^ated speeiaJ 
function are the Rolandic arf>a on bath aidos^ the .cone of language coin- 
prtaiii^ blje foot of the third frontoJ convoiutioiit tbe superior tempoiali 
and the iofcrior parietal gyri on the side of tbe brain opposite to the 
hand nhich the individual uses with mheritLHl dextenty, that ia, of the 
left hemisphere in right-handtid individuala and ot the right hemisphere 
in left-hji^ded individuiilBi and the posterior pole of tha hemispheres or 
tbe cunei, which are the pHuiary visual centteH or the cerebral represeo- 
t&tires of the rctln-'e. Specialized functions have been allocated to other 
areas of the brain, but not so detinitely or completely that eQcroachment 
upon suuh areas is n^anifestad by diagnontica] Bignilic^ant symptoma. Of 
the spfsfialiKHd flr^>aa that have been enumerated, the convolutions on. 
either side of the tisaure uf Rolaudo, known as the motor areas of the brain, 
are by far beat uuderatood. It is tunioi-s of these ^leas that we are ablo 
to diagnosticate aatisfactfvrily and to submit to the eurgeon with great 
prospects of relief. The Kolandio area may be subdivided itito thud^ 
each one of which stands in relationship to different parts of the body, 
the superior third being couaorned vith innervation of the trunk aod 
lower extreniiticB, the middle third with the iuuer^atiun of the upper ei- 
tremiUeSi and the lower tbird with tbe innervation of the c&phatie eitreia- 
ity. The symptomfi that wiU be caused by the occvirrenoe of tumor ia 
one of these areas will depend upon the size and rapidity of tlie growth 
of the tumor, and upou the degree ta which it la confined to individual 
parta of euch an area. If tbe growth is slow and the extent of it small, 
the initial aysiptom may be an exaltation of function, manifeated by 
epaam or convulsion in a corresponding extremity or an individual part of 
the extreraitjT ^s the index finger of the opposite side. On tbe other 
hand, if tbe growth is rapid, there may be a deterioration of function 
amounting to a paralysia. If the tumor is of the superior temporal oon- 
volutiou ia the hemisphere of the braiu that has allotted to it the exec- 
utive speech faculty, then tlie fooal uymptom will be sensory aphaaia, 
the moat atiikinp symptom of whirb will be Tord-deafness, If it is 
of the inferior parietal eoavolutiun of a similar hemisphere, there will 
be sensory aphasia, the most ccmapicuuus symploni being word'hlind- 
ness^ and if tbe encroachment is upon the foot of tbe third frontal con- 



Etiac], Uiere vi]l be sensory aphasia iu whifh the most prominent 

iptom is tli9 Io3B of the motor memones of woida. Ag&in, if the tu- 

ia of the cimeaa of either one of the beiuispherea. there will be lat- 

Ubotnonrmo-js hemianopsia; while if the tumor BCvers the pathway of 

bcti<in between th@ cnn^us and the centre for vlaua] memoriea ia the 

CBrior end of the inferior parietal cunvolntion, there will be homony- 

li hemianopsia plaa ^ord -blind De5A. Thnd il will be seen that the 

■ vymptoms depend entirely upon the pdrtof the brain tha.b ia subject 

W ocTDachment, and these ajinptotDe oaa be reroguued &nd luterpraCed 

cch I7 those who are familiar wiUi the modern tenchiiigs of cerebral 

Imliialion. Tumors of the base of the braiu prDduce foi^al symptoms 

tvliai and mor^ coa&picuoualy thau tumors of any other part of the brain 

bNU«e of the eaae and readiness with which thej encroach upon one or 

■N« of the eraniaL nerres which are in close juxtaposition in the poste- 

rivfovi. Unfortimatelyf such focal symptoms are of no avail to indi- 

oto therapeutic measures, for tumors in tbeee localities are Ijeyond the 

rmk of th? scalpel. The f onal aymptoms that occur with tomors of the 

tue of the brain depend upon the location and size of the tumor and 

diRftlf upon the cranial nerves or nerve that are implicated. 

TmnoT of the cerebellum causes the general symptoms that have been 
■mnaled; optic neurttis, vertigo, and vomiting being more constant 
m& [vofinmdsr than in tumor of the eerebral hemispheres. In addition 
Lfam is ^most always profound disorder of co-ordtuatiou, manifested by 
rUe:??rbg, reeling gait, ataxia of the upper extremitiee, and ocooelonally 
bjnjstagmuft; and alteration of linee-jerka which are most commonly di- 
Diniilwd or lost. Tumors of the vermis are* touch more liable to oauae 
prrfiiKDd disorder of equilibrium and co-ordination than tumors of the 
cmbdlar hemiapheres. It has been thought bbat the aide to which the 
pnient ataggera may be taken to suggest, at kast, that the tumor is of 
tteopposite side of the ceTehoHurD. It is only when tumor of the cere- 
Wtam t£ associated with paralysis of one or more of the cranial nerves 
dBOMBideof the oephalie extremity that any focal symptoms of con- 
D£ai\tlje diagnostic importance exist. For inHtancef paralysis of one 
imir& or eighth nerve would point to the existence of a tutaor in the 
nrnponding hemisphere, if associated with other symptoms of cerebel- 
)c mrolvemeut- 

Treatment — The treatment of tumors of the brain haa very little re- 
Icjnnship to the vanety of tumor save in two inatances, syphiloma and 
©eorisma. In these, medicinal treatment is most important. If the 
Enateritnot amenable to medicinal treatment, and is in a locality that 
pwiBiyt of its removal, it is subject as welt to operative interference, as 
in tiM icon remaining after the absor^ition of syphilitic exudatea and 
iJlldloma. Aneurism of the brain ia amenable to medicinal treatment 
ob]T*inleBB we admit the alleviating iufluence which ligation of an inter' 


oaI cuixki mar lure. Ic will rvttdil^ be infRTcd fitm this Btetannt 
that aa ex^remetr sceptical riew b oken ctf the valve of dm^ in the 
traatmest (tf train tomar. I wish particalarij ta vrnphasK thia at tha 
<nxxir becaaae so manj vrrcen deroce eoosideraUe apaMt to an fmnioeTa- 
uoa of the dm^ that an repated to be of soriee and that should bo tried 
tn tho traacmaic of brain tunuv. Tbb thnr do in eonfiivmitj to pnee- 
deaoe and in fear of being thoaght too ladiaL Thus, aliaost ererj sys- 
tematic wtxrer- upon tumors of the brain f«eU it incumbent npon himself 
to discuss the drajjpj th^t shoold be giren and the time that should elapee 
under su^-h adtnmistrattoa before the c^t^^e ii turned orer to the surgeon. 
The presi^at writer feeU t^ uo teaa incumbent upon himself to saj that in 
everv case of brain tumor m which the localizing diagnosis cul be made 
accEU^tely. and m which there is leason to beliere that the tumor is an 
operable oae. noc a siu^I^ d-ij should be allowed to elapae before the 
skull is o^x^ued a&d the tumor shown to be or not to be operable^ This 
applies to efenr form of brain tumor sare the ^phiJoma. I do pot ocm- 
sid^r that mny trustworthy eTidence has been brought forward to show 
that the administration of arsenic has any infiuoice upmi sarcoma or gli- 
oma* or that tuberculin m anr way influences the coarse of tuberculomSf 
or that streptococcus senxm has been shown to bare anj effect upon in- 
tracranial sanxima. It applies also to sypbilomata that are not readily 
respfUksiTe to treatment. Therefore^ no valid reason can be offered for 
delaying an attempt to remove what seems to be an operable tumor until 
a traditional faith in the efficacy of drugs can be destroyed and a morbid 
ctmformation to precedence indulged, particularly as valuable time is 
being consumed during whioh sudden death may occur for unknown rea- 
sons and apparently inadequate cause, and the vitality of the individual 
80 depreciated that be becomes very much less fitted to tolerate the 
ahock of operation. It goes without saying that when there is proof of 
the syphilitic nature of the lesion, or perhaps even in cases in which the 
physician strongly suspects the neoplasm to be of such nature that anti- 
sypbilitic treatment sbouM be administered for a reasonable length of 
time before the patient is submitted to an operation, which of course is 
always attended with considerable danger. But even in these cases no 
argument worthy of reception can be advanced against operation for 
syphiloma in an operable location which evidently does not recede under 
treatment. To put the matter in a different way^ it may be said that it 
aeems to the writer to be a clear case of malpractice for a physician to 
allow a patient with syphiloma m an operable location to be dragged 
throi^h months of antisyphilitic treatment, during which time irrepara- 
ble changes go on in the optia nervea, when the indications are that the 
aurgeon oould expose and remove such growth. Naturally such instances 
are rare, but two, at least, have come within my own observation. 

The Operability of Drain Tumori.— It has already been said that the 



cogent reason tliat can bo advajiced ttj explain the disappoiutmeut 

itaX baa attended the surgii^^al trea,tit[i?nt of tumors of the brELin Juiing 

tb* laat fifteflu yeara is that the cases that have beeu »ubjeci^d to opera- 

tkm have been Bolec^ted without due diat^riiaination, It is manifeatlj 

oafftir lo attribute to surgical utirefcourt'yrulneaB the mobility to oopo 

vitb a irain luiaor that has been maccuralely loealiaedj or that is of 

SDcli tituaUon, aiav, or nature that it cannot be removed. Yet it was 

diut 'lo the fact that such cases were iadudeil that the surgical breat- 

veul of iQtracf&nial ueoplaama waa brought into aucL dii^iepute in ISPS 

that the moflt tnistwortlij writers oa the subject were compellad to 

Mite from Btatistii^aL Lo^eBtigation that suigieal Interference had sue- 

Mided vn saving only from four to siic per cent of all cases of brain 

tniBDf- It waa tht privilege of Ftrrier at this time to show that at 

\VKft oae-third of all the casea that the physician i^ justified in sub- 

jBittia^ to tlie sur^^u for operation ai-e amertable to surgical interfer- 

wse, if this 13 performed with the skill that should be demanded from 

im who essays to specialise in the field of cranral surgeiy. It there- 

fntG a very importaat hrtedj to enumerate the cunditioua that may 

he flaid to make brain tumors operable, particularly as the majority of 

tijnorfi are 90 situated or are of tuch a nature aa to preclude the poaaibil^ 

tty cif their successful removal. The percentage of operable cases has 

bwa variously estimated to be from twenty per cent tc two per cent, 

h mjij be said that thi^re has l>e«u a gradual decline in the percentage 

ilutiag the past few years. But a conservative estin^ate shows that from 

^1 to eight per c'ont of aU tho cases of brain tumor are opeiable. If it is 

Mme m mind that at the utaioet not more thau dfty per e(?nt of this per 

oicof caae^ that are operable can be saved by operation, it will readily 

bucn that even the moat Hai^guLae estimate of the efTauts of operation 

n not a very high one. Only those casea of brain tumor which are 

fi£vaied upon or near the cortex of the brain to which are allocated special 

tted functions can be conaLdered cperabLct l:kime authontios, such as 

*- H^rgmaniiT rei>trirt this still further by aaymg that only tumors upon 

Or ID the substance of the Kolandic area are operable, but it will be ad- 

■iaittedf ] think, that this in carrying Fturglcal excdusiveness too far^ in 

*i#w of the localLtation of function to the gyri conatitutiiig the zone of 

l&Agaage and tho cuuei^ Tumors of the central parta of the cerebral 

Hcnisphere, of the bafial ganging of the ba^e of the brain, the puns and 

oUoDga^ are inaccessible, and after the diagnosis is made the treatment 

uilcidopt measures that will contribute to the jtatieiit^s comfort and tend 

tfOasiDtain bis vitality and prolong his lifi-. 

The operability of cerebellar tumors muat now be cooeidered. Some 

ivtax writers, such as Oppeoheim and Bruna, state that cerebellar tumors 

lie mopernble. My own experience, as well as the ex[>erieuce of others, 

u^iiieilty inimical to the acceptation of this view, despite the fact that 



the statistics of opc^ratioc« duu^ for the removal of cerebellar tiunors (con- 
stitute a very Jnelfmcholj chapttr iti therapeutics. Brewer reuioved sue- 
ceeefully a tuberculoma from a cerebeUai hcmiaphere of duo of mj p&deiita 
who ujade a very atrUcioff arjd what aeemed to be a complete rc<:ovefj- 
The patleut died suddenly a f*.'w weeks after recovery, wbon it waa found 
that there vera Bevera.! tuberculomata in the sajne bemiapliere^ If the 
tumor had been an encapsulatf^d aarcoma or a glioma, there is no valid 
reason why the putieat ahouJd not have remained flotirely well. The 
experience of a cuDobcr of otbero tends to corroborate my own viewa. 
Gorebellar tumora are inopemble because of the difficulties of exact diBg- 
Dosisi and of the greater diflicultj' ^hioU the aurgeon cxperionceB in 
eKposing a Gonaiderable portion of the cerebelluna than of the eerebrum. 
The prooedare which surgaocia have laLteHy adopted overcomes this to 
aome extent, luid it may be K^id tliat every case of cerebellar tumor in 
whiob an accurate regional diaguosia can be made should b<: looked upon 
as an operable one. 

In same instances it is found after the akitll carity haa been entered 
that the tumor is of such size tlial it cannot he extirpated. Experience 
has shown that it is advisable I'O remove as much of the growth as pos- 
sible, for in a number of cases thu^ treated there has been prolonged 
amelioration cf the symptoms. Wlien tljere is reason to believe from 
the course of the disease or from its crigin that the tumor is reetaatatic, 
its removal should be UDdertaken if the symptoms indieate that it is in a 
locality tliat uan i>e reached. The same njay be said of mnltLple tumors 
— those that caiL be reached should be rtrmovml. 

Exploratory and Palliative Operations, — A question that baa been 
very much deL>ated in later years is, whether or not it is jostiiiablo to 
perform exploratory trepanation to aid in the diagnosis and localisation 
ijf brain tumor. Most ut^urologists answer the question afllrmatively^ 
while some surgeons who have had large experience in biniu surgery 
are unequivocally opposed to it» The position of tho latter is an ex- 
tremely tenable one, being juetiiied not only by logic, but to some extent 
by the results of such trepanation, Physiciana are incliried to juetify 
exploratory trejjanaliori largely from the fact that in many well-authen- 
ticated cases simple opening of the skull has been attended 1^ profound 
amelioration of the symptoms, in some cases indeed aiuounti&K to ceasa* 
tioQ and to a prolongation of tlie patient's life. 

One of the most striking effects which sometimes attend such simple 
tiepanalion, even though there is no escape of cerebiospinal Buid, is tJie 
ceaaation of progress of tho optic neuritis, or even the amelioration of this 
symptom. Nu siitisfactory explanation of this diminntioQ of inteusity of 
optic neuritis has do far been offeredi although ib is generally oot-epted 
that the cssentifil element is diminution of intracrauial tension. 

Among the palliative operations that may bo undertaken in tumor of 



tk bfftio. tbat of luiubar puncture ib the tuo^t iinj^urUntf piutioularlj' 
btcnneof the ease with v^bich the trilliDg operatiou ia perfarmei and 
bKHiBB of tfae fact that it is of coDBiderabLu diagnostic worth in differeii- 
otmg tamor from iudaiumatory iutracranial condition:} such a± mi^niu- 
p^ uid ftbsceos. Lumbar puLctuie bo^ not he^u as ytt autlicienUy util- 
ivd iLsm ptJlifttive meAGure m the treatment^C bram tumors to allow ua 
tt iftf how much effect it may have iu redxir*mg intracranial pressure. 
Tboiftieally, it ought to bring about the samp resnlta tlmt puncture of 
^TED^icle does- It should be bornu in uiiud that in (cerebellar tiimoFs 
Ikn is some danget in the uae of lumbar puncture- A number of ex- 
japle* tare beea published to flhow that sudden death sometimes follows 
ttpcrfomuLnce- It need scaroely be said that it should not therefore be 
tliliMd vbm the clinii?al features of the case iiulioata that, the neoplasm 
llocated ID the <^erebel1uiij. Another palliative measure that is eome- 
VoBt ma^le use of ia trepanatiou, followed by punt^ture of the lateial 
rrntnales. If on ofnening the ekull for an exploratory operation there ia 
bul^g of the cortex, wbit^h m thought to be indicative of ventricular 
iisteritioD, there are scarcely any obj^^tiona to this procedure; but it is 
nrrlj underUkftn entirely as a jialliative measure unless under very 
pfculuLT circuQUtancea in which it is all-impcrtakit to preserve for a time 
Lhe [Qtient's eyeai^ht- 

The Daiifert of Operation for .Brain Tnuor — UitEerqnt writers make 

wj difTerent estimates of the daag«rB of operations for removal of 

Mi tumors. It may truth folly be said that the morf^ity depends 

LQ freat measure upou the skdl of the operator. The oue who caa 

«nn4 Mpeis, contiol hemorrhage, and combat shock, and who brings to 

lb» qierating- table skill and experiencCr will linU that Ins akiU ia fre- 

^rjfotJy rewarded by the life of hia patient- I'ormeHy a large nuni- 

tier of patienta subjected to operatiooa on tbe craoium succumbed to 

ifpprii In very late years this result h^s liecome imrommon, though 

>fc Still occurs despite the care which the luodern surgeon bestows upon 

t^part of the operation. Hemorrhage is responsible for a considerable 

tLumber of deaths that follow operation on tiie skull. 1'he bleeding is 

molotily from the epicranial sLnicturea but from the Teins of ths diploe. 

^ecaniiot here disi.-URS the means of controlJnig this liemorrhage, our 

cab}(!cl being merely to remind him who underCakes the operatioEi that he 

ihcnild be ready to cope with h. The prelimmary operation that was 

popoeed a few j'earfi ago, ol tying the external r.-arotids in order to con- 

inl the hemorrhage, has never been generally adopted. Ths most 

powerful cause of death in operations for brain tumor ia undoubtedly 

»bocL Almost evtry surgeon who does much cranial work has hig 

Uvonte method of entering the cranial canity, and as be has had expen- 

■nflevith it be uses it more expeditiously than other easier and more 

ntkftil metbodsg so that it ia difScult to convince him of the Buperior 



a^vajiia^»*a of such other nmtltoda. Liioked at fnjm nn unhjaafleil Btand- 
poinb and from tbe Btaudpoitit of him who aenOa his patieot to llie sui- 
geou it would seem to me that the method of opening the ekull vith the 
Dtikllet and cbigol is the loaat advisable becauHc of tho ceirebral conou^^ioa 
that it caoeea, while that with tha electric saw 13 tbe most feaeible. The 
plan of opening tbe stiill aa a preUminary operation and waiting before 
InakiDg ajiy atteiupL to locate aud remove thu tumor until thft ttymptoms 
of shock have disappeared, as proposed and pracLiaed by Horsley, is moat 

Symptomatia Treatment, — The eardlual Eymptoms of braiu tiimor are 
frequently bo severe that it ia necessary t<.i employ measufea that will 
flombat them, even though thpy have im eftei't ui>o[i tlie disuado itetJf. 
The most distreasiag of tlxoae symptoma and tho most tonstaab is head- 
ache, particularly in tho early atagoa of the discaat^. It should be 
ameliorated by absolute icst and qujet, by the \ise of hot or cold appli- 
cations to tha bead and the baek <jf the neck, by local depletion snoh aa 
the applii^ation of lae^^hea or dry cups, and by tho use of some of the 
uiodeni aualgesicji, such att pheaac^etiu or autipyriu, or of morphiue. In 
mauy c^ses it becomes abaoluti^ly necessary to administer the ktter by- 
podermatically. There la very little danger of oontractinR tbe morphine 
habit, but even though there were, this should not 1« allowed to stand 
in the way of ite use. The pain ia in many case* so unendurable and 
is aBsooiated with nnch univntrollable vomiting that it is absolutely nec- 
r^sary to resort to the admiuistratiou of niorpliiiie when the sympboms 
arc vfry severe* Phenacetia can be given in from ten- to fifteen-grain 
doaea without danger, particularly after givtDg a few trial doses of 
smaller ijuantity- If ita administration or the administration of some 
other RnalgeaiCr NiU'h as acetanilid, is det^idi^d i][Kin, it can be given 
in conjunction with strychnine or other stimulautan Tbe bromine salts, 
when properly administered, can in aome inalancea be made to serve 
a useful purpose in dimimshmg auenirgeal and cortical irritability. The 
greatest nircumepection, however, is neceaaaiy in onler that the bromides 
do not add to the patient's lethargy and Btupidity. It should never be 
forgotten that the symptoms of bromide intoxicatitu may parallel those of 
brain tumor. It haa been my own e:tperience to be summoned to a case 
of what seemed to tho physician in attendance to b^ one of brain tumor 
and to watch tho staggering gait, proBtration, mental apathy, and appar* 
ent swelling of the optic discs gradually disappear when the bromid^a 
were witbbeld, Si^giiiu has rnpEirCed a similai case in wbieb preparations 
to operate had bi-cn mads. The moral i9 that the u^e of the bromides 
obonld never be prolonged. 

Vomiting 13 another symptom that often demands ^larticular treatment. 
Many of the measures apokeu of aa being serviceable for the relief of 
headache fortunately have an ameliorating effect ou the vomiting- 



WtieQ«rtir it la puaaible absolute r«st nhould be euforced. Very little ia 
Lo be gained by givmg the cuatom&ry Gtomat^hio sedatives and carmina- 
tivea. In tlie early part of the biaCory of braiti tumor tbe patient often 
suffers from jiTofound iDsomnia, whirh if not combated is liable eeri- 
oualy to undermine hiacoiiaLitutioD aud depreciate tbe vitality wliicb might 
i>e expended ill resisting Ibe disease- To combat ib the ordinary hypuotica 
are ^veti, auch aa chloral, chloralamide, sulfoual, trioual, and paraldehyde. 
If sleepkssnees ia aesociatcd with restlesBuesa, throbbing, and Genne of 
tension in the bead, tbe eft^oaciousness of the elected hjpuotic ean be 
very much eulianced by tbe uaecf suinewimplehydriatic procedure, sueh aa 
the dripping sheet, or tbe cold wet pack of a lialf' hour's duration, folloi^ed 
by a cold ablution. Thia hag the effect of drawing the blood forcibly to 
tbe Burfaeo and diminiahing intracranial tension. A hypnotio used at 
this time will be likE'ly to have the desired effect, although given alone 
it may entirely fail. In the same way, Qo\d sh?. baths of from three to 
fire iiirniitnn' duraliiin, rnniung ooM wtiter nil tphe feet and legs for a few 
seconds, or prolonged tepid hatha may be eerviceable. 

Rarely do muscular twitchings, and spasms^ demand apecial treab~ 
ment, for such Bymptonis are iiuportant localizing symptoms which in 
some instances at least indicate that the growth la removable. They may 
occur, however, with unremovable tiimorH, and thifii they have to be com" 
bated by tha use of the bix^midea and morpbiue. 

The general treatment of brain tumors does not require extended con- 
aidetstioii. It should be borne m mind tb«t tbe natural history of many 
of these gruwtha is a long one and tbat thL^ir esislence is not wholly in- 
eumj>atible with mouths and even jears of eomparative comfort and some 
nsefnlnes.>. I have h:id ueder observation for live yeara a patient who, 
m addition to a detinite localizable tniiior of the brain, had very serious 
disease of the heart and kidneys, who had been able to do h<jr housework 
for the greater part of thts time. Naturally, the rapidity of tbe groivth 
and what may be called, its index of malignity depends upon tbe olLaracter 
of the tnmor, ;ia well naupon other facto rn, not the least imjiortant [>f whieh 
iA the patient's vit^l reai&taoct. An iinporlant duty of the physician is 
to impress upon the patient that he shall so order his life that no ex- 
hausting demands be put upon tbe body or upon the mind, and that the 
constriietJve forces be always in advance of the deslnictive. The ideal 
mode of existence would enrail a quiet life, frpe fi'om care or exhansting 
work, with no demands made upon the patieut's energy other tbaLi those 
required to maintain a high state of nutrition. Unfortunately, auch con- 
ditions are impossiblo escept for tbe favored few, and the physician must 
do here aa in the treatment of so many other diseases — make the most 
advuntageoufl compromise possible. It ij needless to say that in young 
persoua great care should be taken to guard theiu against lojiiried to the 
heajl and that aebool and social eTiteitaiumeuts aro not to be thought of. 



The diet of patientfl'witJ] brain tumor aliould be one that pmwidGfi tbe 
greatest amCFunt of noiirislmieiit and r^uires tha Itiast expend iture uf dig^a- 
tiTe energy. The houra of rest aiid sleep ahcMiId be increased. The cou- 
dition of the orga^B cf elimination, the b<3wels, bladder, and akin, should 
be aaaiduoualy attendtd to. During tlie latter part of the diseaae tli© 
euiunctories demand even greater attention thaii Chey doeaHier, and it may 
be ueiifcssary not only to use Ll^o t^atlKiter regularly, Hit to mainlam the most 
scrupuloua cleanliness in order to prevent the developuient of bed sores. 

Aside from the eymptomatio treatment, the medicinal treatment of 
tnXDora of the bram is unfortunately very insigaifieantf save in two rari* 
etiee— gumma and aneurism. When either one of these 13 suspected, 
then it becomes oeceaaary to carry out the a[ipropriate treatment in the 
moat approved and persistent way. The general and Kf>ecial treatment 
of syphiloma of the brain ar^ discuaised aader s^philia of the nervous 
ayatem, while the treatment of intraerauial aneurism may be Bumwed np 
jn a lino: rest, the adminiBtration of cardioTaacular eedntives and iodide 
of potassium, and the adoption of measures looking toward the eesaatJou 
of changes in the blood -vesflels, 

A word may be aaid uont^rning the preventive and palliative treat' 
meat of tuberculoma. The exi^benee of tnberruloaia in other parts of the 
body or in the aneestora Bhould be siiHieient iadieation and incentive for 
the adoption of measures to maintain the nutrition of £Uoh a person, or 
to restore it if it ia overthrown. The»e meaanrea are in nowise different 
from thoi^e wliioh can be used t^.i meet the same indications when these 
exist under other circ urns lances. The peinicionsncas of injury to the head 
ftnd of intellectual stimulation and exhaustion should he kept in mind- 
It; was stated in tho be^inmn^that the treatment of brain tumor is un- 
fortunately most unsatii^fartory, and after discussiugthe various measures 
that are at our dispoaal^ such must Iw maintained at the end. We may 
speak of the prophylaxis of eEtirpatiog a mallguant growth from one part 
of the body in order that the brain may nob bo affected, and of the removal 
of fcuberculonB cervical glands for the same reason, but thia ia not the 
treatmeiit of brain tumor. The truth is that about six per cent cf all 
eases of brain tumor ai^e suHoeptible to remedial measures Himugh the 
sealpel of the surgeoti, and thrOLigh antt syphilitic ti-eatment^ Al>oiit 
twenty -five per cent of selected cases, that ia, cases in which the iadica' 
tions concerning the seat and nature of the growth are auch thut its re- 
moval eeema possible, are amenable to 8Urgi<-al treatment. To knyer the 
mortality rate of brain tumors, tlie most necesaaiy desideratum is a more 
oomprehensivB knowledge of the pbjsiology of the brain — in otherwnrds, 
advance in the knowledge of cerebral loialixatiou and diffusion of the 
existing knowledge- To attain tliia end the symptoms of brain tumor 
should i)e most carefully observed and the moibid condition and its exact 
localization as determined by autopsy recorded. 



The lerm cerebral spoplexy is often used an the ajDoiiym of cerebral 

bBDMvrlug«^ but it is more frequeatl/ and properij apphed to any acute 

htka of tha blood-vcsaels whicb partially or completely occludes the 

fiilkber of one or more of tJiem, either temporarily or permanently Thus 

WNIuaI apoplexy may be due to ruptur^^ thrombosis, or embolism of % 

nmi^ or to the tfdema t.hat attends iicLite congestion of the brain. 

(^iaically coimideredr cerebrLd apoplejij ia a cocdition characterized by a 

lu^dcQ partial or complete anapenaion of cerebration, while the vital fimc- 

bom of the cbJoo^ata. euch as respiration ortd circulation, are relatively 

or «NDpl«lely preaer^ed^ The diatincdve elimcal features are the com- 

plM KLtspenBion of the cerebral functions, and the '^ stroke " or sudden 

owt Pathologically the condition iH alwavd dejiendent upon some 

^^in the bram substance. 

The tn?atmeat of cerebral apoplexy varies according to the morbid 

(fftpsudftncy of the disease. I ahall consider the treatment of apoplexy 

Jb© to 1. Cerebral hemorrhage, 2. Cerebral softenmg from embolism 

VLd thrombosis^ 3. Cerebral congestion and o^IeiiLa; and 4. Apoplexy 

dovki Uausitory Hon -organic changes in tlie blood-vesaeU. 

The txeatnient of cerebral apuple>y due to rupture of a blood-vessel 
|>nicalarly unaatia factory if medication ie delayed uulii after the 
'orreace of the stroke. In other words, prerenlive treatment ia by far 
lLo«t important. Much can be doiio to prevent rupture of a cerebral 
ressel if the aymptoma vhich point to it are early recognized and 
^lerprated, vhile vpt-y little can be done to mitigate the sequele of an 
AUrk, even though the victim recovers from the acute manifestations. 

A diftcuasion of the prophylactic treatment of cerebral hemorrhage 
MMStatea a brief consideration of its causation. This is predispcning 
mificitiiig. Xbecauses that predispose to rupture of blood-resselB with- 
in the brain are advanepd macimty, forty to siity yeara of sge^ the male 
«; sedentary and intellectual <K:<upatiou ; jiroloiiged aod excessive in- 
diiig^ce in ak-obolic drinkd, tobacco* and other narcotics, eyphibs^ the 
ulccboua diseaaea; chronic indigestion, gout, rheumatism, and diabetes; 
mi iatruicatioij by any of the minerals that are bnoim to produce 



deeCnjetive changes in the blood -TeaBsls, such as l^ad, merj'ury, and car- 
boo dioxiile. In brief, it will be ee«n that the prodispoaing caiiaes of 
cerebral apojilexy are tbose^ that predisjioaa to arteriiJ degcDerAtioii, par- 
ticularly the alowlj progreaHive form known aa arteriocapillajy fibrosis. 
Soma of the factors enumerated are more poteut to cause the degeneratire 
ohacges la the blood-ves^eln that predispose to iHipture than aie othdr*^ 
ForinBtaaeeT in florae persons prcilmiged disorder of digestion, the iiric-acid 
diatheHis, the exinten^ie of sj^philiSj and the occurrence of lafectious dis 
tiiAtSt exert;ise ueemiugly ;b special pernicious aution on the blood^veaseb 
to cauao some form of arleritia, which in turn produces a condition that 
makes rupture of them eaej. Other iudividuala will encounter one or nil 
of these etiological factors without developing any change in the hlood- 
vesBels- Tn other wurds, tlm pfrHonal ecptaticMi IH an im|>4>rE.ant one in 
flHtimating the etiology of thiH uccidcnt. This pergonal equatiuit is largely 
a matter of heredity and partly one of cnTironinent. Persons whose an- 
eestore have died of cerebral hemorrhage or its coueequeuc^a are more 
liable to ench an accident than those whose family history is compara< 
tively free fr*»m vascular degeneration. The element in the heredity thst^ 
IS pathological may mjinifest itaelf els a uric-acid diathesis or attacks o^ 
gout* in weakened digestion, in want of resistance to tJie iufecticus dis-^' 
eaaeap or it may sho^ itself in none of th^ae ways, the dcscendaikt bctn^ 
carried otf ljy rupture of the cerebrflt vessels at an earlier age than waw 
the ancestor, A]l thesie factors mutit be taken into full conaiUeratioti 
in deciding ui>on the treatment of arterionapillary fibrosif^, which isdi^ 
prophyiactic treatment of rupture of ttie cerebral blood-veascls. 

The objecta to be m^ist striven for in Uio treatment cf arteriocapillarj 
fibrosis should be the prevention of farther progress of the morbid prooe^s 
and the cessation of the secondary fatty degeneration^ not only in tha 
waits of the vessels but in the pareiichyma of the organs to which th^ 
ace distributed. That these may be satisfactorily acconipliahedT it h 
neoessary so to order the patient's Ly^cne, dietary, and labors that meta- 
boliBm is carried on with the highest degree of perfection. An endeavor 
should be made so to arrange the constructive forces and the expeoditure 
of energy that a careful nutritional balLince is preserved. The most im- 
jjortant medication, aside from that direr.led toward the proper and com- 
plete adaptation of the ingenta and the farilitatiou of the excreta of the 
bf>dy, couaists in the admin i at ration of oxidizing agents and alteratives. Of 
these the mo^t important by far is iodide of potassium or of sodium. One 
of these salCs should be given in from seveo^ to fifteen-grain doses three 
timea a day for prolon^^ed periods, interrupting it or dimiDishing the do^e 
only when it disorders dig<e3LionT causes bradycardia, or depreciates nutri- 
tion. It should then bo interrupted and meaaurea taken to ovcrrome the 
trifling iodism. It may be combined, when there are special indieationa 
in the vascular system for its use, with ^ery small doses of digitalis. The 



BOSt utififactory Dsidiziug ag(?iit is iron when the digesticu ajxd elimina- 

tbn of the patient will permit of its ust, I f the chants ia the bl<M>d-vea- 

^aA are jiirofouiid enough to pause marked diaorder of blood pressure, due to 

ilw laGtcaaed peripheral reaistauce a^ud llie diminished force of the heart, 

(be oitjritfs, particularly tlie Ditrite of sudtum and nilr^lyceriii, the salts 

iiEliTomiite, or aconite in small dosei^, should be u^ed to tide the patient over 

ttj erms. Such a crisis may be announced hy repeated attaoka of ver- 

ti^ by anmbneaa of one or more extremities, by unwteMiiiesG and dimin- 

ilM deiLertty of a member, by muaeular prc^^tration, by syncopal at- 

ivks. by aymptoms of angina pectoriSf by thickness of aiticulattou, and by 

ib^t Ukcatal incoherency. The propbylactio treatment, asidti from that 

fircvted against pro^eas of the loaion of the blood- vessels, should be to 

mid the immediate exciting causes of rupture of the vessels. Tkese ai^ 

f:ddn and violent alterations m blood pressure, due to forced liodlly and 

Hitil acr^vity and the operation of depressing external mQueucfia, such 

M upoQure to cold and attacks of mdig^stion. So far as posaiblei ex- 

hmtm^ tniellex;tual work should be avruded and the patient must be told 

ni Lb ueceesity of temperatenesa in eating and drinking, of the avoidance 
gj ikobolic drinks, which always cause m crease of arberial tension fol- 
bvfd bj ifljarious depression, and indulgence iti acts that put great 
Rrtfs u[ion the hefut, suL'h as eoitus and straining at stuol, 

Tnttment at the Time of the Attack — In a certain proportion of cases 
of otenocapillarj fibrosis, perbnps in the maJDdty of them^ the pbyai- 
bill's idiice is not sought until after rupture of a cerebral blood-vessel 
btt occurred. The conditiooa then demand the use of meaenres that 
toJ to alow the actioo of the heart and dimtnfsh blood preAanro, and to 
tnngiboot coagulation. Uo fortunate ly» wear? not in possession of meana 
ibattend to check the bleeding in tlie brain^ ext^ept those that operate to 
duiLi;iiah blood pressure, uidesq digital compredslon of the earotid be coq- 
riittfd mnh means. This measure ia Favorably spoken of by some 
writes, but it ia applicable only in eaees Been soon after the onset. The 
flMBpnuioa should be kept up for half an hour or longer. Ligation of 
4et»fotid has l*eQ proposed^ but has not yet been dona to any extent, 
IhiFof the best ways of diminishing intracranial blood preiisure ia to in- 
unse the peripheral circalation by meaun of friction to the extremities 
vd to the trunk, revulsives to the extremities, such as hot mustard 
fOQl'baths, or sinapisms to the feet The general indications for treat- 
omt i\ the time of the attack are the same as those for hemorrhage 
fmo SDT part of the body. The patient shoidd be kept absolutely quiet, 
Tlthlhe head slightly elevated, and in a room with plenty of air. The 
buet potent way of reducing blood pressure and thus diminishing the 
mount of hemorrhage is by blood-letting. When patients arc seen eajlj 
ujthi ittaek it is m_v own practiee to perform veneseetion, abfltraciing 
bra 111 to sixteen ounces of blood from the median cephalic vein, pro- 


vidiDg iLi> Special cotitraindtoaEiona exist. When th^re is aity doubt ooQ< 
corning tho nature of tbe stroke, and vhen the patient's genentl condition 
does uol aeem lowarrjuit &t)a faction of blood, audi tteatineiit Is dispeastnl 
vith« tinil thd desired revuUion and depletion ure sought through tb« ud- 
mmiatmttoii of purgatives, Beforo giving a purf^tive it \b wise to in- 
quire whtith«£ or uot ths stoniEioh and lower bowel aie m^Lidemtely empty, 
Althuugb them nre serioua ubjeotiona to giving emoiics, an overloaded 
Btoinnch luust bo emptied despite the faot that the act of vomiting may 
oau»e temporary iucrea^ of iutracraaial blood preaaare. The distended 
lower bowftl should bo emptied by an enemo, and thia immediately fol- 
lowed by tbe admin is tratioa of calomel in two- or three-grain doaea^ »- 
peated in two hours acid followed by a saline draught if the patient ia 
able to swallow. Biniilar and more vigorous results may be obiaiued! 
from small doses of iTotoii od niiied with a ^uerous quantity of Ciutor 
od if the patient is able to aval low, or with a email quantity placed 
upou the tongue if the patient does not swallow, AFt^r the patient has 
had one or two oopioiia pasaageB, the dose should not l« n'peatt^d for 
aome time unless speoial iudiimtions exist, 1 have nerer seen any bene- 
ficial results which f.:iiijld be attributed to the application of blister plaa- 
tera or preparations to the niipe of the neck, behind the oars, or other 
parts of the body, although they ate atill mentioned favorably by some 
writ^ra on the subject. After the indirationa ffir treatment that have ao 
far bet^o s^Hiken of have been met, the duty of the phyaiciRn then consists 
largely in the preventiun of suub accidents aa aceumulation of urine in the 
bladder, collootiou of iiiucus in the mouth which by dropping into tha 
respiratory tract may not only facilitate hypostatic congestion bub infra- 
tioQi partial eeasaticn of the functiona of the Bkin, and the occurrence of 
bed sores. The patient should be catheterized regularly, tlio mouth 
oarafully swabbed out with a mild antiseptie lotion, and the skin kept 
free and active by the uae of warm water and soap. Vory little nourish- 
ment should be given during the period of unoortaolousneea unless it Ja 
prolonged^ Then reotal feeding should be done, particularly if there 13 
any dangi»r that in HWiillowing some of the food will escape into the reapira* 
Uiry passages, (.'nualiy if the patient is going to recover from the attack, 
oouBCiousness will be at leaat partially restored after the first twenty-four 
hours, and the simple food that is indicated, vis., milk and broths, oanbe 
given by the mouth. 

The next moat important duty of the physician ia correctly to interpret 
the indications for using stimulants which oftentimea exist soon after 
the apoplectic attack begins. Information on this aoora is to be obtained 
almost exoluflively from study of the heart and of the pulse. Prolonged 
and profound diminution of arterial tension requires the adminiatration 
of some such rapidly acting stimulant as caETeine, ether, or ramphnr, or 
if the first sound of the heart is particularly weak and the rhythm of the 



irre^nlAr, th« ftdmiuistrabiou of a pure Cftrdiac BtimulaiLt sucli a^ 
IraplkijiLhufi or sp&rteiQe Bimultaueoaaly v\\h very small doses of one of 
ftitntMto diiiimisb p«iiphei^] reaislatKie. Wben iC is desired to quiet 
iheftrtioci oF the heart, acoDite, in small aiid frequQDt doseSf when there 
b iia«a>tlrAiudE(?at]ciL to its use, U niont tserTii^eaUe. If tht^ee measures 
do Dot suffice^ w-Iiea used in coaiiectioa with thoas tLat have beeu eDumer^ 
tfadforbmisitiffabi>utcquaLlz&tiuiiof the oiroul&tiou, no hesitation should 
b»badiii reaortiQg to the intriiveuoufliujectionof adeErinoi-malsaJinoGolu- 
tcii 0?, 1^ it ia sometimes called, artificial serum. Care should be taken, 
bovercTr ^ot lo give itin auc?h large quautitieaaa to put couaideraLle stress 
qoithe fiagde blood-veasda or to cause febrile reaction. Karelj ia it 
i^Tuablo to adiainiater more thaii from tweuty to thiit]' cubic centimettea 
iiatimA. This can be repeated ^very hour or two uatU the loanifcsta- 
UaiJ wf diminished atiertal oirculatioti have bean ovetcojoe, 

Tnannent After an Attack, — The b-eatiDeiLt of t-erebral apople^^j after 
uVtiek. Li of vety gteat imitortance, although one might not infer this 
bOD the verj ecant attention that is given to tlio subject in the literature. 
TTwiimogeoepal indioationa that were epekcnof alvove looking toward the 
Etntenince cf the digestive, renal, and cutaneous functions bold here as 
Tt]\ Bs dncing the attack. Aa soon as the sjnhptoms of reaction whiflh 
!<!» caused b^ the eitravaaation of blood into the parts surrounding the 
mpiural ves^^el have diaappearpd, Ircatmont shoiild bp beg^iu fur the 
piiipc«of preveotiug so fiix jis pt*asiblo the oonBequences of secondary 
degeaeratioii, pattieularly spasticity, contraoture^ and trophic phenomena. 
T^«fB occidjUanB are to be combated by the rational and persiateut use 
deUtricity, massage, graduab^d exerciser, active and [lassive, and by close 
tthmtion to the toilet of the akin and to the aveanes of elimination* The 
iritfiapl treatment directed toward the same end consiata principally La 
tbftttAOl meaaurea to counteract further change in theartenes and arteri- 
d»,anil to mamtJ^m the nutritioil. The utility of electricity to atimulate 
luucuUr eontractLou and help to preserve the nutrition of the ujiracles in 
bemipLtrf ui after c«iebral hemorrhage ia a very debatable question. It ia, 
Wrr^r, generally a^eed that the uae of thegalranicor faradia current is 
leaded vith considerable risk in hemiplegia with contracture, ratieots 
nULGaivtd paraty aid following r-t^rebral apoplexy are nearly always some- 
vhu improved by the persiatenT; application of either of these currents^ and 
lij ^atof the static electricity. The virtue of electricity hero ia unques- 
tioublj largely through its power to improas the patient that he is receiv- 
EBgkoefidal treatment, while at the saiue time it m^yaid in maintaining 
tbeDutritioaof the parts. Massage is another measure which can be em- 
plf^nl, both in the spastio and in the flaccid variety, with considerable 
beu&L Hanual ina^ssa^ (a preferable to me^^hanical. Care should be 
tikflOthkh th« treatment is not so severe or prolonged that it fatigues the 
ftei The most important procedure in helping to restore the para- 


\y2e1l side ntiisists in teui^Llng juid in em^oiimging the padeot Ui pr;ii.'Us« 
gr&Jiiated aiUive aud pasaive ejterciBes, whioli ahoiild tie begun at tho first 
reappearauce of any degree of voluntary control in the estreiuitkfl. An- 
lieipatuig fhe roaloration of a degrte of voluntary activity in tbeae |iwtfl. 
the patient should be |^iv«n passive movemeuta of the paralj'zed extremity 
just as soon asthi' a^utfi accompaniments of the ruptured blocxi- vessels bav* 
disappeared. This Is ueresfiary iiL urder that chaugea Qoiiseiiuent. to Jm- 
uiobili^aLioa do not go on in the jginta. Then as booh aa the patient can 
perform even the slightest voluntary u:ovemeDt this should bo practie^ 
niethodu^ally and with preoisioii at dtated times every day with the M- 
>iatan*^e of an atteudanl. 

Precaiitiona should be takett to prevent the develupineut of tro[ihi<t 
leeionet i/y insisting upon jicmpuloui cleanliner>s of tho akin from the be^ 
giiuiin^i and by tho geiitrous uso of dusting powders, 

SoKTRWisa or thk Biia^n pkcim Raium-isw ASn THNnuBoitra 

(EpfOKl'llALlJUALAL'IA) . 

Softening nf the hrain ia the anatomii^al condition that reaidta from 
emholism or thrombosis of one or more vessels of sume ■'<im|>unei]l of the 
encephalon. Either of thege conditions may 04?nir in the c^rehrivl hemi- 
apheres, the banal ganglia, pous a^d ohloni^ta, ur in the cerebellum. Soft- 
ening of the cerebral hemispheres and basal .ganglia alone will be consid- 
ered here. Cerebral embolism and cerebral Ihromboais cause clinically 
varictipB of cerebral apoplexy, and the prodromal, symptomatip, mid se- 
quential features which attend their or^i-'urreiice are as a rule diagDoatio. 
The symptomB are immsiliatply I'nnditioued by the deprivatiofi of blood 
from t^erbaLu uveas ut the brain depending upon the vessel that i« plugged^ 
while the ronict« flymptonis are the re^idt of aecondary changes that 
go on in auoh ai^coEi and in the pathways' with which they are cimn^ctod. 
The prophylactics treatmtint, of both cerebral dmbuhsm and tliromboaiSi 
ifl of vastly greater iinportauce than aity treatment after their oceutrencc. 
Thei'efoi*', it is neres^ary to consuli-r tlie etiology of thesa conditions. 

The Etiology of Cerebral Embolism. —The embolus which causes a 
complete or partial obstruction of one or mora of the cerebral blood-vessels 
has itt) origin in the VMt majority of eases \pithout the brain, andia carried 
thereto in the arterial i:'.Lrculation. These emboli are either benign or 
septio. Benign emboli ariso from ex^ndative endocarditiH with its conae- 
i^ueut accumulation of vegetations ou the valvular apparatus, which oa 
being separated during states of cardiac excitement or without known cause 
are aai^ned into the aorta and tlirough the CEirotidatJ^ the brain* Theyalao 
arise from thrombosis in the heart the result of aci^uired weakness and de- 
generation of the heart walla, portions of the clot becoming H«parated and 
carried into the circulation the same as from the vegetatioDS of eadocardi- 



^ft C«t«bT&l eoiboliam may bsi^e its origin from ih& reparative ooafn^am 

^^wtM) era carotid aneui-iBin, Ths embolus maj be a particle of fat 

iIbI hu got into ^e cintularion as th«^ result of fi-aclnreof onuof the kng 

iHnuid carried Uitough the cardiac circulation, the aorta, tuid tliv iuterDol 

Miolid to the braia. riually, it may have its origin iu anj parb of the 

mas ■7*tcm wh.]ch iadiEtmeodaud bo '?umed by this circuEiition through 

fttngbt heart into the liing, th^re cauBing pulmonary infarct, which in 

L imnftj allow an embohis to get into the return pulmonary circatation 

^AiQD^ the left heart and thus to the brain. Naturally this ia an ei- 

^Bitly rare coniHtion. Septic or malignant emboli consist of micrc-or- 

IfhirB cjpbedded in the ccUb of the deatmctiTe tissue frgjn the primary 

Insof olceration- Septic oerebralthromboHcsaresGquentialtoiilceratiT& 

fltoardtlis and putrid foci in the lungs. Very rarely ia the aeptic focua 

aplhericperficia.lDrdeeppartaof the body. Tlif remote etiolugj of cere- 

tol etaboliam cousista of all the factora that contribute to the occurreoOQ 

cf anjof the conditions that ha^e juBt been enumerated. To detail them 

LenHOultl be an unnecessEiry expenditure of ^pace, as it woald demand 

n ttrutnention of all the etiological conditions of eiudative and uloera- 

tixi ttidorarditi*» the Tarioua farms of niyocarditia, aneurism, pulmonary 

ififkirt aud septic foci in tlie lungJd, and the puerperal state as well aa 

ttxMMQ of thrombc«is. 

Tbo Xtiolo^ of Cerebral Thromboflia.— By cerebral thromboaia 19 
onst coagulation of theblo^id in one or more of the cerebral blood -ves eels. 
Sufl) 1 condition results nhen the reciprocal reilations existing l>etween 
'^tiloud on the one hand and the lilooil- vessels on the other l>ecome dis- 
laibeii. Thna it is that the remote and inLmediate causative factors of 
fnM thrombosis may be those that are operative upon the blood- 
wpili, either externally to compress them, or internally to produce an 
lifluimttiom and degeneratioM of their walls ^ upon the blood to ptodace 
ikffitioa of iLa constituents; cr upon the cArdio vascular apparatus to 
me iJowing of the blood current- To even enumerate the rarious 
(tONS of endarteritis and arterial degeneration, the antecedent factors of 
twriotioa of the components of the blood that will allow this fluid to 
nagnUt*, and of the conditionB that causie sueh Blowing of the vascular 
mmit that the circulation come^H to a atandstill in one of the smaller 
Uood-reuela, ^ronld re^^uire mote space than can be giren. It must suffice 
A^ajrUiat the most potent cause of cerebral thrombosis is endarteritis 
"J ij^tilitio origin. Syphilitic endarteritis usually occurs in the first 
dwaj* fcUowing syphilitic infection, and not infrequently during the 
&Wlhr*eorfoiir years. The nent most common causes of cerebral en i)ar- 
ue the infectious diseases, alcohol, and the mineral poisons, Weak- 
cif the catdiOTaaculnr apparatna leading to cerebral thrombosis may 
bs the reatilt of acute diseaees, marasmus, senility, and the acute and 
*!l"MBiic cardiopathies. The haemio changes leading tocerebral thrcmboflia 



may be the result of local or geii<ral mfectiOTi of the blood or of interfer' 
ence with the formaiiori a»d TeooiistructicD of tbe blutxl coiistitufota. 

Tie&tmecLt of Gerebnil Emboliam and Thiombosu-^The tFeatmeiit of 
cerebral embolism is quite unUke that appropriate for cerebral thromboais, 
OQd the treatment of either one is unlike tliat sait&ble for (cerebral 
apoplei:y due to rupture of a blood-veesel. A careful differential diagnoew 
of theafl three cooditiona :s therefore veiy necessary before trefltment U 

The importaiLce of prophylactic treatment in either cerebral embolism 
or thromboaia cannot be oveTeatiiuatped, In the former it oouaistd iu the 
utilization of measui^ea to combat the endocarditis, myooarditiSf itortie 
aneurism, or septic focus in the Innga, and to prevent sndden emotional or 
physioal eioitoniRnt whieb might tend to facilitate thedetaohmeutof parti- 
cles of iiiflamtuatory or reparative products iroin theae part&. Tu Ihe latter^ 
prophylactic treatment couaiata in the adoption of meaaurea to counteract 
the disease that is narrowing the lumeu of the oeTcbral blood-vessels, to 
overcome the conditions that are cansing disorganization of the conetitu- 
enta of the blood, and to stimulate the cardiovaacnlar apparatus so that 
it wtU aeikd the blood through the cerebral blood-vessels vith sticli 
rapidity that its coagulation is prevented. To meet the Indications in 
the prerentiOQ of cerebral embolism, it may bo neceesary to utilise the 
moat approved msthoda of treating not only the ondo- and myocarditiBr 
the cardiac thromboaiaj the aortic aneurism, and the septic focus in the 
luiiga, but the diseases tliat give rise to them aa well One extremely 
impoilant point to keep in mind ia that abaotuto physical rest ia of th» 
greateflt aervico in preventing the dctachcaent of the embolus which may 
block up the cerebral blood-vessel. In one case the indications may be to 
teep a cold compress over the heart that cardiac quietude may be insured 
and in another case it may be the ad ministration of strychnine or other 
cardiac stimulant in order to whip up the heart's action bo that a cardiac 
Ihrouibua may not foriii- 

The prophylactic treatment of cerebral thrombosis conaista in the vast 
majority of cases tn counteracting the syphilitic endarteritis, and as this 
is oftenest e. late accompaniment of exudativa ajphilis, both meroury 
and iodide of potaasium ara required. The immediate indications in 
such ;;anditiuus Jiiay be the adruinlatration of some such vasodilator as 
one of the nitrites and a cardiovascular stimulant J5uch as strophauthua or 
Gtiycbniue, to aid the heart in sending blood through the narrow, degen- 
erated, imresilient blood-vessels. 

The treatment of cetehral emboliim or throrabosia at tlie time of the 
attack should cunai&t in studiously doing nothiug except keeping the pa- 
tleut quiet on hia back with lowered he^, in a large» well'ventUatdil 
apartment, in which there is freedom from all disturbing influences, uatil 
the difierential diagnosis between the acute softening and cerebral heuaor- 



rbkge cui be mftile- It is possibly that the cerebral embolism or thiom^ 
bccu 'will lead lo death bo rapidly that chia ciiffereDtiatjon cannot be 

wdH. Tbo r&5t Laajority of case^, however* puraue a eIgw coura^ and 
Keful obBerration of tho mode of cns^t, the preceding conditiooflt the 
tfb of the patientf and the atato of tho cardiovnaeular apparaCos, will put 
nin pofisettaion of the infcrmatioQ necessarj t^ make the diagnosie- 
ift«r the differential dia^o.iU is made* the trentment vitl depend upon 
Tbetb«r Uje acute softening ia dud to embolism or thrombosis. If due to 
nbcilmn, th^ general indications are to administer drags that haro a 
mtiv« iolJuence upon the heart and blood-vesseh. If the patient ia 
PCD BooQ after the oeeurrence of embohsm, the heart will be found in 
kbcnd, ^hgOTons action^ while the peripherikl vascular equilibrinm will 
bvff7 much diaturbcfl. Under 8ut^h cirouni-stiuiiies, and particularly if 
llKpft^oit is partly UDconscioua, it is adyiaable toadmrnister from tnenty 
ttfivr^ grains of bromide of aodinm, which may be repeated in two houra 
jS \i docfl not ha^ti the desired aedative effect- If the patient is not in an 
tfU^nio Btate, the result of disease leading up to the embolus, HOme of 
tie vasomotor depressants, such as aconite or reratrum viride, nnj be 
preu, but they Ahould not lie repeated more than a few times unleaa 
tbfje be special indications euch as a continuoua, full, soft pulse. The 
siflialie is tmfortuaat^lj sometimes made of giving cardiac etimulanta iiL 
wtbral thromboEis, wiLh the view of increasing the blood pressure so 23 
« ^odge the elot, A moment's consideratien euffices to show that 
sell ID idea ia extremely erroneous, and that the administr&tiou of vaa- 
AJu-stiinulaiite only tends to cause a greater area of Eoftecing around the 
phRcd Uood'vessel, by causing thereto greater determination of blood. 

the general measures that may be of some Bcrvice in lim^Lting the 

laouDi and degree of softening are attention to the condition of the bow- 

ih, Drinary apparatus, ajid skin; the application of ice to the head; the 

Qji^aajcnt of absolute roat and quiet: BXid the adoption of measures bo 

ttJucekmpetatute if the fever beboTO 100^ F, Septic emboli are usuallj 

nvltiple and are accompanied by symptoms of general sepsis, ae well as 

tboMof focal, purulent encephalitis^ The treatnueiit does not differ ma- 

Ittiilly from that given for benign embolism, s^ive that if the seat of the 

Mboliam in the brain ia in the cortex and localizable, the advisahdity of 

ncfnation for tbe removal of the abscess that has caui^ed it may have 

to be coaaidered. As a matter of fact, septic embolism tenainatea in 

ijeiifa, no matter what is done. The treatment of the sequelae of the 

hdrr Btag«a of cerebral em1>olism, that is of the symptoms attending the 

Bpizmtlve process in the softened area, aud the HyiiiptumH dependent 

ajoa the severance of conduction or association tracts by tbe softened 

ott sod itfl reparation, will depend very largely upon tbe seat of the 

^cnoD. The eymptonmtic sequels of such lesion may be a variety of 

ipWia, Jacksonian epilepsy, hemiplegia, or monoplegia, and thus will 



roqairo different treatment for difforent oonditions. As ft rule, it vuj 
be Bald that the general indioattons are to maiiLtain the mitritioo, to 
brook no infraction of the laws of mental and jihysioal hygiene, and to 
administer iodida of potcmsium. Aside from this, tlie physician ELould 
concorn himself to prevent the Temote and immediate condition 3 under 
whicb the attack of emboliBm ooourrBd, bo that the patteab maj be spared 
a repetition of it. 

The treatment of cerebral thrombosis is theoretically and practically 
abflolately the opposite of that for cerebral emboliam and cerebral hemor- 
rhage. IfotinthBtandiog this, it la oftentimes, perhaps in the majority 
of the c&ses, gWeu exactly the same treatment. Physiciana who ar« 
called to a case of cerebral apoplexy feel it incumbent on them because 
of the gravity of the aymptoma and the apparent neeesaity for urgenr 
meaHures to give t^oiiaiderafale treatment. Ah a rulp, Burh treatment can- 
not possibly be of any service unless the differential diagnosis is made^ 
and nothirjg ia to be lost by "waiting until this can be arrived at. The 
immedmte treatment of cerebral embolism ^ ill di^pend somewhat upon 
the immediate antecedent facttora. As a rnle it may be said that it con- 
ftista m the ad mint strati on of remedies that dilate the bloorl- vessels, while 
attheaame time they stimulate the hearL Siit^h results can be encompassed 
by the administration of the nitrites and such atimulants as caffeine, 
strophantbus, and possilly digitalis, although the capacity of tho latter to 
produce eioning of the heart and therefore slowing of tlie rapidi^ of the 
blood flow should not be forgotten. On the othc^r hand, if the eoagnlum 
IH the result of marasmus or senility, the indications for treatment may 
be oxygen inhalation, subcntaneoua injection of normal salino s<iliitinu, or 
the transfusion of blood. The after-treatment of cerebral thrombosis is 
not materially different from that of cerebral embolism^ save in one par- 
ticular, which ia that the measures indicated to counteract the progreaa 
of arteml degeneration be given with the greatest oaro and assiduity. 
Unless ci^reliral thrombosis be very profound, the iirst attack ia not 
usually fatal. Tho imminent danger is of & repetition of the attack. 
The indications for treatment vary somewhat with the causal factors of 
the arterial dtgeueration, but they differ in nowise from those spoken 
of under the heading of prophylactic treatment. The sequelae of cerebral 
ihroinboHis are the same as those of embolism, and, like theiUj are 
spoken of in this treatise under separate headings- 

Cobgestive and (Edematoas Apoplexy. — Apoplectic attacks the result 
of cerebral congestion and oedema are very rare compared with the 
former varieties. The pathogenesis of apoplectic attacks from cerebral 
hyperemia ia not weH understood. It ia supposed that the pirenlatory 
disorder ia so profound in th*" brain that some one or more levels of the 
intracranial motor projection system is for the time thrown out of func- 
tion bnt not permanently diseased. Cerebral hjperseraia never ooours 


u a olinioal entity apart from the conditiou to whioh it u secondary, 
ajid the treatment that ia required for whatever manifestation of it is 
treatment directed againat that. CEdema of the brain is always secondary 
to Bome other pathological condition such as obetruotiou of the venooa 
circulatioa within the oraniom, or obstruction to general venons ciicuUtion, 
depravity of the btood as in Brighfs disease, and general infeotions, 
traama, and acute alcoholism are the commonest causes. The treatment 
for its symptomatic manifestations, among which occasionally is apoplexy, 
is the discovery, combating, and removal of the underlying causes. 

It is believed that the blood-vesBela of the brain may undergo spas- 
modic contraction as the result of eicitation from irritant matters in the 
blood and from other causes which will temporarily cause loss of func- 
tion in the brain areas supplied with blood. Such a condition may be 
attended with the phenomena of cerebral apoplexy including hemiplegia 
if one of the middle cerebrals ia involved- The pathology of this matter 
is very obscure, and all that can here be said in reference to it is that tho 
reality of such occurrence seems to be well substantiated. 



Apbabia is B term used to indicate any dUturbaace or porveTBion of 
inteiloutuaL expresaiotj. The signiiicajice of the term liaa expanded from 
tbe time when its appHcation was used to deaiga^te a defei^t in tb« verbal 
Qipresaion of an idea until it qqw inchidea nJl defects or disordera of in- 
tellectual eipresaion, whether such disorders be the result of disarrange* 
ment or deHtmction of the reieptive or of the ^ misstve compoaents of tha 
apeech meohaniam, or of anything which may be employed oa the ana- 
lORue of apoouh, Thus a person who, deepite the intoypity of the ptip- 
ipheraJ apeet-h nioclianisui, is imabla to utter hU own name ot to give et- 
preasion U> thoughts whii^b urise in the usual vr^y, has aphasia. If he U 
inoap&blo of making known Lis thoughts by the employment of some 
equirident of spoken worda, sui^h aa wiitiug of any sort or by expreasiv? 
mimicry or pantomime, he likewise bas aphaam. Moreover, a person 
has aphasia who, with the extra -cerebral apparatus intact, la nnable to 
underatand the language in whooe itae he haa been trained; does not even 
recognize, Ldtbou^h lie hears, the sounds of the most familiar nature and 
words to which he has for a lifetiuie been accustomed, auoh aa his own 
name; altbougU ho may be able to rcadf ia unable to write voluntantj 
and from dictation, and to express his thoughta by words, by Bymbols, 
and by pantcniime. 

Vet evea these shortoominga do not oomprise all that is meant by 
aphasia. If a persou with uormal oi^ular iiiechaniam looka upon a 
printed or written page, and the symbola there with which he baa pre- 
nounly beon entirely familiar ooni-ey no mearing to him in the form of 
approximal*' thought or idea, Biu*h portion hna aphasia, even though he 
may understand all that ia communicated orally to him, and though he 
may bimaelf be able tu express his thoughts (iucomplotely oiid defec- 
tively, however) by spoken attd written worda. 

Thus it will be seen that aphakia, ijk tho broad usage of the term, may 
be the result of conditions by whit-h tbe jiatient ia unable to part with an 
expressive equivalent of the idea which haa bean properly farmed. This 
failure i^ not confined to words, but Inidndes all modea of eipresaion; or- 
it may bo caused by any condition that interferts with the Teueptioii_ 
o£ impulaes or stimuli that enter into the genesis o£ idena used m th^ 
coDatruotinn of internal or external langua^. As movement in som^ 



ia T^uioito for the perfonuftaoe of ftny &nd &lt expressionSf diaofder 

ttwce cotifitituta the conditioua to whioh the term laotor aphasia is ap- 

pMt ftCo&ditiuTi which i& equatly ^ell «ipr^9Bd by the t&rm aphaeia of 

WBM^Ti. In the second form of aphasia the sufferer ia uuable to adapt 

nnf lire OL^mmajucatious aud make tLem Bt the idea represented bj the 

iwbtl symbol, auditory or viaual; that ia, ho haa tost the faculty to 

i^pt the ccmplemetit of tba vord to hie own idea. It matters not 

vMiar tbeae words bd spokea or written, or eommuBicat«d bj some 

ifDralent, s'u-th aai music and pantomime^ Tn a general way. tbi^ ia the 

nkiuacf r^c^ption. or seuaory aphasia. 

Mctor aphasia or aphasia of rmiEaion, which was described by Broca 
uapht^ui, and by many writers after him aa atactic aphasia, luay be 
diTided into a^ many forms :ls theti^ ar^ habitual avenu«s of e^l^rion^tDg 
l^iughts Id^as fir^ QAually exteriorized by spoken wcrits, by wiiEten 
■oMs by symbols, and by pantojuiiue. Thus, we have aphasia of 
vtiimlatiou, or logaphasia; and aphasia of writiug, agraphia or logagra 
pba; Sdjmbolia, aod asemia. Aphasia of receptioUf ur sensory aphasia, 
iiibo made up of a number of coofitituents, th« two great divisions 
Wag auditory aphasia or word deafness, and ^'taiibI aphasia or word 
UhidDeH^ Eacli form of apliasia aduiiis m ttii n of further subdivision^ 
Apiuaia may be claaaified as follows 

1, XsvB Ai'HAsiA Aphasia of npperceptiou due to lesion of any 
«iiuHtuent of the Eoue of language. It may ba siibdivided mto [aj 
final apbAdia^ due to lesion of the visual areas and centre, (i) auditory 
t|]|iaiis, due to lesion of the auditory areas and eeutre^ (r) artioulatory 
kJnnihetic aphasia, due to It^ion of the ceutre iu which are storod 
ntcooneA of the movements necessary to e^iterualize the word by speech. 

2, SExt^oBY ApjiAstA- Due to lesion of the central and periphcml 
Momy pathways, leading to the zone of language, 

3> Motor Aphasia. Due to lesion of the motor pathways, over 
vfudi motor impulat^s travel lu passing to the peripheral fipeech mechaii' 
4, CoMPOl'No Ai-HAsiA Any combmatioa of two or more of these- 
Swb it aeems to me would be amply sofficieut to include every form 
tJiphasia tbacone meets with at the bedside Although it would not 
fit all the forms of aphasia that may be posited throretioally, physmans 
uB^cUuu the privilege o£ not <^rossmg bridges before they come to thein. 
Jevmiideea, afler this has been said, it seems to me that evtrylhing 
idtodd ba done to mako our d assihcation eouform with the dn']Gt;fns that 
W( twen put upon ajkhasia by other writers, and so long as no priiiciplea 
■aiHTJfioed, this may be done. 1 shall therefore adopt the following 
cluii£cfttiaQ as a working one, and desire to eay at the outaet that the 
ntdmotor aphasia is never ^ised Hynoiiymoiisly in my own mind with 
^vurd ataxic i moreoTcr, that the word uiutor is retained to apply to 



Ih&t form of aphasia characterized aDatomiaaJly by Jesion of Broc&'e con- 
volution, aiilely because such uaage has been coDaeerfltad by time- The 
images stored up iu (Lis eeutre are genetically sgdootj, the result of 

1 JLesLona of the ]ciag?ethMic-iTlien\BXoFy eenire. Broca'a affia 
(vid prubably of tbe AMWialive Gbrt^ cODnectiag tbciu ivlU) Uie 
conical nictor urBtUt Lii the KuLaudlc r&giou), cauHing a^UcuLaloiy 
word umneaifl- 

!St Lesion of motor fibres Trhich cofivej speech iiopuI»Mi suIk 
conical [untor apliMia^ I'nre inoLor apbaein of D^jerin*. 
3. Lbfiioii oi tkOf part of tbt^perlpheraL j^euromuBculnrmppualun 
HTviug ftrviculflio cxpie^dioii , djeplijiAiaf laJlaiioUi Bi&lUa. 

h Leaion u( tka recf'pi.i^'B cslla conHiiLnUng the ntiiLuny centre 
e&URiiig jtboliLiop or fDTiciion, word d^^afoofu and ILa entailmeDt. 

a. Ltsiuu ol tlift Ml^oriical Mnaory Iracl Hubcurlicttl auditory 
apliuia ; piira Midlliry npbasmof DeJerliLC. 

K LenLoii of tbo TvcoptiTo oeJU of Iho higher vlBua] Mntro o4us- 
Ing *rord amnesia, grpipbic and Tifiiial ward blindnerta, u^d its 

'2. LeaLoii uf tlie subcortical Imet and the piimuy viioa] contre 
vrhicli enUiLb loss of tlie recognitiou of tbinKS, <wonia, and ob^eaie: 
iJta.t itf loM of their slginfiL^ance, objeai amix^sja ot apraxia, ur 
lru« neunil hliudDfiABr 




OH CariiitiiNi> 

iMiwn of Lhe etitiro loue ef lauguage: dLFJiurbed rLiiiatlea of 
rlBicmal, andilorj-, kin&atbeuc-anicidaiory <!4.'ntr&fl. 

Etiology. — Etiologically aphasia may be dassified as organic aud 
dyn^uiic. Tie organic v^ieties axe tbe result of injury, new growths, 
iuflaiu[tiat'^)ry and vascular lesiona of the coveriQga of tLe brain and the 
brain eubtstaiK^'e, The pnuoipal vascular lesions are: rupture of blood- 
vesaeU and occlusion of their calibre either from embolus or thrombus, 
Uid the conr^ecutrvi^ cban^ea dependent thereon. The lesion of tha 
blooil-v easels may be aa icillainiiiatory one, but eTen then it is not im- 
probable that tiie pathogeueais oF the lesion La the direct result of a sep- 
tic or infoolious process that causes infectious emboli ai^d thtoiahi. Tiio 
traumatic conditions that may produce aphasia are bullet and stab 
wounds, depr^eed fraciurea of tlie skull, and injuries produning nieuiu- 
iteal hemorrhage. 

The tuBaiumatory lefiiona that areiuost commonly c^uaative o£ aphasia 
are atiuto hemorrhagic encephalitis and brain abscess, meukngitis of tlie 
oouvexjlies, especially the tuberculous %-arieiy, and syphilitic pachymen- 
ingitis- Under the dynamic forma may Le included ihoae in ^vhlch no 
organic lesion is res|Min3ible for the development of aphasic symptoms. 
Tho term dynamic ta useil merely as a conveniem'e in preference to tha 
euuvetitional functional. The dynamic variety includes aphasia occurnng 
with the noLiroscs and payohoses wtich are not yet proven to be depeQ- 



^upon Mcoguiziible brain lesion, of wbitsh epUepayt neuraatheQiof uid 

AeriA tn^j be taketj as examples. JC also embraces moat oE tbo cafi«9 

<if iphLsia occurring vith tov;i"tiiia, siich as urptuia, diibetea, and gout- 

illhoogh atkha^ia iu bodis of these ciise&, eapBcially Jipha^ia oocuning with 

URtmiat ia ofteo depeuJeut upon an organic raanjlar teaion of cerebral 

\(W-Te3aeU. Aphaaia caused by tbe vegetable poiaonH, Baotonin, bella- 

^mt^ tobac^ etc., is ahuoat iuvaiiably oE the djuatoic form. Tb« 

ipbis^athat sametimes Dc<<urs in individuals who have been poisoned by 

M and cijppeTf may be of the dyoamio variety or it may he a focal 

ninifeaiaticiD of tlie eucephalopathy that these poisons occaaiouaJly 

tMBb. The dyoAiuic aphasias also incluile tbe apbaaic speech disturL- 

iQrrfl oeoumng vrith neuralgic affectiuus of a migramous order, epilepsy, 

Ijnerii, and nervous exhauation^ those oiirurriTig ^nh forms of itisanity 

^l hav« no kiiowu anatomical baaiH, and finally tbe cumparatively in- 

lipiifitauC Dumber whioli are attributed to fright, auger, so-called reflex 

ooMtaucb as int^inal worms, and tbe transitory apbasias from loss of 


Oriinary etiological factors, such as age, acx, and occupation, ha^e 
ia beihiig oa the causation of apbasia, because it ifl itaelf a symptom, 
ud it results only when the diseases of wbich it is a symptom occur or 
lAproAO to occur; hut as aphasia is so ofton associated with cerebral 
^plesy, and as cercbrul apoplexy oticurs usually in late niatuiily and 
idvuced age, it follows that aphasia is seen often er m people beyond 
fift/ years of age- Nevertheless it would be miBleadipg to leave this 
latemmt unmodified for tbe reasnn that thrtfi? diseasea which not infre 
ijQOiLly bave aphasia as a aymptom, nam«]y, uiseniia, acute hemorrhagic 
accphalitiH, and tuberculous meningtLisj are particularly liable to occur 
m (he young. Moreover, aphasia sometimes develops in the wake of the 
mffcuous diseases, typhoid fever, di^jbtheria, and pertussis, and as the^e 
arqr niiJie frequently is tlie young, then it fallows that aphasia of such 
OTE^ a iiicire common duiing the iii'St years of life. 

There remain to be disi^ussed iu the etiology of aphasia two of the 
BDit important organic diseases of whif'h aphasia is a symptom. These 
Iff, tumor of the brain aitd cerebral at>oplexy. Aphasia as a localizing 
Tpuptom of new growth in thu hrain ia one of the moat important and 
Biutwortly guidta- As a rule, tumor prcaeiits the ideal legion to cause 
iMtietly confined destruction of otte of the centres in the zone of lau^ 
jttgc; at least in the beginning of tlie tumor. Tumors originate in the 
pHl loajority of 4^ases in one of two ways, by a proliferation of the tsa- 
tiecfthe part and is patb<dogical from the Ijegiiiumg, or by the appear- 
uwflf a tissue that is foreign to tlie part. In the beginnmg the ahuor- 
tnalitj I* small, perhaps microacopicil- Tt may be confined strictly to 
uiunthat h&A such bighlj' individualized futiction as thoangolar gyrus, 
ihs firat temporal convolution, or to a definite part of tbe motor area^ and 

produae symptomB of almost mathematical precision, Theao ejmptoms 
may occur before the symptoma of brain tumors that are so coDsecrated by 
time tbat tphey are called, cardlaai, develop. If the plijaiciac recogoiz-ea 
tljem and givi's them proper iuterpreLation, such perapiciiitj ou hit4 part 
may be revrarded by the hte of the patient. It la nob Deceaeary to point 
out in detail what these various aymptoms are. If one has in miud the 
tiipo^-raphy of the surface of tbe cortical Bubstance, and the functions 
iill^^tted to it, as well as an understandiDg of the eonu«ctiug pathways of 
thi'iie ctjriiual areas, it Is unueuensary to make explicit recitation of such 

Aphnnia maybe a prominent symptom of a recoverable form of tumor, 
(fiimma, and therefore the importance of tecogni^ting it and employing 
apprijpriiite treatment i» apparent. 

So fr<"|Ui'ntly ia apha'^ia an accompaniment of apoplexy, a term which 
ifl lined to include rupture of a blood- veasel, obliteration of its calibref 
find hfiiir Boftcniijg, that in the minds of many physicians the word 
ilphanin nuK^oat* aj>oplexy. The genetic and anatonncnl rclationahip ei- 
iitliig botwi>eti th^ Time of laugviage and the middle cerebral artery is wall 

Mf the organic mental diseases that aphasia may be a symptom of, 
ijBOHrul paitNis IB the most important. In the beginning of this disease, 
wrliloh Ik piitliologi rally a widespread degeneration of the cortex, the most 
pn'iniiH'nt iijrmptuin miiy bo aphasia. This pi^bably coincidea with be- 
nniHit dni(i*n*'ratioj| m some part o£ the zone of language. Usually' the 
■plmRift 1« of the Ht'uaory tjpe^ 

Thnre Ht.lll ri'muiuii one form of aphasia to be mentioned, and that in 
ihci form krtown as confjC^nital aphasia, or congenital limitation of speech 
(UvrlopiiLtfiit. Those cases are not very uncommon. iCnssmaul described 
A itumlwr of instan^ee more than a quarter of a t^entury ago, and recently 
4iii1iniitiTirL liai Htiuliod the subject very carefully, Congpnital aphasia 
Uiuy \'** |i|Lriial or it may be complete. I do not iiidude in thia category 
lank uf ii[iniH'h doTelrrpment dependent upon porencephalia or other gto&a 
IfMiloUii L<r t1it> ri>i-(;hral hsmisphero. Aside from the distvirbuncetj in the 
(iriJKM'i v\ jinrcnption wtiifh are a part of idiocy, there is a not incon- 
Hlilwrul^ln iiunilvrof uases in which, without any disease of the peripheral 
|i0i«'i]ih*ut JiniiHiiry apparatuses^ or of th« central sensory pert^eptvial areas, 
llitkiu id a oiiiiditiun of apeechlesaness, and that, too, entirely divorced from 
twiy Apparoht dlaturbonce cf intelligence. It is to these cases that Coen 
^iVvM tin* nanirt of nudit*>ry durabneas m contradialinction to deiifnesa and 
ili^Liibiuiitt A Uhuu^fh these children do not preaunt gross mental or psy- 
lAhliUll lUfvtoti usually oarefnl examination shows that tberp are always a 
iwUuiu Jiikuiunt of nhulin, tardiness in learning to walk ^ slowness in ac- 
tiUUil^ ilhiU i't auy kind, and various either manifestations of psychic 
^ifai WMt%%\^ di^otJeraoy. A very remarkable feature, and one that 



■koulil bfr borne in tniod when in t)i6 ^^TCBenco of such caBea^ is th&t in 

■boat CHie'third of tbem tLere have been found noao-pLarjngeal adeDoid 

iCfBtitioQS^ Tho 00I7 otber etiological factors that can be enumerated 

ue^ th&t this couditioQ has been mot with moro frequeotly in mftles then 

I mfemiUa, a^d that there is atmt>&t always a oeviropathic heritage, par- 

nculiflj from the father's side, and that although a great many of these 

I ^flKts acq^uire considerablo speech faciliby^ it ia oft«n ]at«r ia life fLUO- 

I riaiud mith 9tamm»tag. 

i Sjiaptoma of Aphaeift, — The most import&Dt symptomatio constitu- 

I «il« of each variety of aphasia are herewith abbreviated from the wi-iter'a 
f tna^, '*The Geneeifl aud Difisottition of the Faculty of speech," The 
[ MacniillMi Compauy, N*?w York, 1898, 

■ 1. Cortkai JtMtot apkaaia due to legion of Broca's conrolution (often. 

F MOdatedwith right hemiplegia), 1, Loss of spodtaneoLia speech due 

I todotroctioti vf the sensory iraagen of articulatioa stored up m the foot 

I of lbs Lhird frontal convolution. 2. Inability to repeat. -3. Inability 

Vy tfad aloud. 4. Inability to write spoiitaaauuBly. ft. Dif11i.:iihy in 

■ribiag from dictatioa, iu aome cases amounting to complete inability. 

6, Pr?3etTation of the ability to writf from copy. 7. Comprehension of 

Fhilwaaid by spokea word, Lnt always more or less latent or manifest 

vord blindness. 8. More or lesa amLcnia. 9. In many cases more or 

loiiidioblia aud ref-'iirriQ^ utterances. 

I n. SuUurtiail motrtr u/rfutAiii (almost liHTEiriably associated with right 

I liUGLfilegia). The term Hubcortical motoi aphaala is used to indicate a 

L pvtiil«r complete inaLihty to extcrtiahzo spoerh which has been properly 

r Ibratd in the intact speech centres «^hic-b form the zone of language. 

TVleiion is between the zone of language aud the intenial capsule. 1. 

. iflnof spontaneoda spe^^ch, with preservation of the memories of articu* 

Wn, so that the patient caa call up spoutaueuuuly the articulatory 

Exeraory of tho word. 2, Inability to repeat aloud^ but he can repeat to 

^uaself. 3. Inability to read aloud. The patient can read to him&elf ; 

htth write spcotaneoaalv, from dictation and from copy. -I. Compre- 

^eosiou of spoken and written language. 5. Capaiiity to use pantoiainie 


L Seiu^y aphasia. — This is the terra used to designate impcrfec- 

^Q«ft of Janpiaige, diaability cr innbility to speak, duo to interference 

^ith the reeeptiOLi of speech forms ; that is, to lesion of the perceptive 

%t«uof the brain aa^ the immediate incoming and commissural pathways 

^£ luch areas. Th\s variety <jf apha^sia is not usually iusot;iabed with 

bomiplegift. The important symptoma arc; 1. Tata phasia and jargon*- 

^^pihuia. 2. Inability to comprehend spoken language when the auditory 

^isntre is impliruted and written when the visual is the ecat of lesion. 3. 

f luhiliiy to repeat corret^tly and to read aloud correctly, d. Agraphia 

wdA piragraphia. T*. Inability to write fiom dictatioTi (not complete 



except in the auditoiy viiriety of sensory aphasia), 13. Inability to ccpy 
except in H mechauii^al way, line for liue, curve for curre, anil angle fi>r 
angle (^e3i>&ciallj wUeu tlie riaual arta ia affected), 7. Word blindness 
and word deafneas in varying degree of completeness, depending npou 
the seat of the lesion, li the laBion is of the poeierior end of the inferior 
parietal oonvolutioiij the angular gytus GO<cat]«d, the phenomena of word 
blindueHa will predomiaate, while if predomiuaiitly of tlii^ posterior end 
of the Bupertemporal coDvolution word deafoesa will be the leading Bymp- 
torn. Homonymous hemiaaopeia sometiuie^ oc^^urs with true ee&aory 
aphasia when the leeion iB of such extent or depth that it interrupta the 
fibreii of the optic radiations. 

IJ. 3'tlicrtrticfil ituni ItUrnhifMi, — 1, Word blindneaa always aaaociat^d 
with right lateral homonymous hemianopaia. The patient looks at printed 
and at written letters and sees ouly bkek marks on a white surface i he 
is wholly unable to interpret them because the visual impulse is prevented 
from reaching the left angular gyrus. If the patient has long been babit- 
uateil to writing, he may l>e able to gablier ihe meaning of a writteu wonl 
after tracing it with the 6xtger or a pencil. 2> Ability to epellp 3, 
Ability to write spontaneously aud from dictation. 4. PreaerT&tion of 
spontaneous speeeh. 5. Ability to repeat, ti. Comprehensjon of spokeu 

IJL Suficor-rieal vmrd deafness. — 1. Inability to underBtand spoken 
words. 2. Inability to repeat. ^. Inability to write from diotationn 
4h Preseiration of spontaneous speecbn 5. Ability to read aloiid- iL 
Ability to write volitionally and from copy. 7, Inability to write from 

Total Aphatia. — Aphasia due to lesion of the entire zone of language. 
The symptoms are those of motor afihaaia plus sensory apbaaia. Right 
heoiipJegia is r&i'ely lacking. 

Treatment — I shall dlscusH the treatmeut of aphasia very briefly from 
the standpoint of the physician and suigeon, and from the pedagogue'^ 
point of view. 

Unhappily neither the phyaictan nor the pedagogue «au lie £>f consid- 
erable aaaiiitance to the vast majority of apLasic putlenta. The mediuinal 
treatment depends entirely upou the nature of tlje lesion that cauaea the 
apbasic symptom complex. If the lesion is a foeua of encepbalomalaciji* 
then all that can be expected of medicinal treatment is to asamt nature 
to prevent further destruction of tisane, and particularly to assist in pre- 
venting a repetition of the immediate exciting cause of the softening. 
On the other haudj if the lesion U a gummatous meningitis, or au 
isolated gummatous formation in the »>ne of language or the eubcortieal 
apeech tracts, and theae can be diagnoslitated as such, medicinal treat- 
ment ia of the greatest value. A case of sensory aphasia recorded by 
BroniffeU is in evidence. This patient had the profouudest fiyraptoma of 



tasoTT aphasia, yet she Ivilly recoTored under the infiQenc© of anti- 

iT^Oiti? modic&tion. Another case in which the results ot aatisypbUittc 

Mktment were most gratlfyiiit', «ven thnagh the syDiptoiiift did not com- 

^rtelT pold to medicatioB, haa been published by Mantle. The difficulty 

acttes of this kind is oftenest with the etiological diagnoeiaH Usually 

Aft pib^nt is not in (condition to vonchaaJQ any infcrniation concerning 

^mielf, and aa his family ar^, as a rule^ ignorant of such matterSf the 

phjiimn is compelled ofteTi, if he baa not been familiar with the jia- 

luDt'a history, to make a diagmisis uf previous sjphilitio Infection an 

Insatiafftctory data than are ordinarily considered esaentiaU Pei'sonally 

lun inclined to euspeet a luetic origin in every case of aphakia coming 

nn ihniptly that occurs before or duntig the fifth decade of life, when 

ulndar trouble of tho heart, the recent possession of acute disease, and 

ujary taa be e^tduded. 

h would be a work of svipeie rogation to repeat \a detail the causal 
trcatmctit applicable to t'le different forms of aphasia, for it will occur to 
ever; one vho has in vauni the etiology of aphasia- The treatment £oi- 
aplkttia in one patient icay l« just aa different from the treatment apph- 
ciAltle to the next ocef aa the cauaen are ilifTerent- For instance, tbe tieat- 
mcatia the beginmcig of an uremic aUa<-k ia veneaection if the patient 
baa not au organic form of renal disease ^ yet this kind of treatment 
'^ronll be fatal to a patient whoso aphasia was dependent upon autoch- 
"Omtic thromboaJB. 

When aphasic symptoms develop elnwly without fever and with 

sTUptoms of increasing mtrarranial irritation and preaauTe, then tuiuor 

sbd abscess must be thought of- la making the diagnosie and the 

^ilTeieatiatinf; diagnosis one must be guided by the general rules appli- 

oble to the solLition of these problems. When there are groLiiida for the 

Ufef that the lesion is of a luetic nature, then the «dmini8tration of 

^ nary and iodide of pobasaLum cannot be carried out %vith too great 

J^nunptDeaa and attention. Syphilitic lesiona that develop aome years 

■^tet the primary infection are, it is universally conceded, more amenable 

'o the iodide of potassium than to all other measures combined- If, 

**^>werer, the date of the primary le>iioii is nut very remote, then the ad- 

E^iAistratioti of iodide shouM be simultaneous with the iiAb of merfiiiry, or 

^^A^e one should follow the other in the shape of a course of the ono and 

*^icn of the other. 

The treatment of aphasia dependent upon organic disease, snch as 

-^vunoT, abscess, purulent meningitis, and focal disease of any Ejature^ does 

viKct differ from the treatment of these conditions wheti aphasia la not 

"^KEttnt When their presence ia attended by symptoma which aeem to 

"iik^cate that they are amenable to surgical treatment, their removal 

vbnildnot be delayed. In fact, the aphasia is oftentimes the localizing 

^poptota that makes diagnosis positive and operation possible. The 



fleemmglj wicleHpread belief that aphasia is almoBt exclusivelj on on- 
hangar of the apoplectic? state aeema to neaean itate smphofiziug tho fact 
that aoiuti^ uiiiuifeat&Lionb uf tlio cuiapluxity fjf ej^uiploics cunatitutiiif 
aphasia arc of great dio^noatic importaace iit nearly ererj disetiiBft aff«<^t- 
ing tlie brain. lb is a eommon a^mptom in the reoentlj recognized ftnd 
deacribed disoAse, acute hemorrhagic eacepbalitia; it ia perhaps the most 
constant symptoin of abncess of the brain on account of the pathogenetic 
relationship of ilineaseof the nkidrUe ear to cerebral aL8c«sa, and it ia not 
uncommon at some stage in the career of geaeral pareais and of multiplei 
insular, and difhtae cerebral sclerosis, while ita occurTcnce after injury 
whii'h may cauae localized intlamtnation of the meninges or of the braia 
itself, hemorfhage^ depression of brine and spicules is not uncommoD. 
Katurallv, in order to produce apha.sia thtse nondtUons must inaiiifest 
their Lnjurlouauesa on the apecch centtefif their intercunnectiona, pro- 
jections, or the iuiaediate pathwuys loading to them j to le leas apecific, 
i>u the zone of language of tlie left hejniephere m ri^ht-handed persona, 
and vit& i'f-i'j'a. The form of aplm^ia that any of these diseases and acci- 
denta may uaiise will depend upon the location of tha lesion and not on 
its cature- The only variety dcprndcnt npoa any ot the above enumer- 
ated conditions that is very uncommon is the subcortical form of motor 
aphasia, whilo the subcortical sensory variety is correapondingly freqaent 
This is reaiHly understood if we reeall that the part of the braiu which 
must be dijjeased to cauae BuiH^ortical motor aphasia is well protected from 
injury, aud haa no particular relationship to the iioportant factors that 
condition abscess of the brain. 

Oftentimes a careful cottsideration of the symptom aphasia in theae 
diaeasea will be the must important factor in determining whether or not 
an o^teration shall be done^ i.e., whether the lesion ta sufliciently local- 
izable to warrant advising the anrgeon to trejiaiJ the skull and attempt 
to remove the innftrifji mnrffl. 

Taking it all in all, the question of the medicinal treatment of aphaaia 
never comos up Tor considoTation. The question that does present is* 
How shall we treat the condition of which aphasia is the symptom? To 
answer that question satisfactorily requires an intimate I^nowledge of the 
therapeusiB of all the diaeaacSr functional and organic, that have been 
enumerated in the chapter on etiology, with which aphasia may be aaso- 
oiated. Treatment may eonsist of such a svmple matter as the intordic- 
tiofi of alcohol in a case of toxic dyslexia, or it may require the combined 
akill of the phyjiician and surgeon to diaguostirate and remove an abaceas 
or tumor. The treatiuent of the dynamic aphasias is a differf-nt matter 
from the treatmeat of the or|fanic aphasias. In the former all that ia 
neccasary is to remove the cause and the eymptom will disappear, while 
in the latter the cauj^e may be removed and the pathological condition 
which it baa excited still continues and with it the aphasia. X>esptte 



nAdu muij of the djnamio cr " funQtional " apb^iaa y\e\A to appropriate 
^MOduntioai for the (uuditioaa upou wbich tbey are dependent, eombiued 
vtth fitting tfe&tm^nt addreaacd to tbe mestld, mor&l, and phyaica] sides 
r«f Uko individual. 

Tbft p«d&gDgicai treatment of apbasia ia a matter of recent develop- 
[■MQ^ It has been the legitimate result of an inquiry into the physiolo^i- 
|mI vid psychological antecedents of aiticu]at« speech and of clinii'-al ob- 
^^■VAtJaDs that when a young person became aphasii^r even though the 
rSiion was a very severe and extensive one, the facul^ of speech was tv- 
Wtond to him, Aforeov^r, almost from the vBvy beginning of the histor}' 
of aphasia it has been recognized that even when Che se-ralled " s]ie&cb 
I flontKv" raeaniDg Brora's area, was wimpletely destroywl, the patient 
[ rvfvned occaaioaally some capacity to speak individual wordd or a num- 
ber of irorda. Various hypotheses have hvan formulated to explain these 
oeeorretioea, the most widely accepted apparently being that of J- Hugh- 
I liags Jukson^ who suggested twenty j'Para ago that the'^unedncaied cen- 
Qie* of the opposite side t& iu a w&y related to convetttional, emotional, 
t lad oth^r forms of wliat he terms ^' degraded " speech, in ooatradisiinctioh 
I to inLifUectual s[^«ech. This is the theory accepted by many writers to- 
I ^y. Kecently Wyllie has framed a theory along Bomewhat the same lines 
[ mde ** Oversow of educjitioe into the opposite hemisphere," tha bemi- 
I fl^re that contains the zone of language takes up all that it can in the 
I nj uF education, and that which it ia not equal to taking up Hows over 
I mio the other hemisphere. The entire subject of the reposseneioc of the 
I ifSHh faculty in patients in whom it has been lost must needs be looked 
I HtMlaj from another atandpoiHt than it was a few years flgo» when the 
I fanu of subeortical aphasia had not been satiflfaciorily differentiated. 
I ItBBems to lue that in the light of our present knowledge of aphasia it 
I lUMt be gtanted that not only do the corresponding areas of the opposite 
i luitiitphere sometimes under the stress of eduoation undertahe, in a ver^' 
[ myiTiiplete way, the speech function of the destroyed area of the hemi- 
i^h're phylogenetiealty and ontogenetic aUy prepared to carry on the 
L qetch faculty, but that the immediate environmental areas of the speech 
I Biatn« of the left hemisphere may take up the function in part. In the 
I fiOGas of functional compensation the portion of the speech centre that 
I inot destroyed beoomes connected with the other speech centres in pre- 
I nwsly unaccustomed ways, not by the development of new commissural 
I flbm. but through their acquisition of functional activity. Secondly, 
I lliU the opposite hemisphere, the one that has the educ of language 
I a[itQg;eDetically developed, is not an uneducated hemisphere at all, but 
Uat It is, in one scusCf just as muoh educated as the hemisphere in which 
th« loQe of language is situated . 
1 Tt must needs be admitted that there ia a general auditory area, a 

I s«Ttl riau^ area, and a general kiiimsthetic area in the right hemi- 


H]iLtre u.» well bs in the left LcmispLerf, and ttiab icL-cojning stimuli 
Euake a aimiltu- unpreasioTi on it as they do ou the oocolbd ^*oda- 
cat^d " heiuiaphere. These impreaeiDas &r« btlatei&l in reception but 
iinilsiteral in interpr«tatioD. This unity of mt^rpretation U d^termin^d 
by L'omniis-'i'iiral librE^ af the corpus calloHum. Not the same factors 
Uiat detpermiiie ri^ht-haudedneBs det>erinme also that the left hemi- 
spbere shall he the executivQ speech Bide, but the elententarj ^ho^k ie 
done on lx)th sides. It aeenia to ma that bo for every one vho is will- 
ing to aetiept the siiggeations of experimental physiology must go- Hov 
many ai'e wilting to admit that the execution of speech ia an aiitomntio 
act aud rrtjuires no ponsc^ioufl preparation, if process cf anawnnica! iw>m- 
pletjon ia not eoasidered '^ preparation, " is another matter. Those who 
bebeve that the eKeoutioii of speech is ait automatio act, find it eaeier to 
explain haw att approach tu, or an unliuished automatism con be asuumed 
by the opposite hemisphere, whieh is educated bat which ia not intended 
to be automatic, and eH[»cially in young children in whom the h&bit of 
automatic activity has not tiocoDto ^ed by i-ontiuued practiee, 1 do nob 
think it at all improbable thibt if a healthy child should be kept mute 
until it waa from five to sije yeavs of age, that ia, until such a time as 
the neuromnftenlar apparatua aubserving speech wna fully developed, 
he would go through the lalling and other stages of speech iaiperfrH'- 
tiotia that children who begin "to learn ^^ to talk before the executive 
partd are fully developed do. The words that such a child used (which 
wmiid, of ooutfle, depend upon the words that ho had heard) might, 
I believe, bo perfectly formed. In other words, the execution of 
speech would be as aiitomntic a.4 breathing, and that in mankind sjjeech 
is more an eudowment than an acquirement. Furthermore, the factors 
that determine the seat of this automatic activty are the conditions that 
we have heretofore BUppose<l determined the education of the left hemi' 

A most r ^markable case bearing on this matter has recaitly been pub- 
liahed by BaHtiau. The patient was a boy, twelve years old, who had iieen 
subject to epileptic fits at intervals, The first of thej»e occurred in infancy, 
when the patient wa» about nine months old. Toward the end of the 
second year the Ate seemed to have ceased The hearing was good and 
the child appeared to be of average inteltigenee — to be well, in fact, in 
all respeots except that he did not talk. Wh^n nearly Ave years old the 
little ff l[ow had nob spoken a single word, and about this time two emi- 
nent physicians were consulted in regard to hia ^' dumbness-" But liefore 
the expiration of another twelve months, on the occaiiion of an accident 
happening to a favorite toy, he suddenly exclaimed, *'What a pi^l" 
although he had never previously spoken a word. The aame words conld 
uot be repeated, nor were others spoken, notwithstanding all entreaties, 
for a period of two weeks. Thereafter the buy ptDgresaed rapidly and 



bdily, beeAme most talkative And spokt without tbo least siga of uu- 
iment oi defect. 

OneoUier point tliat has previously been mpntioQed. A Qumber of 

ouu tlttt have been reported to sixow the s^suiuptiDTi cf apt^^'h funo- 

by the opposite hemisphere have been enrkcluNively shown to be de- 

wndeni upon & subcortlc^ leaioa and not upon destruction of a speech 

tr<i, and the partial or complete recovery of speech was coium ens urate 

with a disappearance of the eonditiotia that had d^^termiced the partial 

inMrrapboa of the couducting tihrea. In these cases reeoTerj of speech 

\aM. gme on jtftri jw^tr with di&appearauce of other H^mpUuijSj such a^ 

bendpl^a, for liiRtAiice. In other caaea in which the lesion lias been of 

the speech ceutrea the partial repoaaeAsion of speech has be«D due to the 

faiet tliat the entire speech e«utre, ^rhioh in tlie beginning of an aphasic 

iltaek was cc^mpletely overthrown, has in a slight measure righted itself 

l£W tho exudative and ooelit»iivp conditions hav^e snhsided. Thpn the 

paliBQt finds himself iu possessiou^ tu a \€ry insigniticaiit degree^ of his 

prrriooA speech eudowiaent. In other caaea there can be no question 

itiat the educated areaa of the other hemisphere develop some executive 

rtpicitT^ This ia determined artihcially^ i..., by education, and not 

outAgeoeticallj as it is normally, excrept to the very slightest degree. 

la brief, theo, the educalion of an aphasic patient should consist in en- 
tkearomigtDcaufiethe centre or centres in the left side of thehrain^ that are 
idtdestrojctd by the lesiou vhich causes the aphasia, to take the initiative 
iQ Ibe primary reooU of words and complete the '* circuit " neoessary for 
rntena] language and speech by forcing the t^ducated opposite side to sup- 
;i]j-a centre ainiilar to that which has been destroyed; or, if the iainr-ged 
cvLie is not entirely destroyed, by re-eduoating tbe cell^ that remain, 
unstiDg them aa it were in the acquisition of a function which they 
vm mteoded to perform m uniaou with other cells. For example, if 
ihe irtic^ilatory -kinoes thetic centre ie destroyed, the primary revLA^al of 
tI«¥ord that ahonid be spoken is throtigb the auditory eentrep and thia 
^HoQi u^ m temporal ooiDndeuce or succession the visual and the articula- 
Vlacj. Th€ articulatory centre being destroyed, the speech impulse of the 
f:mifd word cannot be completed and tbe kinesthetic artieulatory centre 
rittu opposite side is acted upon through commeuauial fibres in just the 
wuirayaa the articulatory centre of the left side was^ through inter- 
i«tnl fibres, in the beginning. The process of education is very slow 
udmast be given artificial aid in the way of showing the patient hew to 
unnge Iho organs of articulation for tbe production of aimple vowel and 
voDUfAiit sounds which he should he daily encouraged to do. After he 
tiUMqaJre'I the capacity to produce these sounds and has regained som^ 
KntToL ^f the peripheral speech mechanism, he is tutored in the same 
^T in the production and articulatiou of mouosyllables and their com- 
bm)m Id words. This process is a Uborioua one and requires great 


perseverance on tlie part of the physician. Whenever poasiW^ the task 
alioulfl Ik* entruaipd to a tp^chiT of esperienne. Nntnmlly t^ie gteattat 
progress wtLl be lunde wltb 4imet of subuuitical incitur apbaaia bocauaa 
they take a more ictelligeat; interest in Uifi matter ajkd because thej cuu 
aid theEnaelves by rt^admg and anting. Moat of the pablUhed cafes *>^i 
marked functional oompecsation have beeti caaeB of Bubeortical moto^ 
aphaaia, in whieh ability ti* read liaa been preBer\ed, 

When the auditory centre ia disean'^dr then the objec't of teachiog i% 
either to get a primary reviral of the iilea of worda iu the visual or the 
artieulat(iry ('(<utre, ami then tbrcv into the Circuit the f^ompoueut pazta 
of the auditory that are not dijorganizi'd, or to favor the devolopoiajit 
of the auditory word centre in the opposite hemisphere. The patient 
must be taught to t-jjocc titrate his aiteiition on vowel sounds and then on 
words of vne ayllable, spelt letter by letter, while he tries to repeat thooi 
by the oral method, Thla is a very difficult matter, because in the 
vast majorjty of peoples the primary revival takes place in the auditory 
centre, and when thia is destroyed the patient is left stranded, from a 
speech stand point, The plan of edueation is in r^alily that which U used 
for dt^af-mutea ^vho are taught to thiuk by the revival of verba] mem- 
ories by thd visual ceiitiesi the revivi^oation of visual eyiubola prompted 
by hand or lip movements. In case of those burn deaf and blind the pri- 
mary revival is in the artiaulatory-kiniesthetio centre whtah, in cases like 
that of Laura Btidgman, is conditioned by the tactile senae. Tn faet, it 
ia in all those defectives who learn to read aloud by the use of raised 

Patients vith the auditory form of sensory aphasia should be patiently 
taught to repeat words, the meaning of which is conveyed to them through 
other senses, the visnnl, tactual, and olfaetory. It ia apparent that 
greatest progress will be made with patients whoae general inteUigeoce ia 
\giIaI distuibed. In subcortical word deafness the amelioration ia alwaya 
greater than in sensory aphasia due to destruction of the super temporal 

The treatment of sensory aphasia conditioned by destruction of th» 
visual centre is most unaatisfaetory, and very little can be done to aroe' 
liorste tlie condition of sunh patients, even though all modes of education 
be assiduously employed. An. effort should be mode to teach the patieut 
the recognition of forgotten symbota in conneetiou with the arousal of 
Other memories of thi?m^, the auditory nnd the artiaulatory* In short, 
the pedagogical treatment of aphasia embraces the methods of the kin- 
dergarten and the methods of instructicu for those defective in one or 
more of the special sE^nses. Ev{*n with their aid but little can be dDne, 
except in the subcortiual Tarietioa. 



Xabbb, tabu dorsaJia, Icrcoraotor Ataxia, or posterior spinal si^lerosia 
jSA^iitUO which depeDds auatomically upoa a primJU'j degeaerati'^a uf 
Aituzi £«ts of ae&sory DeuroLS, partii^ulaTly thoee wbcse neiiraKOiis form 
tlic pn^arior columns of tlie spina] 04>rd &ni those wbtnh constitute the 
optic DerrD. The disease ia usually described &9 & acleroais of the 
cohmma of GoU aiid Buidaeh^ but the eclercoiB ia entirely secondary and 
it to te interpreted as the result of an effort of Nature to re£ll the 
TKuoj left t^ the degenerated neuraxoQB, Although in reality not a 
dJMCe of the spinal cord but a degeneration pf the spinal course of the 
pBDi<7 aeuaory neurcns, it may be dedued an a degeneration of that area 
of the fipiual <x»td conatituted by the senaory neurona. Clinically the 
Amm is characterized by its more or less progressive course, by its 
MDcdation of seasory and motor syitiptomB wbicb taken together ore abso- 
lotaiy pithogncmonic, and by its d^obUiou in a more or less typical way. 

Tli« Cauies and Leiioui of Tahei^— Very little ia kncvo of the causa- 
Uu of UiLies sa>e that itoocui-a predotuiiiaijtly ia middle adult life in 
6aft» vho Lave had syphilia. Although opinion is not unaoimous in 
ngard to the sjphilitia origin of tabee, it is almoet universally conceded 
tittfrom sixty to ninety per cent of all tabes patienta either give a his- 
tory of syphilitic infection or bear unequivocal marks of its existence. 
Ibit lesion nf tabea is not a g^hilitic one, bon^ever ; in other wordh, the 
ieajot the posterior colunma is not secondary to deposition aad con- 
tacdon of coQnectiTe tisane. The leaion ia spoken of as a parasyph- 
iEtie one to convey the idea that it is the result of the attiihty of ayph- 
Sis, or of some noicioas agency engendered thereby after the syphilitic 
pwahas been deprived of the power to manifest itself in infammatory 
nMlkiL Thorough aud orthodox treatment of the syphilitic infection 
tf the time of and following its occarrcncD militates against, and is 
ttoufitit to prevent, the development of locomotor ataxia; but my o^tm 
Kpfffiaice has been that the disease ig as apt to develop in patients who 
btB Wq vigoroufily treated for a Icng time as in those who have had 
Be rtti antiajphilitic medication. But Foumier and others who have 
bdUrgv cspeiicoce not only with syphilis but with paraByphilitic inani- 
fWKiofiB are decidedly opposed to this. 

TtL« disease occnrs very mu<fh more tieqnently in males than in 



femrtlea, the prcporiian teiug aliuut HJO to R. It 19 met much oftener m 
private than ia diapensarj practice, aud in the mtellectnal aiid upper 
clj^aacH than in pHtaitive peoples and the lower oluseap It occura oftener 
in the Caucasian race than m th<» EthiopiaiL and Mangolian^ because tho 
sensory nenrona of the focmer are much more highly developed and con- 
sequently less reaistant to the parnidonanesH of the pu-rasyphilitic poison 
aud exhauatiii^ e^perieuces. Exposure to cold, frequent and prolonged 
fatigue, at^xual excesaes, iDtemperate use of alcohol and tobacco, poison^ 
ing by ergt>b and lead, the infectious diQaa&eB and trauma have been con- 
sidered «tioIo^eal factors erer sin^^e the disease was first d^cribed by 
Duchenne in 1S6I, They are c-ontributory fat^tors of some weight, but 
rarely, if ever, ia any one of them tho Kole cause of (he disease. The 
French echool headed hy Charcot have unswervingly contended for the 
importance of a neurotic predisposition and arthritic diathesis aa fac- 
tors in the occurrenoe of the disease. The Eignificanoe of the arthritic 
diathesis, inherited and acquired, has recently been widely taught by 
Grasaet. He believes that the lesion of locomotor ataxia is only a part 
of widespread disease which manifesta itself by scIerDtio ch^mges, not 
only in the central and peripheral nervous system, but in all thd risceral 
organs and constitutes a true visceral polyecleroais. These views may 
apply to the occurrence and development of tabes as seen in Franoe, bnt 
they do not, so far as I can see, to our eases. All that can be aaid at the 
present time of the importance of heredity is that tabee may have at its 
foundation some defect in the development of the nervous system which 
in a few instances is inherited, but in tho many acquired. The neuro- 
pathic diathesis is a pr^isposing cause. Unquestionably fatigue and leg 
we^riuega, as from long standing, forced marches, and oooupationa requir- 
ing exhausting UA& of the legs, have something w do with precipitating 
or perhaps starting the occurrence of tabes. Thus the disease is sBBn 
oftener in commercial travellora and in persons whose occupations require 
them to be on their feet a great deal than in persons of more sedentary 
occupations- I have seen two caaes of tabes develop suddenly in men 
who bad had syphilis, upon their change of a sedentary cn-*cupalion for 
camp life preparatory to the late war. Although traumatism may aocel- 
eiate the progreaa of the eymptomSf it has never been proved to be the 
5ole cause of the disease as has been urged by acme. Anything that ex- 
hauata the peripheral sensory neurons and maintains the exhaustion, is a 
predi a posing cause of tabes. 

The morbid changes con sti tut ing tabea are widespread and are found 
in almost every part of the peripheral and central neuaory neurons; 
but the moat important lesion is deoay of the sensory neurons which 
eonatitnte the posterior columns of the spioal cord. This decay or 
scleroaia may become of such intensity before the end of the disease 
aa to destroy every neuraxon that enters into the constitutioQ of these 


^kuns. If tie cord ts exaiLiitieil l»efore tlie diauaae h&a existed for a 
B* linLOf that port of the puaterioi reticul&i^ zoDBt kuowii ha Liss^uer's 
uttBDht situated at the apex of each posterior honit and tho external 
l^ticii of the columu of LEtirdocb ore oloncs affected. The i&tet affec' 
^ of the posterior iuteinal column, or eolumu of GoL, is to be ejt- 
|tftijt«d in a measure by the faet that it is partly formBd by the aseend- 
pg Sbm of Burdacli^a coluinu which bend itito it at dilFerent levels 
aAe latter receive aucoesslTe celaya of neurons from the posterior root- 
ll oUwr word^, the poaterior colLimiis ate made up of fibres from the 
pBdcfior roots. These posterior roota travel first iu the exterior part of 
EbipMteHor columua that gmw from the spiral ganglia into the eord, 
DC get crowded toward tbe median aeptum by the addition of new root 
fiiuet which come in froia each aucceaaive leveU Strictly apeaJiing, there 
iiv> differentiation between the columns of Goll and Burdach in the 
■ibar r^on, but this i& made to explain the prddoininance of the 
Hbous in tiie part nhL<;h tiorreiipondi; to Kurdach's i^otumns, especially 
Pftfl lombar n^giou, and tbe later iuiplicattoii of GolPs CDlumiia, eape^ 
uQj in the upp^r doraal and cervical regions. In addition to these 
diogea, tbe interspinal portion of ths fiosterior loote, especially the 
IVKbtf routs and the i^pinal ganglia^ are the aeat of profound changes j 
ud it is highly probable that degeneration of the posterior roota is the 
bsi change. In many inatancea the spiual meninges^ the medullary 
bkvtl'veaaeLsT the cells of Clarke's columns aud the while fibrea that are 
ftMibi't thereto from the poati^rior roots, are degenerated. The otLer 
4i;«»ntjons of sensory neurons are found in tbe peripheral nerves» the 
tnniiil nerves, especially tbe optic, and iu the obEongatar pons, eerebel- 
jBdl^ and cerebrum. Degeneration of the peripheral ocular nenron is 
uaanranunou in tabea. This ueuroa Ua^ ita cell body m the retina and 
h vborizatiLjnA chiefly iu the external ^niculate hoi\y% Degeneration 
Iff ^hese ceurona eansea the iiaeaaod oonditioji of the optit' nerves ctklled 
n3J[>ie optie atrophy. The same factors that operate perniciously upon 
Lk peripheral eeusory neurons to cause lesion of the posterior columns 
LT^ responsible for the decay of the peiipheial uciilor ueurous. 

bi^uiry into the pathogenesia of these lesions, i'---., which may be 
TrtUttiry and which flocotidary, baa awakened no unanimity among neuro^ 
puiiokigista. The pnucipal theories are: that primary sclerosis of the 
pBMrior radicular 2oiie is Che essential lesion, and that all other lej^iona 
intt*«mdary and accessory. According to this theory, which, however, 
a {Tadnaliy being forsakon, the disease is exclusively cue of the spinal 
wd. A second theory, and one which merits lass coutidcnoe than the 
fint, a that tbe lesion of the posterior column is aecoudary to a monin- 
ptJi vhmh strangles tlie posterior toots at their entrance into the uord. 
Atmlhtr viaw, which for a time was i^uitu widely pccepte^l, is that the 
docvDentiDn in the posterior columns is aeooudary to a chronic acIeroQis 



femalos, '•' 
private i 

in the < ':■ 

sensory ii 

sequeiil \\ 

and exWs! 

fatigue, y- 

ing l\v *■! 

Bider*'! ■ 


rarely, il 

French .- 


tors in : ' 

diathesi: , 


of wid< 

only ill ■ 

organs ' 

apply ^ 

they <li' 



in a ft" 

pathir < 


ing ^s\. 

or perJi 


them K 


who !;:■ 

erati' i 

sol*> v-y 
in alii.' 
but H- 
const It 
aa to <. 

.^- z^. Themwof thepatho- 

^ T-ilv accepted at the pre*ient 

. .^, _:r .olumus, which seems to 

- . -co^ndary lesion, the primary 

, :^-\-,-:vi cells from which these 

-- 1 \:f tliese ganglion cells will 

^ ^ .*; i.itrihutioii of its neuraxon j 

.?;.iraxon death. Sojne pathol- 

i^iogenesis of tabes is in the 

. ^- ^glionio cells situated at the 

■ .i*:itute the spinal ganglia are 

^ -^j: iho primary sensory neuron 

_^..w ;:" its course in diiTereut cases, 

r, -Tedilection for the intraspinal 

. , ^ ;-j keeping with the fact that 

. ;.".-er occurs. 

^^> 'i:iy be considered under those 

^:\- sidpT those on the siile of the 

. J,? svmpathetic nervous system. 

3_., i, or int'O-ordination, manifesting 

— L::::ie»* more in one leg thau in the 

. ,;^ This atiutia, most apparent 

^ _ >\^ oonimon name of the disease, 

"^ ,-iad;uj: witli ap^oseil feet, particu- 

^ > ^rrtf's phenomenon. 3. Deficient 

^'" 7rt^"ji:ir manifestation and shown 

■" * 4. Some de^jrea cif ataxia of the 

,^-.^.-y and occasionally, ocular par- 

'" ,.- ^.-r sixth cranial nei-ves. 5- ])im- 

■" "^ \^ of the knee jerks (Westphars 

^' ; -eo ^* disease is fully devidoped, the 

'-'*' ^ in those cases in which the acle- 

**■■ ^ ' »V'^ ^^^^ posterior columns of the 

,svil or high Ubes. Tii the earlier 

itv very niuch diminished or even 
- -* '^^.^j t^. striking the patidlar teudon at 
-: * " *..-iui some jnnstular action, such as 
*''*''' _^^ gripping one hand with llie <ithev, 
^ *'^ ,.,'^ phenomenon. r», Luss *'f the 
■ *^Trfwaia motionless \vlien a ray of light 
'*"'"%! phenomenon. 7. Urogenital sy mp- 
K- '^''^im'v>titi'^''"^^'*"T">*ency. S. Irn-gu- 



'.howiforuiT athetoid. and tremulous, 


^ ^^ f-^re motor acconnianiments 



Tbooe on iho sensory aide are : 1. Paine, sudden and short, occurniig 
mcEpAJIy in ihe leg^f but ofteu in other parts of the body, and geuar- 
iQf described as abootiug, lighiJimg-like, TheiiinatiCf or eleocrlc paiua. 
'JbtjtiM aimoat iDvariably pieaeiit at some time during tbe coutse of Uie 
iLjBue, but in a number of instances they are bo overshadowed bj graver 
jjnjftoma which appear later that the patient dooB not Uy much stress 
opoo them^ The pain is apt to occur in paroyyamSf each lasting from a 
bvMconda to a mimite. It is »<!companied by quivering and drafting 
Bpftf the muscJea of Uie part in which it is manifeatad, and often liy an 
^tt aoDsation of soreness^ In many bistances the paiu is for a long 
biM tfac oonapicuoua feature of the diaea^ep Such eases fall into a defi- 
it> category, clinically: the neuralgic type- 2. Anssthesia, delayed 
iDBniy conduction, analgesia, and paraestheaia. In gome cases, espe- 
y in tbe beginniug, cerUtn areaa of the akiu in the lower extremitiea 
b« bypenesthetic. Butivhen tlje disease is developed, the rule is 
■■nthriii B and analgesia of more or leas regular distributioTi in four 
BBS) the lower extremities, the brachio- mammary zone, the geniCo-uri- 
nrj lone, and the cephalia aone (rare), 3. Dimiuution aud loss of 
ilie deep sensibility and espeoially of the muscular sensibility. This 
tintlera the patient from telling where Lis extremities are except by the 
lidof bia eyes. It alao acoounta for the neceeaity of watching bis feet 
vleu be tries to walk, and for the fact that when he erOBses one knee 
onrtbe other he lifta one leg some distance above tbe other. He does 
an ^lide it over easily and sj>curat^ly as does one in pikssession of normal 
d»p seasibitity. 4. Impaired function of the bladder and bowels, which 
itilue to anaesthesia of the mucous uiemb'-ane of these organs, as well u 
lohincticutal perveraiotj cf the sympathetic nerve supply and hypotonia, 
luutuience of tiriiie, difficulty in starting the stream, and inability to 
wapletely empty the bladder are in many cases initial symptoms, fi, 
Ln potency. 

The symptoms on the aide of the special senses are neither so common 
Btir to important qa those already mentioned. By far the moat frequent 
b impairment of the sense of sight due to so-trailed atrophy of the optie 
ti«rTe- The senses of Bniell, taste, and hearing are oceasioitally en- 
cnuhed upon, especially the former. 

Tbe aymptoma of sympathetic nervous origin are common, but not of 

ftvch diagnostic importance &s the motor and sensory symptoms* The 

pndpal symptoms are : 1, Gastric, vesical, laryngeal, and visoaral criaee, 

■ auae given to sudden, unbearable, agonizing pain ot.^curring in these 

[Hrtsof tbe body without np|^>arent 4^aiiae and of variable duration. 2. 

Aitlkropatbies, commonly kiiotpu as Cliarcot^s joint, which may affei^t 

1ST of the joints of the extremities. 5, Ulceration of the skin and 

dee^T tissue^ usually of the feet, but sometimes of the buccal cavity and 

tA the bonds, tPhich shows a tendency to perforate and which is su- 


■::■:' 's^ system, 
^ - .? rnnure nf thi^ l^ng 

., .;: : rxhvmoses- 7. Loral- 
.. l:e:..i:iTrMithy Mini liu^'Jial 

".—'^5 affected, ewn in cases 

^: ;e f'liiud. These lueutul 

* .: ^:-^;i that an' parallel to 

::a. or a luilj euphoria. 

- ■' .i'.!y a proyrejisive disease 

-.'J p^isttrior colujuiis of the 

'..-■ I'luupleie iiselfssut?ss of 

L :V3tali(in <if vit,ility. Tlie 

:,'.:: 5::iveediiiij year visually 

IVspile tliin it :^hoiiId not 

- ', .'r;t':'h" dini'aai'. L'tifoitu- 

. ..It'd into: 1. A pn?ataxie 

:■■. pa:iis» distiirhaiioes in tlie 

•-*. L'. Ataxia p^'tiod, rhur- 

/ wi\ jtrks, and inn[i<iliilit3' of 

■-.■.r,:al sta^e aUeudi-d Uy ^k'U- 

: ::ir" vei^eiativy functions, in 

.':. 'A^ili th<' rxr^i^pliiju of pain, 

^ sM,v, Thi- duration of th-- 

I iTiain <'ases tfnninate i'a- 

:>!;oualih- wlielhfr tliesu I'aii 

:' liHMincktop alaxiu lias kfpt 
, ::io [latuiv and cause of ihi* 
L7,(-'li'. pcisisli'nt, nn-lhdiHcal 

- ■: -if th*' patlii'loL^iiMl proi't'i^s 
., '.'nO:is than in ;iny tilhi'v or- 

•.c"-.. lla[dia/ard» I'asual, nii- 
i.v '.11 tin' handling; of laln-s, 
I'uionOi'' sak<' \n- rffcn"''d tfi 

. _, ■ : h^f th'- all rilmiid fai'Tins of 

. ^, *^ ^. MUiU)^ il:^ an;itoni]i;Ll lirisis. 
.>i v.vrk'ins whirli Un' disoiiST* 

^ . ", 'he re-i'il"'':^tion of t^<* f\- 

•taarr or tabkSv 

&. The ^eaenl sTstemic k««tmeikt, lod plaa of 

ThA roUtit^ iinpartaDce of thcdo isod«a of tmUaoit U ia Ito ia- 
TVBC ovd«r of th«tr eaQAeratiaa, but it U more kgml to consider iJben i& 
the &hoTe onler 

Cuoal Thenpj. Tbe AdTuibOitj of ABtiiyphilitie Ti— f aL — 
Sjpbilis is tbo OC1I7 cauflfttirfl f^clor of lalies ihAt will be coraderad 
bera^ w the otbo- attritnited factora will be meuhooed undcv Um c«Mtil 
hTgimo of the tabid patient- NcurologiflCs do not ftgreeaa to tbB«4rm- 
bilitj of giving antuyphili^c treatment in dMs of tiibw. Son«, like 
Chmrot for exacapt^i steadfutly bold that aui^h trvatmeat is it3»l«ss in 
erftTjr case of true tabes, no mstter how cleai a biatorjr of pr^riocift luetM 
lofectiaQ tho potUat fircB or bow indiffereuUr be maj hare br«o treated 
duriog tbe arti^e period of tbe sypbilitic poison. pn>ridiu§-, of ooune, 
that tbe symptom compkx of tab^g did not dereK>p within a ahoH tine 
after the syphilitic infecdon, from two to four yean, wheu the Lesion 
might If^gitimat^ly ba nm^iiderei] a true s/iiliiUtJc hihX nol a ikurasypbiHcie 
one- Go the other hand, Erb and many others who bare b;id lar^ ex- 
perience with this disease teach that every eaae of tabee giving a aypbi- 
Utio history should be put through a rigorous oourse of auttsvphitUie 
medicatiou, combined with general reatoratE^e treatment, if there are no 
apparent objactiona to such proi^eJure, ani] providing the patient has tiot 
already received such treatment at the bands of another phyfliriau^ No 
hard-and-fast ditecliooa can be ^iveu for the guidance of the begiauer who 
&G6e thia question for thefirnt time. It is my own belief that absolutely 
nothing 1ft to beeipected from the admitiistration of mercury, be it by the 
mcuth, iDunetioaa, or hypoderu^tically, iu cases of genuine tabe^i in 
which noothersyphiliticiuauifestationsarepreseiit. Moreover, 1 Mieve 
that such treatment often does harm. On the other baud, iodide of po- 
tassium, s^ven in small doaes :ind for a loug time, especially in coujunc- 
tiCHi with a course of aJkaliue waters, anli-arthritio diet, and nteasures 
that improve the aulritii>n and huabaud tbe energy, la one of the most valu- 
able substances of tha pharmacopoeia to delay tbe decay of t!ie primary 
sensory neuron, bn il intraA[>inal or iutrameduUary. It need scarcely l:e 
said tliat it is of tlteutmut^t importance to adopt at once the moat orthodux 
anti syphilitic treatment in every ease of tabes in which there are true sj-ph- 
ilitic raanifagtationa of the skin, mucous membrane, bones, or nervous 
system, mllammatory or emdiitire. Moreover, a aimilar plan should be 
adopted in cases of tabes developing witlitn Ave years after Byphilitie in- 
fection -J for it should not bo forgotten that syjihilis of the spinal cord 00- 
casionally produces a syiuptom complei difficult to difTtrentiole from thai 
of true tahea^ If it is deeitJed to put the patient upon an antisyphilttic 
plan of treatment, my cEperienee has been that the best results are 
obtained by the use of mercury by iTiunctiMn- If this method o.irmot be 
adopted, it may be given hypodermatically. T have not net the difficulty 



Bpaken of hj some writers of perm:adiiig patients to onntinue the hypo- 
dermatic iiiedicatiun beciiiae of the paia which it* ia that the iD~ 
jectioDs often caiiae, When it U decided to give the patient a coarse 
of mercury, one should enter upon it in oo half-heeirted way. From gr. 
XXX. to xc. of blue ointment should ba rubbod in daily, each rubbing last- 
injf at least from tw«n^ to thirty ntiuittes, and the course kept up from 
Foarto sin weiska. The grea-test ^atchfalneBB shanld be kept over the 
condition of the p&ttent^a alimeatary tract, skiu^ and body weight. He 
canuot bo kept too clean, toQ much iu tho open air, nor be ti:io carefully 
fed. If one mistake mure than another ia made in putting a tabid p&tieat 
through a course of mercury^ it is that tbe physician is careless of the 
ps^tient'a loag of weight. If this oannot be c^ntrolledj the mercury 
should be stopped at once. After the patient has gone through the mer- 
oury treatment) he ehould receive a vigaroua touio plan of treatment for 
several mouths. 

Treatment Diraoted Againat the Morbid Prooees.— Innumerable mea- 
aurea hftve been suggested lo coiuiteract the progress of the morbid cou- 
dltious forming the basis of locomotor ataxia. The majority of tUeae 
have beeo foiind by eiperience lo be nearly or qnite worthless. On 
the original recognition of tabee by Ducheuue, this clinician and many 
q£ his coutomporariea waxed eu^tbuGiasEiio over the uaefulneee of tbe fa- 
radio OLirrent, while Bemok, on the other hand, upheld the greater ef6- 
eaciousness of the galvADii.1 cun-enl. Wutiderlich dechired that nitrate 
of fiilver possessed greater power to check tlie sclerosis of tlte pos- 
terior column than any other medicine. Ilia experience waa corrobo- 
rated ia a measure by many oontomporarica and followers, and to-day it 
19 oiie of the most widely known and nsed drugs in the tteatm.ent of 
tabea, although in truth it is r:f comparatively little uae. Druga that 
have received far greater credit than tliey deserve in the treatment of 
this conditEOii are ergot, belladonna, arsenic, phosphoruSi gold, aluminum, 
and platinum. Whatever virtue they poaaess. apparently or actually, is 
due to improvement of general nutrition, the blood aud its nutritive de- 
rivativea which their uae for a brief period may produce, or to their 
aymplomatio effect. The truth is that the only substancea which ei- 
peiience has shown to have any efTect in delaying the disiutegration of 
the senaory neuron are iodide of potaseiuni and nitrate of ailver- When 
it 19 elected to give the latter, the possibility of argyria ia to be kept in 
mind aed the patiant should be plainly told of the danger of discolora- 
tion. The drug may be given in piU form in one-half -grain doses two 
hours after lueals, and kept up for a period of from six to eight weeks. 
The patient is then put upon iodide of potassium iu from gi^ vi. to a, 
dosee, given for the same period. If there is not decided benefit from 
one euch course of treatment, it ehoald Dot be repeated. I have never 
seen the slightest bene5t result from, the administTatiou of ergot, which, 


<xx thtt reconucoDdatioii of Charcot and HammoDd, aoliicved a repatation 
wlwlly undeserved. It should never be giv^n. Strycbuino and the gly- 
coro-pbosphiLtea ara esUinsively and deservedly used, but not with any 
view to iufliteuee the aLuatomical leaion of the disease, save by improving 
the general nutrition. 

This part of tbe chapter would not be complete without a lefereDce to 
semm therapy. It is weD known tliat a few years ago Ktown-Sdquard 
startled the profesional and lay public by liis claims foe the rejiivenating 
qualities of extract of the testicle. He and his followers were able to 
formah many plausible reasons, comparative aud physiological, for the 
use of this extract and analogous ones mad© fion: the brum, the spioal 
oord^ eto. These reaaona still hold good. The utUiTatiop of the extracts, 
known to contain subatancea resembling allcalolda having indetintte phyai- 
□logical action, has not bei^n attended ljy nul^oieEit; auce^j^n to warrant one 
in recommending any of them in the treatment of tabes at thi^ date. 

SymptoiDatic Treatment. — In meeting; tha indications of the third cap- 
tion, the phyaioian will have abundant opportunity to display his thera- 
peutio raaoorcss. The pressing olaims are the relief of the lancinating 
paine. These may be so severe and so unyielding to every form of therapy 
that they deniaiKl the aclminlatration of opium or one of its alkaloids^ but 
thid should in every instance be kept as a last resource. Usually the 
painB aan l>e ameliorated by the n^e of the ooal-tar derivatives, such aa 
ph«njicetiDf antipjrin, ncetanilid, exalgin, or by aombiuations of thf^ae 
with aUialieB such aa antifebrin and antikamnia, and by cuunter-irrita- 
tion over the spine, such as by the actual cautery applied very liglxtly 
from the nape of the n^ck to the tower lumbar region, by spinal stretch- 
ing and euspeoaioiii electricity, warm Laths, and the applioatioo of pun- 
gent Boothing TOcdicainenta to the akin, Tha combinationa of the aa- 
algeaics which I find moat aerTiceable are: 

4 CaffeiD. aalic<ylatia, . - gr. 1. 

I^uol. aalicjlalLH, . . . . > . ^i. XT. 

< PhenaceiiD gr. i. 

One puwdflt Lo be Kiien trrmj two tioum until p&in ia relieved. 

If the pain occura at nightf aud the caSeine seems to mcreaee the 
wakefulness, X employ the following prescription : 

^ PhtfQjtcctin, gr. X, 

8, DUaolve iu hoi water ftud ndmlniflter conjointly wiih ohJoralamldc, in 
powder or Elixir form. 

In a Bunilar way the analgesioa may be combined with aulfcnal or 
trional, Oocasionally the pain can be relieved by the prolonged warm 
bath (temperature 98'' to 102° F.), lasting from fifteen minutes to hulf 
an hour, aud general faradization of the extremities* Rarely, wrapping 
the legs DT thighs in flannel wrung out of hot water in which oapaJoum 



has been disaolrodr or moiatened with chlorotorm and ether, is of ser- 
vice, 1 have nerer se^n any bene^t to tLe p^m frDm uiaasftga, m«chaui- 
oal vibration, or percuBsion of tha uerve trunks, ncr from the appUcaticm 
of a spray of methyl cLlorido to the vertebral column. Oa the other 
liand^ I have a^ou material bcnetit attend the application of dry cupa to 
the Gpitio, the use of the actual cautery, uiid of atietching. When all 
other meaaurea fail to relie^'e, it becomes necessary to benumb the eenso- 
rJLtm by the ua^of opium. In full knowledge of the danger that the pa- 
tiejitis iij who reueive^ morphine for tlie relief <.jf paiu w1iii:h is sure to re- 
turn, the phyaitian is nererllielesfl under moral obligation to his patient 
to make use of this measure in certain caaea ; but ho who Icavoa a syringe 
wUh the patient or with otje of the family to k>e used when the pain is 
uiiliearable outrages the privilege cooferred on him with the Hippocratic 
oatli. Even though tha patient may live in the country far lemoved from 
hifl physician, ito shadow of JListification exists for making him a mor- 
phine habitue. 

Treatment of tk& various criBCS that aometimes occur in tabes usually 
demands th& temporary use of morphine, aud the fact that the stomach is 
disoi^ered in its functions in the moqt common of these rrises makes it 
nei;CA:^ar^ that it he uaed hy|>udermatical]y. Therein no dauger of the 
formation of the morphine habit, for just as aoon as the crisia is over 
there is no further indication for its use. If the gaatric crisis is of only 
alight intensity, a temporizing measure of some satisfactoriness is the ox- 
alate of cerium, given in from gr, iij. to v. doses, in the form of either 
a pill or wafnr. Its efficacy may be materially enhanced by combin- 
ing it with gr. ^ of (MKiaine. Duriug aud foUowiug gastric crisis ol 
tabee tliere ia marked deviation of the degree of aoidlly of the stom- 
ach and f^illmg oS of the paptogenic properties of its secretions^ and one 
must be guided X'y the condition of hyper- or hypoacidity ^*hich is present 
in the vomit in reaching a decision as to medication and alimentation at 
this time. Wiile the ciisen lant the patient mufit be fed by Dutrieut 
enemaU. In gastric crises considerable relief is sometimoti had by the 
intermittent application ^^f ice over the stomach, sjjra^'ing the epigastric 
region with chloride of methyl, and by tuuuUiug the ukln of the epigas- 
trium with a glnwing iron. Prolonged faradiTatioo of the abdominal wall 
has likewise seemed tu me of service in a few instiiuces. Vesical crises 
demand the adminiatration of morphine to allay the overpowering dis- 
tress in the iicginning. After this the patient can usually be kept in a 
eomfortable state, until the crisis cea^ies, by the givmg of a niixture of 
chloral hydrate, fluid extract of belladonna, and fluid extract of hydraatis. 
Laryngeal eriaes freipiently reiiuire inhalation of chloroform, but uever 
up to the point of complete narcosis. As in other crises, the two most 
reliable measures are morphine and absolute quietn 

Retention arid incontinence of urine frequeatly call for special medica- 




ttoa and hajiilliiig, amide from tlie dir«'t meGhanical treatin«i]ti su[:h as 
n^gular catheterization, waslmig out the hlodder with steiile water, or 
water ta which some alkali or rnitistiptic hoa been nideil. Some prepora- 
doa of belladoima or hyosofamuflwitbtLuid extract of hjdmstiBcaiia^eDsiB 
itr ergot may be ^t^q internally vith good reaalts. At the same time the 
bladder should be galvasized through the abdonirikal walls in thi^ follow- 
ing waj- : One large electrode, 6 by 12 cm., should be placed ahore the 
sycDphysis, and the other electrode of half the size and with a concavity 
flo that it tiCa up close beneath the pubio arch, then a current of from ten 
to twenty mitliamperea allowed to dow through from three to five miautes. 
In some ca^^ the mixed current, the galvano-faradie, seems to act more 
BatiHfactorily thait the galvanic rtirrRitt nluiie. I liaAe often foujid tliis 
expcdieut of cooaiderabld service both temporary and permanent. When 
the int^oEitinence of uriite becomes complete, it is neeesaaiy for the pa- 
tient td wear a rubber urinal, and to have the bladder waahod out once 
or twice a day, 

Talietic amaurosis is oua of the saddest, and fortunately one of the 
more infrequent mauife station a of labea that call for Lodiiiidual niedica- 
tioiL in addition to that uiidertaken for the amoUoratioti of the disease it- 
self. A most astonishing occarreace, and one which cannot be CKplaiaed, 
is that all tabetie naanifcBtatious occasionally ceaso when the amau- 
rosis becomes complete. There is uo measure that can be depended upon 
to iiifluenee hhe amaurojiB, yst nccaaionally the injection of aulphate of 
stiychoine does good, and it should in every instance lie Lried, beginning 
with gr. ^J-j and inereaaing it every day until the physiological action is 
plamly manifest, Koceutly, the use of the double cyanide of gold and 
potassium baa been recommended in the following eolutioQ: 

3 CfinldG □! K^ld Olid pouiaiutu, 
n^siUlwi woier. 

20 c^^ot. 

Fire drops of this solution ato injected into the muscles of the back once 
a duy, and oacb day the dose is increased by one drop until fifteen drups 
are given. Then it is stopjjed for a few days, or is given in reducing 
quantities until a doau of five drops is reached. Other measures that 
have been retximmended, such as tbe application of electricity directly to 
the eye» and mercnml inunctioaa, have no efficacy. Iodide of potflssiuin 
should never be given in these cases, for it is unquesldonable that Buch 
administration hastens the process in the optic netres. 

In the terminal stage of tabes there is great liability to tbe formation 
of bed-sores over those parts of the body that have been the seat of con* 
linual pressure, and all possible care should bu taken to maintain the 
nutrition of the skin and aubcutaneous tissue of thcEC parts, as it is very 
much easier to prevent their occurrence than to cure thern> Attention 
directed to the texture, evenness, and covering of the mattress^ a daily 




ckaimui^ bath and freque&t aponging with oold water and lUoobol ; utteiH 
tti'ii to iho Atate of the bowels aud bladder, wilt usually i^rereDt the oc' 
CMtreuce of bed^aores. If they occur despite these, they touftt be treated 
aocordiag to the reqitiiements of mudem afi^jtliQ surgery. 

It is Dot Lkecenaary to apeak in delai] of the trefhtment of such coodi' 
tions aa porforatdxig ulcer, tabio arthropathy, aitd the oeteopatltiefi that 
may occurn In additioti to the general troatmtuit of taboa, they Te<|iiire 
the Haiiie surgk-al and ortliopuMlio Eieaauiea tl»at Iropliio ttoublea of differ- 
ent origin demand- The perforating nicer is often extremely reaiataiit lo 
all forma oF troatment, and occafinnally it pro^'reesea tu such a deg^rc« 
and ia aaauciated with adjacent profound eutbropathy that it requires am- 
piitatjon j but thisj fortunatel;, ia very exceptional. Hyperextenfiion of 
the kiiet-d aUo occasionally calla for orthopsdic appliancea^ 

General Treatmant. — In latter years the measurea that phyftioiani 
have cmne to rely on more and tciore in the treatment of tabes are tho»« 
that may b« included under the head of physical treatmentr including 
bydrcthorapy, balneotherapy, olectrotherapy, maaaage, purposeful more- 
menta, BUBpension, and reat. 

Aa in moat other ohronio diseaaea of the nerroua B^fltem, hydrother- 
apy ia a valuable agent in tabea to improve the patient^a nutrition and 
to maintain bis strength- The spedal hydric procedure that sboi]ld bt 
used tn a given oaao depends largely on the patient, hia idicsyncrasiea, and 
his reaction to water at different degrees of temporature, but not a 
littte on the symptomatic variety of the diaeaae also. It is of far 
greater service in the casea attended by marked hypotonia than in the 
se[iaory forms. The usefulness of the warm full bath to relieve the 
shiKitiDg paina and the muscular soreneaa following an acceHsloD of 
the puins has already b^en Dpoheci of. if given oftener than thtee 
times a week, it has a relaxing eReot whi<;h should be avoided. 1q 
many L-aa^a^ ^^d i>specially thoaa in which the pain is not very severej 
Iho lialf'lwth, lemihsraUrh from 8J>° to 70" F., of from two to fiva min- 
ubea* duration, given every day, ia fallowed by a general gain in Irodilj 
vigor, renewed feeling of woll-beiji^, and some iinprovfment of nutri- 
tion. Wten it aeema advisable to get cutaneoiia stimulation or irh- 
tution, salt, pine-ne«dle extract, or a stream of carbon dioxide gas may 
be added to the water. Aa a rule, however, very little is gained by theia 
pi-QceJurcs. T)ie thenaal elemerjt is the important factor, aud to tbis are 
owing the good effects of a aojoum at many watering- places^ Strong, 
full-blooded patienta who react promptly and with pleasant subjective 
seaBations tatheflpplioa,tion of cold water, often lind much benefit from the 
use of water of 6C'' to 55^ F,, given from the hollow band of an attend- 
ant, accompanied and followed by frictiojj, and from the uae of a tonic 
bath according lo the following formula ; Hot box until nuld perspiration 
lesultB^ Charcot douche, temperature 80° F.^ reduced daily from two to 



Ci«degneBiuitil6J>^ F, lareachtHl, pressure tea totiveiit^ poundfi, duration 
^a^ lo »uvy secoaisT a^plted to ibe back, ijbeat, abdomeo, and calves, 
lid fdIow«d bj a Fleurj apiaj, tt;m|ieratuTe G5^ to 75^ F^, prcsmire fif- 
kia to tveuty pounds, duration Mteoi secondB, foltontd b^ light £rictioa, 
ill vnt the bodj for from two to five lutDutes, d'spendiDg on the putiect'a 
fwciuii, uid a brisk valk in tb« open air. 

Wbea it ia impossiblo to aend the patient to a hydriatic iastituto^ thia 
ptooeduM may be aubatituted by wrapping the patient in a dry, hot 
Uiobflt for from ten to thirty minutes, gi^'mg him a hot dnuk^ water, 
T«tkte^ or milk, if hia digestive apparatus is in good condition ; then 
vlian the cui;a.naous circulatioD, eapectdlj that of the extremities, sbows 
the sffwta of thia internal and external heat, water ia foiclbly thrown 
trap a dipper upon the apine and orer the abdomen and ohast, or the pa- 
beat ifl flagellated briskly and quickly ^ith the ends of a towel dripping 
vitb cold water, and followed by frii^tion^ 

Urogenital symptoms are often benefited bj the use of cool flit£ 
ti^ temperature 75° F., duration two to £ve minutes. patienta 
objecl to them becanae of the idea, that it increaaea the pain, but neverthe- 
loi 9iich a bath is often serviceable in helping to retievo the urinary in- 
aututence. Some writers reoommend for the relief of pain and for ita 
pun} tonic properties the use of a cold wet pai^t, whieh, of conrse, 
InXDV & warm pack aiter it has been in appobitioa with the body for 
i^rt time. It la said that the uulform wariuth thua induced tends to 
juiQeate pain and disaipate paraeatheeia. I have not seen much benefit 
Ilia It 

UiAj patients with tabes are greatly improved by a sojourn o£ a few 
whIb^ four to ail, once or twice a year at the thermal mineral springs 
uftbu oountry, aod the role cf balucotherapeutica (mineral- water treat- 
smi in contradistinction to hydrotlierapeutiofi, the external or internal 
ue of plain water) in the treatment of tabes is an assured and an im- 
portant one. In this conntry the hot springs of Virginia and Richfield 
ifpniLgs are the most important, In Germany, those of Oeynhautten and 
yioliBim^ and in France, those of Lamalou and Balaruc are m best re-* 
patrt The m&nner and method of using the warm aajt batbs are very im- 
porUDl, but usually it is necessary, wheD pabents are recommended to 
ruitii certain spring, to leave this matter to the physician of the batbs. 
Sowidaya it is almost unknown for a patient to take a course of waters 
Uiii; of the apriTigs without first putting himself in the care of one of 
lie ujuij physiciaua who are Ic be found there. 

Tibetio patienta are alao often hone£ted, especially if they are ancemio, 
dyip^tic, and inuUned to cachexia, by a short visit to one of the mnjiy 
iBiidlr<uuI Hpringg in this country and in Europe, such as Poland Spring's, 
lU^lz, St. Moritz. The regulation of diet and nf exercise, the open-air 
oiAiBiice, and the devotion of a proper number of hoars to sleep, which 



are the usukI entailmentB cf such places, fiil help to impTOre the patient'ft 
nutrition, to husband hie energies, aud to increase hie strength. 

The U*e of Electricity in Tabea. — Almost from the time when tabea 
was first TEcognizfid as an individual diseaH?, electricity h^s hepn accorded 
an important place in ita treatmeat Duchenne and Rem^ set the ex- 
ample in Europe, and thof soon bad innumerable foIlonerH all over the 
civilized world. Electricity has been praised out of all proportion to its 
real efficacy by some, whiU others seem to take a malign pleasure in deny- 
ing it any virtue, eithef in infliit-nctng the leai'm of the disease or in niit- 
igatiiig its sy injiComa. It is quite impoaaible to estimate rttmralely what 
serrice it leally renders in this directioni but iteeema to me that it mat- 
tera not whether its udefulneaa is due to suggestion or to aome influence that 
it has in counteracting the process of decay in the posterior columns of the 
ecrd, BO long as it helps to prolong the days of the patient's life and to 
make them more livable it i^ lif serving of employment. Electricity is uti- 
lized iu tabea in the shape of the galvanio current applied directly tu the 
apincj the galTanic and faradic currents to the peripheral parts, including 
the cerrical sympathetic nerves, and as static electricity. Of all the pro- 
cedures, galvanization of the spine is the most important. Many modes 
o.f applying it ha^e been recommended. The two following methoda are 
quite satisfactory: the negative pole connected with a large electrode 
(siK inches square) is placed on the cheats and the positive pole connected 
with asmaller electrode (one to tsvo inches sqaare) on the spine, and moved 
slowly from the cervical to the sacral region, while a current of from six 
to ten milliamperea is allowed to flow, the durationof the treatment loeiiig 
about t^n minutes. This should be done daily, and in very few cases it 
is more satisfactory if tha electricity is applied twite a day, each s*^nce 
being of from fire to ten minutes' duration. It is highly probable that 
the benefii^ial efffwt of electricity thus applied ia commena\irato improve- 
ment of the circulation of blood and lymph through the posterior columns, 
nerve roijts, and adjacent tisBue. The other metJiod is to place the cathode 
5rmly over the stiperior cervical ganglion at the aiiglo of t1ie lower jaw, 
the anode over the opposite side of the apiaal column, close to the spinous 
proct'saes, end allow a current of four railliampcres to pass. The poei- 
tive pole is then rubbed up and down the spine for about five minutes on 
one side^ then the cathode is changed to the cerTioal ganglion of the other 
sidSi and the same pr<jcedure used for tliH opposite half of the spinal col- 
umn. In tliia way, the posterior roots and the intervertebral ganglia are 
stimulated, and in view of the important part taken by disease of these 
structures io the pathogenesis of tabes, it oan readily be seen that this is 
a desirable operation. 

Some amelioTation of the paneathesia mny confidently be expected from 
theusaof faradicelectricity applied to the skin uf theextremicies. Great- 
est excitation of the cutaneous nerves is obtained hy using the small brush 

cj<ide. If it ifl deaired to stimul&te the peripheral naurom macular 

ifj4;itu% Hther Uie fftradio or the g&Jvatiic current laaj be emploved. 

Vlhm it i^ «Wted to use the latter, the poaitiTe pole sbould h^ iis«d aa the 

dtfo^tiHtiTig aloctrode- I have aeeo Bome benefit fu]]ow the use of statio 

dkcrieity, a|i|>lied by Tjieaiia i»C a large brass ball electroile or by a roller- 

^Kooood tbeoiife have been Hiiggeated to explain this ben«1^cial action, 

fall is ci^e ia based entirely upon empiricista. Some DiaintEiJn that the 

m^tj nerves conduct the elactric energy along their oouTBe to the cord, 

Bitbe ciureDt thas exert^isea a beneticial action upon the entire sen- 

tcTf aearon. More plausibte ia the explanation that the sharp triuauidar 

oxitrtiftion oaust^d by the impark iniprovuB the n«aroiuaaCLilar toae. It 

need scarcely be said that electrical treatment should pot be relied upon 

esdtisiv^Iy. Ojx the oontrary, it abonld be looked upon aa an adjuvant of 

»oae importance, and giv«n in connection with other physical and medi- 

eiiuL treAtmeut. No more is it advisable to give electrieity Lioiith after 

niouLh iritJiijiit interruption. Its eftec:t!t FteKUi to be beat when It is given 

£of tk period of six weeke three or four times a year. 

Ift oertain cases of tabes the regular, persistent u,B6 of massage does a 

deal of good. At li^aat it gives uiore (y)mfort than almost aiiy other 

i«MU«. Ic is especially useful in cases of Icng duration. It counter- 

muacular hypotonia and a^tlienia in a more gratifying way than any 

<M^ measure, and 1 have often Been the Bjiuptom described as ^* ginng 

^rij of th« knees'' entirely disappear under this form of treatment, 

Vo&eD tolerate maesage and benefit from it far more than men, and this 

m^ holds good Cor tabea^ The mo&t useful masa£^ procedure is strok- 

hf. Diligently and careftilly itsed to the muscles of the back it over- 

vmm the dorso-lumbai hyperaiathesiar and applied to the extremities it 

sttt infrequently assuages the pain and mitigates the hypotonia. Vigor- 

<>u kueading and compression of the back often decrease ih& girdle sen- 

ttica, while general massage may be used for ilu tonic effects, Stretch- 

mf nf the peripheral nerves either by operation or by tlie bliHjdless 

ttwtboil. whic^h formerly had considerable vogue, is to be severely frowned 

a^ No doubt such procedure sometimea relieves paiii, but the aame re- 

ndt^can be obtained by having the patient lie on the back with the head 

tlifhUy elevated and the legs extended; an attendant then grasps the 

ftti ud dranrs them back tovard ttia patlent^s head, the knees remaining 

«itmdMl. I'his position is maintained for from two to four minutes, and 

TiyHied oni% or tnice a day. 

Biupeiuton a Therapeutic Agent of Some Value. — Suspension seems 
laUvo been first recommended by >lotschutkowyky in 1SS3. la the 
dfiru&a folloving, neurj:ilogists of every nationality testified to its efli- 
dq ill nmeborafing the symptnms uf tabes* and apparently in modi- 
Ijittf Uie course of the disease. During the past few years very little 
^ bc«a beard of it. Nevertheless it is atill in use, and a dispassion- 



ato estimate of its value b^i^^d on expencnce would probably hold tbett iLs 
methodical lise ia attended by a leaaemng of the aoverity and frequencj 
of the pain» by an improvement iu walking, by some ameiioraticu of 
the vesical symptoms, and by an improvement in the patient's geneial 
morale. The uontmindicLitriuus for auapen.sion are ciirdio vascular Ir^ions, 
puhuouary tuleiculosiat emphysema, apoplectic and epileptic attacks, a 
tendeticj to syuoope, and olieaity. It should never lie u.sed in the para- 
lytic stage of tabes. Thi^ patient may bafiuspendediutho^ayro apparatus, 
but the mCEt expedient Vity is to suspend him from the head and elbowB 
while Heated by meansof a^iit^i^lly ran struct ed harnera which hangs from 
oiia etid of a horizontal beajji that is movable pivotallj^ on a linn perpeu- 
dicalar. Weights ara attached to tbo other end of the horisontal beam 
and by inoreasmg or decreasing the iiumb<?r of weights tho deaixed degree 
of euapeuaion force can be had. Its tnotfua operon'ii ia not very clear, but 
it probably nets mechanically to Btretch the spinal column and ifa attaeh- 
menta, and thiia indirectly to impmvH the circulation in the spinal veaapls. 

Be'education of the Ataxic EztiemitieB, Fraenkel'H Uethod.— DilQ- 
culty of locomotion eveutually becomee the most oonapicuoja burden of 
the patient's life. So long as hois able to get abont unaided he may 
live not only a uaeful, hot comparatively au enjoyable life^ but when b^ 
has to rely upon the arm of an attendant, a pair of crutuhes, or a wheel 
chair fortitude deserts him, and with it hope and asefulne^a- 

()f all the measures that can be utilized to counteract the development 
of ataxia, Etnd to overcome it after it has developed, the plan suggested by 
Mortimer Granville of tliigland iu 1^81, but formulated and introduced 
to the profesBion by Fraenkel, of HeideUf in 1890, and since then very 
mnoh elal)orated by himsflf mul otbera, la the moat important. The 
easeutial feature of tlie plau ia to aubuiit those muacles which manifeat 
the ificO'Ordination to a series of graduated and systematic exercises. 
Each movement thus performed will be accompanied by kiofesthetic sen- 
satious and memories m the corresponding areas of the brain, Fraenkel 
has therefore referred tcN the ti^atm^ut as one of cerebral gymnaatica, and 
in no way to h& coufoaiwW with gymnastics cf force. The underlying 
priiiciple is that if the patient is made to ovei^come the ataxia by the 
performance of simple movements with purposeful intent and attentioni 
his sensori-motor cortex will become ao re-educated that it will direct the 
movements without attention and cocscioue volition- 

Fraenkel's procedure eonsiats eaaentially in the exact and methodical 
eseootion of purpoaeful imfveirentB whirh require ultiU an^ nut force. In 
the Ixiginuiiig Uiese movements should he very simple, and gradually made 
mora complicated as the patient heoomes capable of performing them - 
They should not be done in a perfimctoty way as are ordinary gynmaa- 
tics, but with the attention cloaely concentrated on every movement. 

The heaeBt which follows the use of the exeroises is often most Bn> 



ooungrn^ to the patient fmd grAtifjit^g to the plijsioiui, eapeci&IIy whtm 
ased SB anailjuvant to the g«nerMttiiinc and supportive treHUiieiLtakeady 
Bpuken of. Nitturally ihej &re of siguul servk'e isi those oavs in wLich 
the ataxia ia Bob eiitreme. Oftentimes, however^ patients who aio dv- 
peadcDt upon crutches laay be so benefited by tbia tteattuent Ihul thtry 
can walk anaided, particularly if tbo hypotonia ia pot prcfound. [t inuhl 
not, however, be forgotten that thpse eiewiees have no icflueoce on th» 
oourEO of thodJGease, and that they benefit only one of tlie numercua ulliii- 
cal manifestatiouA, namely, the ataxia^ 

The cases of tabca that fleom to be moat favorabio to the i-uiploy- 
ment o£ FraenkeVs treatmeat are tliosa in which the atusia ajipeate very 
early in the disease; those in which it ia of cciaparatively alow develop- 
ment; and tho^a Id vhieh the inco-ordinstion tnHnifests some teudtincy 
toward sponlaneoijs a rueb oration. Tlio employment of tliii nieLhud 
of tTeatment is c<?ntraiDdicated ia ^eak aueemle patients and iq those 
who suffer moie or leas constantly vritb paina or crises; in cnacs of Acnt« 
and sabaeute tabea, tLat is, in caeea of euddtjn onset a^td in whia^ the 
habitual manifeatiitjona of the pre-ats.Kio period succeed each other rap* 
idly J inpatients with tabid optic atrophy^ fragile ban ea and those who have 
had what ia generally called bpontaneeus fractuie or ittpturQ of tendons. 
"When anj cardiopathy or aneuriam exists, the method must bo tried vpry 
tentatively, if at all. It is not &pplica1>lc to very obese or artliritic pa- 
tients, and linally it is absolutely contrnindieated wht^n there are groat lax- 
ity of the ligamentd and aevere arthropathy. 

Tho formula for these exercises of Hkill which waa given by Fraenkel 
in his commLmicatioa to the Moacotr Congress lu 1897 fieeinn raLher for- 
midable. The foUowing rhumi will aim to give tho more luijortant 
essentials. Tbe ilEustratione are taken from Uoldach^lder's excelleitt 
brochurs on the subject. The physician who undertakea to employ the 
eiereises must needs rememt>er tljst tbey demand for their suceeuful 
ntilizatioD a great deal of time and more pat]i>tire, Imt ex^jenditurti of 
tbeae wlU be rewarded* Whenever it is poflsible tbe eaerciaes should be 
entrusted to a trumed attendant under the observattoti of tho jdiyHician* 
They should be practised several times a day for a few minutes at a time, 
but never to the point of producing cuuAiderahle fatigue. When thiry 
kGanae gre.'tt f^itigue they should be done prinoipally in the morning or 
wibaz a Jong rest- 

AtAxia of the lower extremities ie cj^mmoner and always moro seveM 
than of the upper, it ia alao more difhrult to overcome by the FrftenkeJ 
movflmenia because of the associated ilivnrdt^r of edjuihbrium^ wfiieh 14 
often ao profound. To overcome the ataxia of the leg* the patient ilioulj 
bj making simple, pninilive moYemeuis that can ha f-xeculM whih 

tg ID be4. For inetwice, lying on tbe back with the leK* nncoKrcdr 
he should be r«<jijired to go tbroogh movements of fleiton, czimtAoo, 



ftMuctioii, and adiliiclioii of tlie different joiiita of Ibe lover extrecfi- 
ties, filowly and deliberately and with all the acciLiafy that can lie 
Goiiunanded, tiiat with oqq leg, then with the other, ani] tindly rnih 
both legs eitnultaQoously. Fig. 15 illustrates one of the simplest and 
most important cf these moTemeritfl, It ia fi|^ken of as the " foiirf&ld 

TDornrntnt cxerciae." It conaiata in laiaiag cf tha oiitstretcHed leg^ £ex- 
ion of the thigh sjid then the kaee to make a double right angle, then 
extending the leg and finally lowering it- It will be found that tbeee 
simple exeTCisea are very fatiguing, nut so much bec&uae of the muscu- 
lar exeri.ion Imt lie<iaiise gf tho att^-zitioii that tli*^y di^maiid. They 
should bo persiated in, however, until the patient can execute Ihem easily, 
accurately, and without much effort. Another very important series of 
exetcieea ie represented by Fig. 10. Aa eeea from the illuatration it 

rio, i«. 

"i^tisiHta of a short step ladder fixed at tho bottom of the bed on whiob. 

the patient ia required to make accurate stepping and cliinLtiig move-' 
jnentB. SimiUr morementa of precision should then be practised by the 
patient while aitttng. It is nnnecessury to detail tho great number of 
modifications cf eaicK moremeiita that oan be devised. Care and procis- 
ion in their axeoution ate most important. These primitive moTementa 



ard absolatelj easeDtiol and ehould not be neglected ovon by thoae whoso 
atp^xia is not eo great as to prevent them from walltmg. 

The patient ehould then pracCise lising deliberaCeiy from the sitting 
positiou witli or without aid, as tlia couditiou of h\a strengbli aiid equili- 
briiun demaad, aiid then sitting elowlj, Ab eoon as poaBiblo bo should 
do thia wiUjout aaaistanco or support. He fihould tlien practise standing 
uptight alone or wilh eupport or aasistjijicey ivith tho feet put firmly be- 
neath him, aided at first by the hand op eje, then as he gradually acquires 
aonfidenc© and BkUl^ without the aid of either and with the feet close to- 
gether. The phjAician eao be of great seryicfl bj assuriiig tho patient of 
Lis capacity to do thia^ for much of the disequilibrium ia the lesnlb of 
fear and lack of confidence. When he has euooeeded in learning to stand 
alone or with the aid of a stick, he should begin movements of bending 

Flo. IT. 

FH-, IC 

forward &5 far as possible^ then slowly miaiug liiiDBelf to a vertical post- 
tion^ beudiug Hrst one knee and then the other, adopting the sqnattmg 
pOBttioii and then rising from it, aud vario^is others. 

After this, raovements of the lower extremities loo^ting toward walk- 
ing are to be ptactiseil. Tlie patient should stand with the aid of 
crutches oi a stick and endeavor to put cue foot forward slowly, deliber- 
ately, and accuratelj upon a certain marked spot, from twelve to sixteen 
inohea in fr^ut of hiin. This should be doneti^e times in succession with 
all possible pceciaion aod aceitraey, while the patient or the attendant 
ooiinta, Th^u the same procedure is to be repeated with the other foot. 
After the patient has acq^uii-ed facility in doing tljis he should i.ry to walk 
with the aid of ati'^ks ot an attendant, talcing each step slowly and with 
the greatest deliberateneas, ten steps forward^ tlien ten steps backward. 
The patient should also be required to praotise walking movemeuta of the 
fifet while sitting. This should he done first with one foot, then with 
both feet simultaneously, as showo by the accompanying illustration {Fig, 
17). Another exereise of considerable aerrice is illustrated by the simple 



Apparatus (Fig- 18). The piLtieiit fiiat Loucbes all tUo ronDil-top shorter 
uprigbta and then all the £at'top taller upiighta ill succcsmod. Of coxirae, 
when the patiQQt cannot staad or waJk even nith the aid of & stick or an 

na. ifL 

aaaifltant, it ia necesiiaTy tu provide him with somd auch apparatus as ahoTo 
iTi Fig. l^J, by which he can Bupport hiiiiaelf while practising the manj 
different exerciaes of ski]!. The aKen^iaes that can bd deviled with such 
a contrivance are abnuat iunurnarable. A few of tJbo iiaport«nt onea are 
illustrated by Figa, 20 and 21. 

Bj aseiduouD practice of these cxerciaea the pnlient will soon bo able 
to walh without holding an iEamor&ble Bnpport. It then remains for bim 

no. ax 

to practise walking in a etvaight line; to trare Rgurea or lines with the 
toes and to indulge in other movementa of the lower extremities that re- 
quire accuracy and skill fur their execution. 

To overcome the atajtia of the upper extremities one proceeds in a 



ciiait&r faahioa. The p&tjeiit ia ta&da to eseout^ Gimple movements at 
first, followed hy more coiapUcated ooea with tha fingers, han(is, and 
fbreanus. When the patieitt ciui ii^e h'li muscles without diMcultj for 
tkoGO movements, he ahould he ei^eu exercises which require mora skill 
Kul patienco for their performance. Fraetikel has devised for thia pur- 
|ttM A nnraher of apparatuses. One of tlieee cohbigU of & piece of wood 
hftTiug the form of a triaugular prism forty centira^tres long, each side 
ttWttfluring five cenrimetrea. This piec^ of wood rents on one of its 
sid&A, Tbe upper ed^ is grooved out, one of the otLers IH smoothed 
off* vrhild the third is aharp. This ap[raratus is placed before the 
pAtiexit, who holds in one hand a large pencil and ho endearoca to pnt 
the pomt of the pencil in the groove ajkd move it back and forth therein 


steaidilj and acnnrataly from the farthest to the nearest end, kraping the 
fia^rs and the wrist iinmovable At first the patient has considerable 
difficulty in keeping the point of the pencil iii the groove, but after re- 
p«ftted exercises he is able to do so. He should then practise retraeing 
with a pencil simple designs conataCing of straight, zigTag, and curved 
lincM. If the tracings of thtse ligurea are kept^ it enjihles one to follow 
tb« progress that the patient makes tovrard acquiring cu-ordmation- An- 
othier opparatna coiisiata of a piof^e of board in which depressions have 
bees hollowed out at regular interviils, into which the end of the finger 
can be pUced. These hulee are munbered. The board ie placed before 
tb« patient, who holrls the right artn riiiaeii and the indeic finger extended. 
He then puta the end oF the Bngfr into Lha depression rapidly and as 
ftecoratety as possible when the attendant calls out the number. At hrab 
bo 19 mado to repeat the sarae iium]>cr until ho can do it with considerable 
aaewagy« This exercise can be made more compUcated by having the 
fMOjegat pat marbles in the holes aa fast as the rumber of the boles Is 




called ont> This simple device may ba replaced by a Iward fi]]^ with 
hiA^t lu u'hioti Uie patient la required to place a uuiulier of pegH, siich 
as a cribbago board. 

The greut number of Tariationa that cui be devised l^y an}' one, ereo 
Uie patieitt hiiuaeJf, will auggest themaetvee at caee to the pbyaicuu. 
After the patient has acquired Bkill in these exei-cisea he can practise 
with a ouuLrivajica couaiHtiug of a series of balls of liiiferent nizes 
suspended hy tlireads from a hurlcoubil bat. Oue of tliese balia, coni- 
meai^iDg with the largest, ia made to oscillate, and ^biie it )3 oacillat- 
in^ the patient U tcld to nei^e it and briug it to a atate of test. At &Kt 
hti i^ left free to choose the moment at whieh to tiei?e tlio ball, but later 
be ia rei^iiired to do bo at a moioent determined by its oi^illatory excur^ 
stou. Thi» exercise U repeated witli all the diffeieat balls. The smallei 
the l>al] the nioi^ difficult the exercise. 

Piaa of Treatmefit. — The im [^ortance of a plan cf treatment for pa- 
LienLs with locomotor ataxia can ei^arcely bo orereatiniated. Tba taedi* 
ciiial trefltmeTit is of little eooBequeoee ^rnoipflred v'llh hygieni^?^ dietetic, 
phyaica!, acid dLsciphuaiy ineaaureB. The aiuehoration of tho patient's 
ayniptoina and the degree to winch c<»mfoTt anil lougeritycan be (fiTeti 
hiui ctimd ia direct relatkiu to the pL^omptltude ivitii which the dia^osis 
LH made liLud jjroper treatment instituted. Every patient who Gonsuita e^ 
physician for ailment of any kind, aside from the acuta iufe^^tious dia- 
itasesp and ulio givea a liisE.ory of ey phi lis, should be carefully put through 
the teals requisite to re^'eal the existence of tabes, Tho neceesity of 
this fitaleuiiT-iil is impressed upon me by the fact that out cf one hundred 
patieuts which 1 havo porsonaUy studied aeventy-one had at one time 
been diagnosticated as, or treated for rheamatiem. It ia B^acoely nec^A- 
sary to emphasize how e§Aeiitial it is closely to Ecrulinlze the patient who 
cornea cLimplaiamg of pains, vesical shortcomingH, uttered geueeic id- 
atmcta and capacity, or any of the symptoms of the general neurastheaic 
condition. At euch an eaily date it may be quite impossible to satia^ 
one's self of the reality of the eicisteaeeof tabea. Nevertheless, the pBtiant 
may without uny other consequpnces than benefit be |mt under a treatment 
for tabes while careful waU^h ia kept for uidie diaguostio uorroboratiTO 

When the existence of the diseaee is immistitkahlc, the qnet;tioii tnuat 
always be decided whether or aot to inform tho patient. Naturally uo 
general rule can be given, but it Is my own belief that nothing whatever 
is to be gaijied by concealing from the patient the nature of his dtseuee^ 
for fear that such knowledge may have an injuriously depressiug effect 
if he has hoard of the disaatrous outcome of the disease iu othera. If the 
first physician whoio the patient consults does not eppri*e him or one of 
th€ family, which is tantamount to telling tbe patient himself, of the na- 
tme of hifl diseaa^ it is very likely that aoouer or later Tie will consult 



ftsutLer plijsiciaa vho sees liis waj clear to Jmpajrt eucL mformation. 

^Di« fint physician will tbcn be held to havo maUc tt iitiistuke fuid to have 

vuted time in tie^trn'^nt which im^ht have beea beuelicially employed ii 

tteei^t nature of the disease had been knovrn. It la not wise in the 

nuLjority of cases to lujike na mimodified ilia^osis of locomobir &tai.E& in 

Ihf begiaaingi uevertheJesa tlie palicut should be luade to underabaiid 

iwi liis disease ia fictioua, aud in order thab it may not disable hiui| it h 

Qftasuj to aiiopt a Tigoroua plan of tteatmpct for the purpose of stop- 

^ig Ha progress of t^e cUsea^e. The important lesson for him to learn 

a ihai i iong period of uaefulriesa and comiiarative healtb waits on 

aiifaridiral And (.'ontiaued treatuieiiL Occasional aud deaultor^ visLta to 

4u[i^ciii:i nhU'h are rewai'ded \ty odo or two piescr]ptioa9| are tanta- 

IMNDt to ito treatment at all. 

Mwr getting en r>kpi>vrt wLtli the patient and securing at least ft 
4i^ of his ccintidence, it is necesnaiy to decide whether ur not he 
tUII forego bis cut^tomary ovcupabiou. providing of conrae lim posi- 
\m io life allcws him to do bu. Individual factors ia eack case must 
nifliLcoco tbia deciaion, Aa a rule, unless special indications exist to 
^baoanmiyT ^^^b as the neuraatheaic atntc, manifestation a of syphilis 
iQ tbe ]jlood-T«fiaels, alight hut progressive entaciatiou, and unless the 
Dfn|itlion is one tbat is nondacire to leg weaHiiesa aud entails worry 
ud car?, it is best to let the patient keep to huflinesa at least to a 
(BTttiD ettCDt' Uis infirmity prevents him from indulging ia many of 
Wepieas'ires and ocoupatioos which help to piias Iho time. And to take 
imu no^mstOToed during all the years of his life to eugrosEing oj!CupB- 
tim ind throw him at oure itito enforced idleaesB, at the aama time re- 
Aiieiiiig him from many pleasures which are harmless to the healthy 
bdiridaal, is taatamount to coaverting him at oqgo into an iutioBpective, 
depreasedt miserable being. On the other hand, if he is allowed to pass 
I porta cf bis lime Lu business, while the rest is giv^n over to meastu-ea 
thit miy be l^itJmately ealled treatment, such aa moderate bicycling, 
pil£ug, driving^ aod not to 3[>eak of the tithe reqidred for hydriatics, 
elocirki^, maaaagi;, and rest, Le will hare little time to think of himself. 
JLnile that admits of few exceptions in handling a case of tabes is that 
tt&itoriam treatment is not advisable, at least not until the last stages of 
the di^^a^e. 

TlWi^cs do nob tolerate bnisk changes of temperature c^r osciUations 
<rf MtliQ^pheric preB3nre. 8uoh changes are apt to be accompanied orfol- 
bmd bj attacks of pain, gaatrio ciisea, exaggeration of ataxia, and gea- 
cnl uth^ia. A temperate climata and a moderately dry atmosphere 
wmDtt f&Torable for patients with this disease. 

b t^itrd to the paiienL's diet, it may be said tbat tea^ colTee, al[v>- 
Mlio atinudants, and tobacco should be used most tempterately or eatirelj 
*>B^«ved. It is poor judgment to insist that a man who has taken 



thGS& dietetic luKuriea in modpratiou and to hia apparent benefit for 
maijy jaars, sliall give them over entii'elj juat because certain nerve 
fibres aria begiuuiny in dei^aj. A miied fliet with a. prepoDderaupe of 
vegetables aud fats, if the pEilieiit cau take tbem, is tha nearest ap- 
proach to the ideal. Aa in all nerTOus diseaeee, functional or organic, 
the patieot ehould be fed ftoquently, Qv^ times a day at Jeast. The 
snpplem^Dtary Eae^a should oousist of utilk or oth^ food, the taking 
ol whirh requirea mi effort on the part of the patient. The tabid pa- 
tient who 8p«nda twelve out of the twenty-four hours in bed is more 
just to himself than he who encroaohes upon thia number. In regard 
to exorcise, very little con be Buid in a formal way^ Leg wearinesa is to 
be avoided at all hazards. It will be ft>uiid that the varieties of exerciHe 
and sport that are in vi^ue in any i^OLmtry or sedion of tJie country tor 
Uie average healthy man ean he indulged iii quite as well by tlie tabid pa- 
tient, pro-viding he is not Lncliiied to be intemperate. It is unneoeaaary 
to Bpeak of the impoTtaoce of avoiding injurious indulgences oE all kinda, 
but patients in the early stages of tabea often seek advice concerning 
attempts at sexual intprconrse, for in many instaiicea eexiial potency ia 
D^b entirely lent unlil the disease is qtiiteadvaiiced. 80 fiiraspossihleoo- 
habitation should be a^^oided, although if tbt^ve is no iiathological excita- 
tion no harm can result from occasional indul^uci\ The general hygiene, 
inclnding clotbmg, cleansing bathu, regulation of bowelfi, maintenance of 
the integrity of digeationf do not require apectilio mention. As in all 
other nervous diseases attention to these detsuU is rewarded by an aooes* 
sion of the patieiil^s nutrition and inrrease of pliyKiral strength. 

The use of drugs to maintain nnti'ition constitutes aii important part 
of the treatment of tabes. Of the general tonics and restointivea iron, 
araenio, and quiuina are by far the most important, while the eimple bit- 
teia aud dilute hydrochloric acid are to be used for their direct effects on 
the appetite and digestion. There wou!d seem to lie a fixed conviotion 
on the part of many pmc'titioiierH tlmt strychnine is a drug of surpassing 
value in all diseases of the spinal cord- In reality it ia not, and in tahea 
its unguarded use may be followed by increQae of the lightning pains and 
irritation in the urogenital sphere. A few year's ago I gave it a tliorough 
trial in ten eases of tabes, most of the patients baing in the end of tha 
second and begiuning of tha third stage am^ hospitalized. It was given 
hyi'udermaticallyr beginning with one-sixtieth of a grain and gra<lually in- 
creased to Dnc-eiRhlh of a grain per diem* Its prooliNdty to cause pain 
was guarded by the simultaneous use of small doses of morphine. No 
discernible benefit tollosied ita use. It luay be used as a tonic, but speci- 
fic eftert should not bp anticipated from it 

Briefly to summari7.e the treatjuent of tabes, it may b^ said that it 
consists of: 1. The determination whether anbisyphilitic treatment shall 
ho undertaken. 2. The ntilization of electrieity, hydrotherapy, masauge, 

THE trkahsent of tabes. 261 

lid ecnrnter-ixTitation. 3. The education of the ataxio memberB, the re- 
yglitotion of purposeful movements. 4. The ftdministration of iodide 
of fOtUAinm in toDio doses, nitrate of silver^ and restoratives. 5. The 
j^ of indJTidual ajniptoms, auch as pain, criaes, dereliction of the fnnc- 
fin of the bladder, ocular palaiea, amaorosia, and trophic diHtnrbances. 
(. Tba adoption of a plan of treatment and carrying it through. This 
^jb4constni«d as psychical treatment if one so desiiee. However that 
^ be, no one who baa bad experience in treating locomotor ataxia will 
bilikel; to deny ita importance. 


the treatment op the hereditary ataxias. 

1. Hbrbditabt Spinal Ataxia. 

Hereditary Bpinal ataxia, Friedreich's disease, is a degeneration ov 
lack of development of the peripheral sensory neuron and the central 
motor neuron in their spinal course, constituting posterior and lateral 
aclerosia of the cord. It is a rare disease of childhood, very chronic in 
its course, and unamenable to every form of therapy. The three impor- 
tant etiological faotora of the disease are: the family history, the age 
when the symptoms first occur, and the relationship of acute disease. 
The name hereditary spinal ataxia is misleading, because in at least one- 
third of the cases there is no evidence whatever of immediate or remote 
heritage of the disease, and in upward of ten per cent of the cases there 
is no history of patholf^cal heritage of any kind. 

The most striking fa<;t in the etiology ia the occurrence of the disease 
in more than one member of the family, though even this is not discerni- 
ble in all cases- It is more apt to occur in large than in smaH families, 
and at times it seems to affect the male members while the females escape, 
and vke versa. Although all the members of a family are not affected, 
unless iu exceptional iustances in which the number is very small^ the 
remaining members may show some other form of degenerative nervous 
disease, and possibly nervous disease of a teratological nature. The im- 
mediate and remote family history may show the existence of some de- 
generative neurosis or psychosis, such as epilepsy, hysteria, inebriety, 
and migraine. The disease develops aa a rule between the ages of five 
and fifteen - it sometimes occurs in a recognizable form before that period, 
and the number of cases that develop after the fifteenth year ia not very 
great. It has often been noted that when the disease occurs in several 
members of the same family, it appears in the first patient within late 
childhood or early maturity, while in each succeeding patient it appears 
at a less advanced age. The factors that apparently have something to 
do with exciting the diseaae^ at least to such activity that it becomes 
recognizable, are the infectious diseases — naturally those common to child- 
hood—and injuries* The influence which these factors have may be in- 
terpreted in two ways. The acute infectious diseases may have nothing 
vhatever to do with causing the disease except so far as they weaken 



ihe neorcmu^ular syfitein and keep th& patient iu bed, duiiiig which 
tiind oomplete oo-ordumti^d mo^'umenta, such aa walking, miming', and 
climbtng, wliict the person may have but recently mastered, are pai-- 
tially forgotten. Either of these fjictora, or both coinhioed, may be 
sufficient to make aoticealile.the moat striking feature of the diseaatj 
Tie., inco-ordinatiouT which had esiated before the infectiou. On the 
othor haiul, iiifoctioua ppocesaea aud their products may act injui'^ously 
upon neui'ona robbed by h<?pitflge of their complementary development 
and eause them to degeTierate. This talter belief T hf^ld to he extremely 
improbable, A number of casta hflre beeu report<d during tho Ia,st fevr 
years in which the diseafie was iiflhered iu by febrility, What the geue- 
Bis of this fever ia has not been euggeated^ but it aeema to mc that the 
cKplauatiou of its injurionanesa is the saiue as that offeretl for tha iufec< 
tious diseases. A number of other etiological fact<irs of com parati rely 
iusignificaut imjiortaiice are tha oi-^curroacaof the disease more frequently 
in males thau Lu females, ofteuer among the poor thau auionf^ the rich, 
and the recoi'diu^ of no caae in obher races than the while. These 
facta, vith the exception of the last named, ore in entire accord with 
the teachings of ether familiary and hereditary diseases, all of which 
show themaelves more frequently in males and in people of the lower 
walks of life. The disease la ini't with in the p(Kir and mi en lightened, 
because parental consanguinity, evcesaive ft^tation^ and malnutrition are 
commoner > 

The dietiE) gnashing clinical features of Friedreich's disBaso are sts in 
number: (1) Ata^eia in all purposeful movements and station; inco-ordi- 
Dfttion due to loss of the sense of etjuilibrinm, and irregular iuvoliintaiy 
movemenla necessitated by continual attempt to luaiutalu eriuilibrium. 

(2) Loss of the tendon jerks; diminiahed myotatio irritability and mua- 
cular woakneea, which may amount to paresia of the lower eitremitiea. 

(3) Deformities of tha spine, usually scoliosis, lateral curvature, and 
some deformity of the feet, commonly pes cavua. (4) Nystagmus, static 
and dynamic. (5) Disturbance ot articulation and intonation. (6) 
Features that distinguish it from tfibes or locomotor ataxia^ absence of 
lancinating pains, intatitncae of aeusibility, normal pupillary reactions, no 
diaturbance of vieiou, and non -involvement of the urogenital sphere. 

The treatment of hereditary spinal aTaxTa crinsista m providing the 
patient with an intelligent attendant or uuise who will practise and iii- 
atnict him iu the system of purposeful gymnastics, known as Fraenkel's 
movementSi This system of eystematic exeroisea for tramin^ the ataxic 
limbb is described in tlie chapter on the treatment of tabes dorsalis. 
Theae, vfc'lth measnres taken to maintain the strength and nutrition of the 
patient, are all that can be oETei-ed in the shape <if therapy. It ia not 
probable, even if we could treat the palieol from tlie very beginning of 
the diaease, that uedioines, such aa silver, alummum, and iodide of potas- 


siiun, wLioh sometimes have a bsDeficial c^ffwt to prevent tb© rapidity of 
devulopment of certain apiual-oord degeneratiunsT fiuch as tab«Bt voald 
be of axiy service in tliia Uiaease* The apiii&l curvatuie raj^ly calls for 
direct treatment, but aome patients are more comfortable when tbejwear 
a li|jht wooden of j^laster jaekeL Parents to whom aro born odo or mort 
children who afterward manifesta dlaeaae of this kind ahouM he implrjred 
to BLircBTiHe prDcreaiiim. If ih^y do i^ol, t.he Hideavor should be Liade to 
avoid tlje fai't^js that seetu At tioiOB to act &b ejLcitiug c&uaea — ttto iufeu- 
t\<t\iti diseasea atid injaries. 

2. Herbditakv Gbki!bellui Ataxia. 

The name hereditary cerebellar ataxia ia given to ft complex of eymp- 
toma ocoiLiring k^d^^'j i^ ^^ later years of childhood and early aditil 
life, couBiating priuoipally of ata&ifi of a cerebellar oharaoter, exaggerated 
knifd jerks, hesitating, nbrupt, exploaire speeob, and mental shortconi' 
iugs. The naciie waa given to it by Marie, not only because of its oon- 
formity with the name of the diaeaae which it leBemblcB^ hereditiuy spibal 
ataxia, but because it indicated the most important symptom of the dis- 
ease as weU as its hereditary nature. The comse of the disease is a pre- 
grcssive one. 

The etiology of hereditary cerebellar ataxia is very obscure- The 
meagre atatiHtioa that are obtainable shuw that the familiary and heredi- 
tary features are much more constant than in hereditary spinal ataxia, but 
it is poBsible that furtheT ohservatioii will show that neither of these 
features is alisolutely esaential. The familiary element is often easily 
made out, while the hereditary element is much more uncoznmon. The 
diseaac firat ahows itself as a rult} at a more advanctfd stage than does 
Friedreich's disease, although cases ocourring earlier in life Lave been 
tecotdod- Males are aihicted ofU'ucr than ft'tnalea. In shoTtj the su^iial 
and sex reJatioua are similar to those of Friedreich's ataxia, and Uie same 
may be said of accidental, factors, such as the occurrence of iafectioiis dia- 
easea, blows, falls, frights, exposure, all of which have been noted more 
tbau ouce by dilTereut observers. If the disease is a pii^tal one, that is, 
one that posits for its occurrence a lacJi of connate developmeDt in the 
constituents of the cetebellumt as I believe it i^, then none of theae 
factors can have any material influence in pausing the disease, although 
they may bring into earlier pTominenoe symptoms that would otherwiae 
be delayed. 

The distinguishing features of hereditary cerebellai' ntaxia are; (1) 
uncertain, reeling, inelirious gaitj occasionally slightly apastio. The 
patient walks with the feet wide apart, body bent forward, head thrown 
backward, chin elevated, and does not watch the feet. (2) The ataxia 
ia very much less or disappears wheu tbe patient is lying down, but in' 



co-ordination ran always he ilemonstratetJ avbh when in this [j[»sition. ifl) 
Overa<:tio[i uf the rahnolic iim3i:lea wlieii speaking or in emotional clisplaj- 
(4) Hesitatiug, abrupt, explosive^ ataxic^ defective Bpeouh. (5) Easily 
€HcLtabIef often t!X^gg^rated Uat^e jerka; ouofiaiottal auble clonus, [d] 
Slight irregular twit(^hingy of the eyelisllfl, hut no true Dyataginus. De- 
fldenry of aotkm of the eitterual recti. (7) Mental impairmeat, var^'iug 
from slight stupidity to completer demeiLtia. 

Tha treatment of the disease does not diHer from that of horeditarj 
gpinal atajcia^ although tha patient lequiies mu<^h greater atteottoa ou 
acoonut of the greater diffieulty ia locomotion and co-erdination. The 
greatest rara should be uaed in difTereutiating tlie diseaj^a frum dissemi- 
nated insular stleiosis because the prci^oais regarding life is much Ws 
serioue in the latter disease. 

3- HuReniTART Ataeici Paraplboia. 

Hereditary atajtin paraplegia ia a priinary degeneration or lack of 
deTolopment of the lateral columns of the cord which oc-curs in children 
BOOH before or about the time of puberty, and is characterized by ataxia, 
principally of the lower eEtremities^ but also of the upper ^ paraplegia 
of a more or less ^pn.stifi nature, and some cotaneoua aniestbesia. In 
sfjme i^jjaes tlie disease seems to be of audilen development, hut this may 
be mor« apparent than real. It likewise ocoadionallj seems to follow in 
the wake of the infectious diseases, but That has been said concerning 
the relationship of infectious diseases to the other hereditary degenerative 
disorders of the spinal cord should be borne in mind. The principal 
eyuiptf^ms are: 1, Weakness of the lags assoi'iaied with ataxia. 2, Ex- 
aggeration of the tendon jerks of the lowHr extremities. i1, Rxtensit^n of 
the big toe on plantar irritation (Itabinski phenomenon). 4. Integrity 
of the urogenital sphere. B. Mental intactncf^s. The disease often pur- 
Aues & more or less progressive and rapid ociLrse, and terminates fatally in 
from two to four years, Oocaeionally the course of the disease ia ex- 
tremely slew. 

The treatment of this disease ia not unldie that of the other hereditary 
diseasefl of the apiral cord. The moat iceiatent measuies ace directed to 
the care of the bladder, bowels, and ektii. The general nutrition of the 
patient must he maintained, and h\s or ber comfort eotitribitted to by the 
use of orthop:edic and supporting apparatus. Aside from this, the treat- 
ment IS entirely symptomatic. 



Sybingohyelja ia a diseaae of the fipinal cord and oblongata, charac- 
terized clinically by an asBOciation of motor, sensory, and sympathetic 
symptoma, closely simulating tabes plus progrcBsivc muscular atrophy, 
and anatomically dependent upon cavity or fissure formation predomi- 
nantly of the gray matter. The cavity or fissure of the cord may be 
single or multiple* It varies in diameter from a mere slit to an opening 
sufficiently large to admit the end of the little finger. Longitudinally 
it may extend throughout the greater part of the spinal cord, but it 
is more often confined to one or a few segmenta. The hole or slit or 
fijsure or whatever it may be doea not preserve the same shape through- 
out its entire couree, nor does it occupy relatively the same position in 
different segments. Xhe cervical cord is most (^nunonly the seat of cavity 
formation, and after this the upper cervical region with the lower third of 
the oblongata. The lumbar segments are the next most common seat while 
the dorsal segments are rarely involved — that ia, hy a cavity that con- 
fines itself to these segments, it being borne in mind that it is not at all 
uncommon to find holes in the dorsal cord in connection with cervical 
or lumbar cavities- When the syringomyelia is of the cervical segments, 
the gray matter is usually rather uniformly encroached upon, while when 
the cavity formation is of the lower dorsal and lumbar region, the pos- 
terior horns and posterior columns are oftener involved and there is rela- 
tively leas encroachment upon the anterior gray matter. A very curious 
fact is that the anterior comua never seem to he exclusively affected, dot 
are the anterolateral columns, although the corresponding parts of the 
posterior half of the spinal cord are frequently exclusively affected. The 
area of special predilection of cavity formation in the oblongata is the 
ascending root of the trigeminal nerve and the vago-glossopharyngeal- 
hypoglossal nucleus. 

Syringomyelia ia by no means a pathol<^icaI entity. The cavity may 
be a congenital condition existing in the shape of an enlarged central 
canal. In some such instances the possessor goes through life without 
any apparent evidences of its existence. Such a condition nmst. how- 
ever, be a locus of diminished resistance wherein inflammatory or degen- 
erative changes may begin. The hole in the oord constituting syringo- 
myelia may be due to a gliomatosis resulting in the formation of a 



vhioK has predomii^autlj longitudinaJ extent, or it m&y be caused 

m pii>liiera^on o£ glia tissue and consequent deatructicm of the 

lynni, that is, tte condition known as gliosiBn It would seem 

iba definitely proven tbat cavity formation raaj be the reault of hem- 

crdi^ into the fiubstance of th^ cord, wbi(^h, acting by cleavage in the 

dwtion of least resistance, cauaes the formation of an empty space after 

liitcvaguliim haa been partially or oompletely absorbed. Syringomyelia 

bibwn found associated with chronic pachy- and leptomeniugitia, with 

okmic myelitia, especially with the form known clinically as lateral 

atUroaiSf and with other organic diaeaaee* Just what relationship theee 

lorbid conditiooa have to the syriagoxayelia has not been determined. 

Oruuiaally it ha^ bt^en found coeiistent with hydrucephaLuSf utrophy 

of tht brain, cerebrum and cerebellunij and with congenital conditions, 

aachu 5pina bifida* 

Very little ia known of the etiology of the disease* Although of recent 
L, its occurrence is by no meaoa very uncocDmon. Men are 
^kJK'tcd more often th^n women. A nenropatbic history is the mie, and 
the disease has been eni^ountered in several members of tbe same family. 
Is u ftssociated sometimes with such functional ncrroas diseases aa ex- 
OftlthalDuc ^itre, hysteria, chorea, neurasthenia, and Kaynaud^a diaeaae, 
bdSit la highly probable that these conditiooa are merely eKpreasions of 
M ncroaiotuneiit by tbe cavity formation upon the sympathetic nervous 
tfStfta represttitaliim in the spinal cord. The nioHt important attributed 
eiciujtg factors aro trauma and tbe infectious diseases. Just how these 
irt,esceptto favor the occurrence of gliosis or gliomatoaia and hemor- 
liu^into the aubstanoe of the cord, it is impoBsibte to scy. Some au- 
Ibn have laid particular stress upon dystocia as an exciting cause. But 
Ttsnit be Bxtreinely uncommon, and when it baa any inSueuce it is through 
pnjdnciug rupture of intramedullary blood-veaseb. The infectious dls- 
cHttt euch as typhoid fever, pneumonia, and malaria, may likewise act 
tt produce degenerative changes in the blood -vesae la, which predispose 
to intramedullary hemorrhage and thus to cavity formation^ Syphilis 
p^i DO r6le in the etiology of tbe disease, although syringomyelia occa- 
■oQally occurs ia syphilitic patients. The endeavor has been made by 
Wat physicians to establish tbe nosological identity of eyiingomyelia and 
iaEitb&tio leprosyi but f&ry little suc^iess has attended such efforta- 

SyBptosu. — The typical symptom complex of syringomyelia is pro- 
pwfive atrophy of individnal mugclea or groups of muscles, associated 
with & widespread partial sensory paralysis, manifesting itself as anal- 
{oift and thennoan^esthesia, wtbb fully preserved tactile aensibLlity, and 
iili trophic manifestations especially of the akin and of the bones, 
Hti uit of the atrophy vill depend natorally upon the location of the 
ni¥ity In the cord. Usually it is of the upper extremities and face. If 
tbe cavity is id the lumbar region, the atn^phy will Ije of the lower ex- 



tremit}^. The muBcular atrophy \s depeudect upon a destructtoti of the 
ganglion cells of the jit^ri^hera.! motor neurone. When the cells constitut- 
ing th(j common origin of the vagus, glossopharyug^al, &r>i] hypoglofiBaJ 
nerves in the oblongata are eocToachei upon, there will be muHcular 
atrophy end other diaorder iudicatiTc of the partial or cotnpkte deetruo- 
tion cf these cells. The motoi- and sensory Loanifeat^tions of the disease 
may be entirely or predominantly unilateral, or they may be bilftteral. 
The dis^otdatioii of sensibility — that is, the ocourreTice of IheriDoaii^titlie- 
aia »iud analgesia with preAcrvation of tactile seDaibiIit;> and of the mua* 
cukr neaae — although not absolutely pathognomonic, aa it may occur Trith 
tabes, h.i.'matomyelia} Pottos disease of the oerviual region, hyEiteria, and 
divers forms of multiple neuritis, is by far the most unvarying symptom. 
If the lateral cohimiiB of tlit* cont are enc'roaphfd upon by the eavi^ for- 
matioQ, tliei'fi will be rigidity and piresis of the extremities corres [ion ding 
to the location of the cavities. The state of the deep refle^tes will also 
depend upon whether or not this port of the cord ia involved. If the 
group of oeik from which spring the neura^ous supplying the muaoles of 
the front of tbe thigh are encroached upon, the knee jerka will be absent. 
On the other hand^ if they are iiot^ aud the lateral columns are affected, 
the knee jeika wilt be increased. In the atrophied muscles, the electric 
contractility is diminished in proportion to the degree of atrophy, but 
true reaction of degeneration is eKccptional, Oculopupillary manifeeta- 
tiona, consisting of retraetiou of the eyeballs and narrowing of the pal- 
pebral fissure and inequality of the pupils (Schultze eye of German 
wi'iiei's), are very common and usually unilateral. 

The ti^ophic symptoms vary euormoualy in different cases. They con- 
sist of softness and pultaoiousnees oF the skin, of such eruptions aa ery- 
thema, eczema, and pemphigus; and of ulcerations, gangrene, and altera- 
tion in the nutrition of the uaiU. The cellular tdssue may he the seal of 
phlegmon, abscess, and lacerations. Tbe joints are sometimes the seats 
of iniiolent arthropathies, especially the shoulder, similar to those of tabe.H, 
and the spinal column ta usually the seat of scoliosis or liyphoscolioais. 
The uioie common vaaoraotop and secretory symptoms are dermographism, 
cedeaa, cyano:iis, and increase in the sGoretion of tbe salivary and lacry- 
mal glands. The sphinj^tpi-a and Reiiial functions rpmain iutai't. 

A symptom coujplex, known as Morvau^s diseaset is identical with 
syringomyelia. It consista of muscular atrophy and weakness of the 
upper extrendties developing simultaneously with analgesia or antestho- 
eia, extending over the arms, and associated with the occurrence of pana- 
ritium on the lingers whicli leads to de^p-saated ulceration and often to 
crumfating of the terminal phalanges. 

The fact that au^eathetic leprosy ^ometim^s produces asyndrome very 
eimilar to that of syringomyelia hEhs already l>ecn mentioned. 

Treatment, — Tbe treatment of syringomyelia consists essentially in 



g the symptomB. Ho treatment has yet been dificoveted that haa 
n^ mf uence to stay of modify the course of tbe disease. The general 
BWAgemeni of a patifiut; witJi syringomyelta Ls ih« name ah that dea<^rib«d 
ender chronic myelitis. It c-ousUls ii\ the adoption of measuita tending 
t) » fortiff vitality that the progress of the disease aad ite com plications 
rilll<e delayed^ For this purpose nse must be made of the ordinaij 
looicSr such aa iron, ftrseoic, and quiuine^ and of hydrotherapy and cnafi- 
flgt. Judging from the pubnahed reports, nothing is to be gained by 
diB use of medicines directed immediately toward modifying the nutrition 
of ite cord, such a3 iodide of potassium, nitrate of silver, and chloride 
ol gold, which many believe a-'e of service in tabes. Certain it ia that 
ao fattn of counter' i^tation, either qv&t the npinal column or to the skin 
of the extremities, should be used. The application of electi-ieilj may 
biTo K>me slight e^ect in delaying the rapidity of the njueoular atrophy- 
Tiit tiophic luanifedtatjons should be treated according to the rules of 
Bodera aurgery. Absceases should be opened early, ulcers treated anti- 
iqiticallyp and the parta protected from all Lnjurioiia agenoies. Arthrop- 
Vbcs require puncture, arthrotomy, resection of the joints, etc., depend- 
a^ upon the nature, degree and rapidity cf the procesB. Deformities of 
llie spine should be counteracted, if they give rise to symptoms, by the ap* 
T^JcatioD of an orthopeedic corsebn The fikin should L>e kept scmpuJously 
IJCAS. and when symptoms of bulbar involvement are present eare should 
tnUken in feeding the pntieat. Rigidity and contractures are oftentimes 
ludftmore bearable by prolonged warm baths, but anything approaching 
uceration of the skin is to be avoided. As syphilis and leprosy have 
iDpirt in the etiology of the diseaae, trecitmeut directed toward antago- 
siiing either of these as supposed causea should be avoidad. Patients 
iSirted with ayriDgcmyelia usually auccumb to some iafectious prooeas, 
oh&QStionB following the occurrence of trophic changes and from hypo- 
ntie pneumonia secondary to the entrance of foreign bodies iuto the 
lin|s through swallaM'ing, Effort should ba made to avert these ac 





1 mjelitis has been aad lb applied hoth clmicftlly Bud patho- 
iogioally with iimnh latitude. It H used to iodioate the chiLDg«i in the 
cord the tSHult of FKute iDflammBtiour di&oaae of the ^&lla and pEirtial or 
complete obliteration of the lumen of the veBsels (myelomalacia), presenf c 
upon the Bubetance of the cord the result of accident, diseo^ei or now 
growth of the BurrouTiding tiaauef and the vascular and parenchyjnatoua 
chADgeti developing from ItiSBtaed e^tnioaphe Ho pressure (cai«soD disease). 

The deaigLiation acute myelitis should be roHtrioted to indicate an acute 
exudative and deatructive iuBammatiou of the spinal cord inrolviui: the 
white and gray uiattet, of variat>te extent in veruoal or tranaverae direc- 
tion, and DOcurring at any levels Aa a rule, the inflammation is of the 
dorsal or upper lumbar segment, aod the focus of the morbid process is 
mure enteuaire in a trartaTC^rrie dir&ubion, Thus th<? disease is often 
a]>okeD of as acute tranaveise myelitia. The pathological producte vary 
with the intlammatorj excitant and with the intenait^ of the mfection. 
The trend of modem a oienti tic thought is to associate the occurrence uf 
indamLnatioD with Honii> bacterial cauae, hut there U uothing approaching 
unanimity aa to vhat coikstitntes the easentials of indanimation or inflam- 
matory teactioo. It ia quite imponsible to diatioguiBh clinically the mye- 
litis which is the result of a pathogenic arganiamf aurh aa that of influenza 
or tfphoid fever, from the myclitia or myelomalacia that acoompanieB 
eyphihtic degeueratiOD aiid thrombua of some of the spinal blood-Teasels. 
Neither is it always possible to distinguish them anatomically, even after 
the casea come bo autopsy, for the ejLudative and deatrnotive (changes that 
go on around axxch a focua or a number of foci are practically identical 
with those of primary inflammation. Indeed, the reactionary changes 
around such foci may be so great that they mors or less obecure them and 
preveut their ovular demoiif^tration. The pathological prodoot of acute 
myelitis is seldom pus, except in those rare instances in which the inyeliti 
is due to pyogenic orgauiams, id which case it may he circumscribed 
constitute a more or lesa diffuse abscess of the spinal cord. I'umlen^ m 
myelitis is almoat invariably aseociatad with and secondary to pumlcn^^m 
leptomeningitis. || 

In apeaking of the oauaes and treatment of aeute myelitis 1 shal] "*^ ^ 
attempt to differentiate the myeloinakiia duo to slowly progressive 



«i» of th« apinaJ blood-vessels, although keenly appreciative of the oc- 
fOrruit^ ot th'iA condition. Ind&ed it fomjs the aiia.tomical basin of a 
ovtun pcrcectag^ of caaea of myoUtia. Coiupreuion myelitia, howorer, 
■ill be ^T«a coueideration in & sepej&t€ chapter. 

Aeule myelitis may be olassifiod rrffiovaliy with rcBpeot to ita Location 
n the cervical, dorsal, or lumbar regions ; topographically according to 
mjoreitensioD as transverse ani] longitudmal ; cff'j^or/u'o^y as traumatic, 
bbctknia, toxic, and refrigerant; and clh\iG(Llly as acute and cLrouic- 
Wltti the inflammation of the cord is accompanied by or Ie secondary to 
jiJiffliDatioa of the meninges, it is known as meningoiuye litis. 

Tl]« £tiolog7 of iLottte HyelitU^ — The canseB of acute myelitis are 

^liu ilt« aame as those of other anute parenchymatons inflammations, 

Xinir^yt certain inHueuces are more harmful to the spinal cord than 

tbey aie bo oth«r tissues. Any depreciation of the ctrculatiou and nutri- 

QOfiof the cord, or, in other words, any diminution of its reeistivit^ 

EQi; act as a powerful predisposing cauee to mioroblc invasion^ In 

iLii <ray is to be explained the action of cold, fatigua, especially of the 

iegi, such as Is iudui-«d by proloiigsd or violent muscular elTurtT sexual 

ocm, and trauma iasufQcienb to cause solutioa of contiuaityH Those 

EicEora are usually considered ercitiag causes of acute myelitis and very 

frft^DMitly some one of them is the sale detectable cause. Of these at- 

cributfti causes exposure to cold is by far the commonest and most per* 

uciooj- Tt ia possible that of itself it is sufficient to excite inflammation 

ID tbe cord, as this has been done artificially in the lower animals by 

Betas of an ether spray. Infection ia more liable to occur in early 

Atfolt life than at any other age. Despite the fact that acute myelitis 

oflea develops in the wake of infectious diseaaea, children are rarely 

effected. There is no preferential liability with respect to hpx other 

than that engendered by the occupation of mates, predisposing by ei- 

poaure, fatigue, the action of poisons, and the liability to injury, and by 

pT^gnancy Eujd the puerperal period in the female. The Lnsiguificaut 

Poasoaal relationship of the disease^ viz., its more common ooourrence in 

iwinisr and spring, is clearly related to exposure and cold. 

The infections that are most f reiiiLeii lly followed byacutf myelktia are 

txxberculosiq, syphilis* pneumonia, typhoM fever, erysipelas, diphtheria, 

K^uonj^, puerperal fever, malaria^ gonortbtsa, scarlatina, and variolEL Of 

t-liEBP the infections of pneumonia and influenza are by far the most per- 

nidottfi. How thesejnfectious agencies actio produce myelitis ia not clearly 

nsderanK^d- Of course, their direct presence in the spinal cord would be 

oartsin to set up inflammation. But it is much more probable that they 

produce poisousof the nature of toxins which aingle out the spinal cord for 

thoir pernicious activity^ In this way is to be explained the occurrence 

of myelitis some time after the infectious disease with which it stands ia 

Giusd relationship haa ceased to exist. Whether or not the immediate 




pathologiOftl precedeut of eut^h infectioxis toy^Iitia ia a miituie embolus or 
thrombus, has not bee^ detiait^ly dH?iied, bvt il would aeem that in 
somt! ousBB, Ht Teftstt this coQstpitutea the tirat p&thogemc step. Acute 
iay«Htifi haa b««ii produced experLmenti&l)^ in jUJituals by tha injectiGQ <(f 
cultures of erjaipelos bacilli, coLoo bacilli. sUpb^IococcJ, poeua^oeoccij 
tetauus bacilli, Locfflor^s UuHlli, Ebevth's bacilli, etc Of the infcctioci, 
tuberculosis is probably tbe most oomDQOii, It is usually but uot in- 
v&rmbl}r associated with i□^'^lTeIn0pt of ths meningea. Id h L^ase studied 
recently I was able to deuiockatrate the presence ot the tubercle bacillus 
iu tbe myelitic area. Sjpliilia is the next most important i^ause of 
myelitiB, Many writai^s would have ua believe tbnt it is tbe most im- 
portant cause. It depends entirely upon the interpretation which is put 
upon the morbid process excited by ayphilia, whether or not we agree to 
this. It has been c^nchisively proven that Hyphllis lb capable of exciting 
iufiamniatioD of the cord, which conforms to all tbe requirementA of tr&o 
infiaiumatioD. Despite this, the pathogenLo evolution of syphilitic aye- 
litie in the majority of caaea is a secondary inflammatory reaction, fol- 
lowing a softening due to tbe focal syphilitic dises-se of one or more blood- 
vessel s. 

The poisons that st&nd in causal relationship to tbe oi^cutreuce of acuta 
myelitis are of emlogeuous aud exogenous origin. Tbe latter are least im- 
portJULt, although lead| arsenit.', mereiuy, phosphorus, and carbon dioxide 
ore occasional attributable aauees. The ri^le played by alcohol in the cau- 
sation of acute myelitis in nut a very prominent one. It acts inr)ireet1y 
by leading to expobure and injury, rather than by its inherent pemi- 
cioLiBiiese on the cord. Toxic agoDcies aiising within the body have a more 
malign influence. The moat important of theea are due to diabetes^ une- 
miaj gout, and rheumatism. Aeute myelitis Bometimes ooours with disease 
of the nrtnai^ organs, soch as cystitis and pyelitis. An attempt has been 
made to eipUin euch occurrences by saying that it was an extension of 
inSammation or of the infiammatory excitants directly from the tissues pri- 
marily diaeaaed to the cord, but this is wholly unlikely, and the myelitit 
is probably due to injurioua agenciea circulating in the blood and having 
their origin from these diseases. The occurrence of myelitis with exfolia- 
tive dermatitis aud aftt^r burns that have denuded a considerable surface 
of the body is explained in two waya : Firsti that these lesions allow the 
development of poisonous aubataui-ea which are absorbed into tbe system ; 
and, SBCondi that they act upon the sympathetic system to produce vaso' 
motor derangements in the cord which go on to inflammation similar to 
tliose resulting from cold- 
Trauma is rehitively an uncommon cause of myelitis^ except in those 
Instances in which the trauma is sufficient to produce physical disintegra- 
tion of the substance of tbe cord, ae from fracture and dialoeation of a 
vertebra. Slighter trauma may open the supfaue to Uie invasion of bac- 



OiT it may oauae marked depr«ciauoa of the circuUiiou and nuti-itic^n 
ccrd< W« m^j consider under tbe heading of trauma tte lessened 
ipherio praBsore which 10 the imoiediate caiuic of the laceratioa and 
matioTi of the t^ord foiinil ii^ oil fatal rasP4 of r?atRsoii disease. This 
occurs in divers aud bridge biilldcrb wlien the> n^turii frutii the 
4f«t'> apparatus to tbe outer air. The occurreace of the accident ia pre- 
JBpoefld to by everything that depreciates vitality asd degenerates blood- 
VMmU' It oocurs more iiommoulj in those who are imaocuaiomed to soch 
vork and particularly in alcohoLie Bud obese persoos. The profound ischfP- 
»k vhich results in the cx>rd ajul [irjsBtUy also tbe occurrence of gas bub- 
HftS whkh have been demoust^alod by several observers to eiist in the 
Ufiod, iie the immediate antecedents of the laceration, disintegration, and 
infliiiuDatioQ of the ccird. 

XjAlilia ifi met with in a number of blood diseasesi such aa pto- 

foQBil vuemia and leukiemia, oceiirring primarily or seeondarily to ma- 

bpial diaeaae, such aa carcinoma, and to BOine chronic dieseaae, such as 

MpluitiA. Here, again, it muat be said that tbe leaiona forming the 

T^y™*"^ basja of Buch fr>rm8 of myelitis ate not trud inl^ammatory 

coo. Their patbog«neaifl consists in the occurrence of minute thrombi 

<a «iQbc»li, with rebutting myelomalacia, vhich cannot be diatiugEiiahed 

(hkl Kote myelitis. Tbe acute myelitis that occuta in animals when Ibe 

Uood npply is shut o^ by preasure upon or ligation of the aorta, and in 

OM iritL aneuriam and partial oooluBion of the abdominal aorta, is path- 

rio^U^a trae ancemie necrosia, with subsequent BLirrotinding reaction- 

trj m^elitis- 

Njelitia may be secondary to an inflammatiun of the anrronnding 
MnfltaR»~the jneoingea and the vertebrae — although tbta la not an im- 
poitaiitCftaBatioii. There 13 aome evidence tending to show that it may 
b» noDodary to an ascending peripheral neuritia, particuJarly from the 
DHvn of the trunk. Such a case has never come under my own observa- 

S^ptoma. — The gymptomaof acute myelitia vary with the location and 
rit^r.tC'f tb*! Lesion, The introductory aymptoms^ which arc independent 
ul rht i<3CatiDn of tbe milummatory foci^ may come on with great abrupt- 
DEK. ronitttutrng thi^ apoplectic variety, or ta a few daya^ constituting the 
acuu TAricty, or in a few weeks and often fiomewbat intermittently, con- 
ititau^g die subacute variety. Usually the first aeueory and motor irri- 
tttiTcsTmptomsarefollowedby moreor les a complete paraplegia. When 
ttekfliodisof the daraal cord, ita commonest location, the symptoms 
ovinaf paraplegia, pain in the back radiatmg into the trunk and Icge^ 
ud more or teas anesthesia, paral^sia of the bladder and eventually of 
tbeiMunii eiaggeratioTi of the knes jerks and later spasmodic twitch- 
lagi ud contractions of the leg; vasomotor and trophic disturbanceSi 
^'^'UifltiDg gf bedsores, slight cndcma of the legs, coldnesa of the extremi- 



ties, Bud occasionally the formatioii of buUse. The miuclea do &ot 
atrophy, and there la uo readnon of de^DGration. When the inflamiEja- 
tory foci are in the luiubar Tegiou, the paraplegia that occurs is of the 
Haccid Tarietj, and there is atrophy of the muscles with reaction of de- 
goijcratiou. The skin refieKes ore weak, and the tendoa reficEoa ate 
iisually lost. There is a variable amonnt of anfesthesia in the paralyzed 
parts, aad the rectal arid vesical inaofflciercy is profound. When tJie 
myelitis ia of the carvical cord, the general BymptomB are more profoond 
aud there is in addibiou to the symptoms iudicatire of dorsal myelitis 
motor paralysis of the arms or of individual miiaclo g;roupa, usually of a 
spaetiu eharacter. Therd may likewise be oculopupillary symptoms, 
disturbance of respiration, and brady<7ardia. If the leaioa is adjacent to 
the oblongata, the bulbar aympioms will lie raore pronouDtied. 

The course of the disease is naturally a progreasire one for a short 
time, and then it becomes mort! or less stationary vith resulting sefond- 
ary degeneration, ascending in the sensory tracts and descendmg in the 
motor tracts, the latCe? predominating. The disease eventually causea 
death by eTLhauetion and by infection from the urinary organs and bed- 
Treatment. — Considering the almost invariable ontcome of acute mye- 
litis, the treatment of the disease is thankless and dispiriting. Never- 
theless muoh can be accomplished by appropriate treatment to limit its 
extent, to alleviate Buffering and misery, and to avoid in a measure some 
of the distressing seoondary oc^iirreueer^. Tlie possiljility of an abortive 
treatment of acute inftammation of any organ ia problematical, but it is 
certain that there is none for sji acute iuSammation of the spinal card. 
Yet something can be acaomplished in the direction of lessening the in- 
tensity of the inflammation and shaping its course toward partial restitu- 
tion. The appropriate treatment naturally varies with the cause of the 
diseasRi although all varieties of ncute myelitis call therapeutically for 
two things; first, ahs'Afite rest; and second, ahsvlutt clearifineM. It 
may legitimately be said that just in proportion as thcae two require- 
ments are obtained so will be the partial recovery of the patient and the 
duration of life. The patients should be pot to bed and Irept there^ and 
they should not be allowed to more under any circumstajices, Tlie 
change of position which is advisable* eitht^r to keep the parts on which 
pi-essure ia most sctctc from beouming the seat of bedsores or to influ- 
ence the circulation in the cord, should bo done by an attendant. It ia 
advisable, if the condition of tlie patient allows it^ to have htm lie on the 
belly or side for n part of the time. The greatest care should be ex- 
pended in the selection of a mattress and in tlte arrangement of the cover- 
ings and clothing of the patient^ ^'^ that irregular prc^miro i>n the surface 
of the body is avoided. Whenever it ia at ail possible, the patient should 
atoncebeput upon a water bed- Unfortunately, the physician sometimes 


iVHia the occurrence of tro^jliio fijmptoms before mrtisting upcn this, 

Koch troable &Bd Hu£FeriDg can be avuided by ojderiijg it at Lhe begiu- 

Dog. The most sorupuloiL^ cle&iUiceBS muat be insiated upon. Warm 

Titer and ai>ap should be used at least twice daily, followed by rabbiog 

ol tiiQ akin with tLlcohol &nd by dusting of the most bland aatiRsptlc 

n*rj^. The GonditioD of the liladder and bovela ehould ba made &n oh- 

JKi of special attention from the sUiit If they are neglected, Bymptoma 

in Buro to develop which poiut to mfection, iutoxicatioo^ and depreoia- 

iok of vibJitj, and which will oerioiiBly jeopardise the patient's life. 

When it U imposaiblo to i?:ithet«c-iz« tbe patient regularly^ malea should 

IflfTorided with a uriuul m-i adapted that every drop of nrine passes into 

ft, vbile femalea should have abaorbent cotton suirt^uiided by gauze or 

ukuiD Eo arraaged that it cati^hes evf ry drop, and thia sTiould le renewed 

aicn tno houra at least for the tirst few daya, and after each renewal the 

piju thofoughly cleaned- The bowels should be moved regularly by the 

mni wmple enemas- If thpre is inpontinenfe of fa^ws, efforts to necure 

ud maiDtaia eleanline^a must be doubled- 

If the myelitic 13 poat-infectioua, the treatruent required, in addition 
totj^at raentioned abovOi oonsiste in the admiuifltratioD of medicines that 
pTfliLpt Lhe emunctorii^a to activity, bo that tbe eliniinatiou of the poiaon 
from the ^stem may be facilitated. It is advisable to give an intestinal 
Instive and ajitiseptic, such aa a dose of calomel followed by a saline, 
uri a few brisk doses of some bland diuretic and diaphoretiCr particularly 
if tbopatieat ia a robust, full-blooded iodividoal, and tofollow thiaby tbe 
>uiuiaL£trat]OD of small doses of aalicyiatce and quinine, both of which, 
'ortujiately^ tend to alleviate the pain. If the case is seen at the begin- 
nings it is very advisable to put aa ice-bag over that portion of the epitie 
At which the lesiou is situated wheupver an opportunity is offered by the 
POvitiiOn of the patient. Ail forms of stimulant and irritant applicationB 
^ the spine should be rigorously avoided during the acute stage of the 
dijcttpe* The skin is subject to profound depreciation of nutrition and it 
doM not tolerate anch irritatioD. The insignificant benefit to be derived 
£ron such applications is enormously dis]'ropoi-tioiiat6 to the ebauces that 
Are taken of causing or hastening decubitus. Of the cliiiga that have been 
vmmmended for their specific action upon the inflammatoty process, two 
cnl; need be mentioned — ergot and belladonna, and these to be adviaed 
afiinft The use of ergot haa been oommon for many yearg, but experi- 
«iK«d physicians are gradually losing faith in it. 1 have never seen any- 
tliog approximating beueSt result from its use- The same may be said 
^bellwionnaf although the latter may exercise a stimulating ciTcct on tbe 
Uidder and bo of some benefit. Pain should be relieved by the admiuis' 
*nnM of phenacetin, combined with one of tl^e salicylalea, and by mor- 
phine, iFhinh should not, however^ be given hytiodermatically, Invnlun- 
tuT tnitchings of tbe lower extremities sre i^ent controlled by the latter 




drug, but when they are not very aevere th&y *^aa be mitigated by ih9 
casional admutistratioii of a do^e of ond of the bromides, TW f&ct tliAl 
this latter drug is a v&aomotor depressaiil, however^ sbould not be loat 
sight of. 

^Vhen the myelitia U due to syphiliD^ or to vasculftr diacaBCfi, tmcb ^ 
uixmia and leukLcmio, in brief, vhen there are grouodfi for the be- 
lief that the jnyelitie ia in reality a uiyelomalacia^ with aecondary inflam- 
matorj reactioD, the tTeatment is somewhat different. In such caaea the 
admiuiBtTAtiou of eliiuiiiativest the appliciitioL of cold, and the ^vinif of 
drugB that haro any Jowetiiig influt^nfe upon tho circulation are contn- 
indicated. We o[m judge of the existv&i^e of these conditious only from 
the history of the patient &ud the ae^ompanjing manifestations^ Such 
patients require supporting, Mtiuiulatiug, and alterative trejitmetil from 
the beginning. It does not seem that active antiHyphilitii^ trealnient ie 
of signal aervice in snch cases, even though there be a distinct aytihilitic 
history- Of course, such treatment is iudie^ted, but it must not be vai- 
ti^ out in the beginning to the eKctusion of treatmonc looking toward 
the Testitiktion of the blood- v^^Si^n Is that are the seat cf degenerative and 
exudative changes. The general treatment is the aaine a» given above, 
but should include in addition small doeeaof cardiac stimolantB, such as 
Btrophitntbus and digitaliSf oombined with moderately increasing doses of 
iodide of potassiuni. If the myelitis ia sei*ondary to bluod diseaaes, tbe 
treatment is the adoption of meaaures looking to the cure of the condition 
to whirh this [pyelitis ta si^couduryT Htul tlie adminiBtrAtion of substancea 
that su^iport the patient's vitality- The same may be siud of myelitis 
ooeurring secondary to autointoxications. They are to be comliateil 
directly quite apart from the superadded ocenrrence of myelitis^ but the 
latter is to be treated as wetL H is unnecessary Ijienitmprate the apeeial 
indicAtiona of causal therapy in eaoh one of tliese oonditions- 

In alL cas(<s care should be taken to brace the patient to withstand the 
onslaught upon bis vitality and to maintain na far as invasible the integrity 
of the peripheral circulation* The firat is to be encompassed by careful 
admin i strati on of nutritious, easily digested food, given frequently aod in 
small quantities, and if neiessary liy the administratiou of alcoholic stiiuv' 
lants in small quantities' The aeccind can be accomplished in part by tbe 
applicationof dry heatto the lower extremities, by frequent and prolonged 
immersions of the extremities or tlie entire body in warm -wator, after 
which they are wrapped in cotton wool, and by the use of mild massage. 
It must again lie mentioned that the vitality of the akin ia such that it 
will resent rough handling of any kind, and care must be tskea in the 
application of hot-water bottles and in tlie use of manual frictiou. 

Electricity liae been recommended for its attnhuted efbcacy in miti- 
gating certain symptoms, such as inrentinence of urine, for prevecting 
muscular atrophy, aad for its direct effect upoD the spinal cord, Ii may 



F^aited poaitirelj that it ahoNld uever be uaed witJi my such end in 
linr u specific actioa od Uie cord. In some rasea it would S(?«tit lh;ib a 
tit|e electrode co&nertcd with the poBitira pole aud plficed above tiie 
|ilM o^it the bUddi^T a^d tli^ negative on aooie iDdifferent point, wLile 
ifDFMDt of from two to tlir^e milliamperes is allowed to flow, is of some 
prte After tbe acut« stage baa Biibsided, eitliet the faradic or tlie 
carreot maj be used to stimulate muacular coDtractioQ and eg- 
] J to prerctiC inactiTity muacidar atrophy. As a nile, it may be 
ylthtt it is muob safer nob to use electricity during the acute stiige. 

Id KVne faaes, even in those in whioh the greatest care has been ei- 

miStd in [parrying out the esnential requirements in the treatment of 

cnj caaa of myelitis, viz. , rest^ clsanllneaaT f rer^oent change of posilioi^, 

aliolitdT »mootli surface to lie apoa^ tonifylng measures, etc., untoward 

jjmploms 3uQb aa (^yetitia, pyelitis, bedsores, acd other trophio pbe- 

MBieaAO(N*nr which require particular aud careful treaCmeat. Such treat- 

BCDI, however, is not at variani^e with the treatment applicatile to simi- 

krccnditJODB developing under other oiicumstancea. CystitiB occurriug 

TiCL myelitis requires for its successful treatmeut a coreful study cf the 

srce ud the administration of substances that make it as blaud and 

imiintatiiig as possible, and the local or intraveatcal application of sub- 

lOM* that corabat the inflammation. Frequent and thoroiigh irri- 

fitna with plain warm water* or, better still, with some simple alkali 

ud uUdseptic solution, such as a five-per-ceut solution of boracic acid, 

A tv»-per^Tent solution of ealicylic acid, or e^tremety weak soJutioa 

4nt3it0 of silver (1:1, OOQ) should be used two or three times daily. 

Vwed irrigations with carbolic-acid solution and sublimate solution have 

tam TKammend&l, but their virtues are not sufficient to i^^Linttirbalanca 

IkiJiBcouifort and danger attending their use. Pyelitis la to be treated 

mofdiDgto general principles of rest, admiuistration of l&rge quantities 

of Titer, &nd small doses of salol, with tbe same attention to tbe diet as in- 

hfiOad ia the ordinary ease of pytUtia. Bedsores are to be treated the 

oae u acute ulcers occurring in a debilitated aiibjeot with antiseptio 

nidtioDs and clressings. Tbe danger of attempting to ubimulate them to 

hmlthj reactiou is great. When they cannot bo controlled in this way, 

thspitient must be put for a time iu a permanent warm-water ba;h. 

After the acute stage of the disease baa paaseil comas the tiuie for the 
adoption of ineasures looking to the absorption of the inBanunatory re- 
isains lad the mitigation of the rajnsequt-niiea of the injury. The nutii- 
lidD d the patient should be carefully studied. It is not only necessary 
tDadaicister appropriate food, but to get tbe patieut in the fresh air by 
neou of in invalid roller chair if uuable to walk, to adminieter measures 
Ihatcootribute to aleep^ overcome eoustipation, and to maintain ncitntion 
<if UieiDDSclflfl and the integrity of the peripheral circulation by massage, 
pwiiTe sieiciae, and aa muob active exercise as it is pooaible for the pa- 



tdent to tmke. It is at SQch timOB and later tphat regular cures ebould be 
ondeitakeii, either at home or abroad, at thermal aprmgs and health re- 
soTtSr Buch as the Hot Spring* of Arkansas and Virginia, Glenwood 
Springs of Ooloradc^ Richfield Springs of Kew York, Lamalon of Franoe, 
Kanheim and Oejnhausen of GermaQj, and such places that have obtained 
repute is the treatment of different varieties of degeneration of the spinal 
oord. A sojourn at one of these places frequently results in much greater 
benefit than can be explained by the taking of the waters internally or ex- 
ternally. It not infrequently improves the patients' morale; the cb- 
lerranoes there require the maintenance of great cleanliness which in 
turn betters the periphei^ circulation, and the disciplinary measures to 
which they aie subject facilitate metabolism, and increase the appetite. 
All of these ar« of the greatest importance. Many men experience a 
partial or temporary restoration of the seinal power &om such treat- 
liMnt; this improvement benefits them by inspiring hope and imbuing 

In oases of myelitis seccmdary to diathetic oonditions, this ie the 
period when there is some hope of using constitutional and non-medicinal 
measures to great advantage. It is also the period when rigorous anti- 
ayphllitio treatment should be carried out if such treatment seems to be 
indicated, as it is in eyery case in which there is a syphilitic hiaU^, 
whether or not the patient has had what seems to have been adequate 
treatment following the infection. 



CoHPiiSBaroN' of the spinal cord may be reused by neoplaams or in- 
fl&mmaUiTj growths thnt take thtrir origin from the cord itsdf, from the 
iueaiiig«9) from the ceilliJo-adipoBO tiaaiiCt and from the rertebriE, The 
amount of pressure which the growth will exert upon the cord depends, 
Daturally, upon ita aitua-tion, size, and eonsiatence. The legions that 
iBOGt fr^u^Dtly cause compreaaiou myelitis have their sefit in the dorsal 
region. The amount of compreaaion UisLt the cord often tuleratea before 
ita functiona are senouBly Interfered with ifi remarkable. Tuberculous 
oarieg of the vertebra: and tuberculous disintregration of the LuterTertebra] 
diec% Fott's disease aa it is commouiy oalled, ia the most frequent cause 
of compressioEL myebtia. The next moat commou eauaea are tumora of 
th& meninges, sarcoma, fibroma^ multiple sarciomatoait^ Ryphiloma, myx- 
oma, aud other rarer forma- Ohi'onic mfl animations of the meninges, 
eapfoiallyof tbedura, suchaatraumabio, tuberculoufi, and syphilitic pachy- 
meniugitta. constitute the nejit moat importanbcauaeof oompreHBioniuyeli- 
tis. These dtse^ises are generaUy aasooiated witLi a variable amount of 
circumferentia] or anuiilar myelitis, which oocura coincid^ntly with the in- 
yolrement of the meninges. Oftentimea, howerer, tha implication of the 
cord is distinctly secondary to the lesioD of the duia and is the r«sulb of 
compression. Tumors having theii origin in the extradufal collulo-adi- 
poae tissue are a rare cause of compTeseiou myebtis. When such tumors 
are primary they are usually lipomatoua; when aeooadaty^ caroinomatous. 
Aseutismal dilatation of the thoracic and abdominal aorta occaaionally 
causes erosion of the vettebne aad penetrates the vertebral canal so as to 
produce pressure upon the cord- The most uncommon causes of compres- 
Bion myelitis are tumors of the vertebra themselves, which are almost 
always a variety of cancer secondary to cancerous formation in other 
parts of the body, and fractures and dialocatione of the vertebra. 
Tumors of the cord fiubstanoe itself donot cause true com preasion. Tbey 
merely replace the substance of the cord and pioduce symptoma aimilar 
to fchoae of oompreasion myelitis proportionately to the amount of the re- 
plaeement. Such tumors are almoat emLusively gliomatous. 

Tha variety of compression myelitic; resulting from Pott's disease ts 
clinically, Hapecially therapeutically, the mosL important. In just what 
way tuberculous caries and the consequent die integration of tissue aod 


<[«^^tuiiv oftus« ^ompr<Mion of the oord U & very debatable queatioD. 
U haa^ \y^n ooutouded that the compreesion is the direct result of the 
ijUi^Ur «(>inal ourvftture or kyphosis which the aoftenlDg and displace- 
tu^ul of th«* inter vertebi«l discs and subseqoent partial dielocation cause 
m oth«r w\>idi, that the oompressioa is purely mechanical, but against 
ihU i« ihe iuiportant fact that symptoms of compression occur wheu there 
ul uo o^usUierable curvature^ and they are often abseot when the angular 
UtftKviuity i? u»^t extreme. As a matter of fact, the compreesion of the 
vvW itt IVtt^a diMiaee is commonly due to an accompanying external 
y4»^b^\ uiduiu^itie aecoodaiy to the tubercul6us process. In rare instances 
it i» dtw ti> thtp presence of extradural abscess. Pottos disease occurs 
uAU4(tlv iu chiUihood and wlj adult life. The causes that predispose to 
lh«i Mvurr^u^^ of tuberoulosia in any other part of the body are the cod- 
Iribati^ oauaw ^if the disease, the exciting cause being t^e tubercle 
bAv^Uttii. tu »imie casee injury to the spine seems to have direct causal 
l^atU4t«hip- It proiluoes disorder of circulation and perTeraion of nu- 
Uit^Ufc which ftw^iUtata the foothold of the infection, or it accelerates the 
^v««a»i» (tixd'-Me vrhioh haa already begun. 

\h,^ \^\i*t^ i^ tumore of the spinal cord, its membranes, and Uie im- 
wvUtJti^ «dtvir<.kn mental tissues are imknown, aside from the infective 
I|h4uu\>4u«(i^ txUi«*roulous aud syphilitic, and the parasitic diseases. We 
Kuk-At U^r iuHUn^*«>, that glioma and sarcoma are more likely to occur in 
th^ \s^U|£ (h*uiu tht* old, and that carcinoma and fibroma are more liable 
th^v^ivuvutlato adult life; but aside from this absolutely nothing is known, 
i*\>HVt itk*,% Mx^ioitallj preceding traum^has some etiological influence, 
thi> vt^ui^ M il has in the development of brain tumor. 

Hu^ tyiiK^K"^ \>i ooiupression due to traumatisms of the spine — frac- 
tu^\^a^ \lt4i^hMtU>UM^ gunshot wounds, etc. — requires no further discussion, 
VA IV \Auihi viith 'm.'h. ease. 

teauMHUk '(^tte eymptoms of compression myelitis vary according to 

■V wsJ \^* ih^ kK^ that is encroached upon, and with the rapidity and 

v^i*\-*t *^ *\**uiv*^'*aiiui, l*ractically they are the same as those of acute 

v.,*,.x^iav itt>^fctU^»f Ih^ dorsal r^on plus sensory symptoms, of which 

L^^ . ta V ■uk'Ab kSttw|aoui^us. This pain is local, usually somewhat below 

^U t V •• y"^ s\4upM«a^oUt and radiates along the trunks of the netves. 

y, L ,1.* ^»h»i»*4vii*it v^^u U uot ai^MTompanied with local tenderness on preiss- 

^x\ ^^ 'xN vWW |»«w^*-u**«falgia. The pain is variable in charayter, 

..<xv ^vv^i^u^^b^ mmU Jtubjeot to exacerbation. Tt is inereaseS ^ 

1^ i,,v ... Awtt^'-fcs^* *H kinds, active and passivb. It is mitigated 'by 

^A \ V ^\>,^ *'-* s'^w* ^"^ (he spine it is usually symmetrical, but in 

^,^^ -.^^^» \Ni*s**iWt> ih« extradural variety, it is not mfrequently 

* <«ys^ *» ,lj^*k.^iym'*^ \% is aocompanied by various sensory phe- 

^ A v%* **"!»'*»^. ^•(•■Mwiiua, polyffisthesia. The motor symptoms 

JL VI ''kv\«*v^ WvJ( ^V^^V^ ^"^ ^^ spine, and more or less complete 


pualysis of the eztremities. The paralysis may be flaooid or ipaatio, 
Uflually the latter, and accompanied with exaggerated reflexes. Although 
the paralyzed parts may be quite auffisthetic, the patient rtill oom- 
plains of pain in them, and this conditiou U known aa paraplegia 
dolorosa. The bladder, bowela, trophio symptoms, vasomotor and ■e- 
cretory disturbances are the same as those of acute myelitis. These 
symptoms vary naturally with the causation and with the looatiou of 
the compression. The important symptoms in Pott's disease are the 
stiffness and rigidity of the back, the deformity, and the radiaUng 

The treatment of oompresaion myelitis must vaiy aooording to its oau* 
sation. The treatment for compression due to Fotf s disease is not the 
same as that indicated for oompression dependent upon tumors or upon 
fractures and dislocations- 

Xreatmsnt of Compreuion Hyelitii Due to Fott't Dissass. — The tr«at* 
ment of compression myelitis due to Pott's disease consists of rest, the 
adoption of measures to improve the general nutrition, and the utilization 
of orthopaedic apparatus to maintain immobilization of the portion of 
the spinal column diseased. Medioinal and hygienic treatment ars of 
great importance, as they are in every form of tuberculosis, but in the 
early st^es of the disease the most urgent requirement is rest. The 
patient should be put to bod and kept in as nearly a horizontal position 
as possible, and extension of the spine secured through axillary trac- 
tion if the caries is of the dorsal region, or pedal traction if it be lower 
down. IKiring this time the dietary should be most liberal and nour- 
ishing, while utilization of the foodstuffs is facilitated by abundance of 
fresh air. Not infrequently the early stages of the disease are aocom- 
panied by fever, and it is wise to combat this on account of its depreciating 
effect upon nutrition by the administration of small doees of quinine and 
phenacetin and the external use of cold water. Two drugs, creosote and 
iodide of potassium, may be given for their constitutional effect, fn 
my own experience the latter drug, given in large doses (gr. xx,-xL 
three times a day for an adult) and appropriately, is by all means the 
most reliabk medicament- After the acute manifestations of the disease 
have subsided, support and extension of the spine should be obtained 
by the plaster jacket if the disease is of the dorsal spine, or the Kajrro 
jury-maat if it is of the cervical spine- There should be no relxnquisfa- 
ment of the effort to maintain a high degree of nutrition during this 
period. The treatment of v««ical, rectal, and vasomotor symptoms mc' 
companying compression myelitis is the same as for a^ute ii>y*;]itis. I 
would warn particularly against the use of c-'runttfr- irritation Ut the spine 
in any form. Formerly it was the custom to employ the a/^tual ^aJiterj, 
blister*, and vesicants to the spine. They add U> the pfttiefit*s suffering 
withont being in th« dightcst way bencfimL Many «aseo of Fi>tt's di«- 


e^aei if taken auJlioiently eatly a&d Bubjected to appropriate treatmoat, 
tcnninate in a.t least partial recovery^ c^cii though the BymptomB cf cota- 
pressiOD of tJie cord have been well proDOuncud. Thia is eapeciallj trva 
in chikhei]. Occasionally the improvement is very rapid, but ufiiially it 
oociirs gradaally. After the pressure on the cord has tieen relieved, and 
tho inSaDimatory proceaH has subaidadt meaaures lo^iking totvoj'd th^ 
functional restitution of tho eitremitiea must be adopted^ For instance, 
muacuUr contravtUTfi must be overcome. In some case^ thia can be don» 
by maAsage and paatiive exeToiao, bikt occsaioually it roqulrea teuotomj^ 
Hjid orthopedic appUftuoed. Muacular atrophy and weaknesi are to btt 
oombabed \>y masftage and the hypod«rmatio use of atiychaiae, while aa 
attempt ia taade to restore the circulation of the Formerly pftr^yzod or 
partially paralysed extremities i^y the use of hydriatics^ 

Treatment of Compreciioa Myelitli Due to Spinai Xumon, — The treat- 
ment of iiDuipresaion myeUtia due to spina! tumors ia very diacourag- 
ing. Tumors of the epinal-cord substance are entirely nnamenabli? to 
cYory form of treatment, and all that can be done is to treat the paticLt 
symptomatic ally— relieve the su^ehng and maintain tbe etrength and 
vitality. Treatment of tiimcTB of the vertebrje is quite aa hopelesSj for 
Biich tkiiiiors are almoet invariably secondary and are beyond the skill of 
tho surgeon- Tumors of the nieninges are amenable bo aur^cal treat- 
ment^ and the results of operations bo far undertakoiii may truthfully be 
said to be encouraging, although they are by no means brilliant. If tu- 
mors can be diagaoaticated before they have made eerioua pressure upon 
the oord, and particularly if they can be removed before secondary degen- 
eration reanltiug from suoh prKssure has gone on, the reijuirements will 
be amply fulUlled, Tumors of the spinal coid have not been oonaidered 
amenable to surgical meaaures until recently. In 1887 Horaley operated 
upon Buch a ca^e and since then at leaat twenty-three caees have been re- 
corded. About thirty per cent of these have been either materially im- 
proved or cured, the remaining number died principally from hemor- 
rhage, shook, and sepaiB. But vtthout operation they would all have 
died, excepting possibly a few caaea of syphiloma. Even these resulte 
are thersfore encouraging. 

The troatment of traumatic affections of the spinal column causing 
oompression myelitiu may be dismissed with brief consideration. The 
treatment varies according to the nature aod degree of the accident. 
Many methods have been deviaed for the reduction of disJocatione of the ^ 
vartebrffi. Such dielocatiou is commonly of the cemcal region, and here ^ 
attempts at reduotioo are almost invariably followed by doath. At the^ 
present time it would Beem that the most justifiable mode of attempling^^ 
reduction ia by continuous eitension, such as with Sayre'a apparatns._* 
When reduction cannot be effected the advisabiTit^ of eiposing the juinl^^ 
and ligaments implicated must be considered. Fractuie of a vertebr^^ 


followed by Bymptoms of oompresaion requires exploratory trepannatioa 
in every inatanoe. The surgeon must then be guided in hia further pro- 
cedure by the conditiona to b« found in each case. The ^luptomatio 
treatment in these cases is the same as the symptomatic treatmebt for 
ordinary myelitia, 



Etiology^— Tbe caitauB of chronit; myelitis are; (1) All the causea of 
acute ju^elktia, aa tho clirouia vdriet^ may be oqq moilo of Urminatioii of 
the acut« ; ('2) flyphilis, wbich la bj all means the commonest Biugle oause^ 
it being found in at laaat one-thinl of all the cases; (3) polsonSf auch fta 
ergot, wbieli haa the peiMiliarity of (raui^ing ^eutruetlou particularly of tbd 
posterior coIuuitl, alcoboJ^ lead, iQemury; (4) autoiutuxLcationaf gout, 
diabetes, and chronio aui^iiua. The prcdispoaiDg causes are prurticallj 
the same aa t))ose of a<;ute myelitis. Escposure to cold and vet la the at- 
tributed cause in many of theiti. Fatigue atid prolonged physical activity 
and strain are anted ia many ethers. The diseasf^islikA^y to occur during 
the yeara of early maturityf and uiucb ofteuer m males than in females. 

A variety of chronio myelitia dependeut upon senile changes in tho 
spinal blood- vessels, seniJe arterioscloroflis with resulting periTaacalar 
aclcroais, occurs occasionally in old age and is known aa senile paraplegia. 

Of 40 cases diagnosticated as chronia myelitia and treated in my 
cliuic 32 were males and S females. The average age of the patients 
was tliirLy-a*iveu years. Out-of-door manual laborers furuisbed 42 per 
venti of the entire number. Fourtrccu of tbe Ct2 patients gave a history 
of syphilis, and in 11 oi thoae the symptoiu complex of myelitis con- 
formed to the typo known aa syphilitic spinal paralysis. Thirty-tbreo 
per cent of the caaps gave a bistury of exposure to cold, and in the 
majority of these tho refrigeration was considered the cause of ths 
disease by the patient* In 15 per cent of the eutire number the dia- 
euse waa secondary to a-'ute myelitis, and in the majority of tbeao 
there was a history of acute infection, such as influenTa or pneumonia, 
or of SKpoeure. In 8 per cent of the rases there was a history of in- 
jury 'without evident of its previous existenre. One patient had dia- 
betes and 2 SLifTeted from severe and chronic aodeinia. Only 1 cage uaa 
of the senile yariety- 

The symptoms of the variety of obronio myelitis kno^n as syphi' 
litic spinal paralysis are: 1, Gradual onset with or without attributable 
exciting cause, uflually within five yeara after the patient haa had 
the initial lesion of syphilis. 2. Weakness of the legs assotuatod with 
muscular rigidity and contracture. This iveakn ess may amount to com- 
plete paraplegia. Often one f'xtremity is mure profoundly aff<^cted than 
the other. 3. Great mcreaae of the tendon reflexes. 4. Weakneaa 



|KJ^BBlioiiAl diaotdtr of the bladder, and ocoa^ionally also of the rec- 
Bl* >L Slight but coDBtant sensory Hymptoiii>i iu tbe shape of pan&B- 
kauA of the I^a- severe pain Js uausu&J. 6^ Loea of mxual potency. 
b^hout OQC'third of tho caaes reapond fayorably to active autisyph' 
^Kt'^^ci^^- OccasionaJty auoh a patient gets quib« well. 

Hie sjmptoios of i:hroiiie myelitis wblob is sequential to the acute 

MpBKv TiU depend v^vj largely upon the aeTenly of the original process. 

Pfcf are practit^^ly tlie same as those of acate myelitis save that; they 

an has profoond. When chrouic myelitis is chronio ab initio, as from 

a|Kt9tue and ex^baustioa, the symptoms usually consist of : I. Heaviueaa 

ttl easily induced fatigue of the lege ; 2. Stiffnoss of tho lower extromi- 

^bvt the beginniug, particularly after arising and aft^r resting, but later 

^Bed&«es la coiisUtit; 3. Unitary sympLoms, manifest particularly in 

Aifirolty ux emptying the bladder, later incontinence; 4. Impaired aex- 

flic^woity; l>. Vatiable and iuconutant sensory symptomsi consiating 

lfflbj«etiTe nutnbn^fis of the legs and feet, tension around the lumbar and 

1dv« ibdominal regions, and ocoaaionally parscstheflia of diSei-ent parts 

flf the lower extrfmities. The symptoms of the senile variety are a 

fn^ual development of a slightly spastic paiapareaia as&oviated with 

cild vesical Byraptoms* These symptoms become more pronounced and 

AtttitDoe the arms present analogoua but less marked symptoms- In 

jQDBfuea arteriosclerotic changus in the brain, flimilar to those respoo- 

aU«for the sc'tiile paraplegia, prodtice the aymptom complex of eenile 

ilemeatia or other symptoms of encephalomalacia. 

rreatment, — The treatment of chrome myelitis dindes itself into treat- 
nnl of the syphilitic cases and tho t] on -syphilitic^ In the former the 
anomt and durattou of antiayphihtic treatment which the patient will 
iiirsxe muat be decided in each case. AVe are guided largely in rea^.hing 
Konclusiun by consJderatiun of the length of time that has elapsed since 
mjection, the amount of an ti syphilitic treatment which the patient has 
iliody received, and the state of his general nutrition. The more re- 
BOTOdfrom the time of infection, the less the chants of profound and 
jKnunent improvement from anttayphilitic treatment. Patients of good 
gTilihty and nutririon are much more liable to be benetitect by aiitjsyphi- 
IiUq treatment than the cachectic. Aside from this and ths causal treat- 
MUt ef myelitis, mentioned in the discussion of the acute variety, the 
ttwtmeat consists in so arranging the patient's life that he lb msnred 
fnta bodily and mental agitation ^d fatigue, that he is spared the in- 
JBTiout aotton of aEcohol, tobacco, and narcotics, and that he is vouch- 
■fed a life of intelligent rest ancl exercise. These, and the employment 
of agencies to meet the symptomaiic ci.mdition3 and measures to improve 
Utfuuthtion, constitute the entire treatment. As soon as the paraplegia 
'■'has that degree of development that locomotion is difficult and fa- 
Upuug, the patient should be eQcouraged to get about in a roll-chair. 


$^ ^ %» ^ ^vatrtfnd Vv frvqnent w^riD b&ths of from ten to 
SJ^iWL iL'-^^trs" ^z^^xxiL. Hist panctits r«c«ivo bai«fit and macb com- 
j4n >7 »aftft:z:^.^ 9zx^ & hid for ui boor or ercn liMiger. 

^ESiKn^t^ V i,<^ 3x^ wrr^w in ind^ifnciiig tbe oonrBe of the pathological 
vntMW^. '.f t^:* u K^BfacrOv Bizia|dhT, of inartivi^ of of other origiSr 
«^>iv«r4nX> 3^ ^ ^^^'^ v:i^ 9kJB» Barcvaa to combat theae oonditioDS. 
Rn » a rt!* H'^i ti* trCrxtx »ad th* fandic curreut tend to increase 
t^ »^*M^,'^^. »3»i sS.-cji w<« i^KKton be used. Manage and pasaive 
«\wv^*M a^ :}:: -x^ 3x^o» "SMi^ Masnge not oolj improres the circula- 
^>tt a^ iW ^-:*^.ix<c^ <i tbe ports, b^t when combined with gymnaAtics 
>*»st» K- yMiK¥^« icvN:x>LtT a=d to fwilitaw TOlontaiy morementa. 

tiMv^tfju <H<v-«ix-ci w'-S^ ^ii* ohj*«t of OTercoming the lesion in the 
^l|M^ cvEsi w Sv** x*ry ♦ts'vcn^ing- Sitimte of silver has been recom* 
^*«i*^v^JC Si» XI \4 -,a*:«»; «sot has been praised, but it is injurious. 
Vlk*x^v(i* *^4 *w«:io ^*e Ivrti snv»*n, bnt no onecmn say positively 
llUtt lW> ^^ a^v 4^x^; \t Ot^T dt\ iK is ptobablj by improving the nu- 
Ui^K« :^;\v^^^^.^t« i» a ^rj^ thai is Jistd extenaivolj in this disease by 
tW $«»^*t ^'£i*HitM4M'r. l^i a^ide fmm its stimulating e£Fect ou the 
>**^*AM^ t ^v* »^\yr a**«i any bme£<4al effects follow its use. By in- 
vi-^JviiJU tSfc^ *4\wtsoiiv \% nxay hamper Ihe padent^s locomotion and it may 
^-V^**^*** iV VJ^^^w«»rr ^witMrtioos, which are so annoying, espe- 

t vVwhl |i\NAtUtt^ti oxvr th^ »vtu<^. tfurh a^ the appUcatiou of the cautery, 
^s^iUihM uu-rAaW* >t«Si.'^u«*. efcv, and ^peoially the former, are scHnetimes 
s^ »;4 \ K'V^ ?**KSt tw*<a»^< s<^™ t^* l**^** q"i»* »a important a psychical 

lh*> tf*w^^ htvfclih i* fr**iu«itly bettered by the employment of a 
uud vvO^t **u*v .'*ii\v Thi» has benetieial effect in that it makes the pa- 
^vul l*v*i Vh^** *^^i»»^hwtV ^* *'*"'*S ^'-^^^ ^*^^ ^^^- ^* symptomatic treal- 
\u,<^\ '« ^*> «iu^ *» xu *h*«i** mye^tis. The condition of the bladder and 

o, t-So ^\>u ^SsHiM U uia^W objei'ts of special solicitude. 

St .. V. 1 \^ \*^\U' rVKALVSia AND CoMHINED ScLEROSlS. 

(.^ . .<x \i\o.liVut \4AwfLted with and probably Dependent upon Lethal 
^ * Auj^mia and Toiffimia.) 

\V'*«A ^*** tfcat dw\>wi^ much labor has been expended to interpret the 

,1^ ^^^l *\'i* ovi*MM(E I'^tW'S^n cerlsin^profound changes in the blood and 

' V* t ■,v>.r'i4»^fc* U«*N*y oJ the spinal cord. That aueh a form of disease 

; \t,t L-i\'vK4ul^\ botfu reoognized by chmcians^ attention having 

,», ..* aaI W It **> t'utiMm, of Boston, and Dana, of New York. 

V* V' \ '■ ' ^"\T^'*^'^ JiwailW with chronic myelitis, a summary of our 

^\ '«\iIk>' *^ ^^ ^i*^****** " given by Dana iu his last contnbu- 

. .^ .^,,;, ^,:ibi* hew given. 


The symptom complex of the disease consists of numbDeas, atoziar 
and pazalysis first manifest in the lower extremities, then in the upper, 
of inBidious oDset, but after the disease has got well under way it pro- 
gresses very rapidly, usually terminating fatally in from six to twenty- 
four months- The phenomena of cachexia are always conspionous. The 
cause is not known, but the trouble is due beyond much question to 
some form of toxaemia. It ia more often associated with pemioioua 
angp mm or profound secondary anxmia than with any other individual 
GonditioD^ It sometimes develops with profound malaria and lead in- 
toxication. It occurs usually in middle life or later and oftener in women 
than in men- It is to be recognized mainly by the presence of ancemia or 
cachexia, the age of the patient, the progressive and rather rapid character 
of the symptoms, absence of much pain or tenderness over the nerrea, 
and the absence of the eye symptoma and of the visceral symptoms of 
h>comotor ataxia. The pathological anatomy oonsiats in a progreaeive de- 
generation of the posterior columns, to a lesser extent of the lateral col- 
umns, and later of other parts of the gray and white matter. In the 
beginning the disease is systemic, affecting most severely the oerrico- 
dorsal cord, but later foci of degeneration, usually multiple, develop in 
the dorsal and lumbar segments of the cord. Pronounced changes in 
the blood-vesselB aometimea accompany the degeneration, which is non- 
inflammatory and often ends in softening. 

The treatment of the disease cousists in early detection of the poison 
or infection of the blood upon which it is dependent and the adoption of 
measures that will overcome or counteract them. In the earlier stages 
the eourae of the diseaae may be modified by the admin iatration of 
arsenic, quinine, tonica, proper feeding, and the transfusion of artificial 
serum, normal aalt solution. Treatment ia alwaya ineffective in the later 



Tbe gray nmtter of the central nervauQ Bysteia is far more flusceptible 
to tlie injurious activities of icfectioos, intoxiratioua, and other deprav- 
ing agencies thaii the whice tiiatter- Its vasM'iilar supply is more abiia- 
daot autl uampleiT and its coustiUieiils are t\\e parts of tba ueurons in 
which Xhe nutritioii of the ueura^^ous aiid tlieir distant ramificationa are 
regulated^ This gray matter may bo the &eat of Eia many diFfetent \arie- 
tiee of inflammatioa as any other tissue of the body, or a^ there are esci- 
tanta of inflammation. The commonest varieties of inflammation of the 
gray inattf rare acute exvida-live, nun -hemorrhagic, and heuKinhagicinflam- 
matioii. The neiL muun common are the acute proliferatiTo and purulent 
inflammations, Thfl gray matter of certain levels seemB to be more prone 
to inSatnmELtion thau that of others. Moreover, certain exL-itanta of in- 
Sammation uf the gray matter seem to hava a predileotion for individual 
jrarta. Thus the hanefnlnesa of iiitlueiiza 13 liable to be expemlwi ou the 
gray matter of the (lereUral hemispheres, that of al^^uhol upon the gray 
mattei around the aqueduct of Bylviua, while the infectious intestinal 
diBeaaes and the intoKications following them are likely to mnnifeat their 
peroieioaflueBS upon the j^ray matter of the spioal cord, N/ituraJly, there 
is nothing approaching a rule wbieh govema sunh predilection. In a gen- 
eral way il> may 1»e naid that the c^iives th^t prfd]fipo?4e to aiid excite in- 
damuLation in one segment of the gray iiiatLer of the central Lervona 
aysbem may do so in onotheT. 

Although the diseases of similar inttammations in the different seg- 
ments of the central gray matter are clLnically (]uite unlike and therefore 
must ueeeBsarily be oon^dered separately, the fact that they are Bimi* 
lar et-iologiially and i)atliologically leada me to consider tUem together. 
Thus in9ammatit.]Q of the ceottal gray matter of the spinal cord ifi called 
spinal poliomyelitis, -vrhUe inflammation of the gray matter of tlie ohlon- 
gata is called bulbar poliomyelitis. InHammatiuu of the gray matter 
Hurrounding the floor of the fourth ventricle is called interior poHopn- 
DBphalitis, and inflammation of the gray matter surrounding the third ven- 
triole and the aqueduct of Sylvius is ktiuwn as anperior polioencephalitia. 
If the inflammatory process is of the gray matter of the cerebral hemi- 


Bpherea, it is called euuephalitJH. The morbid aiiH.tomii-Hl diaii^t^A found 
in all of Lbeae couditioua are very similar, and they may be, aad often 
aie, the unmediaie sequences of infections disease. Witk one cxceptdon, 
superior polioeno+^phalitis, the most common cause of ^hich ia alcoholj 
tb« etiology of these diseases fs the same in nearly every particular. 
They all ooeiir moat freqtwntly in the young ajid in tlie wake of aflute 
diseaseh, afid the rliiiitial coarae of the v&riouH cuuditiouH dcies net differ 
very materially. Caaes of anterior poliomyelitis and of superior polio- 
encephalitis are apt to run a much more rapid course than caeea of iufe- 
nor polioeiH-ephalitin and bulbar poUomyolitiB, but to this rule there are 
the moFit stE'ilcing exceptions^ Two or more of the conditions that we 
have etiiimerated may o(-t:nr uiniultHtieinisly and be Ute expreasioti of a 
widespread pnthologii^al process duo to a single cause, such as an in- 
fection ; usually, huwever, although there may be in the beginning symp- 
tcma indicating iavolvement of what wu may ^all functionalty different 
levels of the central nervous t^ystem, the symptom coicplex booh con^ 
linej! itself to thEf clinical portrayal of m'lre or Ihss narrow anatomical 
involTeuieiiL Tberefoie I shall take up aucretisively i (1) The treat- 
ment of anterior puliouiyeiitis i (1*) the ti^eatmeut of bulbar myelitis ; (3) 
the treatment of inferior and superior polioencephalitiQi while acute 
myelitis and a(?ute encephalitis, even though the patho]cgii\'il proeesa 
eouatituting them and the causations of iheui ar^ similar to the diseases 
tliat are here meDtimied, will lie treated separately. 

1. AVTKUJ^H PiH,lnMVm,lT|fl. 

The term poliomyelitis means inflammation of the gray matter of the 
spinal cGrd. Ah suoh iiiHammation is ulmost invariuhJy restrirted to the 
&iitertot hortiA, it is ijuite unnecessary to prefix the word anterior to indi- 
late the locality of the gray utatter implicated iu the diataae known olini- 
tally OS lEkfuiitile paralysia and esBential palsy of ibildreu- The name 
has taken a dehnite place in nOHonoDiVi however, and therefore no al;- 
teinpt should be made to dislodge it. For a long time fnllo^^ing the 
recxigiiitioii of poliomyelitis, bf^th cliniE^ally and miatomicatljf ib whh he- 
llevad that ttie Uisearin oocutreil ex^^lusively iu children. It ia uqw uni- 
vetfially recognised that poliomyelitis occiirH dunn^ adult life, and in 
laocy books ficpatute description is giv^^n of its oeouvreiice at this age, 
This la quite unnecesaary, however^ for the causation^ clinical eourse, oiit- 
Dome, and treatment of the disease are the same in both instances. 

Poliomyplitis may bo acute or suliacute in itsde-'elojiment and course. 
A chronic variety his been described as tJje co-equal of spinal progressive 
muscular atrophy. It ia dependent largely uiton the use pot upon the 
word inHamuiQtionT whether or not the gradual shriiikuj^e, atrophy, and 
4iway of the ganglion oella in the anterior harne which form the anatomi- 

.' ;'."UoiiivHitirf is ;iit aruTr 

' . i-:aic'ully, ami ejiidi'ini- 

. tMiises (Ui'ectJy, or in- 

, :.arUm of till' ^i"iy i[iait»'i 

*' -:n to lifr hHii'h luuie rom- 

'l.e emiif nervijiis syi^lPiu. 

..r- i^'uniniiiii iinil jirhnipa: 

^- jV ]|]!itUt, <'xf]it- 

.AF eiiiiirju'iiu'ijt is tli-- 

.lT iTt'iiieiit is fn'4 lU 

\ tt> more than two s-'i;- 

^■;:i' siruultaiit-oLi^lv ;ir 

..vr eiiUi-^<'JiLeiit an<J in 

. '.T^atrdfci in uliirh tlit- 

■'.r thiiiu^huiit iherniin- 

' ■/:'-<? i-ast's shovild hot iie 

- -i all iiiiilr iiirtaliiiii;ili'pn 

;i; :. iiTtcr ami in tin- >,mii- 

■:. ;s I'onstilulfiL llUiii- 

, -rimi a<'iLt<i inUaiiiiii:ini>ii 

>:nioi i\*^ni'S3 of the in- 

i -.Mieti^iiy «if tin' r.xiii- 

->< '::A-i a ilfruliMl Tciidein v 

^rt have ji n-iiiarkali]*' 

■;' that til*' ri-j«isianf<* oT 

'i: ^'ii'al**!' tliaii u?;ua]h 

,:^ls uinicr;^'!) frnai tli"- 

, r.x-e wliii'li U I'ansi':^ m 

' ■: \s f,ss"'ijlially *nu- c»f 

-■.\%-r T*^''*ye\\ whirl: is 

- X p;j>t*i"ilir fiLTLrtinn :ii>' 

■i:::^il im-a. whirh fur a 

' .iileldy iara]ia*'iiat<"il. 

^ ■, :, ihf h nijih lirculji 

. i'!!''Hh"d- li js hi:^'hh 

v^j'Ui*, if sti it may hi' 

- ' :, :>»■ Tiiatt'ria! (h-stnii- 

,' ca a j-aiiKli'iTi ii-.l <>l 
, ^ ^** oi il?^ ihtiuspiaiil 


peripheral Jiervea nhick thej go to form, and the iDlraiimsouJai dls- 
tributiou ot tho^e nerrea Tritbin the actively contractile p&rt oC the 
tniidcle — ill other words, the entire peripheral mutor neuron — dcciky 
whea the cell body is destroyed by the inflftiumatory process which forms 
the anatcmical ba^ie of aiittinor jKiliomyelitis. 

All that \s VnowD conceruiiig the causatioii of the disease ju aditition 
to what has alteady heeu stated ia that it sometimes follows in the wjike 
of the iufeotious disfOfies; that it occurs daring the late summer, and 
eapecinlly iit seasona of extreme aultrinesB^ &ud that fati^e, e^coitementi 
enposure Ui wet and rold, overheating, and in general fac tors that exbacst 
the nervoMH system^ iire often tim^^ft immi^difite preuedenta of the occur- 
rence of the diacEiae, both in the infant and the adult. In one recorded 
instance the di^eaae folJowad a wnund upon the hneei to stanch the 
bleeding of which moas from the roadside had been uflfld. The vast ja&- 
jofi^ of cases occur between the first and fourth yeare, 

SyntptomB and Gonne of the Clsease- — The premonitory symptoms 
of t\w dlAfa^f are thoiB l'oululoil to all the milder forms of infection, 
auch as apathy, disinclination to play or work, somnolency, feeling of 
Stupidity, and a desire to be left aloni;. Within a few liours, a day or 
two at tlie longest, the patient has couBiderable rise of temperature, 
reachitjg 102° or IfiS'^ F., which lasts from tweuty-foiir to forty-eight 
hours in children and oftentimes for a week inadnltfl. It niityor may not 
have been prei-eded by chilly scmsatdoua, bub it In usually actromponi*^ in 
dbildren Liy manifestations of irritation of the central sensory sphere, such 
aa vomiting, convulsions, fli^htiness, irritahilityT and a serious disinolina- 
tion to be handled, an if severe pain were caused thereby. After these 
•ymptoiDS have lusted from one to three iays, it is noted that the patient 
la paralyi^eil In one or all of the extremities, uaually one of the lower ex- 
tremitieB. Ah time goes on, what seems to have beeu lods of function of 
an entire extremity may disappear and tha paralysis teotricts itself to a 
aiogle muscle or a group of muscles, especially those fuiK'tionally asso- 
ciatedn At this time atrophy of the muscles begins to show itself with 
some distinctness, althuugh for many days the Uinh may retain its normal 
ooi:tour, and particularly if there is much auhcutaueoua fat. But the 
fact that it is atrophying is plainly apparent to the touch. Before and 
during this tiitie the functions of the bladder and rectum have been dis- 
ordered. This of course will be evident only io patients who ate of au 
age to be obaervaiU of the calls of nature. Tn the beginning of the dia- 
CRse the pattent ftrls sore all over and there is frcriueutty much complaint 
of pain. Ihit after the general phenomena of in Ham ma Li on subside, 
there are no sensory disturbancee, subjective or objective, although eo' 
during pains in the eTtremities has-o occasionally been noted. When 
such syroptomfi ojjcur they indicate an int'ol^-ement by the inHammatory 
process of the posterior ccm-^a and the root fibres passing therein. 


As the individual luuscle or group of muscles continues to atrophj cer- 
tain acooni]>iuiim«nta easily recognized on examination develop. Tbea^ara 
losmif thfi tendon jerka, such as the ku*^ i-pflex, when the muscles through 
whick the}4e reflext's are manifest aru difiea^ed, and some degree of reac- 
tion of degeneration to thefaradic and g:UTamc currents both in tliCDexve 
and iu tte muacJe. The degree of completeness of the degeneratii'e re- 
actioa vanes la every ease. When the atrophy is profound, theie is 
Visually complete absenee of contractiou both to the faradic and to th© 
galvanic ourrenta, but in othei- inatauceB some faradiu excitability of the 
mviBclo remainSj a posaessioa that aiigurs well for the recovi^ry of the 
part. The atrophy uoually reaches its height m from four to eight weeks 
after the oceurranoe of the disease; but it becomes more striking after 
this because in greater contrast to the progressively glowing liuib of the 
other side or groups of muat^les of the aaiue ei^tremity. 7f the atrophy 
baa invoWed au eutira limhf no cousiderabie deformity may result aave 
that at a withered, undeveloped extremity^ but usually the atrophy limit- 
ing itself to p. group of muscles is folJowed by very marked defortnity, 
partictilarly of the feet, difierent forms aud degrees of (^lub-footf which 
\3 caused by the unopposed contraction., the basis of muscle tonus, in 
aiilagouistio grou^H* of muscles. Tlje prevention of such deformities 
foriua an important part of the treatment of jxiliomyelitis. The course 
ftl the diaeaae is indicated in the above description. The prognosis ia 
unfavorable if complete rt^r'overy is the standard by which ench forecast 
is made. As a rule, the life of the patient is not endnogered unlesa Ihc 
inflammatory process is of great extent and profound severity, when the 
respiratory musnles may be involved. 

Treatment- — The treatment of poliomyelitis may be considered uuder 
four headings. 1. The piophylactie treatment. -. Tlie treatment of the 
febrile period. ^. The treatment of the immediate nianlfeatation^of the 
disease, particularly the muscular atrophy and its eonse^iuent paralysis* 
4. The treatment of Ihe remote consequencea of the disease, deformities. 

Prophylaxia* — Very little that is of service can be said regarding Lbe 
prophylaxis because the definite etiologital factor hiis not yet been dif- 
ferentiated, ronsidering the relationship which the orrorrence of polio- 
inyelitis has to the acute infectious diseases, the advisability of looking 
to the hygiene of the convalesrence from these inl'ectiona is apparent, 
likewif<e the iin|iiirtiuiie cf avoiding the exciting fiu'tnrs that have been 
enumerated above, aiid particularly during that time of the year wLea 
poliomyelitis is likely to occur- '^Vhen the disease ia prevailing epiderai- 
rally, the greatest care should l« taken U) avoid all esperiencpa timt cause 
lowering of vitality, while the condition of the alimeutary tract in chil- 
dren should receive especial attention. 

Treatment at the Time of the Attack. The apprnpriate iteatment 
during the febrile period is an ice-bag over the spine, or if this is impoe- 


siLjIe on account uf the age of the patient, the applioation of dry cupa 
or a few leeches; the exhibition of repeated email doses of ealomel, fol- 
loired by a s^ine; and tbe aduaititBtration of salol and pberacetin to 
uontTol the fever, relieve pa^m, and to oombat mtestmal fermeDtation. 
UtifortQnateljp however, in the luajotity of instancea, do suspicion ia 
had of the nature of tliR diaease, unless it be prevailing epiiiemioally, 
until the febrile period ha^ passed and the pai-aLytio nmnifcfitatlona call 
attention to tlie fact that it is a spinal'cord affection. The occurrence 
of coDviiLsiciis rails for inhalations of ehloroforni^ the use uf a tulcenarm 
bath, and perhaps the ajLiiiuiBLratioD of a. few doses of uue of the bro- 
mine Halts. After the fever has teruiinatedr the child liegina lo feel 
well witii siirpriBLiLg promptness and mauifesta an Lnclinntion to play 
aud a deairo to get up. Unfortunately, the mistake is ufteatimee made 
of allowing it to do so. The patient should be kept in bed for at least 
a fottDight after the fever has disappeareil, for during this time dis' 
inLesratioii aud absurpbiou of the products of iuflaujuiabion are going ou 
in the cord. The completeness of this absorption has a bearing upon the 
deji^ree of recovery. l>uring this time the avtnues of elimination from 
the body should be mJMly stimulated, the patient's digestion and assiini- 
latioD carefully attended to, and medi^iines that are known to have the 
property of fsriljlattug absorption^ particularly iodide of' potassium, 
should be adminiatered iu small doses. Ergot and its derivatives were 
recommended by the older writers, and faithfully copied by many of their 
SucoessorB. Although willing to admit that there ara iheuretioal ludioa- 
tiona for its use in the very beginning of poliomyelitis, f am fully con- 
vinced of Its uselessness as a thera[ieiitic agent after the rndammatory 
proceaa has begun to eubaide. Furtheruiore, its administration after thia 
period is quit« aa likely to do harm as good, and mention is made of jt 
here only to advise a^^ainsb its use, Duriug thus stage, when the indaiu- 
matory focna can be accurately localized in the cord, mild counter- irrita- 
tion over the spinal column at a level correaptudiug to the seat of the 
disease may Ik) used lioUi in the i^hild and in the adult, alfl/aya beanng 
in mind that inFaiits are very sensitive to such a procedure. 

Treatment of the Early Cenaeqnences of the Diaeaa«. — After from 
two to four weeks tieitTuent directed toward eounlt^racUng the atrophy 
of the musclea and toward improving the nutnliou of the paralyzed 
parts ahtjuld l>e undertaken The most, vahiahle agecciFs for tins pur- 
pose are electricity, massage, locitl warmth, and exercise. Electricity is 
naed in poliomyelitis with two objects. First, and least important, to 
inflaeuce the circulation of the blood aud lymph through the fo*'U3 uf 
disease and thus to contribute to its rwovery; and second, to stimulate 
the per)[jheral neuroniuecnlar apparatus to prevent inactivity atrophy 
and t-o increase the nutrition and volume of the fibres in the atrophic 
muscle that are not destroyed- The Jirsl indication ia met by the use of 

- -VSTK.M. 

; .i.\. t-ulumn at the 

'. ii curif^iit of !ilnn;r 

. ? :^vu"f iL (Uiy. XL.- 

' ::i the applicatinn cit 

-s tliL' sei'wtKl iiniicii- 

r^ uieil, Tlie thoice u! 

ir;ve iiMi'tioii. If tilt 

^'alvaiiic current, vt'r\ 

:;:rli ilie siiijiiilaiioii uf 

Jaiisi'ri inav ht^ pnfvucii- 
. ■' ijit'il iri i-um'S :n wliiii, 
. - f-.'iue fil'rrs i:i jl iiara- 
. .13 well a:^ rli," ijLusd.s 
'.ir fiiTK'tion, ^LoiiM \,.' 
.:■ eli*('U'Oi.h^*i ^Ei'iilJ ]'■ 
- '-.<. Avhiii' a r^irrt'iLi. ii; 
>. ■ :'. 11 of tik* :iil!aiiiuja- 
-^ anil iinire nm,<i'ular 
; priibaJjIy als-) to xh*- 
:":.\';[raj;eii ami r(.ha\.'ii. 
/, . ourT'^nL is h_v ineaii ^ 
.v?: oitoi" a liaj'. pit'ici - 
; '.^ of the diihl's life 
\ ' ^:t it li[is ;l Ijerif H< iii; 
\ ik- I'alirB iiuiiiTion, 
, r.^ time, rvi-n i}i<nigl] 
- ? /„ivi' iJet'U ivi'ordc.i it^ 
; i^iveiij of I'niiiHe, bi 
■ itupriiveiaeui <»f |ip<.'a! 
* ^ iU'>;ret"s i»f ri'i'iivi-n , 
One woril <*f vvairiiiu" 
.:; ■:(. Wb**!! nil" 'liiiii 
J r > iis iir^f, ii s|iLJiii<! 
.'■■I eiiiiCiiled til Take ;i 
. - .^/iiij; ^^'liii'h atlempti 
.:,■ mum lli:ii) I'ijiailei- 
: tVniii iisafiplii-atioii. 

V -;;-es, uulii till' ''hii*: 

'. A.ii '^r ilisi'MMifurt, all : 

^ [.,» very I'^Ti,:; J"fi>iP. 

, ^ il (ibjt'il'*'^' '^T lb" 


Isolated by the feelings of the patient and th« apparent efFect that it 

Light maasage may be instituted soon after the febrile period is 
passed. It should consist of mild kneading and pinching of the atrophied 
parts, followed by friction and percussion to inflnence the ciroulation. 
Its utilization should be accompanied by gynmaatios given according to 
the Swedish method, the object being to give the diseased mnsde, as 
well as the muscles that are functional antagonists of it, exercise and 
so prevent the one from undergoing changes the result of inactivity, 
and the other the result of unopposed action \ in brief^ the Swedish move- 
ments are thus passive aod active, the patient resists the movements 
caused by the Dperator, aud at the same time indulges in voluntary move- 
ments which the operator resists- Massage and resistance exercise should, 
like electricity, be kept up for a prolonged time, and they may be utilized 
simultaneously, or courses of the one and then of the other taken in suc- 
cession. In large cities it is usually possible and always advisable to 
send the patient to an institution or gymnasium where these measures are 
scientifically and methodically carried out. 

An important adjuvant to thwart the progress of the atrophy in a 
member is local heat. The surface temperature of the paralyzed extrem- 
ity is usually from one to two degrees lower than the unaffected, and the 
limb is cold, objectively and subjectively. The patient should always 
wear flannel underclothing aud stockings, and at night should have hot- 
water bagSf hot-water bottles, a soapstone, or some other subetance that 
retains heat for a loug time in apposition to the withered extremity. 
During the day it should be plunged in hot water, once or twice, and 
oftener if convenient- Other means of adding to the local temperature 
and stimulating the circulation will suggest themselves to every physician 
to meet the indications in a given case. 

The fact that the patient's Hmbs are incapacitated prevents him from 
play, getting about in the open air, and from taking exercise, which are 
so necessary for the maintenance of a high degree of bodily tone and 
Tiutrition. These must be substituted so far as possible by the utilization 
of baths and douches which have a. tonic effect, attention to digestion 
and elimination, by an abundance of fresh air during the day and night, 
by regulation of time devoted to rest and sleep, and, in brief, by attention 
to the patient's general hygiene^ Just how much effect strychnine has 
in counteracting the atrophy of the muscle cannot be estimated- There 
seems to be a consensus of opinion that it has some- It may be given 
internally with quite as much benefit as subcutaneoualy. Its adminis* 
tration should not be begun before all inflammatory phenomena have sub- 
sided. Its usefulness is probably dependent on its qualities to stimulate 
nutrition through the sympathetic nerves - 

Treatment of the Bemote Effects of the Disease.— The fourth indioa- 

-,:a-c-> "V THK NKKVors SYSTEM. 

■'■•:'i.r\'-i iliiti are ^^p av: Ui folIoT the urt'ur- 
-'* '::i' i"H»-o}n'raTu»:. -i t3:e I'lih'ipicdic sur- 
,.. ,;,'i-^.reii<.v. 1: ii^ay he taken fur granted 
ireissjve as u* rf'ri'.ilt :ii ;i uuifnrmly withered 
r- I r-riui'te t'onsi-jjin'iu'e uf the disease, and 
.'■Si? uH guard !■> I'leveuC il. The cujii- 
^ I'l^ortuity are suiue vaHety of ehih-foot, 
V.-'v ihe patii'ot lii'i;iiis to walk around 
■» : i : ULilurally drojkS ami if tJie extniiior 
■ 'i. :'■»? liiinpjTOsed tlexor muscles jiroduce 
t^ ;:i rlu- begiiiuiitg, U soi"ii lixed and 
\. \-.:'.'.is^ aud forcible breaking n|) of ad- 
,:"^.'.:v;s can bi- apjilied. If, however, 
ii:,;:t» byjierextension, hy nieane of a 
:: ,1 simple apparatus ('onsisting ot 
.-.■,. ;t>i (he haU of the foot, eou- 
\. ^ . t :i 7;^:'i'ei- hand, or any eoiitrl- 
^ * ■ .^ :* oi'viateil. The pviiieijile 

\-- ;*r.*:\:s in ]>oliomyelitis alter 
. "f :'i'.: ;;.e iiit'>niiity ivhirh le- 
, -. H .', -jOsni TO those that aie 

-, - A^:;.:u> liavin^j for its por- 
:'!:*?v.seof a liiiih ]i:i!**T he 
f /; f-.K-^X usell]lne^■l ii*]d are 
■.'^e-iupposi* s.iiir..^ '.::i:im. 
It is impossrivf -.r ^::iTi» 
.:..* :hal will he r"'Hj\" ' .i :!i 
* .:■ a:ul degreo nf ;i::<T>hy 

*. ^ \> i-arly tenotomy of ihe 

, y.w. ■;iinng deformities e;in 

/;,:l^ *'( the coutraciud 

,' v/.ijritioii of the jura- 

■.^M'UU'iits <tf tin- parts 

'. * iH*rmit'^- \t \h not 

.^.h'tnii'S, ' Oftentimes 

I- :ulapta1itiu of di" 

■ :,UvY an atlark ^>i 

*'>>mpeiisatory. If 

^ . ..'uU'iK'y for him to 

•."-Af this he at lirsr 

■ :\w opjMijiiti^ side. 

* :ouH maum'r tl;<> 


spinai deformity nj tlio lumbar region kuov^n aa saiJdIe back develops 
when tbe luu^les on the antctior surface of the thigh ore affected- Theae 
deformitiea riirely require any orthopaedic applianee if they are couutei^^ 
acted early by appropriate g}' mil as tics. Aa a matter of fact, nowadays, 
when a depai'tiuent of gymaatics is an etueutial feature uf every institu- 
tioD devoted \o the treatment of tbe crippled, tbese defonnitieH are not 
nearly &o common among tbe poor aa they were in former tinies. The 
utilLzatioQ of gyiunaBticoxoroiBea requires a teacher of osperience. There 
ia no diUioulty in tinding euch persona in every city, euen though it be a 
rather small one. If it be impossible toaefure the ser^i^eaof sui-h a one, 
then some member of the family shi>ii1d make a pilgrimage to a teaeher 
of gymnaaticSt aud then utilize the knowledge acquired for the beaeJit of 
the patients 

Many Bnrg]<]al prooedni'ea have been suggested to overcome the con- 
dition knowii as flail joint, which occurs in the articulation of an extrem- 
ity that b»s heeu withered by poliom^elitia. In some cases it may seem 
advisaliln to perform artlirodesis, that is, to cause arbiEcial ankjlonis, in 
order that the patient may have a firm basis of support. Fur instance^ 
if the ankle-joint is eo devoid of its muactilai^ and ligamentoua support 
that the foot wobbles about in ei^ery direction, the artificial ankylosation 
of this joint may give the patient a useful extremity, NiituraLly^ an 
operation of ttna wit should not i>e undertaken by the gsuei'al practitioner, 
and therefore specific directions are not given here. It must sutHce to call 
attention to the occasional ncceaaity for its production. 

Another surreal procedure that is aomstim^s uaed to much advantage 
19 tendon grafting, or "function transference," which was propoflcd by 
Nicoladoni in 18S-, afid which has since been done quite eTrtensivBly, 
The end in view ia to attach or graft on to paralyzed muscles tbe teudou 
of a neighboring healthy muscle. The technique of the operation will 
vary, of course, with the muacica paralyzed. Therefore each case re- 
quires separate consideration and ingenuity. If, for Instance, the 
■boulder aud upper arm muscles are involved in tbe atrophy of polio- 
myelitis, the patient iiia^r be entirely devoid of the |X]wer of dexion and 
supination of the forearm^ In such caaes it is proposed and lias been 
accompliehed to cut the tendon of the biceps and to implant it in the 
muscles of the forearm lower down. 'I'hQsme qua nnn of its performance 
is that the muscle or group of muscles to which it ia attached must be 
possessed of a fmr amount o! power in order that tbe reqitisitB force may 
be obtained. The muscle that is functionally moat nearly allied to the 
paralyj^ed one should be selected. Eve has ehown that in some cases it 
ie adviaable that an [intagoniat of the paralyzed mnacle be grafted with a 
view to weakening tha action of the muscle whose unop]>osed contraction 
li causing the deformity. The method of uniting the tendons proposed 
by GoMthwaite seems to have found most favor. It consists im splitting 


loii^ttiLit:uii]]y ^)th » t^notoni}' hnLf«^ the tejitiona of the parntyzeil muac 
nnil drHwiiigtlie divided t«Diloi] cif tbe fimotioning iiiuscl^ Through the 
bole juet made, union being aiTm^ted by a few niiturefi jiaswd througli the 

Det«rmw«(l uae of tbeee vaiioue measuree will coDtnbube to Buch rea- 
toration of funotiou, and so fapilitate the uufortunate patient's rew>verj 
from thia diflr.resshig diaea«e that he may earn a livelihood ar^d paitaJce 
of man^ i>f th« pleasures of his healthy hrather. 


Aoute balbnr parftlyt^is depeuding upon inflaniniation of the rdntraT 
gray juatttir of ihe ohlongata is tlia dintiiic^t analugiie of anterior polio- 
myelitis, and the little UiaL la known of its ctioJogy rorreapunds most 
closely ^ith the causation of tbe latter affection, Very few cafes in 
which the diagnosis has been corroborated by autopsy Lave been reccrded. 
Iq Buah, however, as well aa in thf»e whose recognition ia baaed on clini< 
cal data, the disease seemed to ocinir in yniiih and in ear!y life, following 
or coincident with some acute infectious disease, such as infiueu^a, pneu- 
monia, diphtheria, and dysentery. Alcohol and rheumatism Laro be«n 
predicated as i-autiea Viy T^yden, Reinhold lias report^^d u case of pro- 
greflsive bulbar paralysis in which aiHite inflaiaiaation of ilie gray matter 
of the oblongata supervened. 

The Ryniplonift of amte buUiar jtoUouiyeUtis seeui to 4^01 ue on very 
abruptly, but on close investigate on, as in acuto poliomyelitis, it is found 
that prodromal nympboma, such &s obscure sent»ation3 iti the head, di^d- 
nesSf vomiting, precordial distress and palpitation, and indetinabl^ feel- 
ing of dr^ad and exhaustion pr(?^ede the real bulbar 8ym|itoiua, Aa a 
rule, th« onset of the disease is attended by the concomilAnta of acute 
infectious processes, aurh as rigors^ shivering^ acceleralion of the pulse 
rate, and fever, Thcfie are quie.kly followed by nasal intonation, regur- 
gitation of liquids through the nose on attempting to dnok, inereased 
difficulty of swallowing, exhaiisiive paroxyamH of couching, due b? the 
passage of foreign matter into the glottis, jiaresis of the lingual and buoGaJ 
muBi'ulature, weakness of the extremities, difficulty of breathing, attaeka 
of suffocation, tachycardia, and syncopal attacks. Occasionally other 
cranial nerves, smh as the sixth, are involved, aud in one eaae reported 
the third was afForted. This heEpenka an extension of the iuflammation 
along the floor of the foiirtli ventricle into the pons, or a contempor 
ous involvement of the two levels. 

The eourse of the diseaae is uuiformly progressive, usitally torminat- 
iug in death within the first weok. 1 have seen one case recover ]d 
the very acute forms oLmiibilation of the mental faculties and hebetude 
uhich leads to coma go hand-in-hand with the development of paralytic 



>;nipa>maw A eubacuU^ form similar to ths subacute varit^ty of niiterior 
pQlKmf^itia af^metiiues occura. 

Considering ichiit has been said concerning the cuuiae of tbia variety 
1^1 intluumatioD of the central gray matter, tr^^tmeot d^jvs uut coutit for 
tojthbg. Occasionally in the aubacute variety life may be apared for a 
bn^ XisDC. Tbe general ludiuatious for trt*atinent do iiut differ from 
ttunuf bolbar apoploiy and tlioae appli cable to autcrior poHouiyelitis. 
THk cvential tbinga to keep io miiid are tc search, for the cause of the 
sndiiioa, and to take meoaarea to ovdrcome it. After that, tba local 
ippiiatioQ of i^e combiued with measLires that contribute to obtainiug 
0lUid quJet fulfil the immediate indicationa, Trgent symptomSj such 
■ ^DQope, may be somewliat ameliorated by the administration of dif- 
fuUi atimolaots and by the application of cold to the extrs^mitiea, but 
Mtnle they are of no service- The f^reate^t care should be taken iik 
bnlii^ the patient. It is absolutely n«ues9ary to give nourishment ex- 
<huirplj by the rectum until after the arule syTuptouis have auhsided. 
If ihe paliant iturvives the ucute niauifeetations, the treatment dues not 
differ from that a|t[jliGablo to degenerative bulbar paralysis. 

(3) Acnrrns Sitpbbior FoLioEscEPOALiTie (Aoutb Nitclbab UriiTnAL- 

This is a form of opbthalmoplegia dependent upon an acute hemor- 
fii^ mQammatiou of the central gray matter in the Aoor of the third 
tBDtr^fl. and the aqueduct of Sylvius. Jl has previously been said that 
lUhiJo^cally it ie analogous to the acute hemorrhagic form of encepha- 
Iftii* polioeocephalomyetitia, and acute poliomyelitis. It was first de- 
mbwi b^ Wercicke in ISHl. He baaed the descripliau and tlxe endeavor 
lottUlih^b the disease as a clinical entity an three caaedp in wbiob after 
i termination qui^^kly reached, acute hemorrhagic and intlammatory 
Wtmcitioa vras found in the i^ray matter around the third TCntrJcle. for 
'IMmterof year* after Wernickd gave a description of these cases ob- 
iCTTitionfl by other clinii*iats were very few, bnt m all the caEca it was 
fomted out that the diM^a^e Heeuied to have but oue causation — alcohol- 
im— Ami CDC termination — death- Latterly, other cases have been re- 
which, although they do not bespeak thi; frequent occurrence of 
IdisMse, show that the original clauna in regard to the pathogeny and 
KrmiTtation of the disease are without foundation. Cases reported by 
Cilwiff, SalomouBi^bxiH Wolfe, and otlit^rs show that the dise^ee may 
oem ia those whu are abstainers from alcohol, whUe the report of the 
Ittleria wpll as those of Tbomaen, Werner, Boedecker^ and Herrnheeaer 
»boTtUt the disease may terminate in complete recovery- 
It vould now seem to be quite well established that neit to chronic 
tlooWum the same acute infectious proees9 that cariscB acute bemor- 



j'liBgiu eucepWitiN, vi^.^ inHuetiza, Ih oftBD^fit responsible for this disesae- 
It cccute al^ occ&aioiially iu tlie ivako tjf pneumonia aud diphtlieria. 
Botae writcTB would have ua believe tkat the dise&ae is & complic&tioD 
of alcoholic poljTieiiritiai but this view cannot be EUatained, It has been 
iibeerved after poisoning by lead, oxide of carbon, and eulpburic acid. It 
<nie eaae the only attributable cause was severe fright. 

The ht^muri'bagic iiidaiDiiiatoiy process on whtuh tbe ilJaease H de- 
]>cndeut need hj no meana be contined titrictl; to the central gts,y njatter 
in the fioor of the third ventricle and the aqueduct of Sylvius, It may 
extend through the poita^ the cerebral pedunele, and the basal ganglia in 
an irregular way, or it may be asseoiated with manifefltatioaa of ladam- 
malory iiivolvemeub in other levels of the cerebrospinal system. On the 
other hand, there are certain caeea that have a very eimilar symptoma- 
tology, bat are cf leea ncuta onset and intensity. In which alter death no 
lesioQs are found. These cases are to be considered as analogues of 
astheuie bulbar paralysis (bulbar paralysis without auatomiGal founda- 
tion) in whiRh it is supposed several levels of the different segments of 
the eeuLral nurvous system are bo overwhelmed by some toiic a^eucy that 
they becot[ie fLUictlonleHS to a cerbaiu de^^iee, and occasionally totally so. 
It is supposed that the injurious agenty, whatever it may be, is not of 
sufficieot severity to cause diBcernible morbid changes iu the «ells. 

The symptoms of acute nuclear ophthalmoplegia consist of Tertigo, 
headache, diplopia, uncertainty of gait, somnolency, mental torpor, which 
is often the predeceasor of delirium; within from lwent>-faur to forty - 
eight houra there develop partial ot complete ptosis, internal convergence 
or fixity of the eyeballs, and a, whimperings pathetic facial eTcpression. 
Ophthalmoscopic esamiriatiou often reveals a degree of optic neuritis, la 
some cases there is profound atada and marked ditliculty of speech. 
TIlq psychical mauifestatious are very similar to those occurrin^f in aico 
holic nmltiple neuritis. 

The general measuree to he adopted in the treatment are ibe aamc a« 
thoBd applicable in acute encephalitis. It ia only in the cases following 
indiieuza and other infectious processes that any hope of recovery can b« 
held out. In these it is not posaible to say how much treatment contrib- 
utes to that end- An insidious onset* a subacute ooursei and the ab- 
sence of subnormal temjwrature are symptoms that poiut to a favorable 
outcome; an i brupt onsets a bizarre course, and subnormal temperature, 
even without an alcoholic history (which always predicates dissolution) 
indicate a moet grave prognosis. Wheu the disease passes into a chronic 
state, the treatment is the same as that described under chionic nuulear 
oph thai mo plegia. 


(4) Acirric Infbrioh FoiiiOKNCKPHAUris. 

It hu been uid above that the patholt^cal process m Aoate sapeiior 
polioencephalitis does not always oonfine itself to the gra; matter aronnd 
the third ventricle; it maj extend in this substance bejond the oqnednct 
of Sjlrivs to the fourth ventricle, and even to the cord. The olinical 
pietnre will varj, depending oo the level of the lesion and npon its ex- 
tant, according as it involves gronps of ganglionic cells which are the 
nuclei of origin of the cnmial nerves. We have seen that when the lesion 
is oocfined to the giay matter of the third ventricle, the third, fourth, 
and sixth nervee are involved, and the pathological condition is known as 
mperior polioencephalitis. When the inflammatory process is limited to 
the graj matter caudad of this level to involve the nuclei of origin of the 
tanth ftnd twelfth nerves, the condition is called superior polioencepha- 
litit. These two conditions not infrequently exist together, and the 
multing clinical syndrome is that of superior polioencephalitis^ plus bul- 
bar symptoms due to implication of the npper bulbar nuclei- When 
these two conditions exist simultaneously the prognoaia is extremely 
grftve, but cases of recovery have beeu reported by Utfaoff, Oppenheim, 
Qvjtib, and others. When the pathological process is so extensive that 
it T«aohes into the cord, the name of polioencephalomyelitia is given to 
it. A much larger nomber of such cases have been reported than of 
anperior or inferior polioencephalitis alone. 

In cases of inferior polioencephalitis the external muscles of the eye 
an first involved, but this is soon followed by symptoms of bulbar impli- 
«atUQi, such as immobility of the tongue, paralysis in the domiun of the 
■ereath nerve, defective innervation of the soft palate, dif&culty of swal- 
lowing, attacks ctf dyepncea, and tachycardia. The disease may run a 
febrile or an afebrile course. 

The treatment of this condition is not different from that of superior 



pHuQRiCBarvK muaGiiIar a.trophy is the u&ine giren to a pr<^reaaiT« 
criLstiug b4<giDiLii]g in certain mascks or groups of muscles and eEtanding 
fti different parts of the body until it finally ends in deaih, either from 
iiiJifartiiiiia or by Uie iavtilvemeiit of iwuBclfia whcwe activity is necftssary 
for tlie performance of vital funt^tiona. The uttophy Is depeudeiit upon 
dogeuerativo clmtiges in the neivc cella of tho veutral part of the cerebro- 
spinal LiKis, The clinical form which the atrophy takes depends upon 
the groups of cells that are diseased, and npoti the levels at which they 
are affected. The three moat common seats of the diueaNC are the ['ervical 
{^ord, the oblongata, and the pons. Gra^lual deoay of the cells in each of 
these tegiona produces res^jectively the symptom corapleses characterizing l 
(1) Spinal progressive muscular atrophy (tl^e so-called ArttT»-Uu<:'henne 
type of the disease)^ (2) progressive bulbar paralyais, or gloaso-labio- 
laryugeal paralysis; and (3) progressive ophthabnoplegia, or gradu^ 
wasting uf the mnttculature of the motor oculi nerve. These three varie- 
ties of progreaaive nniscular atrophy uitj attended by the occurrence of 
individual symptoms which give rise to thiec distinct clinical pictures. 
In treatises on ncui-ology they are Donsidered as three distinct diseases. 
So far as they are known, the pathogenesis, causation, elinicat acoompani- 
menta, course, and termination aie the same in each one; and for this 
reasnn I shall consider them together. They are neuronic diseaaeB in 
the atricteat scuso of the word, that is, the morbid condition undeilying 
them is a progressivci gradual dcay of the peripheral motor neurons, 
starting in the cell body or in the dendrites of tho cells in the veutrai 
part of the cerebrospinal axis, and extending throughout the nenraxons 
or axis cylinders to tlie actively contractile part of the muacular auhstance 
in which the neuraions termiuate, hi other words, the spinal progres- 
sive muscular atrophies are chronic degoneratiye diseases of the periphernl 
motor neuroufl, with pnimxry involvement of the cell Ixxliesn There niaj" 
be as many clinical tyiiea as there are groups of cells or functionally asso- 
ciated groups of cells in the eerehrospiual a^is- Altliough tlie ventral 
celb of the cervical enlargement^ the oblongata and the poos, are most 
frequently the scat of this degenerative dbease, either singly or collets- 
tively, not infrequently, coiupared with the occurrence of any one of 
ihem^ the cells of the lumbar or him bo -sacral cord are diseased, giving 


nw 10 II cliaiciJ type of ttio Btropby whioh coiroapouds to the oells in- 

WImo the morbid prwess afFerta Brmultanecuslj the aell bndiea of the 
periplieral mtitor UQLiroufi in the ventral horn &ud the tennina] arboriz^- 
QiQ of the central motor oeuxong (in other vordsi the endings of the 
ppOTixooa that rome doivu through the car<l aa pyramiiial trac^ta), the 
eration extends centrifugaUy in the peripheral luotcr ue^Lrons, fljid 
iplhfug&]ly and (rentripetally in the central motor ni^iiiijns, to constitute 
mtoDiic^ly a de^JtriicUoEi of tlie cells of the anterior Lorn and a dagene- 
ntkn of the pj ramidal bracts. This process may develop in any part of 
ibupiaal cord, but the location that il ba^ eperiol affinity for i3 the cer- 
riai region. The prooaea uKuaJly extendB from here into the oblongata 
ud occasionally in the pons and farther toward the origin of the pyram- 
idil projection. This morbid coaditioD gives me to progreaHive mus- 
dji atrophy, that haa a distribution entirely parallel to other forms of 
MKSitre muscular atrophy dependent upon lesion of similar cells in 
ifctrentral horn, hut in addition and owing to involvement of the pyram- 
id tracts (whieh involvement ii not sufficiently severe to cause com- 
p)iLe impairuient of their conductivity) it gives rise i.u the phi^iiomena of 
)|Aaticity- The diaedse, therefore, vrhioli this- lesion oiiLises \s a progres- 
ntt muscular atrophy plus spasticity of vajiahle degree. Because of 
ik hei that it depends upon legion of the autenor trophic gray matter of 
tii^cord and the lateral conducting white matter of the cordj it is known 
u unyotrophic lateral flcleroais. Without entering into any dt^cussioo 
uunvbetlitr or not aaijotrophic lateral sclerosis is entitled to sejiarate 
mtnlugical consideration, I shall discuss its treatment uuder the general 
hiding of progressive muscular atrophies, but at the same time state what 
uixown ooncerning ite etiology apart from these conditions 

The progressive museular atro]>hieB occur uader two very different 
ngpices: [1) An aoquired form; and ('J) a Tajjiily form. The truth of 
lliit gtatement Itaa IniL recently dawned upon the profeseiou. Foimerly 
itvaa believed that the progressive muBCular atrophies were acquired or 
incidental di^eaees. Then an hereditary form of spinal progressive lam- 
nilu atrophy was degcribetl ; a familiary form of bulbar paralysis and of 
i^tbdmoplegia, and finally a familiary form of spieul progressive mns- 
cdu atitjphy. Giaduallj, however, it has become apparent that the 
Bclamup of motor cells in the ventral portion of the cerebrospinal axis 
mar be so defectively developed, or immaturely constituted the result of 
^Birii^, that they die in certain levels at variable times after the birth 
oA lh« individual, varying from the first motith up to the age of lata 
ouibinty. When the cells of the lumbar enlargemejit die in early infancy 
tad in DjQre than one member of the family, we call the disease a family 
tn* *f spinal progressive muscular atrophy, and the same when the cells 
of til* cervical enlargement are diseased. Under similar ciroumatances, 



when the celU of the oblcug&ta dia£ippe&r, ve c^l it the f&mily tjp&of 
progreaaive biilbfir paraljBls ; and when the cella of the ocular ci«rT«a 
fttroph^r^ Hinder flimllar circumstancea, we apeak of the dJDicaJ manifeata* 
tloiia aa a famil; fiirm of opbth&lmop legia. In a treatise of tbifl kind it 
ia impoasihle to speak of all the clinical varieties of the progreBsivo mm' 
culv atrophies in detail^ bo after tUesd iutrodaotory Temarks I ebaJl di«- 
caaa only the more important etiologioal featuresj ftnd the treatia«ot of 
the different cliniual types ^ 

(1) AugumcD Spiuaii PRooasbervE Mirscn.Au Atsofhv (Trr» 
A}tAV- D V d itavTf B ), 

Before the recognition of Byringomjelia, lorali/.ed hsmatomyelia tad 
chraaic poliomyelitis, and before the time that iiitraflpiuaj tumors were 
differentiated^ it waa belicTed that this Yorietj of progresaive muscular 
atrophy was much more common than it is dcw known to be. That it ti 
the rarest of Bpioal^cord diseases n conceded hy all. Few, if any, hare 
shown a villiDgnesa to follnw the lead of Marie, who states that tW 
diseaae has la reality uo eiusteuce; for after Edl of the eooditioas that 
are capable of giving rise to a similar symptom complex aie eicludedt 
there still remains a small niimher of caaea in which the diagaosia of 
progressive muscular atrophy dtie to deBtnirtlon of certain groups of 
cells in the venFral Epinal cnrd ULuat be made. The symptoms that 
attend the development of such decay iu these cells will depend upon 
the groups of cells involved and upon the severity of tho morbid proi'- 
eas. It has previously becu eaid that the diseaao is primarily located 
ill the majority of cases in the lower cervical regioD, This c-auaea an 
atrophy of the muscles of the hand, principally of the interossei, tb» 
thenar and hypothenar eminencea, which allows the hsnd to asgume 
^adually a typical vlaw-like appearance- The atrophy eilends to in- 
volve the muscles of the forearm, the shoulder girdle and arm, and, 
later still, the piusculature inneTvated by the motor cells of tbc oblon- 
gaU- The atrophy may finally involve the trank and loader extremi- 
ties, pointing to tlie implication of cor res ponding cornual cells. The 
muscular atrophy is attended by fibrillary twitt^hiugBr which are severeo^ 
in proportion to tbe severity of the trophic procoHs. The nnopposei^^j 
mnaclea pass into a stnte of more or less contracture, depctiding upon .^ 
the rapidity of the atrophy in the aHeeted part, and there is functiona .^ 
inability of a part or an extremity proportionate to the degree anc» j 
extent of the cont^'flcture. If the trophic procesa is a rapid one, there i -^ 
true reaction of degeneration to the faxadlc and galvanic oiirreuts in th^c| 
neuromuscular apparattis^ but If it is slow and insinuating, as it £- j 
usually, the electrii'al reaction!! are quantitatively dimLUished, or theiv:!^ 
la o&Jy pftrtial reaction of degeneration. There are no other sympto&^M 


^%|fe tlioee attributabTe to and depeniJeiit upon the (tepreojation of vitality 
I mA natritioii whidi are ct^exiateut witli tLt^ ilbeafie. Tbestr, Luwe\er, 
I mafteatimea pronoimced and aie the only ones that arc at ^1 amenable 
f |)trtatm«at. 

rbe 4rours« of the diaease U progreaaive, but not nntformly ao. It 

[ ^iTfbps ill an iiiBLDikatitig vmy, and citJDtinues by irregular eEacerbationH 

I ifldi it tCDiLers tbe parta absolutely fuQCtionless^ Tben the fori^o cf blie 

\ djouo APcms to be speut, but after a variable time evidenaes of iavolv«- 

I BtBtof couliguouB or remote groups of oeUa appear, and tho Bymptoins 

W Ifaui iadored ftintiiiue until the resp^tive part becomes ussUss- All this 

I tai the vitality is getting gradually impaired, until finally through a 

[ rontiuuaut.'e of this, or through the appearauce of the disease iu iciisclen 

tbe fuDcrtioning of vhiob ia ueooasary that vital procefifies may ^ on, the 

ptticnt sutcumbsH 

I Ktiolog;.— The causes of this variety of tbe diBeaae are utiIcqowd. It 

MUi more often in men than in wcmec, mid &-^pecially during the yeara 

uf nmture ailult life. It is raioly seen ia any other classes than laborers 

md arliAVka. It baa beeu attributed to reoeut aud remote iajjnry, both 

of tte parts that ahovr iha atrophy and of tht apioal iiord^ but it ia un- 

li^«lf that tr&UEua has any determlumg lutiuenoe, nor has exposure to 

Bold. On the other hand, the relationship uf occupation to the oecur- 

IVQM of the disease is a well-establihhed one. and theoretically we can 

wmaoB that thert> is au bxliaustiou uf the peripheral ueuronH Buyplyiug 

the naunutature that is put to ezceaaive activity in smiths, polishers, 

Mbrnderore, ete. The ocouneuoe cf the disease has likewise relatioo- 

iliipt>the infeotious fevers and to some of the metallic poisons, espe- 

ni3lj h^d. Syphilis plays no r^Me in the oauaatioii of the disesse, uor 

dofa heredity. 

Treatment. — The h-eatmeut of acquired spinal muscular atrophy i^ a 

rory foflorn ohapter in tlLerapeutics- There is an iuiprasaion abroad thnt 

Cba disease can be brutigbt to a standstill by the ufie of strychnine givftu 

hypoJ&miically in large doses. To a certain e:ctent my own enpeneuce 

eom^rates this view. I have had uuder observation for the past eight 

f'c^iit a patient in whom the atrophy secnis to have come and remained 

»t k atandstill after such treatment^ eombined with the use of faradic 

©lectrif^ity, massage, and geperd hygieaic measures, I hai'B treated two 

drtlur patients in the same way with encouraging lesiilta. But it has 

f«a]ed me in several other cases. The suggeatfon to use strychnine ema- 

■kWed from GowerA, and be is more enthusiastic iu its recommeudation 

Uun alniost any other writer. The nitrate ia the preferable salt to use, 

ajid it should be pivi>n in from one-oig:htieth to onp-sistieth of a grain, 

^*-iui gradually inereaaed until the dose is brought up to from one-aisteenth 

to me-eighth of a grain, depending upon the rseults whieh Attends its 

vdmrnistration, and continued for a period of from two to four months. 


H svm|it4hm3 y*t imjiTovement do not follov such a trial it ahould be 
kU^cuni^, «xoe|«t &J3 it may be used to meet certain symptomatic indict- 
tioiiitH A|ittrt from this, uothiug has been recommended that approaches 
H|kM'itio lunlioatioik. The most important measures in the treatment are 
w»t *.*t \\w musL'les that Are be^nning to atrophy, the use of electricity 
and iiLa«sn^ to j>rt*vetit the superiniposition of inactivity atrophy, and 
tho iH»iuU*uanw of % high degree of nutrition by regulation of the diet, 
ttxt^n^ir^ hy>,-it«ni*, rest, and steep, and the general state of the patient^s 
Untilv and tnt^ntal health. So far as the causal therapy is concerned, 
It K^Mvi without saying that there should be at once a' cesiiation of 
1li(i iHiouptttion niider tlie auspices of which the disease developed, and 
if aiiv reUltoniihip can be traced between infectious diseases or intoxica- 
%\M\ii and tht« MVurreiu-e of the disease, medicinal measures taken to coun- 
Ivrai't ami tni^reome them^ The uselessness of electricity and mass^e 
\u \iw Irt^tini^ut of progresiiive muscular atrophy is unswervingly con- 
ttuvitml for by nvmift bnt it is the experience of moat physicians and my 
ti>^ n thai when iist-d with (^t-eat moderation they are agencies of consid- 
v^iabli^ MiUw xii delaying the progress of the diseaBe. Massage is more 
M«rx useable than etinarieity. In using massage, only the gentlest knead- 
w^ mo\en»i^hlH[thould Iw employed, A very weak faradic current should 
W upplii'd daily ti> the affected lunscles for about £ve minutes. The 
dai^K^'t I* that ttK» Mtroug a current will be used. If the faradic current 
^bt«M n(4 i^uao any reiiponse, tlie galvanic current should be used, both to 
tinldi^u ihe Hkin and to eause very slight contraction in the muscles. To 
uii4Utlaia the |*i«tieral nutrition, use must be made of luild forms of tonic 
h>dtothorHpy« i»f exercise, of touifying medicines, sui-h as arsenic, iron, 
ikuitll dom:! ol' kuertniry, and iodide of potassium. The animal extracts 
U4\e \'wn uHHm>iiiended, particularly i-xtract of the thyroid gland, but 
Uto (>xUJidhed e\|KTtetu'e seems to be decidedly against it Change of 
t^uiuie, viitiluliou of the different health resorts, and sea voyages, all 
id \^ Uieh ikw> not iiifvetpiently advised, are servicelesSr save as they may 
OfcikiinUulo U» tlie maintenance of the patient's morale and courage. L^n- 
bk»' Its ^'piK'aite lalv8, or pr.>gre8sive degeneration of the peripheral sen- 
.K-i\ HK-uHtiix ^hi.uw progress is ahnoat invariably hindered by persistent, 
■iisU^JtliKatdo tn^atntent, progressive muscular alrophy is not infrequently 
V . i^l*uai*'il b> anything approaching active treatment. It remains to be 
, o'l. I Kiiudims l-hat the results of treatment should be carefully watched, 
yuA .1 Oii^ As <e.i>e iH progressing all attempts at treatment directed apeci- 
iw \'''\ ^* tho kilLvphxe process interdicted, while the therapeutic efforts 
.M' «i iiLit^l ui uutnit-aming the general health. 

iW* i*inn\\ t\pe ot' dpinal prc^r^ssive muscular atrophy is reverted to 
\, .^1 imu.hiU U^ Lhe ^iike of completeness. So far, no therapeutic meaa- 
i.Ly 'n» \xn «'iiifi^«^l t^*' '^** *^* slightest effect in staying or modify- 
".i ^v' ■ ^^i^'tt^ *^ i-**^' iji***««4e. i^inically, there are two types of this af- 


feetJOQ^ one ttiat correaponds in the distribution of the muacular atrophy 
with the Araii-Outihenne type, and secondly, the luove frequent variety 
;Lp[»arei]tly, in vhifJi the juuacular attophy begiua iu the muscles of the 
lumbo' abdominal girdlif, aud sutrceflaively iiivclves tlw^v. of the hips^ the 
thighs, and the Jege. The disease ia eharacterizod by its beginning in 
infancy or early ohil^ood^ by On manifefltation in more than one mem- 
ber of thy same family ; by its progreaaive oourae^ by the aymmelrical 
iixatioii of the atrophy ; and by Liie aljaei^ee of any other symptoms than 
those due to the decay of the peripheral motor neuron. The disease 
etida fatally in from one to three years. 

(2) CiiaoSK.' PROftRFsaiVE BuLHAK PxRALVhiis (Labio-Qlob40- 
K LAKvrtfUKAL Pakalvsib). 

Clinically this disease fi>iisista» as ita naiue implies, of a paralysis of 
the lipa, tongue, and laryniT causing n destruction of some or all of the 
functions <tf these partSj s^sociated with ati'ophy, particularly of the lips 
aiidtongite. Anatomically it ia dependent upon a progreasive atrophy 
of the motor nnclei in thp ventral porcion of the ohlongatfl. The clinical 
phenonieijji uf the disease are gradual disturhauce of aiticulatiou, oharac- 
teri^ed by slowness and indistiuctness; ditRcnlty of mastication and of 
Bvajlowing; in bnef, difficulty in executing any of the movements sub- 
BervEiL by the musculature supplied by the ninth, tenth, eleventhf and 
twelfth nerves. The inability to cloee the mouth and to pucker the lips 
gives to the lower half of the fai'e a e^mi'acteristiu expression, while the 
atttTphy of the lips an<l tongue, aciiompauied by fibrillary contractions, 
are appareut to the eye and to tlie toucb. As the difiease progresses, the 
manifestations vf labial and Jiugnal prehenstun, articulation, mastica- 
tion, swalloning, aud laryngeal activity become more and more impaired, 
while evidences of encroachment upon the lateral niifleus of the pnen- 
mogastrio are mauifeat by attaohs of oardiac palpitation aud syncope* 
There are no seLSory disturbances. The electrical exi^itahility of the 
muscles i:^ the same as in tlie spinal fi'rm of progreasive muacular 
atrophy. The actual cauaea of the disease are uukiiowTi, Like in pro- 
gressive spinal muscular atrophy, the disease ocoura in individuals who 
have put the muaculature supplied by the peripheral motor neurons 
of ihe oblongata to exhaustive nse, and the degenerative changes in 
these neurons ate tlie natural sucoessors of exhaustion- Thus the diaenao 
has been obaerveil lei glass -blowers, buglers, and eornet-players, l*ro- 
gtftsaive liulbar paraly-^is is a rare disease at any age aud particularly ao 
in the young, except the familiary form, whieh will be referred to later, 
Otcasionally, it is Ht^en in advanced life. The dispase occurs about one- 
third more frequently in males than in females, aud the caaea observed 
in females develop at relatively a more advanced age. Factors which are 





often brH reapouaible as oausatire of degeoeration in other parts of the 
nervoita ByBtem, B\ii.-h ae i-hedmatianif aypbilis, and gout cannot bepoaited 
vt etiological factors in thlH disease, it being rare lo hiid that the poiscii 
of these diapaflea has ever foimd teriBncj in the Hystem; nor cait it be said 
thnt Uie diattt8« is cIosE^ly associatiid with degeneration of blood- vessel*, 
aside from the fact that it commonly dccuih at an ejK^h when arterio^ 
BcJerosis usniilly t^ike place - 

The exciting cqubhs are first and mo^t important overexertion, 
tioularly of the month and vocal apparatiig, fright and anxiety, ener' 
vating habits, exposure to rohl| and ^all f'lrms of depraving jndu«ucei. 
Theoretically, it ia considered thai toxic factoia may be operative in some 
caseOi bxit the only proof of such that can be advanc;cd \s one of analogy, 
Tn a few cas^^f hovever^ it baa l>p^n observed that the di^eaee occurr^ 
after lead poisoning, diphtheria, and iuflLienza. But in considering th^se 
casM it niiiHt be bept in mind Umt msJiy of Uiem were reported at a time 
nhen the symptom comple:^ now dca^^nbed under bulbar ueuritia waa un- 
known, i>ccafl ion ally degeoerativc Ujibar paJay Booiua to develop aeccn- 
darily toaenteinfiammatory bulliar paralysis, just as progressive muscuJar 
atrophy seema now and then to follow many^ears after a poliomyelitis of 
infancy, Nat rnfrei|uently progressive bulbar palsy is merely an eaten' 
Bioo upward of tho degeuerative process that ia at the bottom of spinal 
prugr^at^ire niuuouiiir atrophy atid amyotrophic lateral ^nJeioais* A glio- 
niatosis of the conti^ol t^nal extending into the fourth veatnrle aiij the 
development of a tumor m the oblongata may likewise eause the syn- 
drome of bnlhar palsy. Very rarely the formation of an islet of multiple 
eoleroHifl or a immbei' of them in the ventral portioEi uf the oblongata ma 
ea^iae the ayndromo of tlii.'^ diaea^e^ 

The duration of the disease is a Terr variable one. Some cases 
a uniformly progressive couras, and terminate fatally witbin one op two 
years. In other casefi the course of the disease ia characterized by 
periods of i m prove Etiei it., nr at least by remission of some of tlie dtatre&t- 
uig symptoms. Such remissions are temporary, and have no influence 
to alter the eventual fatal outc'ome, although they may ndd to the pa- 
tient's days and comfort. Very rart^ly, probably never, doea the progreea J 
of the diseflE^e come to a staiidstilh The course is essentially chronic, and J 
month after month the gradual increase in the inlensityof thchymptoms, ^ 
notwithstanding the most a-b^iduxiua treatment^ is lanieTttable and difiCour--< 
a^g. It ia nncommoD for the diaeasa to take Uiore than from three Ux^ 
four years io nih ita course, but occjiHionally it lasts more than twice thaVq 
length of time. The immediate causes of death are universal eahaustion. j| 
death occurring from heart failure, attacks of syncope, or tlie pneumonia or^ 
swallowing^ foreign eubstaiicea, principally those taken for alimentations 
paaa into the larynx and into the respiratory passages and cause atrangula^ 
tion and suffocation, bronchopneumonia nnd localised pulmonary gangren^U 




I TrvBtmeDt.^Ahhougli this diseafie lea.dj4 iiulfcrrmly to a tcriijtaatiuci 

I ihicb UD therapy is Mr to avert, and altbougli oftootLmes our most 

I lOCDiious efforts to delay the f^tjkl outcome are ne^tivci nevorthelefifl, 

I IB the majofitj ol cases, not ouly can the patient's comfort be coa- 

I tfibiitcd XUf bat his exist^ntre materiaUj prolonged Lj assiduous ^nd pro- 

I prr trail titi en t, the real caus&Uon of tlii^ disease being unUnuwa, it \s 

I Luipouible to speak of cauaa-l or prophylactio tieatmeiit other than to saj 

I ibtLt DcciLpatioD or iujurioua indulgcucca that may poaaibij htkvc any in- 

I flaniM upon the diaeflee should bo interdicted and avoided. The mo&t 

I importAct fstctors in the treatment of chronic progressive bulbar paralysis 

I iTi the maintenance of the patient^s nutrition, and the ae^urement of 

I n neftrlj aa possible complete rest to the muaclea that are undergoiag 

I tffophy. A seniUolid and liquid diet should be adopted from the begin- 

I ung, and tbij of the most nouHshiDg kind. Milk and its various prepaia- 

Uim, eggs, T^w or slighUj- boiled, the most concentrated meat soups and 

I moTiahing grtiela, should form the principal part of the dietary. The 

I inouiitof Force required tomofitii^ate and swallow meat and the cunsequent 

vzhanstioa more thsm counterbalance any benetitB to be derived from it. 

I ThfipioteidSf olthonghimpartanteiiorgiEing agents and tissue builders, ore 

I Dot 10 nrgently required as to wari'snt giving ihem m the ahape of meat 

I ihatntust be chewed and swallowed. ProteiiU that atlmit of being given 

I ID hi|uid or in semisolid form fulfil every requireinenL (lareful diet lista 

I ^kiculdbe prepared and tlie form of food changed with sufficient frequency 

I to ^venb the patient from tiring of it. It is a mistake to consider that 

I nkrger amoont of food than is necessary to keep up the patient'd weight 

I tinfsny considerable benetit. It ia advisable to remove dry bread-stuffs 

I culyfram the dietary^ as they are most liable tu enter the gloctia and 

f piDToLfl severe attackaof epasmodic coughing. Semii^olids are swallowed 

vith greater eaae than liquids. As s<}Ou aa swallowiu^ becomea esE>eciany 

iliJ&eitIt, resort should he bad to the feoding tube. The diminishod ^eu- 

iibiliCj of the palate and vu.ult of the pharynx nhieh these patients have 

<fiiring tlie later stages of the disease contributes to the ease and comfort 

^lli which the tul>e can be pa.^fied- It cannot be too strongly emphasized 

^^katthis mode of feeding sbr^uld not be left uutilthe patient ia absolutely 

ii^^ctpable of making deglutatory efforts. This mode of feeding may oll:en 

^^^ Gufiplemented by limited recta! alimentation. A4 a fule^ all forma of 

^Jc^ulic drinks are harmful in this disease. Their ingestion tends not 

^J^cne ^t> make the jtatieiit more uucomf<jrlable by contributing to palpita- 

ticm of tie heart and flushings, but ihoy have a depressing after-effect, 

^^'*^'tEch is materially, bad. Any beneficial intluence they have tostimulato 

^(■s nutntioD is easily obtained from the administration of a naildly alco- 

■lolic or non-alcoholic malb extract. The samo may be said of tea nnd 

^'^'Ice; cacao, however, is a nutriment of real value. The patient should 

^^ ^vested from using* hia Toloe with the same sorupuIousiLeHs as in. 



paemxLOniiL. The early foL-jualion of tli« habit cl coiDmuDicatLng d^Airtti 
and thoughts gruphiealtj can only be advantageous and it la to be cuiu- 
mended. Feeble efFortft to dislcni^ food that gets between the teeth und 
cheeks by tbe tongue, as well as all other iinnecefisary movementfl per- 
formed by the labio-gloBHO-loryLigeal musculature, ar^i td be depreautud- 

Tho two therapeiLtio ineoHurea vrhioh f^aii be rootle ^ise of by the phjAi- 
oian with the best pi-oapwte of affording aouie relief are electricity And 
atryehuine^ Various ways of applying the former havt been adviaed. 
ParBOTiallj. I lielievB that any benefit to be derived from this procedure i« 
ubtaioed through its preservative inBufnce on tbe degenerating uiusetes, 
and not in any nay on tbe degouerativ^e process in the oblongata- Therr- 
fore, pulsing the galvanic current from one mastoid process to another, 
or gatvanizatioD of the cervicoJ vertebral column, is not advocated. The 
use of the constant current to cause slight contraction of the muscles of 
tbe face, toiigua, Hps, and pharyngeal muBcles, aikd to cause &rtiltoial 
awEtllowing moveiaeutB for a feir minutes each day, is tbe electricaJ pro- 
cedure that ia advised. As in aII sut^h degencrationar the dajigct ia that 
too much rather than too little electricity will be given, Hy tbia I do 
not iTieRD to noTjvey that electrii'ity is not of real B^rviye in delaying the 
progress of the atitrphy^ and particularly in fainUUtlnif eaae of degluti- 
tion. The electrical treatment ahonld be kept up ©very day for two 
months, each xin'tt-G lasting fur fr^m fire to tcu minal<ja, and then &Q 
estmiate taken i*f its efFeut. Partieular warniugmust be given against the 
use of thd galvanic current in this difiease without a rheostat aiid mitli&nj- 
psremetre. The [tatient^s c<jmfort and wetl-beiug are freqjently contrib- 
uted to by a moilerate amount of general faradization, and by the use of 
massage, 1 hare never i^een able to conciuce myaelf that massage of the 
Atrophying parts was of the slightcet serrice, bat general massage, if gii'en 
with fiuthcient nuldnes9, may exercise a tocifyiiig effect on t)ie nntrition- 
Althongh tlie ben^^fiiiial effects of strychnine ore never ao apparent in thia 
disease as they are oi'CAsinnally in its analogue, progressive muscular 
atrophy of spinAl origin, yet it ia the moat satisfactory vaacular andinus- 
oular touic available in chronic progressive bulbar pnlay. 11 fihould not 
be given bypodermieally- [q many cases it can lie advantageously com- 
bined with small doaea of morphine, especially when the patient oom- 
plaiiiB of dyspiuta. Tbe morpbiiic, given in from one-tbirLietli to 
one-tifteenth of a graiu tvrice a day^ acts as a reliable cardiac alimulant, 
vhile it exercises a soothing elTeot upon the patient^a mind. The latter 
effeut is well mao^fcst in the relief of the dyspnipa, whirh is almost 
always partly psychicab The use of iodide of potasaiumr mercury, and 
the aolifylateSf with the idea of apeciiic and alterative action, as has been 
leccmmmided by some writer?, is a fallaiy. Unless a history of com- 
paratively recent syphilis or rbeumatiam can be obtained, or unJesa there 
are other reasoes for snspei^ting theee diseases, such drugs are barmfuh 


Xitnit« of 9l1v«T, pliOBphate of tbo, anrl ergot, have b«en used ^iten- 
uiefj, but they csuivoi he reoommended- 

A&id« frojiL fiteadyuig the nutritl'^e bftl&nce hy r«at<»r&tive8 aud &ida to 
di^^tioQ uid giiaj-di&g the patient Eigaitist factors that produce excibi^ment 
oj Jepresaion, the tr^^tiuetit is syrnptociuktic. Ihe patient should laad a 
(fliet, uneventful life, aa free as poaaible from strife, worry, and imxiety. 
£ien*Lae in the open air, In inwlt^rdLJon, is eaaentifd, but care is to l>e 
taken that k is not carried to tlie pntJit uf fatigue. The utilization of au 
ccouionaj course of mild cold-water treatiuent for tta tonifying effects 
Hid bo keep up the patient's general nutrition is advisable. The symp- 
toms that Dot infr^uently re^iviire particular treatm&nt are drooUugT 
eoagbtng, dyspnea, syncope, c^ardiac palpitation^ and hysterical typ^- 
Drcioliug is not ao cuniuion a symptoni us Lui^ht ba tuferred from read* 
iag wuie of the older authors, but occasionally it ia not only depressing 
ind exhausting to the patient, but rery annoying to those about him. 
ll ja btLt slightly influenced hy belladonna and its alkaloid, or by any 
Dtber Ta^di'^ation save morphine. A^ it is not advisable to give the latter 
ia quantities sulTident to a?ect the aeeretinn, the JrooUtig must lie eom- 
biled by absolute quiet of the patient- When, however, it eeems to be 
ray czhauating, no bcaitatiou should be had in the use of morphine for 
i hvr doses. Attacks of spasmodic coughing and which are usually due 
10 the entrance of foreigu particles into the air passagej owing to incom- 
plete closure of the glottis^ are oftentimes a roost annoying and exhausting 
ajDptom. Tt can be reUeved temporarily hy the administratiun of meili- 
OMS that tend to blunt the ^nsation of the larynx, such as the broroiiles 
and morphine. But there is some dauger in uaiug these flubataucea. 
The spasmodic cough 19 nature's signal that foreign subatanees are at- 
temptitig to enter the respiratory passages. Tf the sensibility of the 
luyuge&l niuc<ius membrane is blunted, the eutranr'ti uf sm-h foreign sub- 
sbscesmaj be uDsignalledf and lead up to the occurrence of " swallowing " 
fmeumoTua. Despite this, smaUdofies of morpbine orcocaine must often- 
tuues Lie used to combat the symptoms, hut during their administration 
flltra caution must he liad icj the fei^diug of the patient, 

Dyapiuea, syncope, and cardiac pal^utatiou are all iu the liegiuniug of 
the disease partly psychical, and more may be accomplished for their 
un^lioratioik by suggestion Bnd by assurance that these symptoms are of 
AD pottentouaness or signilicance than by the admin istiati on of drugs. 
Bovever, tiie effects of a eold-vater eompresB over the heart, the admin' 
istration of a pungent ai^matie eardiae stimulant, such as ammonia or 
CtliBri may t>e partly psychical aa well as physical, am) beneficiul for 
both teaaooa. Hysterical attacks superiinpoaed upon bulbar palsy are 
nost distressing to witness, and exttemely exhausting to experience. 
The treatment that is applicable for them Joes not differ from that which 
il lemceable in hyaterieal attacks occurring without organic (liseaae. It 

liOA not aet?iiied t'j me tliat ihti hysterical attairk» have added to the graritj 
of the diaeaae in two piitienba Willi chronic bulbar progressive par^jBis 
who bav« bcon for a nunibar of jeara under obBE?rvatioa. 

If paralysiB of the Tocal ccrds or the eatraiice of Foreigu Aubstacoes 
into the reapiratorj pasaiiges makee suffooatiou immineut, one ebould 
hesitate to perform tracheotomy. 

Family Form of Chrooic FragrcBaive Bulbar FatalysiH. — Tbo f 
iary or herodiliiry vaiiety of cbionio progreaaivo bulbar paraljaia 
of comparatively recent reco^ition. It ia apparently very iD&eqneDt, 
even compared with the variety just deaoribed. It occurs under prae- 
ti^ully the same fonditions aa the infantile artd famtfiary forma of Hpinal 
progreaniTe muAcular atrophy- It oeaura in infauny and during the de- 
veSopnLGDlal yeara of life, and has no particular symptomatic fcAturee, 
aaidc from the ordinaty form, save a participation in the atrophy aod 
paralysia of the upper facial musculature- This ia espef^taLly true of 
the cases of familiary bnllmr paralyHis d<*tected in iijfajiny. Fiimiliary 
bulbar paralysis in the aduh would seem to be unntteuded with involve- 
intent cf the upt'^'' f^^'ial) but it ha^ the uuuaual complication of muacular 
atrophy, especially of the muaclea of the neck, Ae in chronio degeiiera' 
tive proj^easive bulbar pul^y, the disease is a progressive oTie toward a 
fatal eliding, but the course of tlie diaeaae ia oftentimes very slow, from 
ten to twenty years yla|i-iirig Itefore the terminatioo. The course of the 
diHcaHB iri uppart^iilly urinf!uenced by treatment, save in general and 
symptomatic indications pointed out for the idiopathic form. Theae 
should be followed out as conaiatently as poesibJe in this form. The in- 
fantile famiUary variety is not infrequently superimposed upon tbeapinal 
i/ariety of ppogreflaive muscular atrophy, or a forerunner of th© Former, 
and the treatment for the oue is likewtae the treatment for the Othor. 



Aathenic bulbar paralysis, myasthenia gravis pseudo-pamljrtica, bul- 
bar paralysis without auatomical foundatiou, are the designations given 
tro a class of caaeo in which the aymptoma in their entirety resemble very 
eloaely chronic degenerative bulbar palay, and in which after death — a 
termination to whifb the majority lead after a variable time — examina- 
tion of the motor neurons as well as of other aystema of the body fails 
to reveal any striking departures from normal. 

Notbiug \s knimn of tlie cauf^atioii of the disease. Of the casea re- 
-ported the majority have been under the age cf thirtyn It has been ob- 
served in a patient vlth profound chlorosis^ The possibility that it is 
dependent upon a chrcjnio intoxieation of endogenous, or possibly of exog' 
enous origin has been suggested. Tbere is much in the irregular iu>urs« 
of the disease as it mauifesti itself in some patients that lends color to 


ifit near that il ia depeodeut upon injurious agencies, the source of 
■fairh is vitliiu the botjy- 

The ajmptoma uauflUy develgp elcwlj. Tlia patient way have oom- 
pkiaod for &n indetiuite ttmo of easily iDdueed fatigue and il fueling of 
(irerpi>w Infills eihaustion after comparative J j slight effort, The derelop- 
aimt of the syoiptomfl ^^^Sj however, be raptd bo that the diaease reaches 
iti height in a few weeks. P^rei^ueatly the luiLial njniptoui tliat eltrtt^as 
ih0 pati^Dt'fl Atteution is ptosis of oue or boLli aides. The ptosis iiiiiy 
«p|KV liiet on one Bide, thea diaappeEir, and the upper lid of the op- 
innte Bidd befotnes a^eoted, or it ma.y ooour ou l>oth sides fsimulUneovu- 
Iftini be associated vith paresis of some tnuselea etipplied by the oc^ulo- 
CkOttir narv^, such as tha interDal or euparior rectus. FolJowing this, or 
foax% before, tht- re occur weakDesa of the luLiscIea of mastication, parefiis 
oCthe lower part of the face, and defect in aiticutatioiL and la voca.lisa- 
liou. trliich ie associated with paresis of the abductors and addurtoraof 
^ uoeal cordis. The voiea hecomes naaal and talking tires the patient 
ud quickly eifhausti hia capacity in this direction. The lipa are un- 
vield/ SJid theie may or may not be pareHia of the tongue; swallowing 
difficult or itapossible. fluids tegurgitate, aud the soft palate is lax and 
(Wpends very uluggiahly to mechanical irntatioa. ticooral weakness 
rOh a feeling of exhaufitiou in the trunk aiid extremitiefi, true amjosthe- 
bit of all the motor parts of thR hcidy iWvelops ayiumetricallj, at the 
^snifi time with or after the bulbar symptoms, lu eiceptioual cases the 
naknew maiiifesLa itsetf hrst in the arms, extends to the le^a, and eveut- 
utlj shows itself in the cranial nerres. As the disease pi'ogresaea, and 
ibu it may do with ocineiderable rapidity, respiratory aud cardiac aymp- 
toms become very distressing aud foreshadow diBBolutiou. The course 
vf die Jisease is irregular, made np of periotk ot remissiou and improTe- 
loeat and of periods iu wLich the functions of the luotor and syu^pathetic 
tWToua ayotemB are profoundly impaired. Tho manifestatioiAS through 
ibe syaipathatie nervous system are practically those ot shock and they 
IK irregu laxly periodic in ooeurrenoe. 

In eontrast to true bullsr palsy tha musclea jireserve their volume, at 

kut there is no true degenerative atrophy. Electrical irritability of the 

aaumuusciilar apparatus is preserved, but frequently exhausted after 

biief etcitation, aud irritability ia not regained until after prolonged rcsb- 

Thero are uo tibrillary twitchings of the muHcles of the face and ezttemi- 

tiF^T sad the deep relieves are present, but, like the eleeti'ical irritability 

of tJie muscles, their excitability is (jiiickly exhausted aud recovered only 

lAer rest. There are no disturbances of sensibility, either ol^jectiTO or 

mbjeetiveT and the special secses are unaffected, although all of them 

teeome speedily fatigued. Digestion is impaired and normal inteatinat 

activity ta bandieapped by lack of uiuseular tone. Thei'e is no drooling ; 

the sphineteri are intact; and the psyphirai] facnltiBS are unimpaired. 


The .nhurtcsl duratioti uf uiiy iHctirdeil cam' is six nioiithii- I ibva kuO 
uuder almoat tlaWy oiracrviitiou ii typical ca^e fur ujtward uf Jivt; yean, 
t^he 19 now ncfirer rer^overy than she baa Leeti at oiij time during tliU 

Treatmerit — Uompleto and ubaolute i-eBt to all parts of thv body, ths 
eyes, the tungiie, the throat, aiid tbe extremities, i^ the most importajit 
factor. Itestorativea aiid the careful and judicioua use t>f mcasmea to 
maiatain a high atate of nutntioni while at tho Aanio tirae erery precaution 
ifl tabea to prevent unDeceaafiiy expenditure of energy and bodily wafite, 
will bo followed hy the best reaultd. Artificial feeding by ni<?ane of Llie 
atomaeh tube should not be resorted in, as themov«iii«>iits of rej^irgitatioo 
nauaed by the passa^ of the tirbe ar<i more exhanstiug bi the patient than 
ia the act of swatlowing artificially mastitrated aiid liquid food. Oppen- 
ht^im warn* against the «se of electnoity for the purpose of caufdog mus- 
nular eontraetioD, but teouiumerjdfi oenlraL golvaniication. The uaefulaees 
of the latter bus been corroltoraied by fioMlUra, who report* the reooTery 
of four patients. In ll^e tri^atmeut af oue nf luy own u.vsea vvhirh haa been 
very euccessful 1 employed central galvanizaiion and the galvanic current 
to produce the wt^nkeot possible routraction of the muscles manifeeting 
the asthenia. 

If it is borne in iniud that in this disease all ih? voluntaiy mnsciea, 
and eapeL'ially the oblongata musculature, are in surh a state that alight 
stimulation soon e^hullate Lheui, it will not be necesHary to warn against 
the incautious use of fltryi.'huiiu% maaaa^^'f and electriciityf the three mnat 
available musde tonica- All of th<^&e may he employed if iTiteliigcnee 
directs their use. Strychnine should be given in extremely email doaeFt 
while its effects are raTefiilly watched and the moment it prodiirea any 
feelings comparable to fatigue ai^d e^hanstiou after itb physiological 
effei^ts have worn off, the dose should be materially dimiAisbedK It is 
moat v»fli'ful when symptoma of iiioflipiency of the syiupathetio nervom 
system are conapicuouB- Another drng that 1 have used t'> good advan'- 
tage under lilce auspices is the ealioylate of physostigmine in from , \^ to 
^ grain doees. Massage and galvanic electricity niay, T believe. \h* used 
to advantage if caie and attention is given to tbelr application, and if 
they are given in suflieiently small dosage^ 

43) f/iiitoMr FuuuuK«sjvK Ophthalmoplbom. 

When the gEiuglion cells in the ventral portion of the puu^ uudergo 
disease changes similar to those constituting the pathology of progroaaiva 
muBOular atrophy and progressive bulbar paralyoia* the result clinically 
is bilateral atrophy and palsy of the external muscles of the eye, to which 
the name chronic progressive ophthalmoplegia is given. Like thd other 
forms of progressive ntuscnlar atrophj'^ then^ are nosoLogitially two varie- 


bc»~the Hereditaiy iafantilo form find the acquired idiopathio tona. 
th^ acquired varictj is the more common. The pathological change 
BdArtying it is simiiur to that of ctironio bulbiir puraljais and chrouio 
pRIgnuive nmacnUr Atfopby, and tt may complicate or be complicated 
hr either of these tiro conditiona, partirularly the former. The variety 
id bulW paial^air^ that id associated with ohroiuu progress! vq ophthalmo- 
jk^ is, however, not &o typical cluiically &a the unroiD plicated "vanety. 
The 8UJtfl is truo for progtessive muBCuIar atrophy of the Aran-DueLeniio 
tjpc: In other words, v/hen the bnmt of the leaion is borne by the cells 
of the poDS and the obloagata, ar the ptjua and the oervicral uord^ tbe re- 
folting degeneration is Beitliei ao Bevero nor so extensive as it is when 
ihe pathological changes are confined cxclnsirely to one of these seg- 
wots. It would almost Ream that thL3 cause of the pathogenetic prooeaa 
Then difltributed over a larger area vaa inaiifficient to pruduoe deatrue- 
Tioa of all the cells in a given area. 

Chronic progreaaive ophthalmoplegia ocriirs nnder about the same 
impicea aa the other two varieties of progressive muscular atrophy that 
lure been described. It ia most liable to develop in persons from twenty 
to forty years of age, and somewhat more often in males thoQ ia females. 
iDTo^ieations and infections, as well as traumatism and eicposuxe to cold, 
biTS tieen held re^pouaible in some iTtatauces, but their relationship to 
ihij diseaae is no closer than la their relationship to the other progressiva 
nuafular atrophies. This, in truth, la very iriaignificant. It ia more 
than likely that some of the eases that have been reported aa occurring 
ifMr diphtheria and poisoning by the minerals, such as lead, were de- 
pendent upon a nidimeiitiry form of neuritia of the ociilf^niotot nerve. 
Itax!d£ianally develops in fiyphilitie individaaU who are benefited by the 
administration of antisyphilitio remedies, and thua this infection is con^ 
udered of some ciuaal Importance. It 13 moi^t commonly a comphoation 
fJT iQt^ral pari of some other diaeaao, Euch as general paresis, locomotor 
jUuia, multiple sclerosis, and the progressive muscular atrophies already 

The disease is evidenced almically by the gradual and progresfiive 

oeeuretjoe of functional disability of the external musclea of the eyes 

which progteasee until theee muscles are completely powerless, usually 

usociated with a slight or moderate degree of ptosis. The initial sjmp- 

bOJD ia diplopia, but the patient siion u neon scion sly Buppreaatts one of the 

inugea and depends upou monocular vision^ so that after the disease Las 

luted for a time the patient does not complain of seeing double. The 

tatemal eye muscles are usually spared, but they may bo involved to a 

oonsiderable degree. The diagposis can readily be made by process of 


The rongenital variety is invariably osaooiated with lack of develop- 
ment and funt^tional incapacity o£ the facial nerve. This form of the 


disease ia skin to the fouiiJiary varieties of Ijulbaj- atiil spi&&I fttn>i 

that are aufiposed to be dependent upon incompleie de^rdopmeDt ot a1 
\\hy ot the r<.^a|:^ctive nucld. The oourae of the disease in this variety 
ia apt to be uiore sta.liQiiary and is sometimuB associated with «Tidi^jic«« 
of liypojplaaia of gtlier parta oL' tlie central nervotia sjsteai. 

Tre&tiaeat.^Less cod be dcme in the treatment of chroaio ptr^reaaivo 
ophthalmoplegia than id any foTjn of progrdBsive muscular atrophj, and 
foi' the simple reasoc that we are utkable to apply the measurea, such as 
electricity, masriaget and re^t, that have sfnim capacity li» dpiuy the prog- 
r^aa of the atrophy in othar vatintiea of progreHsive uju^nnilar atrophy. 
ULdeaa there be goiuc apecUic causation of the difioafie^ auch as sypbilia or 
niQCallic iutoxicatiott, that allows of Bpeoi^o medication, elforts at treat- 
ment are limited to maiutaJning the general nutrition of the patient^ and 
adviiing complete rest of the muscles involved. Strychnine does notseeni 
to be oF any nae, except as a general tonic, nor do ai'secic and iodide of 
potassium. When the disease occurs as a forerunner or concomitant of 
other discaacB, such aa have been meationodj tieatmfint must bo directed 
toward opposing them. 

4, AuTOTbOFEiic Lateral Sclerosir. 

The noAoIOKicaJ relationship of omyotrophio lateral ecletosi^ to tho 
pTOgteseive muiioular atTO])hios has already been spoken oL This disease 
is characterized by the symptoms of pTogresaive muacular atrophy of tba 
Aran-DueUeuiLe type, complicated with bulbar involvement, plus apa&tic 
paresiHf particularly of the lowvr cKtremitiei^. and eiaggtsratioii of the 
tendon jerks all over the body. The aymptoma of spasticity ueually pre- 
cede those of atrophy, and it is therefore believed that iniplic^ation of the 
terminations of the oentrjil or cortico-motor neurons antedates that of the 
peripheral motor neurons. That tbia is so ia shown not only by thn oc- 
[^Liirenice of spaatio symptoma before Ulo trophic »ymptomH, but l^ the fact 
that when cases come to autopsy the morbid process in tlje central motor 
neurons gives every evideu(;e of having been complete for some time, 
while that in the peripheral motor neurons is in progress. Although 
occasionally the disease ia accompanied by pathological changes in other 
parts of the cord^ such as degeneration of the posterior eolnmus, aa a rula 
the symptom complex does not include any disturbances of aenaibilil^ or 
of the cutaneous reflexes, or diflturbanco of the f unctiona of the bladder or 
bowijls. The absence of such symptoms bespeaks the limitation of Ulo 
disease process to tlie anterior horns and pyramidal tracta. 

The etiology of the disease is practically unknowDH From analogy and 
from infareuce, particularly those based upmi the findings lu cases studied 
microscopicalTy, it (a believed that the anatomical basis of the disease is 
conditioned by somo chronic intoxication acting through the vascular sya- 


TKe forces that detenDine Ibe inrolrbmeDt of the termin^tioELfl f>f 

Ae c«litr&l motor neuroud and the Leginmngs of the peripheral motor 

Mcuous f&n onlj bo conjeotured- Such injiulous indaenoea aa hereditary 

4npo«it^GD of ganglion aelJs in different parts of the ceTebroHplnal a^ig to 

ifttego decay wtlhaut ailm^uate caufief Jiiniiife»ted by the or^currBnce of 

BldMl or nouronic diaoHS^s in tho collateral ancestry ; CAhausting uver- 

vork of the ext remit lea ; trauma toouoof \^& extTemitdea or to tho apine^ 

fianUar depravity following repeated eiposurfl to cold, intoxication b and 

iftf«ctonfl, may have this effect, but we oannoC prove it. As a matter of 

bet iniectious disease, syphiLia^ in toxica dons, cold, oToessea^ and the like, 

lire iippoiently very liLtle relationHhip to the occurrBDL^ of the disease. 

Itoccura in males and femalea with e^ual fieqaoncy, and develops ordi- 

urlly between the thirtieth and fortieth year. C'ccaBionaUy the onset 

d the disease is rather abrupt and tbe patient succombs in from twelve 

iprtghteen months. As a rule, however, symptoms develop insidioualy 

ID^ tbe course of tbo disea^a aver^ea from two to threi) yenra. 

Ttcto is a well -eatabli shed familiary variety of amyotrophic lateral 
idwoais, which like all other familiary disease of this does occurs in 
doJdhood and porsuea a very chronic courscj being oftentimes stationary 
top* number of years. 

Treatment. — The treatment of amyotrophic lateral sclenjsis la ptaoti- 

al}f the same aa that for chronic myelitia in addition to the general 

i[i«tfar?s that are of service in maintaining the nutrition spoken of under 

ipafll progressive muscular atrophy. No drag medicatioQ has the slightest 

dbct npon the course of the diaeasa. Tha intensity of the spaaticity may 

bi wunewhat decreased, and the Buffering engendered by thia condition 

nitigated by the oae of prolonged lukewarm baths, in which the patient 

may remain for from two to four hours out of tho twenty-four. The crip- 

of the patieut through the B]T£Latioity and contractures that occur in the 

ed mu3oles after atrophy has become well pronounced can be over- 

to Gume extent by the persistent use of active and passive gymnaa- 

tira, but oftentimes the annoyance and fatigue attending such indulgence 

more than counterbalance the slight beneficial effect. When the morbid 

procffis invades the oblongata^ the symptoms of bulbar paralysis should he 

tTOt«d ic the same way as has already been mentioned nnder that captiOD. 

The s.ime r-nre must be expended upon the Feedings and all that this im- 

phsft, that is necessary m true bulbar paralysis. The entire treatment of 

uiyotrophio lateral scleiosia may be summed up in a word: make the 

patimt aa romfortable as possible. For patients who can aSord it, this 

is most satisfactorily accomplished by providing them an mtelligent nurse. 

Thote who cannot should seek the shelter and care of a hospital. Despite 

this gioomy view of the treatment of amyotrophic lateral sclerosiSf the 

pbynciao should not despair- It is net too sanguine to oz}>ect that na^ 

tiLr« ha» provided a remedy to check the disease if it can be found and 



applied liefore the neural i'tinstitueHtSj tJ>e decay of which fonua the 
anatomical bofiis of the diseaAO, have pembed. This is aurdy true if 
the pathogeny of the disease is the result of flome chrouio intoxication* 
li the flisease ia a tettitologiaal defect, a disease of iDvolution, it is idle 
to eearch for suc>h a remedy. 


{Tht Peroneal or L«g Type of Proffresaive MuscidaT Atrophy.) 

ThiB variety of progresaive moscular atrophy has been studied espe- 
cially by Charcot, Marie, and Tooth, and is not infrequeotly referred to 
by rhe names of one or all of these investigators. Billing the past 
f«w years it has TsofiiTed extenHive consideration based upon iiiose clinioal 
and anatomical studies, both heio and abroad, so tliat at the piesent time 
the clinical delineation is well known and tho morbid procesaes upon 
which it is dependent bid fair to be satiGfaotoriiy elnoidatpd, although at 
the present time th^y ar^ not entirely so. After the disease was first 
d«seribed it was contended by many winters that thd morbid pniceHs was 
predominantly J if not exclusively, a degeueratioD of the nerves with 
secondary involvement of the spinal cord, particularly the columns of 
Golli but at the prespnt timo there can bo no doubt that the so-called 
"neural form" of progreaaive muscular atrophy is dependent upon dif- 
ferent anatomical processes. In some cases il is primarily a diseaae of 
the peripheral nerves, while in other cases it X'a just as certainly a primary 
myopathy. Furthermore, it is wholly probable tJjat in some caaes the 
pathological changes occur simultaneously in the spinal cord and per- 
ipheral nerves, or even primarily in the cord. The clinical picture of 
this variety of the disease, it may therefore be said, does not depend 
upon an individual patbologino-anatomical foundatioTi, 

The s^niplonis of the disease are, it may be readily inferred^ subject to 
variation in kind, In intensity, and in course. As a rule, the muscular 
wasting begins in the musculature of the peronea] nerves, and is manifested 
by the gradual occurrence of club-foot. Occasionally, the atrophy shows 
itself first in the upper extremity, especially the small muscles of the hand 
and the extensors and flexors of thefur^^aria. Wherever the primary mam- 
fesialionB of the atrophy may be, it may extend to any part of the body. 
In a case recently reported by Siemerling, in which the initial muscular 
atrophy was of the thighs and the bands, there evontunlJj' developed loss 
of the pupillary reaction, nasal speech, tremulous voice, in addition to an 
extreme degree of paretic atrophy of the forearms and entire lower ex- 
tremiiy The diatinguiahiiig cliuical features betwe*«n this form of pro- 
gressive muscular atrophy and the spinal form are the sensory disturb- 
ances which are never absent, and the more complete reaction of 


;r«tion id the atrophied muscles to the electrical eurrcnt. The 

of this dtseaM, aside from the fa^c ih&t it is a f&mily afr^tiim, tun 

eatii^jr mikiiowi]. It usually begma daring ihe early years of life, 

tltEiCst invariably before the age of pabcrtj. and pursues an extreiueljr 

^uooio and irreffalar course. That tht-re are esceptiona to this rule is 

ihova hy the fact tbat Oppeuheim a-nd Cassirer have reported a patient 

ia whom the disease began in the forty-second year, aud Kgger haa da- 

SfTTibed the disease as it occurred iu two brotliera, aged reapei^tively thirty- 

tbrni and thirty-eight years of age. Tha male aei ia affected oftener 

ihaa the female. The customary attributable exciting eauaos, such as 

«ipoeare, intcucatioas by Jead, alcohelT and syphilis, aa well aa the In- 

liinted diminished capacity of resistance of the nervous systenir ara 

i^ea of In the etiolugy of the, but prnctieally nothing is known 

•\'. Its real causation sava that it is a faiuily affair. 

Tieatmeut — Tha treatmeut of thia form of prograsaive muscular 
iLro^by oalla for the measures that have been ouumeratad in dieoussing 
tU treatment of progressive muscular atrophy of spinal cord dependency 
ud the progresaive muscular dystrophies. The fact that all family 
nervous diseases pursue a much slower courHe and are oftentimes ehnran- 
trniai Ly mcie oi leaa prolouged eessatiou of the apparaut activity of 
tLe dueaae, affords opportunity for tha use of Glaatricityf moaaage, and 
^omaAtica looking toward tl^e retardation of the morbid process and the 
cLugea in tha muscleB. The fact that the disease usually ba^ns in the 
fHC ud the legs, causing soma vartety of club-foot which seriously cri]>' 
plra Ihe patients, prevents them from getting the eiercine antl indulging 
lA soma of the pleasures of life that might otherwise Ire afforded. These 
defrmuities ahmild he ai^bjected to the same kind aad grade of orthoptedio 
treatment as similar deformities arising uuder Other conditions. 



Tbi3 term musoular dystrophy is applied to that form of aticph^ in 
wbicli the primary changes are in the muscles themselves, in coiitTadiB- 
tinctifm to ordinary progreaaive muscular atrophy iu which the atrophy 
is Beoondary to disease of the ventral hora cellB of the spinal coid, or the 
peripheral motor nerves. Formerly the progressive muscular atropbieB' 
and dystrophies were not differentiated, but so soon as it began to be 
reaognized tliat tlie former were aliimst iiivariahl^r acquired dise&ses of 
adult life, and that the latter were either family or hereditary diaeasea, 
occuTTing iu infancy and early adult life, the distinction be^an to Le made* 
In latter joars the tendency haa been to draw the line of separation very 
cloaely, from :m anatomical standpoint, between the progresflive muscular 
atrophies and the dystrophies. The result is a more op lesa widdy dls- 
aeminated belief that in the dystrophie[4 Uiere are no pathological chang^es 
in the spinal cord. Aa a matter of fac^t, it is highly probable that iu 
every case of the latter affection there are secondary changes throughout 
the entire peripheral motor neurone^ especially after the disease has ex- 
isted a long lime. 

Auatojnically, the [irogtessive muscular atrophies may be claBaiflsd' 
according to the segment of the peripheral motor neuron that is affected 
into myelopathiesi neuropathieSf and myopathics, according aa tke cell 
body, the nenraKon, or the intramusculLir ending is primarily involved* 
In muscular dystrophy the legion in the beginning ia in the intrannisoular 
nervous substance. The pathological changes that are found in the neu- 
raxon and in the ventral hum cells are secondary and have nothing to do 
mth causing the phenomooa of the diaease- 

Formerly a number of clinical varieties of muscular dystrophy were 
described and much energy was devoted to the eslabJishment of dijiferen- 
tiations between the types; but to-day it is futly recognized that niusimlar 
dystrophy ia a distinct disease suhject to variations in the time of its de- 
velopmentr in the groups of muscles which are aSeited, and, to a lesH 
important degree, in its clinical features- Separation of the clinical 
forms of the disease is of no service, save as it may facilitate prompt 
reoognltion of the disease and thus indirectly contribute to an estimation 
of the course and prognosis. 



Itfany clioi^al typea of progresBive muscular ilyatropliy are described, 
bat I ahall refer only to the thteti important ouee. These are: 
1 Pseudo-hype ttrophic paralyaia, which oocura in eatly childUood, more 
often in malea tlian in femakflT E^pd wUicti showa itaelf first in the lower 
eitremitiea, especially the calves, by apparent h3'pertrophy of these and 
other groups of musclea, asBOCJated, however, with loss of Btteugih, The 
enlargement of the muscles is due to a progressive li|iouiati^iB vhioh goej 
on at the expenae of the muscular fibres aud a myoacleroaifl. The dis- 
ease then extends to the truuk, eapecially to the musclea of the ancro- 
luiobar region, and givea riae to a characteristic gait^ station, aui mo<Je of 
assuming the erect posture from a reoumbent one. Later the upper ex- 
tremities become affected, especially the Tunaoles of the shoulder girdle 
and upper arm, and as a rule thcHe muHtiLea atrophy without undergoing 
a preliminary apunou:^ hypertrophy. The muscles of tlie forearm and 
face are spared until very late in the course of the disease. Aa the 
disease progresses, the apparently hypertrophic niUBolT^ shrink pro- 
portionately to the completeness of the fatty trausformation aud uiyo- 

Leyden and Mobiua individually callad attention tu a form of mus- 
cular atrophy that resemblea this typo in every respect aave that the 
dystrophy is not attended with any conaiderable paeudohypertrophy. 
Some writers have endeavored to create a apecial type lo which theae 
ctiniciana' names are attached, hot happily without suceesH. 

2. A fado-scapulo -humeral type, to which attention waa first specifi- 
cally directed by Laudouzj and Dejerine. The atrophy, aa the name 
indicates, reveals itself firat in the face, especiEdly in the orbicular inuaclea 
of tlie eye and mouth, winch givps a peculiar cherubio expression to the 
connteiiance, known as the myopathic face and tapir mouth. It then 
extends to the shoulder girdle aud arm muscles, very rarely to the lower 
extreniitiea. This variety of dystrophy la not a^fiociated with any manl- 
featationa of pseudo -hypertrophy. It occurs iu early childhood and oooa- 
flionally at any time up to the period of adolescence. 

3. Juvenile form. This variety has been particularly studied by 
£rb, aud firnt reveals itself ithiiut the time of pulierty, acid has a distri- 
bution very similar lo tlie faacio'Scapulo- humeral t^ pe^ although the pri- 
mary macifeetation of atrophy ia almost invariably in the shoulder girdle, 
while the face is involverl later- Occaaionally there is a alight degree of 
pseudo- hypertrophy accompariymg the devfllopm#nt of this form, 

Tha accompanying table, taken from Sacha^ shows the comparative 
^tSmilarity and differences of these three forma of the same disease : 



Parl n rat al^. Lt^jB (calve*) 

DJoLributinn of^ Cslvca, nttsly thighn. 



TJitghn, ctf^tp initsclfw 

aiid nCBpuLiir iiiiiV' 
cli^, CalveA during 
Jater poriod , \l th^v 
ilm« aIbo niDueritl 
¥iui&. loraAmi, nnd 

JuTenUp l^cm nf pro- 
Hn«lv« iiiLi*«ulAf niruribT 

BbDiilder glnllc ..,,., 

MiiHclon uroiUDd AbouL- 
d»r a;irdle niiilp«lv[c 

TJtl^he, deej) mnitcleft 
of baok, upper aruk, 
[hptilriipliicd part0 
ujftj iHicome nlrophlc 
in Uter filoge. 

Fict. fin'earifK hind 
nnd Itg muwilea. vx- 

GVpX iU IftKl bLlgCBk 

Fftce ftod 

gird to. 


cludlng lips and 
orbicultiri* P^lt'^ 
braruiu , Blioulder 
Ami dupulAT muff- 

Fnreimi, hftiul, uid 
li^)^ aitd deep mu^ 
cIm o( bsck. 

Treatment of the Dyalrophiei.— The ineffii'iency of Uierapeutic meoa- 
ureq to ri»]m wilh tmisciil^r d^slrtiphy is iti a Inrge nieaaiire eiplain- 
Me hy the f&ct thnb we are dealing 'irith iui evoUitionary defect io the 
iDLiacIeA, find aa there ia rerj libtlo kK>rrowiiig from art to lend to itature 
very little can bo acoompliahed in (.lelajingtbepmgreas of Iho disease aft&r 
it hna 011(0 become manifest, nor is there any way of prevpniing tlie diaeaae 
esrept bj" the Toliititary reniiiiciatioii of pmerealion by tliose who*B ances- 
trol and collateral family hisUirieB shew ibis dbeaae. It should be kept in 
mind that n<'b all of tlioso whose ancestry or family reveals the eui«tenee 
of dyatrophy develop the disease. Many of them do not. It is in such 
inrbviduala that great care should be had that x\o strain or eic^aa be put 
mmn the neuronmsnular system, which might awaken to realil}' the dor- 
mant dyHtn^phiu tecideuoy. As muscular dyatrophy iu all its clinical 
varieties la a disease of infancy and early youtht it need not he naid that 
these preeantionEiry measiireB are to be ta^en partieularly during the 
eirly years. It goes without saying that individuals who are affltcted 
with the disease should not marry. Thoaa whose immediate family hia- 
toiy ah^Wfl the existt^uce of the diaeaae should be warned of the danger of 
reappearance of muscular dystrophy in their deaoendants, even though 
they themselves remain eutireiy freo from it, Such individuals should 
be urged to remain unmarried, and if they are married^ to reoain cbild- 
leas- As a matter of fact, the phyHician rarely has the opportunity of 
advisijtg ur applying prophylactic treatment except in those instances in 
which aom& member of the family who is already under treatmeiit for 
this disease. In such a caae the apparently healthy children should be 
carefully iuatnioted ia the development of their muscular syal^ma by 
systematized exercises. The 'difficulty is to choose a happy mediain 
between over-eierciHe which might arouse the latent tendency to the dis* 



iftse and insufficieut exercise which miy;ht atlov the muautett la fall into 
a itite of iiirtCtiTity atrophy. The general care of Buch an iudividual 
lliCFald b« dirooi^d to maiDtaiiiiDg a aupieme degree of uulribioii. 

Alter the dystiophiea have h^giiu to develop som^chiug cau &lvaya 
bfi doEie, &iid r>fte[i :t very great deal can be acoomplLshed, ia delayicig 
the course of the disea^, by Uie pro|>er utili/aLJun at gymtJAHlicH, mfts- 
ng«, electricity, proper dittary and hygiene, and the co-operation of 
ibe erthoptedio surgeon. All wrxtcta are aeemingly iu accord that ayate- 
Bftiic exercise is the most important uieasure- Afevcases have been 
repined in whif^b it would seem U^at the progress of tlie diabase hid been 
liTuQ^bt to a stjindHtill hy the usu of tliia measiiri^ akme. It ia iiripnaaible 
ic MV, except ill a general way, what form of gymoaatic LiidulgflncB wil] 
\i! bfoeEoial iu :l given case. It depetida eomewhat upon the cliuical 
Xf^ uf the diaoasc, u[>on the ataga of the diacaaei and upon the age of 
11* j>atient. Aa a rule, it may be said that some form of resistaxioe eier- 
(iv, carefttEly graded, partieular cav^^ htilng taken not to put too great 
miaUiicc upau the atrophied ujusclea or groups of niuHcIes, ia the moat 
Uu^tit^ial- It has thd advactage that it may be eniployed iu very young 
efaddrea vho cannot be taught ordinary gyumaetiea. Although the ca^iea 
ihkt have been reported in which systematje at^ti^e and passive exercise 
Tas followed by conaideratla benefit urs uf the facio-acapulo-hnineral type 
uid ;he juvenile type, tljeoietically tliere ia no reason why it would not 
be 3£ iTadable in the paeudo-liyjrcr trophic groap. In these latter casea^ 
DDforCunately, the appurcnt hypertrophy is often taken by the family and 
b; tbe phyaioian to indicate exceasiva muscular derelopnieut, auU the dis' 
OM is not recognized until it has p^sed into the moderately advanced 
sage uf iJpoEuaUfsi^ and myoaeleitjais. Then usually much time is wdHted 
in lieauhory application of electricity before Bystematic eiercise ia begun. 
The truth is that up to date the moat iukportont measure in delaying the 
progieeft of muscular dystrophy ia systematic exereiae, aad the sooner it 
is began the greater 15 the prospect of improvement. The hazard attend- 
ing its use ia that it Tuay be overdone. The physician should be content 
«itb comparatively alight resLitta even after the expenditure of prolonged 

Electricity is cf very alight aerviee in the treatment of the dystro- 
phies. This uifiy be explained in part by the fact that it ia rarely 
apptierl aa metltudically and pEH'M^stently a4 ahould be done to make 
legitimate fratimate of its capacity to delay tlie atrophy. Iu muscular 
4ly9tn>phy the electrical reaction is quant itativtjly diminishcfl in keeping 
with the degree of degeneration of the muscular Sbre. There ia no true 
Motion of degeneration. This, of course, allovrs the galvanic or faradic 
cttrrent to he used so as to produce must^ular contrat'tiou, and auch mus- 
cular contractioEi, if brought about carefuUy and without much inlenaity, 
m theoretically of scrvico to prercnt at least inactivity atrophy, and it 




may be of some use to delay the specifio atropby. The greatest care 
maBt be exercised not to OTerdo tbe apiiliration ot electricity. A lev 
coiitractioua in the Ktro^Lied muwrlea ptoduceU otice ot twice diuly m'e far 
mow advisable ibaii a prolonged niaricc. Tbe ooaraely interrupted fttradic 
oarrout is mord &dviaabb than tlie gaLvauie, tapeeially id the early etages 
of the diseBBO, Tbe galvaula currtut baa tbe advuitage of Htmulating 
tbe krf;a] uireulatioii luure tban tb« fftradic, aud it miiy therefore be legiti- 
mately olbenjated with tbe former. The effects ivbich electricity bai to 
iiopTove the local Qutiitioa are much more dcSmtely obtained hy the lue 
of massage, whicb flhiiuld be applied in the shape of very light muscle 
Xneadiiig to every c&se of muaoiilar dystrophy. In tbe utUization of 
these three measures, exercisef electricity, and maanage, sight should net 
be lost of tbe fact thai in the interval of their application the patient 
should be aa nearly as poaaible at complete rest. Nothing can be oiiuie 
injurious than the attempts of patieutB to drag themselves about wbec 
the lower eictremitisa are tbe seat of muscular dystrophy', or to use tlie 
upper eitretnities in some occupation when the disease ia of tbe ;uTeni]« 
typ0. Thiaflbouldnotbe construed to mt^an that tbe patient should not be 
in the open air, and under auspices that contribute to general tonificMioo 
of tbe uiuaouLar Bystem, The aid of the orthcpcedio surgeon should ht 
sought jiifit as soon as deformities arising from oontra.cture of unopposed 
niui^tFs iiiterfei^ with tbe getting altout of the patient. Such contrac- 
tu?(4a should be overcome by partial or complete tenotomy and the parts 
retained In an approximately normal condition hy tbe use of tbe iudi* 
cated prothctio apparatus. Occasionailyt soma aucb apparatus may be 
beueiicial in giviog support to the parts that are not deformed by tbe 

During tbft past few yeartt various njihual eitrarts have been 
thoroughly tiied in tbe treatment of dysLropby with the bo]>e tliat benetit 
might accrue in some unknown vay. Extract of the thymus gland has 
been ojctensjvely uaed and to lesser ojteut that of the thyroid also. In 
my own experience there is not the fllightest eemblanoe of evidence that 
they are fif any beiiefit. 

In brief, tbe treatment of the inusculai dyatiophiea consista iu the em- 
ployment of those physical measures that are known to tonify the muscu- 
lar syfltein; in the adoption of dietary and hygienic means that serve to 
maintain general nutrition, and the adoption of meaeures that overcome 
deformity and contribute to tbe comfort of the patient- So far, no drug 
baa been discovered that exercises any inHuenoe upon the course of the 




Toe n&me myotonia coQgetiita is givca to a peculiar family disease 
first descrtbed by Thomaen, a Sitesiau phyaioian in whose faraJy more 
than twenty cases occurred. lb is chnracterlwd. by the octiunence of 
diramc contTartiou in all Ihft voUmtarj niust^lt^s ou attempt at inaerratioa 
ormovcineut, ffMl« nt real t))e ncufomuacuUr sy:»t«m a^/peftrs to be qi^ite 
DdiDal Eiave for tlic hypertrophy of the mueclea which always exists 
ti\et the disease has lasted for some time- The disease is classiBed as a 
fimiiy affeetiOQ, Lrnt that it is not always familiary has been pcoveu by 
a amnber of renent reports. The hereditary faotor iu its causation may 
ti« Euauifest as a diiect transfer from an aac^eudant or indirectly by lu- 
herited dispo&itioa. The predispositioLi to its occiureQce loay be atavis- 
^. Jaoohy, among others, has showa that the symptom complex of the 
disease may ocour independently cf neuropathic beredity, developing 
after a/rute infectious diseases, such as typhoid fever and diphtheria, and 
transitorily after depraving indueucB^T such as piolonged eiL|}OBiire tu 
cold. He suggests that the iianiea myotonia acqaisita and myotonlA 
tranaitoria he given respectively to these forma of the disease. 

Myotonia cougenita usually maoifeata itself m the early yeai-a of 
childhood, or at least before puberty^ aud frequently under the immediate 
Allspices of fright, shock, or mental excitement. The essential feature 
of lh« disease ia the occnrreuco of tonia apjum iu the voluntary muaclea 
<ID attempt at purposeful movements, and the inaljility of the patient to 
nlan this tonio condition by force of the will. At the end of tifteea to 
ttarty seconds the contraction reloEes spontaneously and after several re- 
peated attempts at motion followed by a ainjilar tonic sjiasm t€ a lesser 
d«gree, the patient ia finally able to perform such purposeftil movements, 
ind for a long time, ua walking, running, and dancing. The muscles 
pFWeat a characteristic mild tonic reaction constituted of normal me- 
^hnieal, faradic, and galvanic irritability of the motor nerves, and 
Lticraaaed irritability of the muscles. These, combined with absence of 
all symptoms pointing to a grohS iiivolvempnt of the itervuijiij syst^^jj, go 
to make up the essential featuie cf the dieease. As in moat nemop&thio 
souditioas, the occurrence of this disease is not infrequently associated 
mih other symptoms pointing to an unatable nervous system^ such as 
jwjchical symptoms, epilepsy^ and migraine. 



It is reij doubtful that the disease can be looked upon as a congeQita] 
almormality of the Deuroisusoular eystem, particularly id light of the 
fact that fuiquired oiid transitory forTiiE ocour. It nouLd ae«m more legiti- 
mate to poatulate aii inherited or fauiiliarj instability of this system which 
ean he called into autivemorbHity by factors arising from within And with- 
out the iodividuaJ. Such aa iiiaUbility of the iteuromuacLilar system may 
&]bo he aaqoired. Id the congeoital form very little can bo done to pre- 
Ti^Qt this instability, but much may be doue to dolay the advent of itfl 
manifestatioos. The patii>iit whoae hirlhrlght entails the potentiality of 
this disease should he Advised coucerniTig the Belection of an oc^jpatioo 
or profefision, and couceruiug the queatlooa of ujarriage and propagation. 
He should he warned against those indulgences and habits that have ft 
tendency to increase the irritability of the nenromuacular system. Such 
are sCrainBf exposure to exceaaive cold and teat, exceeses in eating aad 
drinking, mental excitement^ and the like' It should he made known to 
such pHtieiita that a quiet, uiiftventEul life may bo Full of usefulueaa to 
themselves and others, and the DJtistence of their disease need not neo««- 
aarily shorten their allotted days. No treatment has so fnr been aug- 
gSBted that ia of any semce in overcoming the luiLntfestationd of the 
disease, save the adoption of measures looking toward this kind of aa 
eiistence. Naturally, elentrieity, mnsaage^ gymnastics, and fiwedisli 
movements have all been thoroughly tried. They do not seem to havf^ 
any paiticular Iwneficial offai^t, Some physicians have claiojed that they 
have noted tunelioration of the disease from the use of massage uid 
graduated gynmastJo exerciBCB, but the conaenBua of opinion is that thoy 
are nf v**py slight R^'tvicfl. In the acquiied .form causal therapy should 
be employed in addition to the general measures alvea^dy mentioned. 



Tetaxtts IB an iLQute infectious disease luanifesting ita injuriousDeaa 
principally on tbe neuromuacular S3'5teiu to c^ubg tonic apasmai iritb ex- 
iRibAtiOQS wliioh show tbemBclvee fiist in tbe musulea of the jnw tutd 
Itier in all the voluntary muscles. It a due to the teUntis bacillus and 
to ihe toiin which it forms. The bacilli gain entraijce to the sjswm 
throtigb a wotiiid iu the slcin or muooua membranB, which is ofteDtiines 
wtnrial that the patient has uo knowledge of it, or has forgotten iu 
occurrence. It ia univerBally believed that tbe bacilli cannct peuetrate 
tbough the unbrokeo integument, but there is tnui^h teatinionj going to 
iboT that the muoous membrane does not offer fiuch complete resistance. 
it Hf nevertheless, probable that when thej secure entrance through a 
membrane, the latter has previously suffered some loas of its epithelial 

Stiolo^.— 'Tetanus is deaoribod as of four varieties from an etinlogic&l 
itandpoint; (1) traumatic^ (2) idiopathic; (3)neonatoram; ('l) puerperal. 
As a roatter of fact it is entirely probable that they are all due to one 
DiBfle, the tetanus liacilhia^ and that in the idiopathic or rheumatic form 
thf bacillus hafl gained entrance through some vjnknown abrasion of the 
tegumental surface. In the laat two varieties the bacillus securea en- 
tfttuce through the funis and through the denuded inner surface of the 
Dterus. The tetanus bacilhis is prpsent in countless numbers in the 
nrtbt particularly in certain localities. This accounts for the fact that 
tiia diaeaae is more liable to occur in laborers, such as gardeners and 
hfinare, and in those who get wounded by aonie implenient lying on or 
in the ground^ ^uch as a nail, a BCjthe, or a splinter, arid in those who 
blTiag got a wound of any sort attempt to stanch tlie bleeding by the 
ippliration of earth. Lowered vitality is undoubtedly an important pre- 
diaposiug cause- Thus it is more liable of occurrence iu those who are 
lurrounded by depraving inRuencea. It occurs more often in the spring 
ud early summer and during wet eeaaons than at other times. In this 
xraitry the negro race aeema especially predisposed, especially those liv- 
ing in the Smithern states. In certain sections of the country, such as 
ia LoDg Islandf it seems to \te endemic. In the larger cities the disease 
is rardy seen. This is probably accouuted for by the fact that wnunda 
iw properly dressed in dispensaries and hospitals soon after their occur- 



rem^e. Naturally the decrease in frequeocy of tetanus is due to the 
almost iiQivcraal plan of treating wouuds of any severity flaeptieally. 

The baeilli of tetarms do not multiply and propagate within the body. 
Their locus b Immediately Burrouudiag the wound, and tLere they muj- 
ufaoture tLa toxins which on heing absorbed into the ayfltem c&use th« 
pbetiomena of the disease, The knowled^ of this f^t h&s led many to 
advise that the seat of the wound and Ita iTUtoediSite aurroLmdinga b« 
completely extirpated in order suocesBfully to prevent further intoxioa- 

Symptoma. — The period of inmbation ia not definitely knotrn, but in the 
majority of inatanoes it would seem to be about from two to tea days. Id 
some insta&cea it is much longer. The onset of the disease is usually 
marked by slight stJffneBS of the neck and face^ which may become so 
i!Omplete before other manifestabioiis of the disease ura;ur thaT^ the jaws 
become firmly set aud approximated, thus givingnae to the popular name 
"lo(7k-jaw." Oflentimea the facial muaclea of expression ate more in- 
Yolred than the maeticatory muacLea, and when they are the result i9 a 
distressing diatortion to which the name riaua sardonicua is given. The 
extensor muartlea of the bank and eittremitiea ar^e next most liable to in- 
volvement, aud Che ououri'ence of the tebanio spasms here giv&s rise to 
opisthotonoa and other painful poaitioos of the body. The muacles of the 
arms aud hands aro least often affected. Not ho the respiratory muselea, 
for in nearly all the itLi&} cases dissolution ia immediately conditioned by 
the ooonrrence of tetanic spasm in them. Cutaneous irritability is enor- 
mously' increased, and oftentintea the slightest breath of air or any cutane- 
ous excitation that would not be detected in the uoru^al person cfiusea 
profound exacerbation of tlio tetanic spasms. These exaoorbations are 
attended by extreme pain. The patient whose consciousness remains un- 
afCeotedia iuniortaldread of such irritation and lies with bated breath and 
with every evidence of anxiety lest aome should come upon him. The bodily 
temperature rises from two to four degrees; the pnlae in tlie beginning is 
tense and rapidi and later becomes feeble m keeping with the exbanaticn 
or asphyxia that occurs if the disease is of great sovority^ The akin ta 
bathed with perspii-ation, which becomes very profound during the aeees- 
sionof thespasms; ajidall the somatic furctionn are moreor leas disturbed- 

The clinical picture that attends the occurrence of tetanus follow- 
ing wounds of the head, so-called head tstanoe, or cephalic tetanus, 
differs ooneiderably from the Tarietiee just spoken of. The moat con- 
spicnoiis feature is a spasm of the gullet like that occurring in lyssftT 
whii'b prevents the patient from swallowing. The next most striking 
peculiarity ia the occurrence of facial paralysis, which is oc'caaionally 
associated with paralysis of the eye muscles. The facial and ocular pal- 
sies art3 dependent upon an iufectioua neuritia of the respective nervea. 
The tetanus toain manufactured around the wound in the head is eartied 



■Jong Ch» flhe&ths of the nerres by the eudolyniph, thus being given 
BpecuJ f&cilitie8 far cau^tci^ a periaouritis. lu thie cotmecticn il naj be 
uiilthBt tlio toxius of betauoa liUTa a peculiar tendeuc; to cause altera- 
liou of tho luotoi uQuroQSf not only in tlieir peripheral diBttibittioQfi, bat 
ia the oell bodice of the ventrnl hoinn and the briua. Galdscheitler and 
fliuu, Stiiitzing, Matthes, aud others have demons tr^t^d the occurreuce 
af tcute degetie ration in lli** gauglicui oella of the ventral horns iii artificial 
and acoidental telADua, It is Dut uoIik^Jj that the to^iaa secure their 
KCMsioD fo the eell bodies throagh tho neural eudolytuph aa well oa 
ttroogh the blood. 

lAfttmexit — The Ladicationa for treatment of tetanus may be Bum- 
mamed iioder t7o headings: FirHt, the prophylactic, tlisit ia, U> prevent 
llie bacilli and the toiiiiH that are the result of their exiHteiiee andactiA'ity 
from gettiTLg iatc the system; and BCcond, when this is impoeaible, which 
tuiforhmawly is ofteu the case, to prevent the further production of toiina 
sad their absoTption and to coimteract the effects of toxins upon the cen- 
tral nervous ayatem. 

The general prophylaxis consists lq educating those liable to the kind 
of wounds that are commonly infected by the tctanua bacillus that the 
only Tellable safeguard against the development of tetanus i3 to have the 
voosd, triding though it may appear, thoroughly and aseptieaily cleaned 
lad (Iresaed^ The fact that the bacilli propagate only in the wound and 
in itfl very immediate environnteot has led iitany t<i a<i vacate the complete 
eicision of these parts^ Undoubtedly auch a radical and drastic pro- 
cedure would be aucceaeful in many instances if patienta would submit to 
it, hot the majority of them will not. The wound whioh gave the bacilli 
aa aienoe of entrance may have long siDoe healed, and it is difficult for 
tbe patietit under such <\ircunjnt.ance<4 fulTy to cornpreht!iid how eicUrpatlnn 
or the part would lead to a cure. If the patient is seen while the wound 
isitill present, it should be excised or thoroughly curetted and treated 
tutifieptically. For this purpose the ordinary antiseptio BolntionB, such 
>s i^iLrbolio acid and bichloride of meniury, are of little use- The beat 
antiaeptte is a solution of iodine, which should be applied freelj. 

There is no drug that haa any iufluence to kill iha bacillus or to neu- 
tnlize the toxma, at^d the plan of treatmcot that has becu relied upon 
UTLtJ lately consista in the administration of an ti spasm odics and the 
sdopticn of measures to jnatntain the patient's strength. If life can be 
ptDluDged and auch accirlenta aa siiffix^tioTi and inanition prevented, the 
l}3Um will be able to rid itself of the noxious agencies through the nor- 
Q4l avenues of elimmation. These should be stimulated to a moderate 
Icgne, especially the skin and the intestinal tract, but not to such an 
pttttit as to weaken the patient. The akin is usually functionally ao- 
lire b thia disease, bat its activity may be enhanced by giving an 
abULdaoce of water, by diaphoreticB that do not prostrate, and by et- 



temal vva-rmth if the patient hajj no fever. To lessen the iutenAitj of 
the Bpasma in the volujitarj musrlHS a uumber of medidnes ma^ be 
given, the most iiD^jortaiil being the bromides, i-lilor&J, aEnl morphine 
interQallj, ami tho iuhalation of clibroform and chlorida of ethyL It 
is necessary ofteotimes to give the former in large doaea, especially the 
biomidea and chloral, ("aaea have beeu recorded in which a half-oujiee 
of tlie former and ninety graiiia of the latter have been given with good 
reaulu. NforphiDe ai^rvea a dod>lH purpose m tetaiiUA: it hluiita sensorial 
j>erccptivity, and acta powerfully to prevent taotorial reaponod. Theae 
diugb should he given through a feediii)^ tube or by the rectum, in caeca 
ID which there ii dysphagia from spasm of the gullet. Indeed, in aome 
casee it is iieccSBary to adminUt^r Dutrlment In this way on account of 
this ('.onditioa and uf the lonkjaw. The (uitaiieouH hyperafositivpness is 
often elfectually countei acted by keeping the patient immersed iu warm 
-water for hours at a time, and then by applying the wet paok> The 
greatest care should be tuken to spare tht^ patient all forms of sensorial 
irntatiiin. In the fio-callHd rheuiuatio variety ^iallcyktee have naturally 
been recommended and given. But it is well to l>ear in mind that the 
belief that i»uch ca3ei» are dependent upon the tetanus bacillus ia Ijecom- 
ing accepted. In the light of tlibi so-called rheumatic tetanus calls for 
the Boma kind of treatment as any othor elinicaL variety. 

In many eases the plan of treatment outlined has been and ia BtiU 
BucteEHful. But during the paet ten years evideui^e of a convincing kind 
has Iteen gradually unburn idating to show that there ia a speciiio treat- 
ment for tfitannKS, whith tojisiata in the adutinwtration of the etrum of 
immunised onimnls, the tetanus antitoNin, There are many preparatiooa 
cf antitoxin to he had, B.itd, ao far as can be judged from the publishel 
reports of theit use nne ia as effiiainona aa anotber. The commoner 
varieties that an^ use;l in Europe are thuHe of TiKi^otti^ Hoechat, B«rn, 
sud Ifeliring. Theso aro to be had iu this country, biLt they have no 
advantages over that auppliad by the New York City Board of Healtl^. 
Entire reliance should not l>e placed upon this measure any more than 
upon the administration of diphtheria atititoxin ns encompassing the duty 
of a physic iau iu treating a case of diphtheria. On the cojitrary, when 
the tetanus antitoxin is administered the wooud should be thoroughly 
curetted aud cleanaed, excised if the patient will consent to it and if a 
very long time has elapsed since the inliiatiaa of the wound, sj^d the gen- 
eral treatment already spoken of carried out In the lirat few years fol- 
lowing the reeomniendatinn of aeriim therapy in tetanus, the results of its 
trial did not tseem to be very eneouragiiig, but during the past two or 
three yearn a suflicient number of cases have been reported to democsttate 
its superiority to every other form of treatment. For iuBtanoe, Engelmann 
has recently published a review of thirty-six oases treated according to 
Ti£zoni's plao, in which there were only eight deaths, and eighteen cases 



«nh Beliriiig*a seruin with seven deaths. Many nufavoTabie results hhve 

bna recorded, but h is probable that iu aome of thetie the aiitito^^m waa 

notoaed in ftuffioientlj large doBes. From gt. iJ.-Ixxi. of the dry onti- 

tcoin diflsolred in ten times the quantity of water maj be opnaidered &□ 

iftngB doee. The priiiciplea undoTlying ita applicntiou htq exactly tiie 

flVie %t those for giving diphtheria aiititoxiu in diphtheria, :ind although 

Ihetesults so far Lare not been bo brilHajit as Uioae which have attended 

ibHuiieof diphtlie^rial auUtoAiii, they are, nevertheleari, liufllcient to war- 

iinEits uniiualihi^d reconuDcndBtiE>D. In order to neutralise the poiaou 

d die tetantis tosin the sise of the dose must be increased with eaoh 

kour that the treatmeot ia delayed. For this reason it is very important 

thtl the antitoxin be admiMi>itered aa early as possible^ Wben, however, 

IbsJufectioD Is of cijnsiderHble intensity, &s evinoed by tho rapid develop- 

aest of »ymptcim9f shoit incubation period, from fire to eight daya, cr 

c^»pi(^Liotig bulbar phenomenal or when the tteatu^ect 13 delayed uotil 

•everal days after the appearouoe of the sjmptomSf at least lOU ChC. Bhovild 

bi iu«d during Lhe first twenty-four hours of trentmentr the contents of 

OMphial beiDg given at the iirst JDJeotiouT aiid this duse repeated at sljort 

mterrak. When the wound haa oot been treated, even though the aymp- 

koaa are alight^ the toxin is administered in large doses- The beat 

aethod of administration has not aa yet been fully determined, but at 

t±«prefleDC time the method of intra-cerebral injection as euggested by 

Bona and Boarrel has not shown itself superior to deep hypodermic in- 

jcttion ioto th& aubcul^neous rellular Liasue (see page TrO) . The tetanus 

mtttoiiii may bo obtained in this country from the New York Itoard of 

BMlth and probably from the laboratories of other munijipai health 

bouda. The Italian and German antitoxiDS are also imported by Merok. 

la addition to the general measures already epokt^n of, it ia often necessary 

40 administer some sleep -producing agency in addition to chloral. The beat 

of ihcaeieparaldebjdOi It is of the greatest iujportance to anticipate aud 

tvoid complications, especially inanition and asphyxia. The former must 

^ ccmbated by the use of highly nutritious and coacentratcii nourish- 

iNut, and the latter by the use of the rapidly acting antiBpaAmodics. 

5arees should be in cJOHtant attendance ready to employ artifieiaJ ree- 

pu^oa on the sUghte^st ei-idence of asphyxiation. Tracheotomy in nae- 

\ta, for the spasms will occur in the mnsclca of respiration just as snrety 

Thm there is aa opening in the trachea^ If the patient can be tided over 

tbe tint week, the ohanoes of recovery are exoellent. 




Trtaj^ ia & pecuJiax motor neurosis of toxio or mfectiooa ocigiiit 

oharootemed b^ intoniiittoDt recurrtng tonio spnsm in the miiacies uf the 
band &ud Bometimes in other paita of tho body, sQch a^ the foot, rerj 
rareljin muscles of tbe trunk; by inoteaaed mechanical irritability of th« 
motor nerves, ChvosU-k's symi>U;in; by increased elertricnl irriuibdity 
of the motor nerve, Erb^s ejmptom; by increaaed mecbLtnica] and elec- 
trical irritability of the sensory nerve, conatitutlD^ tho condition known 
ELS Hoffman's eyntptgrn^ and by tho occurrence of a cramp conditiob 
when dticp presaiire t& made on the musoles of on extremity wherein 
the tonic apaaia haa been nmnifest, known as Tronsa^aii^s symptom- As 
a rule, there is no disturbitiiue of [^nficimisneaa, atthongli in many In- 
atances the patients is oiuotional and of a more or less hysterical dit^poal- 

Tetany is mofe common before the fiftJi year thau at any other period. 
Males are a£Fdoted ofteuer than females. Overwork., iGsutfieiGnt and iiti* 
HuitKble food, and bad hygiene are imjK>rtant predirtpositig oanses. It is 
not dependent n[>on any individual infection or intoxication^ that ia, it is 
net assooiatod with anj' epecial organism or poiaon. It sometimes occurs 
with ohrouio oatarrh of the atomach and uitestineSj and in such instances 
it is probably due to the action of peptotoxina and InteBtina] tasina. Oc- 
aasionally it fullon's one of the acute infectiuus diseases^ sn^h as typhoid 
fever, dysentery, and cholera. It sometimes follows the injection of one 
of tho vegetable and mineral poisons, such as ergot, alcohol, chlorofonn^ 
lead, phoaphoiua, and toL>acco. It o<!-0ur8 oocaaioually after partial or com- 
plete ablation of the thyioiii gland undertaken for the cnre of goitre, and 
in such instances it la duo to the presence of toxioif in the system that am 
normally counteracted by the secretion of this gland, or that develop on 
account <jf tho abaence of such oef^retion. It occurs with conditiona of 
bodily depravity, euoli a3 are inducted by pregnancy Euid lactationf and 
with the disturbauceof nutrition at the basis of rbachitis. En wme casee 
DO cause whatever can be found. In al) probability the phenomena of 
the dia^aso are conditioned by the activity of the attributed poison on the 
central nervous system^ usually the brain- 

Constitulional Treatment.— Tlio treatment t^ tetany may be sumtDar 
i^ed io a hao: discover the caase, then render it non -operative, and, if 
potisible, remove it. The discovery of the eanee is usually much easier Ibaii 



iU remoTiJ^ For iost&Dce, cased of tetany oocuning iritli dilaULtion of tht 
ittmich luay be treated aymptomatioallv with (Jonaidetable rehci, but the 
e^todio nltwnttoii near tlie pylorus, Thi^fa frequemty attends this nuidi- 
tjna^ will r8i|uu-e sissiduous ami t^oj^-coDtiiiued trv&tJiieDL Ev«d then, 
from cne-hilf to t«i>-tL.Lrds of Xhtsae |jatierits sncciimb, vbile in tho onli- 
juaj fonua o£ tot&ny ftlmoat every c&se recovers, eren though no tieatmeot 
le instituted. After the enures of the disease are combated and retno?ed, 
DMSUKS should b« taken to prevent furtlier impoverishnjent cf the bItHxi 
■od to restore it as soon as |>oH8ible to a normal condition, Tlie treiLtniaut 
dtrvcted to mainteiiani^flof the genera] bodily tone should be ardently car- 
ried oat. Exc^aire work and enervating indulgcneea should be foresworn 
■ndtliC patient ur^d to get complete rest if possible. When the Byniptoiu 
OMDjtl^x followg an infectious disease, the administration of Hnlieylic neid 
tn ten- to li f teen-grain doaeSp taken with large quantities of water, seeniH to 
ha^e a decidedly b^nehcial eEIect. If tlie patient ia i^ot already weakened 
from previous infection or intoxication, diapLoietica are Bometimes ad- 
TUitageously given. There is no specific medication. The hability to 
lbBOo<:urrence of tetany should always be borne in mind wlien oj>erationa 
on the thyroid ate advised, and whenever pusHible the surgeon shoidd be 
coonaelled to do a resection rather than an eitirpation. When the aynip* 
tDQD occurs after operation on tlie thyroid, transplantation of the thyroid 
tud tbytoid adniinistrati on, either in shape of tho fresh thyroid gland 
or Cabl^ta of the desiccated extract, should be employeil. When the dia- 
OK occurs in pregnancy and iaf;tati(jn, measures taken to combat the 
lijdTfeniia may be suliii;ient to cope with iL No hesitation should be had 
in idvising weanbig at once, it matters not how young the infai^t is. 
Ocdinimilly the symptoms become bo severe in pregnancy that the qnes- 
t»n of emptying the uterus mnat be considered. All meane for the c<}£i' 
troJ of the tetanic spaam should be exhausted before this is undertaken. 

When iha disease oc-cuth in chihlreD and ap[)arently without cause, it 
15 veil to bear in mind titat the symptom complex aometimea follows tlje 
brdieemia produced by iittestinal wonna, and that a few sharp doora of 
ID utbelmintio will start these patients toward reeovery- 

In very rare instances the tetanic s]>asra oEteada from tbd muiclM of 
the hand and forearm to the trunk and extretnities, and cansoB symptomt 
of uphyxia which may lead rapidly to death. If such a condition accam, 
tKiDTv should be no hesitation in employing inhalations ot chloroform if 
^ patient can be induced bo make inspiratory effort. £f he cannot, 
BUfphine should be given hypodermatieaUy and a clyster containing » 
foil dose of bromide and belladonna administered later. In a caia re* 
poitedby Kost^r general tetanic spasm wa>^ found after death to be depend* 
ftit apoa widespread arterial scleroaia and small hemorrhageM on the 
Utbenor surface of the cauda equina and around tho roots of the tbirdt 
icurth, and fifth cervical nerves. 




The CQHTaleAocnae of pa^tieota wLo h&ve hAd tetany ia often tedioog 
iLad Italia for tli€ iuo9t ni^siduoua dietetic aud hj^ieniu euperviBion^ 

Treatment of the Spasm. — An «J£ort should be maiie Ut aJlay pam 
and to overcome the tnii^oular contraction. The raedtoines that bAve 
beei) fouDcl moat uj^eful icr these piiq}oses a-re a roDnbiuaticn of chloral 
and bellaUonuaf or clilorfLl aiid brotuide. In aeverer casea, hyoacjaajine 
m one- one- hundredth -grain doses for &n adult, and curarinei tbe dose de- 
pending xjpon the prepfLTfition employed, may be given hypodevioatically. 
As a tiilfii the tirat- mentioned uieasurea, if associated with prolonged 
lukewarm baths for their Hedative effect; upun the peripheral scnaorj 
nervea, combined witli revulaive aiid alimulatiiig applications over the 
apiiie and light mattAage of tXxe extreiniti«B, ^rill be quite fiufticicnt. 

The use of quiuine, opiatea, valerian, and cocaine should bo avoided, 
except to meet epeciol indioation«, Even then they ehoold be employed 
meiety as aytnptom medicines. A word must be aaid concerning the n8« 
of tlie broniiJea, AlLhough they are often of algual service in alleviating 
the apaam, they should not be given for a prolonged time, aa Uiey cier- 
0156 a deleterious action upon the blood vhich is already in a bad way. 

Thd galvania citrrent cc^n often be employed with great eflicaciouaneu. 
The belt method of applying it would aeem to be to place the cathode 
attached lo large electrode on the back of the neck or on the cheift, and 
the anode, in connection with a smaller electrode, over the nerve trunk 
supplying the parte* which are the seat of spasm, and allowing the current 
of three to eix milliamperea to flow uninterruptedly for from five to teti 
muuutes- This procedure should be repeated twice a day. The faradio 
current should never be usedj for its effect would be to aggravate all the 

Tetany ooeurring in infantB aeema to t>a a much more aerioua diaeaM 
than tetany of adults. Happily it is of rare occurr-ence. In the foitDor 
it not infrequently leads to death, while in the latter, unleaa it be aaso- 
ciat^d with ulceration i^r dilatation cif the atomach, almost invariably 
recovers. In infantile tetany the liigestive tract should be carefully ex- 
amined, and undigested eubatances in the etomaoh removed by the admin- 
istration of a mild emetic, cuch as a considerable quantity of lukewarm 
water. The patient should then ha given a brisk cathartic or the intes- 
tines thot«ughly irrigated. After that, reliance must be placed upon the 
cuAtomary measures for the treatment of this condition in the adnlt, and 
in the efhcaciousnesfl of means taken to counteract the rhachitis with which 
it ia almost alwaye associated. 



TfTB siiniiltuieouB pafticipation of many nervea^ neither fu&ctiondlf 

nof anatoiDicalJy ttsacx-i&Ced, in an inflammatory process involving tbe 
she&th or the saiaX core, is known &s muJtiplo DGuritis, Tbo clinical 
lictoie tbAt it prodaccais oftentimes that of disease of theoentralDerrous 
s^^sem* It is a diseaae whoae recogrution and oausation baT€ been fully 
iaterpMtad only in modern times. The etiology of maltiple neurilie, if 
TTTtten in dt-tail, would req^uire a cliapt^r to itself. THe principal facja 
Bay be summarized as follows: 

PndiBpoaing Oauses- — By far the moat imporbojit is a neuropathic 
piodupoaition which may be inherited or acquired. The role played by 
pT^iaposition may beat be illustrated by examples^ Two apparently 
BQtinally developed and healthy persons consume the same eicesaive 
^^^^(Baiitity of aJcoholic liquor for a year. At the end of that lime aas has 
muilipla neuritis; the other ib apparently unharmed. Again, out of a 
aomber of healthy workmen, eiposed to the fumes of bisulphide of car- 
bon, one or two only may develop polyneuritis. Almost innumerable 
oanples having tbe same bearing and open to similar interpretation 
mtgtt be eitdd. It is difficult to statd in so many words the nature of 
ihe prediflpoaitiou which makes them vulnerable- Tbe remarka on the 
T^duerabilitj and resistance of nervous tl.ssuo to injurious Bubetancea 
iltould be road m this coimectiou (see page 4)^ Jt must Buffiee here to 
UT that if the ancestral ajid persono,] history of the patient is ini^uired 
imo^ either inherited or acquired deviations from the normal will fre- 
qo^ntly be found. Otber predispOEing causes may be summarized in a 
lioc^ Anything tbat depresdea general vital Teaistance, and especially 
uijlhing that at the same time caiiace local depression, m^y be a predis- 
pnBtQg factor, 

Ezcituig Causei^ — The actual eauses of polyneuritis may besntCTnarlzed 
nader two headings : 

t, 2nlvxii:afi"Tt», which may be snbdirided into: (a) Endogenous 
poisons that a^ise from within the system, and that are ori^ally dee- 
tioftd for elimination, may by their retention and absorption into the 
<jitem produi^e Intoxication, whoae pentieioasneBa is operatii^e particular- 
IjoD the peripheral nerves (polyneuritis which occasionally occurs in preg- 
Uucj may he of this sort), or the intoaicatioa may arise from aubatancea 



thnt are the result of & diseflse process gni^g on in the ayat^m, whicb pro- 
duoeft ia turn agencies thttt are deatrut^nve to certain tiaflues- U utter this 
latter cnptioii are iodudeU the poI^Deuritides of iliabetes, of gout, uf ar-ute 
articular rheiimatiAoj, aud possibly aliio those accompaajiiig ca-ucer aad 
cither forms of cachexia. OccaaionaUy a case of multiple neuritis i» tuet 
iv'ith in whLch there ia no r^ttribut^ljle cause sa-re tho precedence of gaetto- 
itttestiiial markifestHtioas, Thc-*4B csaea are thought to be das to uutoin- 
toxication from tha alimentary tra^t. The enfly conoiirrenf^e of inental 
symptoma givea crior to this riew. (ft) Exogenous |>oLBoikSf therefore in- 
toxioatiou coming from withuut and exeri^ising a destructive action upon 
D(3uraxous, aiii to a les&er extent on the cnlh-e neuron. These poisonoos 
ageiu'iea, enumerated in the order of their importsupe ageAuaative factors 
of nLultpi]ile Utiuritiar are: alcohol, araeriL^ lead^ copjier, mercury, silver, 
sulphide of carbon, oxide of cnrhou. Liirpentiue, aniline, and iiieotincL 
Of theao by far the most malign ia alcohol. It is not unJikely that it 
oansefl more multiple neuritia than all the other into^iicante. Alcoholic 
multiple ne\Lritia la liable to occur at any age, although naturally it 
is Been most frequently in adults. I have now under observation a 
seven -year-old boy who ia suffering from a aeooiid attaclt of alcoholic 
multiple neuritiSf dud to tlio beer habit* Th« £rat attack occurred vrhen 
be waa four years old. Muttiplo neuritis occura aa frequently in women 
ftfl iu men. My own atatiatie9 show it to be mora common in women- It 
aeema espeaially lilcely to attack those who di-inlt secretly, t have seen 
a number of instances of its o<^ciirreure in women aud clergymen who 
began taking sliiuulaota to braco them up, an J who fell into a coatora 
which the Scotchman calla *'oanny," that is, taking it with milk, the 
nulk U'ing put in the glaaa Jirst The quantity of whiskey taken can 
then be eatimated ouly by results, and as tbeaa are usually pleasurable, 
ttiU plan appeals to th^m. The condition of the general health has much 
to do indtibermining the onset of alcoholic multiple ueuritia, Tho^e who 
are vigorous and whose eliuiinative organa and channela are in active con- 
dition are practically immune to thia manifestation of alcoholic poisoning^ 
especially if tbey inherit a stable nervous organization. 

Arsenical poljneuntia occura most frequently as the result of taking 
arsenio with suicidal lutEmt, and for therajieutiQ effect, aa in ohorea and 
progiefiaive pernicioua anemia. Occasionally the source of the poison- 
ing is from ooametics and decoration. More than one factor is operative 
in causing the multiple neuritis which sometimea follows the t^ing of 
atsenio for suicidal purpose. In addiUou to the colossal depressioti 
which e^tiats, there is the altock to the ge[jeral uervoua system incident to 
the noil -completion of the act, and oftentimes the crimo ia perpetrated 
toward the end of a driukhig bout. The different intoxioanta which cause 
mtdtiple neuritis have more or less of an elective effectn Alcohol, for in- 
stance, ia especially liable to alTect the extensors of the lower eiftremitiesr 



(cpoeiAlIj at ^&t. Ars«Ji^c, on the other hacidT liss a gpeui&l pr^dilectiou 

fo* tbe fleior lauaclea, both of tite lower and of ih** iq^ijer extremities, 

vbtle lead siiiglas out iu a must remarkable way l.lie extensor luuacles^ 

■pvliciUa.rljr those innervated bj the musculo -spiral nerves, 

■ 2. Jnf'frfwuA. — The cauaea incluiled under thia heading are very ou- 

aerwis, and only the more important ones will he mentioned. Nearitia 

ioe lo infection may be subdivided into: {ft) The endemic form, known 

ID the Orienl], to vLii-h region it h confined exoept when ex]>orled, as 

beri-heri, or kakke, pfob^bly due Ut a pathogenic cigauism; and (ft) 

tfuve forms occurring afti?r Bimple infectious fever, and due to the i^er- 

oicioufl e^ect cf toxins v^hich have Leen engenUertd dunng the procetis of 

iuto-imm EL nidation. This form of multiple neuritis is eepooially liable to 

ioUov diphtheria, typliuid fever, sepflia and its various lociali/ed form!*, 

nch ts puerperal fevpr and aijptjo eudocarditisr bubercidosiH, dyBen- 

iQiy, leprosy, malaria, erysipelas, diplococcua pueumouia, influenza, siui- 

pie angina, and ^anorrh<ta. Some writers have contended that ocoaEiou- 

illy multiple neuritis is dije to syphilis, but the experience of Anierii^an 

Bwmlogists is opposed to this view. A slowly progressive form of poly- 

antribiH ot^cnrring in the aged b dependent upon senile changes in the 

Uood- vessel a. 

Symptoms, — The disease may develop in an acute, subacutOi or chronic 
Iaahi(ia, The latter way ia the nile when the polyneuritis is dependent 
upon ond associated with cachexia, snch aa cancer. The mode of onset 
T&rjps n^^' .-ii-i'ordiik^ to the causation. tf alcohol is the attributable 
ifency, mental symptoms such as depresaicUj emotional ifim, mental ud- 
i«l on the one band, and unaccountable fatij^ue, amyoatbenia, cramp of 
the muscles of the legs on the other, are the customary forerunners. 
ttTheii the disease eomes ou ahmptlj-, it will be aecomiianied by the ordi- 
nary febrile manifestations: elevation of temperature, whlrh may reach 
103 F., general feeling of illness and prostratioD, loss of appetite, dimin- 
ished quantity of urine, and occasionally a slight amount of albuuiinuria. 
With or without these introdiLutory symptoms the disease presents ilaelf 
QBtier thr«e clinical forma: (1) motor form; (2) sensory f one j (3) aa 
Uazis form- Although motor, sensory, and ataxic inantfestatiuns are 
present in ne&rly every caae, usually one of these predominates. 

The motor form is by far the most commou. It is called motor form, not 
that sensory symptouis are absent, but beirause the motor manifestations 
are soconspicnous-^ The motor symptoms are paresis of voluntary mustles, 
which may be nf s;jch a degree as to result in extreme Raccid paralysia; 
difficulty of co-ordiuatiou, which manifests itself on using theextremitiea, 
•ad peihapa also in speech ^ and very rarely paitial loss of function of 
invo!uata.ry musclcG, auch aa those of the bladder and rectum. The lower 
^xtremitiM are Ciftt^neat th^ seat of the lesion arnJ the peroneal group of 
mtiscles is most likely to be paralyzed. With the paralyjtis there are 



aa&ociated pain of Tafjing aeverity and character along tlie course of tht 
nerve; painfiilnetia of the nerve ttuiikjt anil branches on deiep-sested 
pressure^ loas of electrical irrit&biHty in the nerves and in the muacteSi 
whicL may he bo great as to constitvite oomplete reaction of degeneration, 
loga of respouse to the foradic current ftiid altered polar irritabilit3' to 
the galvanic; rapidly pTOgr^aaiiig atrophy of the musj^lea; iuipaTTtnent 
of the deep reflexes, audi as the knee jerk, which will be completely 
ahsent when the nervea supplyiug the muacleB entering into the form^- 
tior of the quadricepa extensor are inflamed; and eoiad degree of trophic 
diaQgefl, especially that kncivo as glossy akin. If the nenritia ia due 
to poisoaiQg by aleohol, niental eymptouis varying from pathologies] 
emotionalism through various degrees of mania and dementia may be 
present. The aei:oitdary syinptums or late Bymptomatie phenomena of 
(he motor fotin of multiple neuritis are thuae of deformity in the cz< 
tremitiee^ due to aeeondary oontraoture in tKe iuBtuued aeuromuaculaf 
tissues and to the iino]»posed contraction cf the heaitliy muflclea, and a 
p^uhar mental state, characterized particularly hy a c^oitvictiou amount- 
ing almost to an obwsaiou of motor irapotency and a general hysterotd 

The Boijsory form is charooteriaed partioularly by pain of varying 
degrees of intensity, referred to the eourse and distribution of the afTeeted 
nervM, aud of a more or lens contJnuaus natiirt^r though liable to brief or 
continuous periods of exacerbation. The pain in described as stabbing, 
buruing, LearLnj^, and shooting. It la increased hy active or [raasive 
motion, and ofteiitinjea by the pressure of theiied clothing. The affected 
extremities in this variety are in the beginning extremely I13' partes tbettCi 
but as time goes ou areas of au^stheaiar irregularly distributed over Uie 
extremity^ i^an he made out. The byperjustbeaix, however, continues in 
other areaa throughout the entire course of the disease. Voluntary move- 
ment is more or leas affected, and the reflexes are usually exaggerated, 
eepeeiatly ia the beginning. 

The ataxic form, often called nevro-tabes or pseudo^ tabes, because the 
more obvious symptom b parallelize t hose tjf true tabes or locomotor ataxia, 
usually develops insidiously, or in a subacute fashion. The prineipal 
pbeuomenon is ataxia, of either the upper or loner extremities, according 
to the part involved, associated with subjeotive seoaations of mimbneas, 
formicatioD, and pain, and with more or less loss of muscular sense^ 
Cutaneous sensibility is usually preserved, while the reflexes, both super* 
^cial and deep, are diminished ami s^rmetimes lost. The nerve trunks 
and tnuBcIes nre sensitive to deep-seuted pressure, and tliere may be par- 
tial reaction of degenerdtion in both the muscles and the nervei. 

Theee thi^ee clinical types of multiple neuritis have many sympto 
in common, which, however, are not ueoessarily present in any given 
case. These are local or general (sdema of an extremity, eBpectally lia- 




Ut to b« laaniffist orer aji artirolatioii ; tachycartlia nnd cfi.nliac palpita- 
Um, orideDcee of tiuplicatioD of the vagoa ut^iva ljy the Injurioiu ageDcy \ 
itiining, glooej skin; sluggisbneos of the pupils^ ^ometimea opbo aeu- 
niu. 3uid heraorrhages into the retina; &nd the formation of bedsoreip 

Ilie course of the ijtaeaae is a progressive one for & iew weeka in the 
■Date nriety, aud for a few Hjuuiha in the subai'ijfe variety. The ooiirse 
(if ths throDic varietur dependa entirt;ly upon the cacheria vitli wKich it 
a «eoctabe(J, The progDoeis in all forms of multiplo n«ur]ti9 in which 
Ikt ^Lise is disnoverabl^r removabU, or its aotiv^itj Eelf-HmitingT to favor- 
tb^ except ia those ca&es in u'hioh the respiratory muscles are involved 
isd in those showLiig early or prufounil implication of the pneuinogaatrir^ 
Bcrre. Despite this, however, more patieuta die from multiple nesiritia 
ihafi from niiuoat any other disease of oomparable severity. This ia due 
to tlie fact that their infirmity and its entailment render them particularly 
halJe to tul>erculou3 infection, while in other eaaes that apparently recover 
rertirreace of Llis mflammation h dins to inability of the patient to avoid 
the injurious sabatance, hti ib taken into the flysteiii for pleasure or m the 
TOfting of a livelihood, which first caused the disease. 

Treatment. — The treatment of multiple neuritis will be referred to 
andw three headings; (I) prophylaetio treatment; {2) Ireatraeul of the 
fame; (3) the remedial treatment^ which will include a diicnssion of 
measures necessary to bring about oJiatomioal and phjsiologiual reatitu- 

Prophylazis. — Considering what has l~«en eaid of the importance of in- 
h«nt#d or acquired, neuropathic diathesia in the geneaia of multiple neu- 
lida, It is not at all Hurprising that the prophylactic treatment may be of 
iraat uaefulness. Tosummarhe briefly what might be said under this cap- 
tion: IVraoua exx)osed to the activity of intoxicatiouaor infectiona known 
to be capable of causing multiple neuritis, whether these be incurred pur- 
posely, aa in taking alcohol; aocideutally^ aaaiter the iufeotioiia disease; or 
of necKsity, such as e^tposure to the tnetallio poisons^ should be apprised 
of the dangers and advised nob only to avoid these injurious agencies buL to 
indulge iu measures vhich are kucjwn to be contributory to the productiou 
and maintenance of a high degree of vitality and health. As a matter of 
fact, the phyaii/ian does not often have the opportunity given to him of 
meting out such instrcictioas, ex^'ept when the patient conaulta him for 
9<jat^^ symptom, the presence of which indicates the beginning of disease 
of the peripheral nerveA, or the presence in the nysl^m of a Aubatance 
that may cauac such disease. It is unnecessary here to euumerale the 
Tarioua means to be utilised in overcoming the shortcomings of an sc- 
4|iiired or inherited prediaposition- No more is it necessary to enumerate 
the Tariona hygtenif^, dietetic, eliminative pmcediirea utiJizable fat coun- 
teraiciing the pernicious eifects of sulutnncea capable of inciting [iiultiple 
neuritis, as alteution has beeo given to this in I'art I. The general practi- 



tion^r should kx^at in mitid the liability to occiureoce of multiple ueuritia 
after the infpctious ilistiaat^s, and so conduct the p^Hod of convnlescenoft 
UlaI no exhttusiion bIihII be jiut pre ma tii rely ii|ioii Ihe iifarcunuarular 
tDechfiuisDi. t am convinced that maay oaaea ol dipbtheiitic and inBuenz&l 
multiple neuritia would not occur if tho period of convaleacence waa iDore 
carefully guaided. It ia Qot sufticietit to p'Tevent the patient from ei- 
baustinghiB strength and dpfiresFiing hiavitality at this time, tli^ weakened 
and depraved ayateiti should Ua fortified by recunatructive ati men tat ion, 
by the proper uao cf freah aU. aiinhght, and sleep, aalure^a reiuedi^a, anJ 
by friction, niaBariye, bydrothorapyT and gyumaaticR. It is partimiarly to 
individuals who do not havo a clear bill uf bealtb from inheritttncy that 
auch c&re Bhould he given. 

Cauflal Treatmeiit^The rausal treatTiient of mcilriple reuritia u 
theoretically a very siujplo matter, rraclii^ally, it ia oftentiutea very 
diflicult to put iu application. In the first plaoo, the cause cannot al'vrftys 
be discovered. In mauy <:-ase3 of aluohohc^ njuitiple neuritiE, eapccially ia 
wouieu, tho drink habit is ol>atinately denied, often, with a. semblance of 
TighteouH indignation. Oftentimes in surh cases the ingeatiun at alcohol ia 
kept up^ even thoa^h tlic patient Ije cognizant of its deleteriun sneHH. On 
tbe other Kand, the metallic poiaona may amofrommosbunexpected aourcea 
and their presence in the flyet<^m bo for a long ticue nadetootable. Iu some 
cases the previouB occurrence of induenzaor other form of mild iofectious 
diaeaBe h&s either been forgotten or it la thovigbt of too little importance 
to be ineLitioned to the physician. Thus it ia evidetit tlij^t before cauaal 
treatment can be ayr]klied it ia oftentlmea necessAry to make a prolongei] 
and diligent search of the etiology. Even then it ia not always poeaible 
to convince cim^R self of the rOle played by eert^in deteciahic eondttions^ 
more than one of whi<^h may be thought is siinicient to ca>ise the disease^ 
This i^ partifidarly true of the HutointoxicattoDH. (IhemiHtry has not as 
yet devised means whereby it can be aald positively fkojn eKaminatioiia 
of the excreta or tho aecreta tl:iat auto in toxicants eulficieut to canee in- 
flumninlion nfe_ l>einft manufaHured within the body. We may bo led to 
tie Buspii'ion of their existence by the oi-^'iirroTifie of symptoms generally 
believed to be dependent upon svmh nmditions, and on aocouTkt of these it 
may be legitimate to infer that the inftammation of the nerves should be 
reckoned among the congeqELCncesH In certain antmn toxica tions, Hucb 
as diabetes, the relation between causa and ofTcct is obvious, and the in- 
dications for treatment are very evident. It has already been stated that 
syphilis proliftbly never oanses multiple neuritis. Mindful, however, of 
the fitcb thibt a few writers have reported leases of 8uch occurreoee, jt may 
be said that if one were able to convince himself of a caubul relatioir^lup 
between syphilis and multiple neuritiR, it would lie a signal for the vigor- 
ous iise of antiftyphilitic remedii^s. 

Remedial Treatment. — The rsntedial treatment of mnltiple neuritis 



lloold be undertaken early. The must iiiiportaiifc part of it ia reet. It 

oot bowfilLgLittLeu^uritiiiiiiay be, bulU tlie rapidity' luid the ccjuj' 

of racorery wilibeetibuiceii by reat. Whenever poaaible, the pa- 

I tjfnt should be eonliued to bed oud not allovred to perform atiy voluntary 

g0f«[n«Dt ; although able to atamd or walk, he ahoiild not bo rLllowed to get 

Odtaf bed even lo r^Hpund to the eidla of iLJLture, no iiiDiti situuld \\& \xf 

I iljowed lo feed himself or to usa tbe hands for any purposfl. Tlw 

I undedUto treatjuent should he concerned m relievijig fiikiLi, coiubntiiig 

ipfyft"", alleviating bladder symptoms, Euid vatchiiig for aud autieiptktmg 

oidiao and respiratory implication. Occa^ioiially it will be Decesaary to 

<litwl treatment imtDediately to delirimn or- oib^r mental aocfimpanlutecita 

of multiple neuritis, but usually tbe iiulH'Atioua mentioned eiipompass the 

irvtematic treatment. After the inHanxmatory ptoccaa haa reached ita 

keight and the regeaerativo atngo seta in, the Ltidicatioua for treatirient 

tni (I) to eoinbftt the muscular atrophy, {'2} to prevent the oeovirreuoe 

of deformity, (3) to reha-bilitate the loss of muscular sen 5e and oonjii'iiueiit 

ditorder of functioUf aitd finally (4) to assist in the regeneration of self- 

©afidence and mental equilibriiim the lack of which are sm-^W etriking 

features in many cQSca, 

The moat immediato and pointed indication ia for the roLiof of pain- 
Dflctitiineg the pain ia of suc^h severity and contiiiuousnsaa that it ex- 
bxaatd tba patient. If for no other rtason^ tljia alone would urge the 
Qved of aualgeaics. Moi'itliine in saaio fcrm is naturally the surest mem- 
ber of thb class, and in tlie beginning of the diaoa^o it abould be admin* 
iitered preferably by the alimentary tract, but only when the patient ia 
ooder thd eompleCe tonlrol of the pljyaioian aud the efipiuuage of a uurae 
uc hospital. Otherwise rslief from the pain might \te followed by the in- 
dulgent^ ia alcohol, which would in tnrn uEwesNibitd a rt^petition of the 
njoiphine, and thus a drug habit might be easily acquired- In E.ho majcji- 
i^ of oasea absolute rest» combined with esteriml opplicationa of dry 
heat Of eoJd^ depending upon the thermal elciiient that ja miiet grate- 
ful to the patient, i^ Etiltoient to make him moderriti^ly comfortable, 
and specially if tlie modern analgesics, such as phenacetin, antipyrin, 
nUcylato of sodium, aalophen, and like Bubatanoea be given. It la 
itceeesary to bear in mind, however, that all of thene ayntbetio products 
havft a teodency to depress the vegetative ayetetu, particularly tliat part 
of it represented by the paeumogaatric nerve. Their adminiairalion, 
therefore, should be coupled with the utilization of fortifying measures 
and remedies. Of these dry heat applied to the extremities and over tliO 
abdomen ia of great Eervk«. Forms of multiple neuritis thab seem to 
have oeourrod as the reanlt of refrigeration or from such hjemio diasooia- 
tiotia as those forming the basts of rheamatism are favorably influenced 
Vy th» administration ot thu sal iey lateis, which it is wi^ll known are anal- 
g^esic agCTits of coosiderablH (x>wer. X have had encouraging results from 



tlio adminiatration of metliyleiLe blue, aa suggeated bj Eirlioh ft&d Lit' 
iD&nn, wlitfi p4iuiiiifltered iu pill furuj. C^JuaiderLag the eleotiTe afflQity 
which this ajbstaiics has for nerve truukfl when applied post mortem, itia 
legitlmntre to infer that its ndiutniBtratifin causes somo chamges that make 
for T«Htitutiou iti the diBeaeed ner^e. On Uia otlier band, I have had no 
«]cpeneDce witli the nuboutaneoua admiDi strati on of carbolic acid given in 
a lwo-[>er-ceut solution directly into tbe area of the ioHamed nervcCr ^ 
recomuK^Ddt^d b^ KuEenburg. Nor &m I able to foriuulato any satiaf actOTf 
hypothesis to explain the working of such medii^ation. 

Oue of the most troublflBome accomiiauiments of the eELrl/ stages of 
mahiple neuritis is iiisouuua. It ia especially liable to occur in the aloo- 
holic form, Meaaurea must bd taken ^arly to combat its existence, fo 
little reparative proceaa caa go on in the eystem duriug itd oocurreo^^ 
There la nothing in the (Character or occurrence of the insomnia to call £ 
difFerent medioation than that utihzable in ii>soiniiia of the acute and t 
hatJBlirig dintaaes, flave that chloral nboidj be avoided. It nut orily ha« 
a tendency to loner blood pressure hy an elective e9^ect upon the pneu- 
mogastrio netTC, but it is a powerful bmmatolytio agenoy. Although the 
bromine salts are not true hypnotics, neverthele^^s ibey are oft^ con- 
dt(cive to the occupvcuca of alopp by acmthing peripheral irritation, and 
their sdminisiration in multiple neuritis, especially if cxhjbited with 
morphi[iG to relieve fmini givea gratifying results. The administration of 
aulfonal and trtonal iu tvreuty- grain duaea iifliinlly eulhces to bring about 
A degree of sleep, especially if given in oonnection with some diffusible 
stimulant, sunh an carbonate of ammonia and administered in hot milk. 
Pjiraldeliyde is likewise a driif^ i.hat may of tenti mi^s be given witli greai; 
efTeutiveneaa for the relief of this symptom. Its doss ia from half a 
drachm to a drachm, but double this quantity may be given without 
deleterious teaulta. Were it not for its disagreeable flavor and taate and 
all -pervading, enduring odnr, it would deserve to be used more exten- 
alvely. lusuinnia may likewiae be combated by the prolonged warm 
bath, or by tJio ajiplication of the dripping sheet, bath of which have a 
soothing and beueMal effect u^Kin the peripheral nerves. 

Oilier eymptoms that may occur calling fur therapy directed immcdt- 
ately against the eNistenee of the condition which their preflenci* signifies 
are paralysis of one or more of the cranial nerves, such aa the pueumo- 
gaatric, e^itension of paralysis to the respiratory organs, end acute trophic 
manifeata lions- Very rarely are vesical shurt-iominga of sufficient inten- 
*ily or gravity to call for direct interference. When they are, thej 
easily yield to regular catheterization. The involvement of a single 
cranial nerve has no other signitieance therapeutically than to direct atten- 
tion to the posslhility that other, and perhaps more vital, nerves of this 
group may become iuvolved. When tachycardia is associated with fee- 
blenos3 of canliac and arterial impulse, irregular rhythm ot the palae, 



thraatm^ synoope* cold extremities, eto., and suf^h £ubjective maQlfesta- 

tions «A profound mcittnl unrest and fear, diffaaibl^ stimulants aud cardiac 

vEcibuiVs tliat ATG kuowutoacb ou the miisciilatiire of the heart walla should 

Ia citcq at oace. For this purpose carbonate of auinioaift may be utjed 

m two-giain doses every hour if uecesanry, irhile camphor aud cafTeine, 

tdmuiistered mtemaUyf are alternated with the use of strophanthue oi 

OijcIuiiTiet administered subcutariefiusly. Much (ran be doue in averting 

vfaat maj seem to be an iinpeudiug cata^Lrophe by the use of these meua- 

nm, partioLilarly if the patient ia kept iu a state of moat profound re^t^ 

lad by the application of warmth to the extremities aud a cold rcmpre«a 

ID the cardiac region. Faradization of the pneumogBatiio has often been 

t««ommended to arert the disagreeable symptoms poiuttug to implication 

of the pueumogastrii?. in CA&ef* of dipljtheritic palsy, aud at times it h&s 

AHiDed to me to be an ageucy worthy of cousidei-aUe cuulidence. It ih 

Jiffioolt^ howerer* to estimate just how much good it does. There can be 

BO doubt that ite intemperate application may be qu agency for harm, 

IteefOM, it Bbould be given iu short etait^e